# A nurse is caring for a 78-year-old client with end-stage heart failure who is actively dying. The client is unresponsive, has a respiratory rate of 8 breaths/min with periods of apnea, and has audible upper airway secretions. The family is at the bedside and requests that everything possible be done to keep the client comfortable. Which actions should the nurse take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505798&lang=en  
> language: en  
> subject: Basic Care and Comfort  
> category: BCC

## Question

A nurse is caring for a 78-year-old client with end-stage heart failure who is actively dying. The client is unresponsive, has a respiratory rate of 8 breaths/min with periods of apnea, and has audible upper airway secretions. The family is at the bedside and requests that everything possible be done to keep the client comfortable. Which actions should the nurse take? Select all that apply.

1

Administer prescribed morphine for dyspnea and pain.

2

Suction the oropharynx deeply every 15 minutes.

3

Provide frequent oral care with moist sponges.

4

Reposition the client to a side-lying position.

5

Measure vital signs every hour to detect changes.

6

Encourage the family to talk to and touch the client.

## Explanation

Administering prescribed morphine addresses dyspnea and pain, which are common sources of distress at end of life. Frequent oral care with moist sponges maintains comfort and prevents dry mucous membranes. Repositioning to a side-lying position can reduce noisy respirations and promote comfort. Encouraging family presence and interaction supports emotional and spiritual well-being. Deep suctioning is not indicated because it can cause discomfort and trauma without clear benefit when secretions are not obstructing the airway. Measuring vital signs every hour is burdensome and does not contribute to comfort; monitoring should be minimized during active dying.

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