# A hospice client with metastatic prostate cancer and a pathologic fracture of the left hip is in the last hours of life. The client has been unresponsive since 0400 and no longer swallows or coughs. At 0600 the client grimaced and moaned while being turned onto the left side; at rest the face is relaxed. Findings at 0800: rattling sound with each breath, mouth breathing, dry oral mucosa with cracked lips, pauses in breathing of up to 20 seconds, and mottled knees. The client is lying on the back. The daughter at the bedside says the breathing sounds like drowning and asks the nurse to do something. Which actions should the nurse take? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617271&lang=en > language: en > subject: Nonpharmacological Comfort > category: BCC ## Question A hospice client with metastatic prostate cancer and a pathologic fracture of the left hip is in the last hours of life. The client has been unresponsive since 0400 and no longer swallows or coughs. At 0600 the client grimaced and moaned while being turned onto the left side; at rest the face is relaxed. Findings at 0800: rattling sound with each breath, mouth breathing, dry oral mucosa with cracked lips, pauses in breathing of up to 20 seconds, and mottled knees. The client is lying on the back. The daughter at the bedside says the breathing sounds like drowning and asks the nurse to do something. Which actions should the nurse take? Select all that apply. 1 Offer small sips of water by teaspoon to relieve the dry mouth 2 Position the client on the right side with the head raised 3 Continue turning the client every 2 hours to protect the skin 4 Moisten the mouth with swabs and apply a lip moisturizer 5 Advise the daughter to avoid talking to the client to limit stimulation 6 Explain that the breathing sound does not seem to distress the client ## Explanation Side-lying helps pooled secretions drain, but the client grimaced when turned onto the fractured left hip, so the right side is used. Swabs and lip moisturizer relieve the dry mouth without aspiration risk, and the relaxed face at rest lets the nurse tell the daughter the sound does not appear to distress the client. Teaspoon sips are unsafe because the client no longer swallows, rigid 2-hour turning causes pain at the end of life, and hearing may persist, so the family should be encouraged to keep talking. ## In-depth explanation Quick answer Turn the client onto the right side with the head raised, give mouth and lip care with swabs, and explain that the sound does not seem to distress the client (options 2, 4, 6). Why this is correct Three scenario details decide the answers. The client grimaced when turned onto the left side, where the pathologic fracture is, so side-lying for secretion drainage is done on the right side. The client no longer swallows or coughs, so the dry mouth is treated with moist swabs and lip moisturizer instead of fluids by mouth. The face is relaxed at rest, which is the best available sign that the rattle is not causing the client distress, and this is what the daughter needs to hear. Easy analogy or mental picture Comfort care in the last hours is like tuning a room for someone asleep: you adjust what touches them (position, moisture on the lips) and what the family hears, but you stop anything that wakes them up or pours in what they cannot handle. Memory hook Last hours: drain to the pain-free side, swab do not sip, reassure with the relaxed face, and keep the family talking. NCLEX decision rule In the actively dying client, choose each comfort measure by what this client can tolerate now (swallowing, painful sites) rather than by routine schedules or hospital-wide protocols. Why the other choices are wrong Teaspoon sips (option 1) are tempting because offering fluids is a normal comfort measure for a dry mouth, but this client no longer swallows or coughs, so fluid pools in the throat, adds to the rattle, and risks aspiration. Turning every 2 hours (option 3) is standard pressure-injury prevention, but in the last hours repositioning is guided by comfort, and this client grimaced and moaned with the last turn. Telling the daughter not to talk (option 5) sounds like reducing stimulation, but the client is calm, hearing may persist near death, and family presence and voice are encouraged. References 1National Cancer Institute PDQ: Last Days of Life (Health Professional Version)Terminal secretions, positioning, mouth care, oral intake in the unresponsive client, and family communication ## Clinical scenario Scenario An unresponsive hospice client with a painful left hip fracture has noisy respirations, a dry mouth, and a relaxed face at rest in the last hours of life; the daughter is distressed by the breathing sound. ## Key concepts - **Terminal respiratory secretions** — The rattling sound caused by secretions pooling in the throat of an unresponsive dying person who cannot swallow or cough. - **Pathologic fracture** — A bone fracture through bone weakened by disease such as metastatic cancer, often painful with movement. - **Mottling** — Blotchy purplish discoloration of the knees and extremities from reduced circulation, a sign that death is near. ## Related questions - [A 68-year-old client with end-stage pancreatic cancer is receiving morphine 4 mg IV every …](https://mymerci.kr/pages/nclex_q.php?qn_id=363265&lang=en) - [A nurse is caring for a 78-year-old client receiving comfort-focused end-of-life care. 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