# Stage 1 — Recognize cues. Review the 0700 hospice handoff. Highlight the findings that require the nurse's follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=en > language: en > subject: Personal Hygiene > category: BCC ## Question Stage 1 — Recognize cues. Review the 0700 hospice handoff. Highlight the findings that require the nurse's follow-up. 0700 handoff. Mr. K, 78, has stage IV non-small-cell lung cancer and advanced COPD and has been on the inpatient hospice unit for five days for refractory dyspnea. His plan is comfort focused, and a DNR/DNI order is on file. His son has asked to be called if signs suggest that death may be near. Throughout this stay he has had pursed-lip breathing, clubbed fingernails, and respirations of 28/min, and his saturations have ranged from 84 to 88 percent. This morning his breathing is labored with a new Cheyne-Stokes pattern, and SpO2 is 86 percent on his usual 4 L/min. His BP is 96/58, compared with 112/70 yesterday, and his knees are mottled. He is arousable only to firm voice; he has received no lorazepam for two days. With a small sip of water he coughs and pockets fluid in his cheek. He intermittently grimaces and reaches into the air. New pooled upper-airway secretions are audible. Temperature is 37.2 C, ankle edema is unchanged at 1+, and his last bowel movement was two days ago; his abdomen is soft and nondistended, and a bladder scan shows 90 mL. ## Explanation The findings needing follow-up are a new Cheyne-Stokes pattern, blood pressure that has fallen from 112/70 to 96/58, coughing and pocketing fluid with a small sip (the oral route is no longer safe), and grimacing with restless reaching that signals possible pain or dyspnea. Pursed-lip breathing, clubbing, a respiratory rate of 28, and SpO2 86 percent are his documented COPD baseline this week. With no lorazepam for two days, reduced responsiveness is not explained by sedation, and a soft abdomen with a 90 mL bladder scan rules out constipation or retention as the source of distress. ## In-depth explanation Quick answer Highlight **new Cheyne-Stokes pattern**, **BP is 96/58**, **pockets fluid in his cheek**, and **grimaces and reaches into the air**. Why this is correct Each correct cue is a change from Mr. K's own baseline that alters today's care. A new periodic breathing pattern and a blood pressure falling from 112/70 support a probable last-days transition; his son has asked to be called when such signs appear, so these changes require notification and family explanation. Pocketing fluid means oral medications are now an aspiration risk and the prescribed subcutaneous route is needed. Grimacing and reaching are behavioral signs of pain or distress in a client who cannot self-report and require a prompt comfort assessment. Easy analogy or mental picture Imagine a weather log for a place that is always windy: the steady wind (his COPD signs) is not news, but a new pattern in the sky and a falling barometer tell you a storm is arriving today. Memory hook In chronic illness, act on what is new, not on what is abnormal. NCLEX decision rule For a client with chronic abnormal findings, compare each finding with the documented baseline; a stable abnormal value is context, while a new pattern or downward trend requires follow-up. Why the other choices are wrong **Pursed-lip breathing**, **clubbed fingernails**, and **respirations of 28/min** look like respiratory distress but have been present throughout his stay from advanced COPD and cancer. **SpO2 is 86 percent** is within his documented 84 to 88 percent range on usual oxygen, and in comfort care oxygen is adjusted to comfort, not to a number. **Temperature is 37.2 C** is not a fever, **ankle edema is unchanged at 1+**, and **last bowel movement was two days ago** is expected with minimal intake; the soft, nondistended abdomen and 90 mL bladder scan show it is not the source of his distress. References 1NCI PDQ — Last Days of Life (Health Professional Version)Signs of impending death such as Cheyne-Stokes breathing, falling blood pressure, mottling, and loss of swallowing; symptom management 2National Institute on Aging — Providing Care and Comfort at the End of LifeAssessing pain and distress in clients who cannot report it, and family support ## Clinical scenario Scenario (Stage 1 — Recognize cues) A client with advanced lung cancer and COPD on the inpatient hospice unit shows several changes at the morning handoff while his family asks whether he is suffering. ## Key concepts - **Cheyne-Stokes respiration** — A cyclic pattern of gradually increasing then decreasing breaths followed by apnea, commonly seen as death approaches. - **Mottling** — Patchy purplish skin discoloration, often starting at the knees and feet, caused by reduced peripheral perfusion near the end of life. - **Behavioral pain indicators** — Signs such as grimacing, restlessness, and reaching used to assess pain or distress in clients who cannot report it. ## Related questions - [A hospice nurse is planning pain management for a client with metastatic cancer who can ta…](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=en) - [A nurse is creating a pressure injury prevention plan for an immobile older adult admitted…](https://mymerci.kr/pages/nclex_q.php?qn_id=366392&lang=en) - [A dying client's family asks to perform meaningful spiritual and cultural rituals at the b…](https://mymerci.kr/pages/nclex_q.php?qn_id=368302&lang=en) - [A nurse cares for family members after a loved one is told that an illness is terminal. Wh…](https://mymerci.kr/pages/nclex_q.php?qn_id=368324&lang=en) - [A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg…](https://mymerci.kr/pages/nclex_q.php?qn_id=369152&lang=en) - [A community health nurse is leading an advance care planning education session at a senior…](https://mymerci.kr/pages/nclex_q.php?qn_id=372705&lang=en) - [Stage 4 — Generate solutions. Select all nursing actions that belong in Mr. K's individual…](https://mymerci.kr/pages/nclex_q.php?qn_id=372807&lang=en) - [Stage 5 — Take action. Place the five nursing actions in the safest sequence for the initi…](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617305&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._