# Stage 3 — Prioritize hypotheses. Mr. K, 78, has stage IV lung cancer and advanced COPD and is on day 5 of inpatient hospice care with a comfort-focused plan and a DNR/DNI order. His saturations have ranged from 84% to 88% throughout the stay. This morning his breathing is labored with a new Cheyne-Stokes pattern, SpO2 is 86% on his usual 4 L/min, BP is 96/58 mm Hg (112/70 yesterday), and his knees are mottled. He is arousable only to firm voice and has received no lorazepam for two days. He coughs and pockets fluid after a small sip, intermittently grimaces and reaches into the air, and pooled upper-airway secretions are audible. Temperature is 37.2 C. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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> language: en  
> subject: Personal Hygiene  
> category: BCC

## Question

Stage 3 — Prioritize hypotheses. Mr. K, 78, has stage IV lung cancer and advanced COPD and is on day 5 of inpatient hospice care with a comfort-focused plan and a DNR/DNI order. His saturations have ranged from 84% to 88% throughout the stay. This morning his breathing is labored with a new Cheyne-Stokes pattern, SpO2 is 86% on his usual 4 L/min, BP is 96/58 mm Hg (112/70 yesterday), and his knees are mottled. He is arousable only to firm voice and has received no lorazepam for two days. He coughs and pockets fluid after a small sip, intermittently grimaces and reaches into the air, and pooled upper-airway secretions are audible. Temperature is 37.2 C. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Acute exacerbation of COPD
Aspiration pneumonia
Oversedation from a benzodiazepine
Transition into the last days of life

Actions to take

Select 2
Give the prescribed opioid by a non-oral route
Suction deeply every hour until the gurgling stops
Give scheduled oral medications in thickened liquid
Position him side-lying and provide mouth care
Obtain a chest x-ray and a sputum culture

Parameters to monitor

Select 2
Arterial PaCO2 level
Respiratory Distress Observation Scale score
Oxygen saturation by continuous pulse oximetry
Temperature trend
Nonverbal pain behavior score

## Explanation

New Cheyne-Stokes breathing, falling BP, mottling, reduced arousal, and pooled secretions in a client with advanced cancer describe the transition into the last days of life. Because he cannot swallow safely, dyspnea is treated with a prescribed opioid by a non-oral route, and positioning with mouth care relieves distress from secretions. Progress is judged by observed distress scores, not by oxygen saturation or laboratory values.

## In-depth explanation

Quick answer
Condition: transition into the last days of life. Actions: give the prescribed opioid by a non-oral route, and position him side-lying and provide mouth care. Monitor: Respiratory Distress Observation Scale score and nonverbal pain behavior score.

Why this is correct
The combination of a new Cheyne-Stokes pattern, BP falling from 112/70 to 96/58, knee mottling, decreasing responsiveness, and pooled upper-airway secretions is the classic cluster of the final days. The goal is comfort, so the nurse treats what he feels: opioid for air hunger (not by mouth, because he pockets fluid) and positioning plus mouth care for secretions. He cannot self-report, so observed scales such as the Respiratory Distress Observation Scale and a nonverbal pain scale are the parameters that show whether the plan is working.

Easy analogy or mental picture
Picture a candle burning down: you cannot make the wax grow back, but you can shield the flame from drafts. Comfort care shields the flame; it does not try to lengthen the candle.

Memory hook
Mottled, Cheyne-Stokes, can't swallow = comfort first, nothing by mouth, measure distress by what you see.

NCLEX decision rule
When goals are comfort-focused and death is near, select actions that relieve observed distress and parameters the nurse can observe; numbers such as SpO2 or blood gases do not measure comfort.

Why the other choices are wrong
COPD exacerbation is tempting because of dyspnea, but his SpO2 of 86% is inside his usual 84% to 88% range and the mottling and falling BP point elsewhere; a PaCO2 measurement serves that differential, not comfort. Aspiration pneumonia is tempting because he coughs on sips, but he is afebrile (37.2 C), so an x-ray, sputum culture, and temperature trend are low-value burdens. Benzodiazepine oversedation is excluded because no lorazepam was given for two days. Hourly deep suctioning is distressing and does not reduce secretions produced lower in the airway. Oral medicines, even thickened, are unsafe when he pockets fluid. Pulse oximetry does not show whether he feels breathless.

References
1NCI PDQ — Last Days of Life (Health Professional Version)Signs of impending death and management of dyspnea and death rattle
2National Institute on Aging — Providing Care and Comfort at the End of LifeComfort measures for breathing, mouth care, and positioning

## Clinical scenario

Case update
Hospice day 5: new Cheyne-Stokes breathing, falling BP, mottling, declining arousal, unsafe swallow, grimacing, and pooled secretions.

## Key concepts

- **Cheyne-Stokes respiration** — A cycle of gradually deeper then shallower breaths followed by apnea, common in the final days of life.
- **Respiratory Distress Observation Scale** — An observer-rated scale of breathing distress for clients who cannot report dyspnea.
- **Mottling** — Patchy purplish skin, often first at the knees, reflecting reduced peripheral circulation near death.

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