The daughter of a client, who is at the end of life, is concerned that the gurgling sound she hears is her father drowning in his own secretions. What is the best initial response by the nurse?
A) "This must be very upsetting to watch, but he isn't suffering."
B) "It might be best if you leave the room."
C) "You may not be giving him enough fluid."
D) "I'll suction him now."
A) "This must be very upsetting to watch, but he isn't suffering."
Explanation: A) This response acknowledges that this is upsetting to family members and provides reassurance that the patient is not suffering.
B) Asking the daughter to leave the room does not acknowledge the daughter's feelings and fears or provide family education.
C) This gurgling sound is an end-of-life phenomenon, and although dehydration may be a factor, it is not due to any lack of care by the family or nursing staff.
D) Oropharyngeal suctioning is usually not recommended because this procedure causes discomfort, is ineffective if secretions are beyond the reach of the catheter, and does not correct the underlying problem.
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