A nurse is caring for a dying patient. The family asks the nurse why there is a rattling in their loved one's chest. Which response is most appropriate?
A) The client picked up a virus and has respiratory symptoms.
B) The client has been lying in bed and secretions pool in the lung bases.
C) There is an accumulation of fluid in the pulmonary circulation and secretions throughout the respiratory tract.
D) Thick sputum accumulates as the client dehydrates from having little oral intake.
C
Feedback:
Failure of the heart's pumping function causes fluid to collect in the pulmonary circulation. Also, there is an accumulation of secretions in the respiratory tract. Both account for noisy respirations or what is called the death rattle. The client is typically not exposed to crowds where virus can be passed. Also, the symptoms the dying process would be different from that of a viral infection. It is true that secretions may pool in the lung bases; however, further symptoms cause the audible rattling in the upper bronchial tree. Although oral fluids may be limited, thick sputum is not common during the dying process.
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