The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate?
a. Suction the patient.
b. Administer oxygen via face mask.
c. Place the patient in high Fowler's position.
d. Document the respirations as Cheyne-Stokes.
ANS: D
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of the bed slightly and/or turning the patient on the side may promote comfort. There is no need to place the patient in high Fowler's position.
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