Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

What should the nurse's first action be for a patient nearing death with noisy respirations?

1. Slightly elevate the patient's head

2. Suction the patient's mouth and throat

3. Request an order for an anticholinergic

4. Take no action

The correct answer is: Slightly elevate the patient's head

In a situation where a patient is nearing death and experiencing noisy respirations, which are often referred to as "death rattle," the most immediate and effective nursing intervention is to slightly elevate the patient's head. This position can help facilitate easier breathing by allowing gravity to assist in managing secretions in the airway. Elevating the head can help prevent the pooling of secretions, which contributes to the noisy respirations, ultimately providing some comfort to the patient. While suctioning the mouth and throat could potentially clear secretions, it is often not necessary and may cause discomfort or distress, particularly in end-of-life care, where gentle, supportive measures are prioritized. Requesting an anticholinergic may also be appropriate for managing secretions, but it is not the most immediate action a nurse can take. Taking no action does not address the patient's discomfort and may lead to unnecessary suffering. Therefore, slightly elevating the head aligns best with palliative care principles aimed at comfort.