A nurse is caring for a client who has end-stage lung cancer.

The client has a decreased level of consciousness, extreme shortness of breath, and a respiratory rate of 40/min. The client's family member states to the nurse, "My sibling doesn't have any advance directives.
Can they still receive palliative sedation?"

Which of the following statements should the nurse include when speaking with the client's family?

Choice A rationale

Rhonchi are low-pitched, continuous snoring or rattling sounds caused by secretions or obstructions in the larger airways, such as the bronchi. They are often associated with conditions like chronic bronchitis or pneumonia and may clear with coughing. The description of a high-pitched, squeaking sound does not align with the characteristics of rhonchi, which are deeper and suggest the presence of thick mucus in the larger passages rather than narrowed smaller airways.

Choice B rationale

Crackles, also known as rales, are discontinuous, popping or bubbling sounds heard primarily during inspiration. They are caused by the sudden snapping open of small airways or alveoli that contain fluid. This occurs in conditions like heart failure or pulmonary edema. The sounds described in the question are continuous and high-pitched during exhalation, which is the opposite of the brief, non-continuous nature of crackles caused by fluid movement in distal air sacs.

Choice C rationale

Wheezes are high-pitched, continuous musical or squeaking sounds produced by air flowing through narrowed or constricted small airways. In asthma, bronchospasm and inflammation narrow the bronchioles, typically causing these sounds during expiration. The description of high-pitched squeaking during exhalation is the classic clinical presentation of wheezing. This indicates a significant reduction in the diameter of the airway lumen, requiring prompt assessment of the client’s respiratory effort and oxygen saturation levels.

Choice D rationale

Stridor is a harsh, high-pitched, vibrating sound caused by an obstruction in the upper airway, such as the larynx or trachea. It is usually loudest during inspiration and can often be heard without a stethoscope. Stridor is a medical emergency indicating a compromised upper airway. While high-pitched, it is localized to the throat area rather than the lower lung fields and sounds more like gasping or crowing than the squeaking associated with asthmatic wheezing.

Choice C rationale

Assistive personnel are trained to perform routine, non-invasive tasks on stable clients. Obtaining blood pressure is a standard data collection task that does not require clinical judgment or nursing analysis. A client scheduled for discharge later in the day is considered stable, making this task appropriate for delegation. The nurse remains responsible for reviewing the value and ensuring it falls within the normal range of 90 to 120 mmHg systolic and 60 to 80 mmHg diastolic.

Choice A rationale

Tracheostomy care involves the management of a surgical airway and requires sterile or aseptic technique, assessment of stoma integrity, and monitoring of respiratory status. These actions require the specialized knowledge and clinical judgment of a licensed nurse. Assistive personnel do not have the training to recognize complications such as subcutaneous emphysema or tracheal stenosis. Therefore, this task cannot be delegated because it is an invasive procedure that requires frequent nursing assessment and complex decision-making.

Choice B rationale

Patient teaching is a core responsibility of the registered nurse and cannot be delegated to unlicensed staff. Educating a client on the use of an incentive spirometer involves explaining the physiological goals of preventing atelectasis and ensuring the client demonstrates the correct technique. Assistive personnel can encourage the client to use the device after the initial teaching has occurred, but the primary instruction and evaluation of the client's understanding must be performed by the nurse.

Choice D rationale

Assessment is the first step of the nursing process and requires the professional expertise of a licensed nurse. A client returning from surgery is considered unstable and requires frequent monitoring of vital signs, surgical sites, and level of consciousness to detect early signs of hemorrhage or anesthesia complications. This level of clinical evaluation involves interpreting complex data and identifying deviations from baseline, which is a scope of practice restricted to the nurse and never delegated.