A terminally ill, unresponsive patient exhibits Cheyne-Stokes respirations. Which action by the nurse is most appropriate?

• A. Suction the patient's mouth.
• B. Administer oxygen via face mask.
• C. Document Cheyne-Stokes respirations.
• D. Place the patient in high Fowler's position.

Answer: (C)

Cheyne-Stokes respirations in a terminally ill, unresponsive patient reflect the dying process. This pattern consists of cycles of increasingly stronger and weaker breaths followed by a pause, caused by a diminishing respiratory drive as life ends. In this context, the priority is comfort and accurate documentation to guide care and set expectations with family and the team. Recording the breathing pattern communicates what is happening and helps tailor comfort-focused care, goals, and discussions about prognosis. Suctioning doesn’t treat the pattern and can cause discomfort; oxygen therapy is not routinely beneficial for this pattern and may prolong dying; positioning may provide comfort but does not change the underlying process.