NR-325 Adult Health II - Set 5 - Part 1

Correct Answer: Begin lactated Ringer solution at the ordered rate

Huge volumes third space into the retroperitoneum, so hypovolemia and poor pancreatic perfusion drive the early deterioration. Lactated Ringer solution at a moderate, reassessed rate is the first priority alongside pain control. Option b is incorrect because antibiotics are withheld until an infection is actually documented, even when necrosis is present. Giving them by reflex breeds resistance and treats nothing in a sterile inflammatory process. Option c is incorrect because prolonged starvation has been abandoned. Oral low fat solids are offered within a day or two as tolerated, which protects the gut lining and shortens the hospital stay. Option d is incorrect because gastric decompression is reserved for ileus, vomiting that will not stop, or marked distension. Placing a tube in every client adds discomfort and electrolyte losses without improving outcomes.

Correct Answer: Lay the client flat and notify the provider

Removing a large volume drops intra abdominal pressure and lets blood pool in the splanchnic bed, so circulatory collapse is the priority risk. Lying the client flat supports perfusion while help is summoned. Option a is incorrect because sipping fluid cannot refill a circulation that just lost several liters of volume support. Waiting an hour while the pressure keeps sliding hands the client an avoidable episode of shock. Option b is incorrect because raising the torso worsens hypotension by draining blood away from the brain. Upright positioning helped during the tap itself, but it is precisely wrong once the pressure has fallen. Option d is incorrect because pallor with a pressure in the eighties is a complication, not an anticipated outcome. Charting it and moving on delays albumin replacement and leaves the kidneys at risk of injury.

Correct Answer: Have the client empty the bladder

A distended bladder rises out of the pelvis and sits directly in the needle path, where it can be punctured. Voiding just beforehand removes that hazard, and catheterization is ordered if voiding fails. Option b is incorrect because lying supine spreads the fluid across the abdomen and floats bowel loops toward the puncture site. Sitting upright or in high Fowler position lets gravity pool the fluid low. Option c is incorrect because albumin follows the tap rather than preceding it, and only when a large volume comes off. The usual trigger is more than five liters drained, replaced after the fluid leaves. Option d is incorrect because holding a diuretic is not part of preparing for this procedure. Diuretic decisions rest on potassium, sodium and creatinine results, and skipping a dose does nothing to protect the bladder.

Correct Answer: Give the ordered low-dose morphine for comfort

Breathlessness is whatever the client says it is and does not track with the pulse oximeter, so a small opioid dose is the first-line treatment even when the numbers look reassuring. Option a is incorrect because a normal saturation never overrules the client's own report. Telling the daughter the machine settles the question teaches her to distrust her father the next time he says he cannot breathe. Option b is incorrect because waiting for hypoxemia leaves a terrified man gasping for no reason. Air hunger and low oxygen are separate problems, and only one of them is what he is living through. Option d is incorrect because imaging delays relief and rarely alters a comfort plan this close to death. Films are ordered when a reversible cause would be treated, which is not the case being described.

Correct Answer: Diverticulosis without any active inflammation

Diverticula are herniations of mucosa through weak spots in the colon wall, most often in the sigmoid. Their mere presence, with no pain or fever, is diverticulosis and is usually silent. Option a is incorrect because inflammation of a pouch would bring steady left lower quadrant pain, fever and a raised white count. This client has none of those, so the pouches are merely present. Option b is incorrect because toxic megacolon means the colon has dilated massively while the client turns septic. It is diagnosed on imaging in a very ill person, not on a screening examination. Option c is incorrect because colitis shows a red, friable, continuously inflamed lining that begins at the rectum. Discrete outpouchings in an otherwise normal colon are a different structural change altogether.

Correct Answer: Notify the provider and set up seizure precautions

Fat necrosis binds calcium into soaps, so a falling level produces perioral tingling and a positive Chvostek sign. Laryngospasm, dysrhythmias and seizures can follow, so the provider is notified and airway safety arranged. Option a is incorrect because rebreathing raises carbon dioxide to treat tingling from hyperventilation. Here the cause is a chemical calcium deficit, and an acidosis strategy would not restore the mineral being consumed by fat necrosis. Option b is incorrect because turning changes nothing about a low serum mineral. Position helps the boring back pain of this disease, and comfort measures matter, but they cannot prevent the airway spasm that threatens here. Option d is incorrect because oral food cannot correct a deficit of this speed, and dietary intake is not the deficiency mechanism. Replacement is given intravenously, with magnesium checked at the same time.

Correct Answer: Helicobacter pylori infection and NSAID use

Nearly all peptic ulcers trace to Helicobacter pylori, which inflames gastric mucus, or to NSAIDs, which block prostaglandins that maintain mucus, bicarbonate and mucosal blood flow. Both strip the barrier. Option b is incorrect because seasoning and stress were blamed for generations before the bacterium was identified. Spicy meals may aggravate an existing sore spot, yet they do not erode the gastric lining. Option c is incorrect because dairy briefly buffers acid and then stimulates a rebound of secretion, which is why it was dropped from ulcer therapy. Meal timing alone creates no mucosal defect. Option d is incorrect because coffee can increase acid output without causing an ulcer, and no inherited enzyme defect is behind ordinary peptic disease. The rare hormonal cause is a gastrin-secreting tumor.

Correct Answer: The appendix has perforated into the peritoneum

Sudden relief comes from decompression of the distended appendix as it ruptures, not from healing. Rigidity, fever and tachycardia signal spilled contents irritating the peritoneum, and generalized peritonitis follows within hours. Option a is incorrect because resolving appendicitis would bring a softening abdomen, a falling temperature and a slowing pulse. Here every objective marker is moving the wrong way while only the pain report improved. Option b is incorrect because analgesia dulls pain without producing board-like rigidity or driving the heart rate up. Crediting the medication delays the surgical call that this client urgently needs. Option c is incorrect because referred visceral pain belongs to the early periumbilical stage, before the parietal peritoneum is involved. A rigid abdomen with fever places this client well past that point.

Correct Answer: Reassure the family that this pattern is expected

Cheyne-Stokes respirations reflect a brainstem that no longer answers carbon dioxide normally and are a common part of dying. The pattern alarms watchers, so teaching and presence are the nursing response. Option a is incorrect because rescue breathing is a resuscitation measure that contradicts a comfort-focused plan. It would break the peace of the room and could not reverse the neurologic failure producing the rhythm. Option b is incorrect because suctioning targets secretions, and nothing in this description mentions gurgling or pooled fluid. Repeated catheter passes would irritate the airway of a client who is simply breathing irregularly. Option d is incorrect because chasing the pauses with extra flow treats a monitor rather than a person. The apnea comes from a dying respiratory center, and added oxygen will not restore a regular rhythm.

Correct Answer: "We should press him to drink so he stays strong."

Pushing fluid on a dying client causes distress rather than strength, since the failing body cannot clear the volume and responds with edema and louder secretions. Sips for pleasure and mouth care replace it. Option b is incorrect because periodic breathing with long apneic pauses is an expected brainstem change in the final hours. The wife has described it accurately, and her understanding will steady her when it starts. Option c is incorrect because hearing is thought to persist longer than the other senses, so speaking to a sleeping client is exactly what nurses encourage. Nothing in that statement calls for correction. Option d is incorrect because mottling and cool extremities do reflect slowing circulation near death. She has repeated the teaching correctly, and the nurse would only add that heating pads should stay away.

Correct Answer: Reactive hypoglycemia from an exaggerated insulin release

Late dumping arrives one to three hours after eating. Carbohydrate absorbed too quickly spikes glucose, insulin overshoots, and the resulting low sugar brings tremor, sweating, hunger and confusion without any bowel symptoms. Option a is incorrect because the early form strikes within the first hour and carries cramping, borborygmi and urgent stools with it. Neither the timing nor the missing gut symptoms match that picture. Option b is incorrect because a leak shows persistent tachycardia, fever, rising pain and hypotension, and it appears in the first postoperative days. This client is six weeks out and symptom-free between meals. Option c is incorrect because bile washing back into the remnant causes burning epigastric pain and bilious vomiting. Those complaints have nothing in common with tremor, hunger and clouded thinking two hours after food.

Correct Answer: Emptying often, checking the seal, using deodorant

Most odor complaints trace back to a leaking seal or an overfull pouch, so regular emptying and seal checks come first. Pouch deodorants help, and yogurt, buttermilk and cranberry juice may reduce odor. Option a is incorrect because stretching wear time lets the adhesive break down and effluent seep under the barrier. That is precisely how a faint smell becomes a constant one at the client's desk. Option c is incorrect because those two items belong on the helpful list rather than the avoid list. Buttermilk and parsley sit there as well, and removing them gives up an easy dietary advantage. Option d is incorrect because eggs, fish, onions, garlic and asparagus are classic odor producers. Building them into every day would worsen the very problem that prompted this question.

Correct Answer: Scarred liver tissue forces portal blood into collaterals

Fibrosis and regenerative nodules block flow through the liver, so portal pressure climbs and blood detours into thin walled collateral veins around the esophagus, stomach and rectum. Splenic congestion appears for the same reason. Option b is incorrect because acid injury produces esophagitis, strictures and Barrett changes rather than dilated veins. Reflux damage sits in the mucosal surface, while varices are engorged submucosal channels fed by portal pressure. Option c is incorrect because a low albumin drives fluid out of the circulation into the peritoneal cavity and the ankles. That mechanism builds ascites and edema; it does not carve out new venous pathways. Option d is incorrect because forceful retching splits the mucosa at the gastroesophageal junction, a Mallory Weiss tear. Such a tear is a sudden mechanical injury, not the slow vascular remodeling seen with portal hypertension.

Correct Answer: "You remain nothing by mouth, but I will give frequent mouth care."

Nonoperative management means nothing by mouth, ice chips included, so the gut can rest while suction removes what is trapped. Oral care every two hours relieves the dryness without adding fluid to the stomach. Option a is incorrect because melted ice still enters a bowel that cannot move contents forward. The added volume stimulates secretion, and suction then removes it along with sodium, potassium and chloride the client needs. Option b is incorrect because pausing suction does not turn an obstructed gut into a working one. There is no scheduled window during which oral fluid becomes safe, and the order stands until peristalsis returns. Option d is incorrect because water is no gentler than ice on a blocked intestine. Substituting one oral fluid for another misses the point of the order, which is to keep the lumen empty.

Correct Answer: Blood in the gut acting as protein load

Bleeding into the bowel delivers an enormous protein load that gut bacteria convert to ammonia, and a damaged liver cannot clear it. Gastrointestinal hemorrhage is the classic trigger for hepatic encephalopathy. Option a is incorrect because a diseased liver leaves estrogen circulating instead of clearing it, which is why spider angiomas and gynecomastia appear. Hormone excess alters appearance and libido, not level of consciousness. Option b is incorrect because deposited bile salts cause maddening itching and scratching, a comfort and skin integrity problem. Pruritus never produces drowsiness, disorientation or the coarse tremor described in this scenario. Option c is incorrect because albumin falls in cirrhosis and keeps falling as synthesis fails. Even if it did climb, drawing water back into vessels would relieve swelling rather than cloud thinking.

Correct Answer: Paralytic ileus from surgery and hypokalemia

Ileus is failed peristalsis without a physical blockage. Abdominal surgery is its leading cause, low potassium worsens it, and the pattern of constant discomfort with sounds absent from the start fits functional obstruction. Option b is incorrect because adhesive blockage produces colicky waves of pain and high pitched rushes before the bowel tires. The steady discomfort and early silence described here follow a different mechanism. Option c is incorrect because strangulation announces itself with fever, severe unrelenting pain, tachycardia and peritoneal signs. None of those appear in this client, whose vital signs and examination remain unremarkable apart from distension. Option d is incorrect because a closed loop traps content between two points and drives massive colonic distension with rapid deterioration toward cecal perforation. Such a client looks far sicker than the one described.

Correct Answer: Direct a fan across his face

Cool air moving across the face stimulates trigeminal receptors and eases the sensation of breathlessness within seconds, which makes it the immediate step while a low-dose opioid is obtained for continued relief. Option a is incorrect because a blood gas is a painful test that will not change comfort-focused management. Dyspnea is defined by what the client reports, so no laboratory number confirms or refutes it. Option c is incorrect because lying flat pushes the abdominal contents against the diaphragm and worsens air hunger. Upright or forward-leaning positions with the arms supported give the accessory muscles room to work. Option d is incorrect because breathlessness tracks poorly with saturation, and pouring on more oxygen mostly adds noise and a smothering mask. Oxygen earns its place at the end of life only when it relieves the symptom.

Correct Answer: Give the dose and explain the reasoning

Untreated pain is the problem in front of the nurse, and opioids titrated to comfort do not shorten life. Giving the dose relieves suffering while teaching corrects the fear driving the request. Option a is incorrect because a family member cannot consent away the client's relief. Withholding a scheduled analgesic from a grimacing, guarding client leaves him in pain and rewards a belief the nurse should be correcting. Option b is incorrect because acetaminophen has a daily ceiling and no strength for metastatic bone pain. Swapping it in trades an effective drug for one that will leave this client crying out during care. Option d is incorrect because dose reduction moves in the wrong direction entirely. Behavior at this bedside points to undertreatment, so the plan calls for titration upward with reassessment rather than a smaller order.

Correct Answer: Spread by the fecal oral route

Hepatitis A moves by the fecal oral route through contaminated food, water and shellfish, and through person to person contact in crowded settings. Hand hygiene and safe food handling stop it. Option a is incorrect because bloodborne spread describes hepatitis B, C and D, which pass through needles, sexual contact and perinatal exposure. Those three are the ones that become chronic and scar the liver. Option c is incorrect because mother to newborn transmission is a hallmark of hepatitis B, where up to ninety percent of infected infants carry the virus for life. Shellfish exposure points somewhere else entirely. Option d is incorrect because none of the five hepatitis viruses travels on respiratory droplets. Airborne and droplet precautions would not change this student's risk, while sanitation and careful hand washing would.

Correct Answer: "There is no hepatitis C vaccine, so I still avoid sharing needles."

No vaccine exists for hepatitis C, and clearing the virus with antivirals does not create immunity. Reinfection is possible, so this client must keep avoiding shared needles and other blood exposures. Option a is incorrect because vaccines are available only for hepatitis A and B, and the B vaccine also covers hepatitis D. Nothing this client received could have been a hepatitis C vaccine. Option b is incorrect because sustained virologic response means the virus is gone, not that the body learned to repel it. Someone who keeps injecting or shares equipment can acquire hepatitis C a second time. Option c is incorrect because lasting protective antibody follows measles infection but not hepatitis C. Antibody to this virus marks exposure rather than defense, which is why risk reduction counseling continues after cure.