NR-325 Adult Health II - Set 5 - Part 2

Correct Answer: Reinforce hand hygiene and standard precautions now

The preicteric phase is when hepatitis A sheds most heavily, before anyone suspects the diagnosis. Reinforcing hand hygiene and standard precautions protects staff, family and other clients during the most infectious stretch. Option b is incorrect because hepatitis viruses do not travel through the air, so a negative pressure room adds nothing. Contact precautions are added only when a client with hepatitis A is incontinent. Option c is incorrect because starving this client worsens an already poor nutritional state. Small frequent meals with the largest served at breakfast fit the pattern of nausea that eases early in the day. Option d is incorrect because rigid bed rest was abandoned years ago. Activity balanced with rest periods supports hepatocyte repair, and confining someone for weeks brings deconditioning, clot risk and low mood without benefit.

Correct Answer: "I will sit up straight for a half hour after each meal."

Sitting upright lets gravity speed the meal into the small bowel, which is exactly what provokes an episode. This client should recline or lie down for about thirty minutes after eating instead. Option a is incorrect because dividing intake into roughly six modest meals is exactly right. Smaller volumes keep the jejunum from receiving a large load at once, so this statement shows correct understanding. Option b is incorrect because separating liquids from solids is a core part of the plan. Waiting roughly thirty minutes before drinking prevents fluid from washing food quickly out of the gastric remnant. Option d is incorrect because protein and fat form the backbone of this diet while concentrated sweets are dropped altogether. Candy, syrup and sugary drinks are the most osmotically active offenders on the plate.

Correct Answer: The bowel is deteriorating and needs urgent review

Silence after loud rushes is not improvement. The distended bowel has exhausted itself and may be ischemic, and constant pain with growing distension points toward strangulation, so surgical evaluation is needed now. Option b is incorrect because a resolving obstruction brings flatus, softer distension and falling tube output rather than a rigidly quiet abdomen. Feeding a client in this state risks perforation of an already failing segment. Option c is incorrect because effective decompression shows itself in comfort, smaller girth and less nausea. Worsening pain and a bigger abdomen say the opposite, no matter how well the suction canister is filling. Option d is incorrect because peristalsis does not shut down overnight in a healthy pattern. Treating a silent, tense abdomen as a normal variation delays the call that this client urgently requires.

Correct Answer: Metabolic alkalosis with low potassium and chloride

Gastric fluid is rich in hydrogen ion, chloride and potassium. Vomiting and suction strip all three, leaving hypochloremic metabolic alkalosis with hypokalemia, and the low potassium then slows the bowel even further. Option a is incorrect because acidosis with a rising potassium follows loss of bicarbonate from below, as happens with heavy diarrhea, or it appears once obstructed bowel becomes ischemic and lactate climbs. Option b is incorrect because blowing off carbon dioxide drives that disturbance, and this client is not hyperventilating. Alkalosis here arises from lost stomach acid, and it actually slows and shallows the breathing. Option c is incorrect because retained carbon dioxide from hypoventilation would be needed, and chloride falls rather than rises when gastric hydrochloric acid is suctioned away hour after hour.

Correct Answer: Continue cleaning and explain this is expected

Stomal mucosa is fragile and carries a rich blood supply, so slight oozing during cleaning is expected in the early weeks. The nurse continues the care and reassures the client about this finding. Option a is incorrect because stopping stoma hygiene allows effluent and adhesive residue to sit against fragile tissue. Skipping cleaning raises the risk of peristomal breakdown, which is already the most common ostomy problem. Option c is incorrect because sustained pressure treats brisk bleeding, and a few drops of ooze do not qualify. Pressing hard on new mucosa can bruise it and frighten a client who is still learning. Option d is incorrect because a report is reserved for bleeding that persists, soaks dressings or comes from inside the stoma. Minor surface oozing during routine care does not meet that threshold.

Correct Answer: "He stopped eating because he is dying, not the reverse."

Reversing the causal story is the core teaching here. Metabolism slows as the body shuts down, dying clients rarely report hunger, and pushing food or fluid adds burden without adding comfort or time. Option a is incorrect because tube feeding does not relieve hunger or extend life in advanced illness, and in dementia it fails to prevent aspiration. Careful hand feeding of favorite tastes is the recommended alternative. Option b is incorrect because setting meal targets turns eating into a chore for a man whose body cannot use the calories. Pressure at the bedside risks aspiration and turns visits into arguments about the tray. Option d is incorrect because intravenous hydration at this stage produces edema, ascites, and noisier breathing rather than strength. Dry mouth is the one real discomfort of low intake, and mouth care handles it.

Correct Answer: Eat small protein-rich meals and drink between them

Six small meals emphasizing protein, fat and complex carbohydrate slow gastric emptying, and taking fluids between meals keeps liquid from flushing the bolus into the jejunum. Simple sugars are eliminated. Option a is incorrect because juice delivers concentrated sugar and extra liquid at the worst possible moment. The osmotic load speeds straight into the small bowel and reliably triggers the very episode being prevented. Option c is incorrect because staying upright uses gravity to hurry the meal along, which is the opposite of what this client needs. Sitting up after eating belongs to reflux teaching instead. Option d is incorrect because large portions overwhelm a stomach that no longer holds or regulates volume. Fat is helpful here rather than restricted, since it slows emptying and steadies the release of nutrients.

Correct Answer: Dizziness, sweating and cramping soon after eating

Early dumping appears fifteen to thirty minutes after a meal with dizziness, palpitations, flushing, sweating and weakness, alongside cramping, borborygmi and urgent diarrhea. Lying down usually settles the episode. Option b is incorrect because dumping speeds transit and produces loose, urgent stools rather than sluggish ones. Its timing is tied directly to meals, not to a particular part of the day. Option c is incorrect because substernal burning that worsens when flat describes reflux, and reclining actually relieves dumping. Confusing these two leads clients to sit up after meals, which makes symptoms worse. Option d is incorrect because fever with rigors and aching joints suggests infection or an anastomotic leak, both of which demand a provider call. Dumping is a postprandial circulatory event without any fever.

Correct Answer: Report the output and start ordered fluids

Sustained high output from an ileostomy causes hypovolemia and potassium loss, and this client already shows both. Circulation comes first, so the nurse reports the volume and begins the prescribed replacement fluids. Option a is incorrect because withholding fluid from someone who is already volume depleted deepens the deficit. Output from an ileal stoma does not slow when intake falls, so the tachycardia would simply worsen. Option b is incorrect because a pouch change addresses the appliance, not the circulating volume. Skin care matters greatly for this client, yet it waits until the perfusion problem in front of the nurse is handled. Option d is incorrect because bulk does not correct a fluid and electrolyte deficit, and fibrous snacks risk blocking a stoma this new. Food choices are a later conversation, once the client is stable.

Correct Answer: A gastric ulcer of the antrum

Gastric ulcers hurt within thirty to sixty minutes of a meal, and food makes the pain worse, so clients eat less and lose weight. Biopsy is required because these lesions can be malignant. Option a is incorrect because duodenal pain arrives two to three hours after a meal, once the stomach empties, and eating relieves it. Weight tends to hold steady or rise in that pattern. Option b is incorrect because dumping requires a stomach that has been resected or bypassed, and this client has had no operation. Its symptoms are vasomotor and cramping, not a gnawing burn. Option c is incorrect because inflamed colonic pouches produce steady left lower quadrant pain with fever, unrelated to when the client last ate. Epigastric timing points to the stomach instead.

Correct Answer: A durable power of attorney for health care

A durable power of attorney for health care appoints an agent who reasons from the client's values in situations no form anticipated, and the appointment survives the loss of decision-making capacity. Option a is incorrect because a living will speaks about treatments rather than about people. It can state that he refuses prolonged ventilation, yet it cannot give his brother authority to weigh an unforeseen choice. Option c is incorrect because that order addresses one intervention, cardiopulmonary resuscitation, and names nobody. Written by a clinician and effective immediately, it belongs to a different category of document altogether. Option d is incorrect because consent covers permission for one operation and expires with it. Nothing on that form guides the team about ventilators, feeding tubes, or who should decide when the client cannot.

Correct Answer: Measuring abdominal girth at the marked site

Measuring girth with the tape lined up on the pen mark is a standardized task with a predictable result, so it fits within the scope of trained assistive personnel. Option b is incorrect because reading a weight trend and deciding what it means for diuretic dosing is clinical judgment. Assistive personnel may record the number on the scale, but interpreting it stays with the nurse. Option c is incorrect because eliciting the liver flap is a neurologic assessment that detects early encephalopathy. Assessment cannot be handed off, and a missed flapping tremor delays treatment of a rising ammonia burden. Option d is incorrect because client education is a nursing responsibility that requires evaluating what was understood. Unlicensed staff can reinforce a menu choice already taught, yet the original teaching about sodium belongs to the nurse.

Correct Answer: "I will take ibuprofen when my joints ache in the morning."

Nonsteroidal anti inflammatory drugs block platelet function, injure gastric mucosa and impair kidney perfusion, which is a dangerous combination in someone with fragile varices. This client needs a different choice for joint pain. Option a is incorrect because preventing hard stools is exactly right. Straining drives intra abdominal and portal pressure upward, and a softener keeps that pressure spike from reaching the thin walled vessels. Option b is incorrect because black tarry stool is digested blood and signals bleeding that must be reported at once. Recognizing melena early is one of the most useful things this client can do. Option c is incorrect because handing off heavy loads shows good understanding. Lifting forces a Valsalva effort that raises pressure inside the portal system, so delegating the bags protects the banded vessels from rupture.

Correct Answer: Walk in the hallway and lie left side down

Carbon dioxide left in the abdomen irritates the diaphragm and refers pain to the shoulder. Walking disperses and absorbs the gas, and lying on the left side with the right leg drawn up helps. Option a is incorrect because staying still traps the gas under the diaphragm and prolongs the ache. Immobility after abdominal surgery also invites atelectasis and clots, so resting quietly makes two problems worse. Option b is incorrect because cold does nothing for gas trapped against a nerve. Warmth from a heating pad or compress is the measure that eases this particular discomfort when the surgeon permits it. Option d is incorrect because this referred ache is an expected and well described effect of insufflation that fades within a day or two. Treating it as chest pain alarms the client without cause.

Correct Answer: "Wanting her suffering to end is not betrayal."

Naming the emotion and normalizing it addresses anticipatory grief directly. Relief and guilt sit together in almost every long caregiving story, and saying so out loud relieves a daughter who thought she was alone. Option a is incorrect because an opening like that minimizes the loss and implies her sorrow is unwarranted. Length of life is no comfort to someone watching her mother disappear week by week. Option b is incorrect because ordering her to hold herself together forbids the grief she came into the hallway to release. Caregivers who are told to be strong stop confiding in the staff. Option c is incorrect because claiming identical feelings shifts the focus onto the nurse and is simply untrue. Asking her to describe what these months have been like would keep the door open instead.

Correct Answer: Ask the son what worries him most

Assessment comes before any other move, because demands like this one usually carry grief, guilt, or a belief that stopping feeding causes hunger. Exploring the fear opens the way to a family meeting. Option b is incorrect because an ethics consultation is a later step for conflict that persists. Calling one before anyone has sat down with the son skips the conversation that usually resolves the disagreement. Option c is incorrect because carrying out the request would override a valid document written by the person whose body it is. The nurse's obligation runs to the client, not to the loudest voice. Option d is incorrect because quoting the paperwork at a frightened son ends the conversation and leaves him feeling accused. Honoring the directive still requires helping the family understand what their father chose.

Correct Answer: Empty it when about one third full

Emptying at roughly one third to one half full keeps the weight of output from pulling the seal loose. A full pouch bulges under clothing, leaks onto skin and often causes the odor clients report. Option a is incorrect because heaviness means the pouch is already straining the adhesive. Waiting for that sensation puts the client one movement away from a seal that lets go in public. Option b is incorrect because a completely full pouch stretches the barrier, forces output back against the stoma and breaks the seal. Emptying that late is the usual cause of a broken seal. Option d is incorrect because output from a sigmoid stoma is formed and arrives on its own rhythm, not on a meal schedule. Rigid mealtime emptying often finds an almost empty pouch.

Correct Answer: Review the clotting studies and platelet count

Hemorrhage is the major complication of liver biopsy and coagulopathy is the major contraindication, so the nurse confirms the prothrombin time, international normalized ratio and platelet count and reports abnormal values. Option a is incorrect because the client stays without food for the ordered interval, commonly four to eight hours. Feeding beforehand risks vomiting under sedation and may push the diaphragm and liver out of position. Option c is incorrect because the maneuver taught is the opposite: exhale and hold still at the end of expiration. Continued breathing moves the liver under the needle and invites laceration or lung puncture. Option d is incorrect because right side lying is what follows the procedure, letting body weight compress the site for at least two hours. Beforehand the client lies supine with the right arm overhead.

Correct Answer: Stop oral intake and notify the provider immediately

Sudden severe pain with a board-like abdomen and silence means the ulcer has perforated. Circulation is threatened by spilling gastric contents, so oral intake stops and surgical help is summoned without delay. Option b is incorrect because neutralizing acid does nothing for a hole in the gastric wall, and swallowing anything adds more material to the peritoneum. This client must be kept nothing by mouth. Option c is incorrect because shallow breathing here is protective; deep breaths stretch an inflamed peritoneum and hurt. Coaching relaxation treats a comfort problem while a surgical catastrophe goes unreported. Option d is incorrect because heat over an acute abdomen increases blood flow and inflammation, and waiting thirty minutes lets hypovolemia and sepsis advance. Time to the operating room drives survival here.

Correct Answer: A duodenal ulcer with nocturnal pain

Food and antacids buffer the duodenal bulb, so pain eases with eating and returns once the stomach empties. Night waking between midnight and early morning is highly suggestive of a duodenal lesion. Option a is incorrect because eating aggravates a gastric ulcer instead of soothing it, which is why those clients skip meals and drop weight. Relief with crackers points the other direction. Option b is incorrect because reflux burns behind the sternum and worsens when the client lies flat or bends forward. Its timing tracks position and large meals rather than an empty stomach. Option d is incorrect because alcohol-related gastritis gives diffuse epigastric soreness, nausea and sometimes vomiting without the tidy meal-related rhythm described here. Nothing in the history points toward heavy drinking.