NR-325 Adult Health II - Set 5 - Part 3

Correct Answer: "The sound troubles us more than it troubles him."

Terminal secretions collect in the throat because swallowing is lost, and evidence suggests the client is not distressed by them. Naming that honestly, then repositioning and medicating, is what actually helps the family. Option a is incorrect because a suction catheter reaches the mouth and throat, never the lungs. Promising a complete clearing sets the daughter up to demand a procedure that would only make her father gag. Option b is incorrect because this sound is fluid moving in the upper airway rather than a sign of falling saturation. Tying it to oxygen levels invites monitoring that changes nothing about his comfort. Option c is incorrect because the decision rests on harm, not on paperwork. Deep suctioning is avoided here because it injures tissue and increases secretions, and hiding behind an order avoids the daughter's real question.

Correct Answer: Notify the provider and stop all oral intake

Peritonitis is a surgical emergency threatening circulation through massive third spacing and sepsis. Alerting the provider and stopping oral intake protect the client while fluids, antibiotics and source control are arranged. Option a is incorrect because waiting an hour wastes time in a client already showing fever, tachycardia and peritoneal signs. Circulation is failing now, and delay allows septic shock to develop. Option c is incorrect because anything swallowed adds volume above an inflamed peritoneum and may need to be suctioned back out before anesthesia. Rehydration in peritonitis is given intravenously, not by mouth. Option d is incorrect because surface heat widens local vessels and worsens inflammation in an abdomen that already holds spilled bowel contents. Comfort measures never substitute for urgent surgical evaluation here.

Correct Answer: Liquid from the ileostomy, formed from the colostomy

An ileostomy empties the small bowel, so output stays liquid to pasty and carries enzymes, water and potassium. A sigmoid colostomy sits far along the colon, where water has been absorbed and stool arrives formed. Option a is incorrect because a distal colostomy produces predictable formed stool once postoperative swelling settles. Expecting months of liquid drainage from it would drive unnecessary worry about dehydration in the wrong client. Option b is incorrect because it reverses the anatomy. Water absorption happens along the colon, so a stoma made from ileum drains thin effluent while one made from sigmoid colon delivers a solid product. Option c is incorrect because no amount of time turns ileal effluent into formed stool. The client may see slight thickening as the small bowel adapts, yet the output remains loose for life.

Correct Answer: A daily stimulant laxative such as senna

Tolerance develops to sedation and nausea but never to constipation, so every client started on an opioid needs a stimulant laxative from the first dose, titrated upward as the opioid climbs. Option b is incorrect because bulk-forming fiber needs a large fluid intake to work. In a dying client who drinks very little, psyllium adds mass to a sluggish bowel and can worsen impaction. Option c is incorrect because naloxone reverses analgesia and throws the client into a pain and withdrawal crisis. It has no scheduled role and is not part of routine opioid initiation at the end of life. Option d is incorrect because opioid-related nausea usually fades within a few days as tolerance builds. An antiemetic may be offered if it appears, yet it is not the standing companion prescription this drug requires.

Correct Answer: Absent bowel sounds with involuntary guarding

Inflamed peritoneum shuts peristalsis down, so bowel sounds disappear, and the abdominal wall tightens involuntarily to splint the irritated surface. Fever and tachycardia accompany this picture as infection spreads. Option a is incorrect because loud rushing sounds accompany diarrhea, gastroenteritis or laxative use, where the gut is still highly active. Peritoneal inflammation silences peristalsis rather than driving it faster. Option b is incorrect because a relaxed abdomen and comfortable deep breaths describe a client without peritoneal irritation. This client splints and holds still precisely because the parietal peritoneum is inflamed. Option d is incorrect because bloody mucoid stools with urgency belong to ulcerative colitis, a chronic mucosal disease of the colon. Postoperative peritonitis presents with silence and rigidity, not with a stool change.

Correct Answer: Advise a warm bath, fluids and position changes

Cramping with output that stops, swelling and nausea describes a food blockage. Warm baths, position changes and fluids often move it, and the client is told to call back if nothing passes. Option a is incorrect because stimulating an already blocked small bowel raises pressure behind the plug. Cathartics in this setting cause more cramping and vomiting and can push the situation toward emergency surgery. Option c is incorrect because irrigation belongs to a descending or sigmoid colostomy, never to a small bowel stoma. Instilling fluid into an obstructed ileum would add volume to a segment that cannot empty. Option d is incorrect because more fiber is exactly what created the plug. Clear liquids are used while symptoms last, and roughage returns slowly once output is flowing freely through the stoma again.

Correct Answer: The order limits resuscitation and nothing else

A do not resuscitate order says only that cardiopulmonary resuscitation will not be attempted. Antibiotics, oxygen, dialysis, surgery, and full nursing care all continue unless they are separately limited by the plan. Option a is incorrect because comfort measures only is a separate goal that a provider writes after its own conversation. Treating the two as identical is how clients quietly receive less care than they should. Option b is incorrect because a resuscitation order changes nothing about who holds decision-making authority. A client with capacity keeps directing care, and a surrogate steps in only when capacity is lost. Option d is incorrect because these are unrelated decisions. Plenty of clients receiving aggressive treatment for a curable illness choose to decline chest compressions, and hospice enrollment never becomes a prerequisite for that choice.

Correct Answer: Notify the surgeon and keep the client fasting

Constant severe pain with rigidity, fever and tachycardia means strangulation or perforation. Circulation to the bowel is failing, so the nurse keeps the client nothing by mouth and calls the surgeon before anything else. Option a is incorrect because oral medication of any kind is unsafe with a rigid abdomen and a probable perforation. Swallowed drugs also sit in a gut that cannot absorb or move them. Option b is incorrect because heat raises blood flow and inflammation in an acute abdomen, increasing the chance that an inflamed or ischemic segment ruptures. Nothing warm belongs on this abdomen at all. Option c is incorrect because walking helps a sluggish postoperative gut, not a bowel whose blood supply is cut off. Moving this client wastes minutes and worsens peritoneal pain with every step.

Correct Answer: Provide mouth care with moistened swabs

Bathing, mouth care, repositioning, and other comfort measures fall within the aide's role, and the aide reports what is observed. Assessment, teaching, evaluation, and medication titration stay with the registered nurse. Option b is incorrect because adjusting an opioid dose requires judgment about the symptom, the trajectory, and the parameters written by the provider. Unlicensed staff cannot make that call at any point. Option c is incorrect because evaluation of learning belongs to the nurse who did the teaching. An aide may report that the wife looked confused, yet interpreting that observation and reteaching is nursing work. Option d is incorrect because sorting out pain, retention, impaction, and drug effects behind new agitation is a complex assessment. The aide contributes by describing the behavior seen, then hands it to the nurse.

Correct Answer: Slowing circulation with blood shunted centrally

Mottling comes from peripheral vasoconstriction as the failing circulation shunts blood toward the core, and it signals that time is short. The change is painless, so warming devices are unnecessary and unsafe. Option a is incorrect because drug hypersensitivity shows up as urticaria, flushing, itching, or wheeze rather than a lacy pattern on dependent skin. Stopping the morphine here would only return the client to pain. Option c is incorrect because pressure damage appears over bony prominences that bear weight, such as the sacrum and heels. Mottling crosses skin that carries no pressure at all and blanches differently on examination. Option d is incorrect because cellulitis brings warmth, tenderness, spreading redness with a defined border, and often fever. Cool, dusky extremities point the other way and belong to the shutting down of the circulation.