NCLEX RN

The Correct Answer is B. Cover the exposed viscera with a sterile saline gauze.

When abdominal viscera are exposed (evisceration), the nurse must immediately protect the organs from drying and infection. The correct action is to cover the viscera with a sterile dressing moistened with warm sterile saline. This keeps tissues moist and viable until surgical repair can be performed. It also prevents adherence of the organs to dressings, which could cause further injury when removed.

Why the other options are incorrect:

A. Apply a clean dressing to protect the wound

A clean dressing is not adequate because it is not sterile and does not prevent drying or further contamination of exposed viscera.

C. Gently replace the abdominal contents

The nurse should never attempt to replace eviscerated organs, as this can cause tissue damage, perforation, and further bleeding. This is a surgical procedure only.

D. Cover the area with a petroleum gauze

Petroleum gauze should not be used because it is occlusive, does not provide necessary moisture, and may stick to the viscera, causing damage when removed.

Correct Answer A. 3 → 5 → 1 → 4 → 2

Explanation:

The RN should prioritize clients using ABCs (airway, breathing, circulation) and immediate safety risks. The client recently transferred from the PACU (3) must be seen first due to high risk for airway and hemodynamic instability. The pneumonia client (5) with O₂ sat of 93% is next because of impaired breathing. The post–cardiac catheterization client (1) is stable but needs monitoring for vascular complications. The discharge-ready client (4) comes afterward since care is stable, and last is the client requiring diabetes teaching (2), as education can be safely delayed.

Why the other options are incorrect:

B. 5 → 3 → 1 → 2 → 4

Placing the pneumonia client before the PACU client is incorrect because postoperative complications can occur suddenly and are more life-threatening in the immediate recovery period. While oxygenation is important, airway and hemodynamic stability after surgery take precedence over stable pneumonia with mild desaturation.

C. 1 → 3 → 5 → 2 → 4

This option prioritizes the post–cardiac catheterization client before the PACU transfer, which is incorrect. Although monitoring for bleeding is important, a client just out of surgery is at higher risk of immediate complications than one who has already been stable for several hours after a procedure.

D. 4 → 2 → 1 → 5 → 3

This option is the least safe because it delays both the PACU and pneumonia clients. Addressing discharge and teaching tasks first ignores the urgent needs of unstable or potentially unstable patients, which violates the priority-setting principle of addressing life-threatening concerns before routine care.

Correct Answer C. Autonomy

Explanation of Correct Answer:

C. Autonomy

Autonomy refers to the client’s right to make their own decisions about healthcare, including the choice of provider. By supporting the client’s decision to seek another surgeon, the nurse is upholding the ethical principle of respecting the client’s independence and right to self-determination in care.

Why the other options are incorrect:

A. Beneficence

This principle is about acting in the best interest of the client to promote well-being. While important, this situation is less about the nurse doing something to promote health and more about respecting the client’s decision.

B. Veracity

Veracity is the obligation to tell the truth. Although honesty is always critical in nursing, this scenario does not involve truth-telling—it involves respecting the client’s choice.

D. Privacy

Privacy refers to keeping personal health information and details confidential. The client’s decision to change surgeons does not primarily involve confidentiality concerns, but rather the right to choose.

Correct Answer C. Endoscopy procedure

Why this is the correct answer:

Endoscopy is the most reliable diagnostic test for peptic ulcer disease because it allows direct visualization of the gastric and duodenal mucosa. It can identify the presence, size, and location of ulcers, as well as detect bleeding or other complications. Additionally, biopsies can be taken during the procedure to rule out malignancy or test for Helicobacter pylori. This makes it superior to other non-direct imaging or diagnostic methods.

Why the other options are incorrect:

A. Upper-gastrointestinal x-ray

An upper GI x-ray may detect abnormalities, but it is less sensitive than endoscopy and cannot directly visualize or biopsy the ulcer.

B. Gastric analysis

Gastric analysis measures acid secretion but does not confirm the presence of an ulcer. Many clients with ulcers have normal acid secretion, so this test lacks reliability.

D. Barium studies x-ray

Barium x-rays can show the outline of ulcers but may miss small lesions and cannot provide tissue samples. They are less accurate and are generally used when endoscopy is not available.

The Correct Answer is B. Urine specific gravity 1.020

In diabetes insipidus, the kidneys cannot concentrate urine due to a deficiency of antidiuretic hormone (ADH). This results in large volumes of very dilute urine with a low urine specific gravity (<1.005). DDAVP (desmopressin acetate) is a synthetic ADH that promotes water reabsorption in the renal tubules. A urine specific gravity of 1.020 indicates that the urine is concentrated appropriately, showing that the medication is effective.

Why the other options are incorrect:

A. Blood glucose 92 mg/dL

This is a normal glucose value, but it is not related to the action of desmopressin, since diabetes insipidus is not caused by glucose abnormalities.

C. White blood count of 7,500

This is a normal WBC count, but it has no relationship to DDAVP’s effectiveness.

D. Glycosylated hemoglobin 3.5 mg/dL

Hemoglobin A1c is a measure of long-term blood sugar control in diabetes mellitus, not diabetes insipidus. It is unrelated to the therapeutic effect of DDAVP.

Correct Answer C. Emphysema

Explanation:

Timoptic (timolol) is a topical beta-blocker used to reduce intraocular pressure in glaucoma. Although administered as eyedrops, systemic absorption can occur. Beta-blockers may cause bronchospasm and worsen conditions like asthma, chronic bronchitis, and emphysema. Therefore, clients with emphysema must use timolol cautiously, as it can exacerbate respiratory compromise.

Why the other options are incorrect:

A. Diabetes

Beta-blockers can mask hypoglycemia symptoms, but the primary and most significant caution with timolol is in respiratory diseases like emphysema or asthma.

B. Gastric ulcers

Timolol does not directly irritate the stomach lining or worsen ulcer disease.

D. Pancreatitis

Timolol use is not linked to worsening pancreatitis, so this is not a major concern.

Correct Answer A. Document and continue to monitor chest drainage

Explanation

Two days post-thoracotomy, chest tube output is expected to trend down from serosanguineous to lighter volumes. A one-time rush of dark blood immediately after repositioning usually reflects mobilization of pooled, older drainage from the pleural space or tubing—not new active bleeding. The amount (125 mL) is modest and the character (dark, not bright red) indicates old blood, and the client’s hemoglobin has been stable/improving (12.5 → 13 g/dL). Prior outputs (400 mL in the first 24 h, then 50 mL in the last 12 h) are within anticipated ranges. The appropriate action is to document the event, recheck vitals, reassess breath sounds and the insertion site, trend hourly drainage, and continue monitoring.

Escalate only if concerning findings emerge: sudden bright-red output, persistent drainage >100–150 mL/hr (institution-specific thresholds vary), hemodynamic instability (hypotension, tachycardia), increasing oxygen requirement, new air leak, or loss of tube patency.

Why Other Options Are Wrong

B. Immediately clamp the chest tube

Clamping is contraindicated except briefly when changing the drainage system or per specific orders (e.g., to locate an air leak). Clamping risks tension pneumothorax or accumulation of blood (hemothorax), worsening respiratory status.

C. Notify the health care provider

Notification is warranted for ongoing high-volume, bright-red bleeding, sudden large increases (e.g., >100–150 mL in each of several consecutive hours), or instability. A single 125 mL dark bolus after turning, with stable hemoglobin and prior appropriate outputs, is expected; immediate escalation is unnecessary. Continue close monitoring and notify if thresholds are met.

D. Request repeat hematocrit and hemoglobin levels

With stable/improving hemoglobin (13 g/dL) and no evidence of continued high-volume bleeding or instability, urgent repeat labs are not indicated. Trend clinically first; obtain labs if drainage remains high, turns bright red, or if vital signs/assessment suggest ongoing blood loss.

Correct Answer B. Graves' disease

Explanation:

This client has classic findings of Graves’ disease, the most common cause of hyperthyroidism. The clues include:

Suppressed TSH (0.02, very low)

Elevated T4 and T3 (20 g/dl and 253 ng/dl, both markedly high)

Symptoms: anxiety, insomnia, weight loss, difficulty concentrating

Eye complaints: “gritty” sensation, consistent with early exophthalmos seen in Graves’ disease

Radioactive iodine uptake: diffuse and elevated (85%), which is characteristic of Graves’ disease (as opposed to patchy uptake in toxic multinodular goiter).

Why the other options are incorrect:

A. Thyroiditis

In thyroiditis, thyroid hormone leaks out temporarily. Uptake is low, not diffusely high.

C. Hashimoto's thyroiditis

This is primarily a cause of hypothyroidism, not hyperthyroidism. Early on it may cause transient hyperthyroidism, but uptake is low, and eye symptoms are not typical.

D. Multinodular goiter

This usually produces patchy uptake on radioactive iodine testing, not diffuse uptake. It is also less associated with ophthalmopathy.

Correct Answer D. The patient will gain a specified amount of weight each week as agreed upon by the healthcare team.

Explanation:

The most appropriate initial goal for a patient with anorexia nervosa is restoring nutritional health and preventing medical complications. Establishing a safe, gradual weight gain target under professional guidance is realistic and measurable. Body image satisfaction and social engagement are important, but they are longer-term goals. Weight restoration is the priority because anorexia nervosa poses immediate life-threatening risks related to malnutrition and organ compromise.

Why the other options are incorrect:

A. The patient will express satisfaction with body image within one week.

Body image distortion is a core feature of anorexia nervosa and requires long-term therapy. Expecting satisfaction within one week is unrealistic and not an initial priority compared to restoring physical health.

B. The patient will engage in social activities with peers during meal times.

This may be a useful supportive goal later in treatment, but early stages focus on ensuring adequate nutrition and preventing complications. Social activities cannot replace the need for immediate weight restoration.

C. The patient will independently plan and prepare all meals.

Initially, patients with anorexia nervosa lack the ability to make healthy food choices due to their distorted thinking. Meal planning and preparation should remain under healthcare team guidance until progress is made.