while receiving normal saline infusions to treat a gi bleed the nurse notes that the patients lower legs have become edematous and auscultates crackle

NCLEX-RN

NCLEX RN Exam Questions

1. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

A. Stop the saline infusion immediately
B. Notify the physician
C. Elevate the patient's legs
D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

2. During an intake screening for a patient with hypertension who has been taking ramipril for 4 weeks, which statement made by the patient would be most important for the nurse to pass on to the physician?

A. ''I get dizzy when I get out of bed.''
B. ''I'm urinating much more than I used to.''
C. ''I've been running on the treadmill for 10 minutes each day.''
D. ''I can't get rid of this cough.''

Correct answer: D

Rationale: The correct answer is ''I can't get rid of this cough.'' Ramipril, an ACE inhibitor, commonly causes a persistent, dry cough as an adverse effect. This symptom can be indicative of bradykinin accumulation caused by ACE inhibitors. It is important for the nurse to inform the physician about this side effect so that a medication change to another class of antihypertensives, such as an ARB, may be considered. Choices A, B, and C are not directly related to the common adverse effects of ramipril and are not as concerning for a patient on this medication.

3. A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?

A. Anesthesia reaction
B. Hyperglycemia
C. Hypoglycemia
D. Diabetic ketoacidosis

Correct answer: C

Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.

4. Which client is at highest risk for developing a pressure ulcer?

A. 23 year-old in traction for fractured femur
B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

5. When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?

A. Leukopenia.
B. Hypokalemia.
C. Polycythemia.
D. Hypoglycemia.

Correct answer: B

Rationale: When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.