A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder.
Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Hypoglycemia.

Excess salivation.

Urinary retention.

Dysrhythmia.

Answer and Explanation

The Correct Answer is D

Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.

Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.

Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.

Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.

Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.

Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.

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Correct Answer is D

Explanation

Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.

Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.

Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.

Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.

A. The task involves making ongoing judgments about client data. B. The task is within the AP’s range of function to perform. C. The task can be performed in the same manner for most clients. D. The task requires a specific sequence of steps.

Correct Answer is A

Explanation

The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.

Choice B is wrong because the task is within the AP’s range of function to perform.

This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.

Choice C is wrong because the task can be performed in the same manner for most clients.

This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.

Choice D is wrong because the task requires a specific sequence of steps.

This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.

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A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder.
Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?