A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?
Prepare for gastric lavage.
Hold the medication and assess for early manifestations of toxicity.
Check the client's medication record to assess whether the client has been refusing her lithium.
Administer the morning dose of lithium.
The Correct Answer is B
Choice A reason: Gastric lavage is typically not the first-line treatment for lithium toxicity due to the risk of aspiration and potential complications. It is usually reserved for cases where the ingestion was recent and massive.
Choice B reason: When a client presents with an extremely elevated lithium level, it is crucial to hold further doses to prevent exacerbation of toxicity. The nurse should monitor for early signs of toxicity, which include gastrointestinal symptoms like nausea, vomiting, diarrhea, and neurological symptoms such as tremors, confusion, and ataxia. The normal therapeutic range for lithium is 0.6 to 1.2 mmol/L, and levels above 1.5 mmol/L are considered toxic.
Choice C reason: While it is important to review the medication record, the immediate concern with an extremely elevated lithium level is addressing the toxicity. Checking the medication record can be part of the assessment process but is not the priority action.
Choice D reason: Administering the morning dose of lithium could worsen the client's condition by increasing the lithium level further, which is already extremely elevated. This could lead to severe toxicity or even fatal consequences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Considering a transfer might avoid the immediate issue but does not address the nurse's countertransference or promote professional growth.
Choice B reason: Requesting another nurse to take over may be appropriate to ensure the client receives unbiased care while the original nurse addresses their countertransference.
Choice C reason: Discussing personal issues with the client is not appropriate as it can blur professional boundaries and may not be therapeutic for the client.
Choice D reason: The nurse should examine their feelings and responses to prevent personal experiences from affecting professional judgment and interactions with clients.
Choice E reason: Talking about feelings and emotions with a trusted colleague can provide support and help the nurse process their feelings in a safe environment.
Correct Answer is B
Explanation
Choice A reason: Focusing on one issue can help in understanding the client's situation better and does not necessarily hinder empathy.
Choice B reason: Interjecting personal experiences can create a barrier to empathy by shifting the focus from the client's feelings to the nurse's own experiences.
Choice C reason: Asking leading questions may not hinder empathy but could direct the conversation away from the client's concerns.
Choice D reason: Asking the client to restate statements for clarity is a part of active listening and can actually enhance empathy by ensuring understanding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.