A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L.
Which of the following findings should the nurse expect?
Muscle irritability.
Constipation.
Hypoglycemia.
Increased BP.
The Correct Answer is A
Muscle irritability. A client with a lithium level of
2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.
Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.
Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.
Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.
Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.
Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.
Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.
Correct Answer is B
Explanation
Obturator.
An obturator is a device that is inserted into the tracheostomy tube to guide it through the stoma and prevent tissue damage. It should be removed after the tube is inserted and kept near the bedside in case of accidental decannulation.
Choice A is wrong because povidone-iodine is an antiseptic solution that is not routinely used for tracheostomy care. It can cause skin irritation and damage to the mucous membranes.
Choice C is wrong because an irrigation set is not needed for a tracheostomy tube.
Irrigation can introduce bacteria and increase the risk of infection. It can also cause coughing and bleeding.
Choice D is wrong because hemostats are not used for a tracheostomy tube.
Hemostats are surgical instruments that are used to clamp blood vessels or tissues. They have no role in tracheostomy care.
Some other supplies that the nurse should place in the room are a trach tube the same size as the current tube and one size smaller, a portable suction machine with battery backup, and tubing that connects to the suction machine. Other supplies may include saline solution, syringes, gauze squares, gloves, a trachea tube brush, a waterproof drape, non-woven sponges, pipe cleaners, cotton tipped applicators, a T-drain sponge, twill tape, a trach holder, a speaking valve, a stoma cover, and a nebulizer.
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