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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.

Choice A is wrong because wheat is not a latex cross-reactive food.

Choice B is wrong because strawberries are a low or undetermined cross- reactive food.

Choice C is wrong because peanuts are a low or undetermined cross-reactive food.

Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.

A. Place the client’s bed in the low position. B. Encourage the client to wear socks when ambulating. C. Position the client’s bedside table at the foot of the bed. D. Raise four side rails on the client’s bed.

Correct Answer is A

Explanation

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a newly diagnosed latex allergy. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer is D

Explanation

A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?

Correct Answer is A

Explanation

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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?