A nurse is reviewing the medical record of a client who has been taking lithium. Which of the following findings should the nurse notify the provider of immediately?

Ferrous gluconate is an iron supplementused to treat or prevent iron-deficiency anemia. Iron is best absorbed in an acidic environmentand is known for causing significant gastrointestinal irritation. Patient education focuses on enhancing absorption while minimizing common side effects like constipation, nausea, and esophageal irritation.

Rationale:

A.Black stools are a common and harmless side effect of iron supplementation, resulting from unabsorbed iron in the gastrointestinal tract. The client does not need to notify the provider unless the stools are also tarry or accompanied by abdominal pain, which could indicate bleeding. Misinterpreting this as a danger sign could lead to unnecessary anxiety or discontinuation of therapy.

B.Taking the medication with milk is incorrect because calcium and phosphates in dairy products significantly inhibit iron absorption. The client should avoid consuming dairy, eggs, coffee, or tea within 2 hours of taking ferrous gluconate. To maximize absorption, the medication should ideally be taken with a source of vitamin C, such as orange juice, or on an empty stomach.

C.Staying upright for at least 15 minutes after taking ferrous gluconate is a correct measure to prevent esophageal irritation. Iron supplements can be caustic to the mucosal lining if they reflux or lodge in the esophagus. Remaining in an upright position helps ensure the tablet or liquid moves efficiently into the stomach, reducing the risk of erosive esophagitis.

D.Taking an antacid with iron is contraindicated because antacids neutralize gastric acid, which is required for optimal iron absorption. If the client experiences significant stomach upset, the nurse should suggest taking the medication with a small amount of non-dairy food. However, the client must be aware that taking it with food or antacids reduces the overall percentage of iron absorbed.

Stop the infusion.

Disconnect the IV tubing from the IV hub.

Aspirate the medication from the IV catheter.

Elevate the affected extremity.

Brief Introduction:

Extravasationis a severe clinical complication where a vesicantmedication leaks from the intravascular space into the surrounding dermal or subcutaneous tissue. Vesicants, such as certain chemotherapeutic agents, cause cellular necrosis, tissue sloughing, and permanent nerve damage upon contact with extravascular structures. Emergency management focuses on immediate cessation of the insult and the removal of as much residual toxin as possible to mitigate localized destruction.

Rationale:

A. Disconnecting the IV tubingfrom the IV hub is the second priority action. Once the pump is deactivated, the tubing must be removed while leaving the catheter in place to serve as a conduit for further intervention. This step prepares the site for aspirationand prevents any further residual medication within the line from being accidentally flushed into the compromised tissue.

B. Elevating the affected extremityis the final step in the immediate response sequence. Elevation utilizes gravity to promote venous returnand lymphatic drainage, which helps reduce localized edema and limits the spread of the vesicant within the interstitial spaces. This maneuver is part of supportive care and should only be performed after the chemical threat has been physically addressed.

C. Stop the infusionis the absolute first action the nurse must perform the moment extravasation is suspected. Continued administration of a vesicant exponentially increases the volume of tissue exposed to the toxin, leading to wider areas of necrosis. Halting the flow immediately limits the scope of the injury and is the highest priority for limb preservation and safety.

D. Aspirate the medicationfrom the client's IV catheter is performed after the tubing is disconnected but before the catheter is removed. Using a syringe to pull back on the hub allows the nurse to extract residual vesicant still sitting in the catheter and the immediate extravasation pocket. This critical step reduces the total concentration of the drug remaining in the tissue, potentially decreasing the severity of the subsequent chemical burn.