A nurse on a medical-surgical unit is caring for a client who has hearing loss. Which of the following actions should the nurse take?

Speak in a louder than usual tone of voice during conversation.

Mute the client’s television before beginning a conversation.

Avoid the use of hand gestures when talking to the client.

Use short phrases when talking to the client.

Answer and Explanation

The Correct Answer is D

Use short phrases when talking to the client.

Some possible explanations for the other choices are:

Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.

The nurse should speak in a normal tone and enunciate clearly.

Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.

The nurse should use appropriate facial expressions

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Correct Answer is A

Explanation

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.

A. Begin an amnioinfusion for the client. B. Prepare the client for a cesarean birth. C. Administer ampicillin IV to the client. D. Initiate an oxytocin infusion for the client.

Correct Answer is B

Explanation

Prepare the client for a cesarean birth.

This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.

Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.

It is not indicated for a client with herpes simplex virus with active lesions.

Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.

Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.

Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.

It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.

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A nurse on a medical-surgical unit is caring for a client who has hearing loss. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

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Correct Answer is B

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