The nurse is continuing to care for the client.

Exhibits

The nurse is providing teaching about lithium to the client and the client's adult child.

Select the 3 statements the nurse should include.

"Blurred vision is an expected adverse effect of this medication,"

"This medication can cause weight gain."

"This medication can cause nausea and drowsiness."

"It will take at least a week before this medication reaches a therapeutic level."

"You will be placed on a low-sodium diet while taking this medication."

Answer and Explanation

Correct Answer : B,C,D

A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.

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Correct Answer is D

Explanation

A. Revise the current policy for catheter care. Policy changes should be based on evidence and root cause analysis. Revising the policy prematurely without identifying contributing factors may not address the actual causes of infection.
B. Schedule nursing staff training for infection control procedures. Education and training are important but should be guided by identified gaps. Implementing training without understanding the root cause may result in ineffective interventions.
C. Meet with providers to discuss measures to decrease the infections. While interdisciplinary collaboration is valuable, it should occur after gathering and analyzing relevant data. This ensures targeted, evidence-based recommendations.
D. Identify possible precipitating factors related to the infections. The first step in quality improvement is to investigate and assess contributing factors. This helps guide the most appropriate and effective interventions to reduce infection rates.

A. Use tubing that does not have a filter in the drip chamber B. Use an IV catheter that is at least 24-gauge C. Attach a single line administration set. D. Prime the tubing with 0.9% sodium chloride

Correct Answer is D

Explanation

A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.

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The nurse is continuing to care for the client. Exhibits The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

Nursing Test Bank

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Explanation

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The nurse is continuing to care for the client.

Exhibits

The nurse is providing teaching about lithium to the client and the client's adult child.

Select the 3 statements the nurse should include.