a client on lithium has diarrhea and vomiting what should the nurse do first
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NCLEX-RN

NCLEX RN Exam Review Answers

1. A client on lithium has diarrhea and vomiting. What should the nurse do first?

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

2. Which of the following is an example of a breach of a client's right to privacy?

Correct answer: D

Rationale: A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.

3. A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?

Correct answer: C

Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.

4. Asepsis is defined as ________________.

Correct answer: B

Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.

5. Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?

Correct answer: D

Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time. Choices A, B, and C are incorrect. Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test. Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test. Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.

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