a client on lithium has diarrhea and vomiting what should the nurse do first
Logo

Nursing Elites

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. Choose the BEST answer. To ensure adequate protection for legal issues, offices should maintain patients' charts for:

Correct answer: B

Rationale: The correct answer is 'Forever.' Maintaining patients' charts indefinitely ensures comprehensive legal protection by having all relevant information available in case of litigation or if patient history needs to be referenced in the future. Choice A, '10 years,' may not be sufficient to cover the entire period within which legal issues may arise. Choice C, 'Until the age of majority,' is not ideal as legal matters may extend beyond this age limit. Choice D, '2 years after the patient was last seen in the office,' is inadequate as legal actions can occur beyond this timeframe, necessitating the need for long-term retention of patient charts.

3. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

Correct answer: D

Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments. Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.

4. How can the dangers associated with wandering in Alzheimer's disease patients be prevented?

Correct answer: D

Rationale: The correct answer is 'All of the above.' Bed alarms, chair alarms, and door alarms are all effective measures to prevent the dangers associated with wandering in Alzheimer's disease patients. These alarms can alert caregivers when a patient tries to leave a designated area, helping to keep them safe. It is crucial to respond promptly to these alarms to ensure the patient's safety. Choices A, B, and C are incorrect individually as each type of alarm plays a vital role in a comprehensive wandering prevention strategy.

5. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

Correct answer: B

Rationale: In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs, known as deep vein thrombosis (DVT). These clots can dislodge and travel to the lungs, causing a pulmonary embolism. Myocardial infarction (Choice A) is less likely in a young patient without a significant history of atherosclerosis. Anxiety attacks (Choice C) may present with similar symptoms but are less likely in this context. Congestive heart failure (Choice D) is less probable given the acute onset of symptoms and absence of typical signs like peripheral edema in this case.

Similar Questions

A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
When a nurse is asked by a physician to speak to a colleague about their unprofessional behavior in front of a client but chooses not to confront the colleague and avoids the physician the next day, what type of conflict resolution is the nurse exhibiting?
What consideration is important when caring for a female Muslim patient?
What does the 'B' in the SBAR acronym stand for?
When planning care for an uninsured diabetic patient, which strategy should be a priority?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses