a client with a diagnosis of bipolar disorder is prescribed lithium which electrolyte imbalance should the nurse monitor for
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Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. A client with a diagnosis of bipolar disorder is prescribed lithium. Which electrolyte imbalance should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Lithium can affect sodium levels in the body, potentially leading to hyponatremia, which is a condition characterized by low sodium levels. This imbalance requires close monitoring as it can lead to symptoms such as confusion, weakness, and even seizures. Choices B, C, and D are incorrect because lithium is not primarily associated with causing hypokalemia, hypercalcemia, or hypernatremia. While these imbalances can occur in certain conditions or with other medications, the main electrolyte imbalance to monitor when a client is prescribed lithium is hyponatremia.

2. The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?

Correct answer: B

Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.

3. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

4. The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?

Correct answer: B

Rationale: The most appropriate dietary recommendation for a client with peptic ulcer disease (PUD) is to avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of PUD. Increasing fiber intake may be beneficial for other gastrointestinal conditions but is not the primary concern for PUD. Avoiding dairy products is not a general recommendation for PUD unless the individual has a specific intolerance. Consuming a high-fat diet can increase the risk of exacerbating PUD symptoms due to the delayed gastric emptying associated with high-fat meals.

5. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

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