A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr later.

How should the nurse interpret the following findings?

For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

Vision

Lithium level

Urine output

Mucous membranes

Vital signs

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Vision (Blurred)
- Interpretation: Potential worsening condition
- Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.
Lithium Level (1.2 mEq/L)
- Interpretation: Potential improvement
- Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.
Urine Output (40 mL/hr)
- Interpretation: Potential improvement
- Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.
Mucous Membranes (Pale, Dry)
- Interpretation: Potential worsening condition
- Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.
Vital Signs (BP 88/50 mm Hg, Pulse 96/min)
- Interpretation: Potential worsening condition
- Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:
Inspecting the mouth for signs of inhalation injuries is the priority action. Inhalation injuries can lead to airway obstruction and respiratory failure, which are life-threatening conditions.
Choice B rationale:
Administering intravenous pain medication is important, but it is not the priority. Pain management is necessary but secondary to life-threatening conditions.
Choice C rationale:
Inserting an indwelling urinary catheter is done to monitor renal function and fluid balance, but it is not the priority action in this case.
Choice D rationale:
Drawing blood for a complete blood cell (CBC) count is done to assess the client’s overall health status, but it is not the priority action.

A. 8.5%. B. 6.3%. C. 10%. D. 7.8%.

Correct Answer is B

Explanation

Choice A rationale:
An HbA1c value of 8.5% is above the recommended range for good glucose control.
Choice B rationale:
An HbA1c value of 6.3% is within the target range for people with diabetes, indicating good glucose control.
Choice C rationale:
An HbA1c value of 10% is significantly above the recommended range, indicating poor glucose control.
Choice D rationale:
An HbA1c value of 7.8% is above the recommended range for good glucose control.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Correct Answer is A

Explanation

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

Correct Answer is B

Explanation

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F) and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?