Try Naxlex NCLEX-RN (Free-Trial)

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.

A.

Vision

B.

Lithium level

C.

Urine output

D.

Mucous membranes

E.

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.


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Choice A rationale:
Alcohol-based hand rubs are not recommended before administering eye drops as they can cause eye irritation.
Choice B rationale:
Chlorhexidine is recommended for hand hygiene when caring for immunosuppressed clients as it has broad-spectrum antimicrobial activity.
Choice C rationale:
Alcohol-based hand rubs are not effective against Clostridium difficile. Soap and water should be used instead.
Choice D rationale:
Artificial nails can harbor pathogens and are not recommended in healthcare settings.

Correct Answer is D

Explanation

Choice A rationale:
Painful and red-tinged urination could indicate a urinary tract infection or passing of a kidney stone, not necessarily a contraindication for an intravenous pyelogram.
Choice B rationale:
The end of a menstrual period does not affect the procedure.
Choice C rationale:
Adequate fluid intake is generally beneficial for kidney health.
Choice D rationale:
An allergy to shellfish might indicate an allergy to iodine, which is used in the contrast dye for an intravenous pyelogram. This is a potential contraindication for the procedure and should be reported to the provider.

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

Register