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A nurse is caring for a client who is taking lithium. The nurse should monitor for which of the following findings as an adverse effect of the medication?

Positive Chvostek's sign

Increased potassium level

Constipation

Increased urinary output

Answer and Explanation

The Correct Answer is D

A. Chvostek’s sign is associated with hypocalcemia, not lithium toxicity.

B. Lithium does not increase potassium levels; it may cause mild hyponatremia.

C. Lithium is more commonly associated with diarrhea, not constipation.

D. Lithium can cause nephrogenic diabetes insipidus, leading to increased urinary output.

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Correct Answer is B

Explanation

A. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.

B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.

C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.

D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.

A. Infuse the transfusion over 5 hr. B. Hang the transfusion with dextrose 5% in 0.9% sodium chloride. C. Use a 20-gauge IV catheter to transfuse the blood. D. Monitor vital signs every hour throughout the transfusion.

Correct Answer is A

Explanation

A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.

B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.

C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.

D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.

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A nurse is caring for a client who is taking lithium. The nurse should monitor for which of the following findings as an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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