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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 A

Explanation

A. Suctioning device – Correct. A suctioning device is essential to clear the airway in case of excessive secretions during or after a seizure.

B. Bite block – Incorrect. Bite blocks are not used during seizures as they can cause injury. Nothing should be placed in the client’s mouth during a seizure.

C. Vest restraint – Incorrect. Restraints should not be used on clients with seizure disorders as they can cause injury.

D. Padded tongue blade – Incorrect. Tongue blades should never be inserted into the mouth of a seizing client due to the risk of airway obstruction and oral trauma.

A. Switch to a lactose-free formula. B. Reposition the NG tube. C. Increase the rate of formula delivery. D. Add water to the formula.

Correct Answer is D

Explanation

A. Switch to a lactose-free formula – A lactose-free formula is necessary for clients with lactose intolerance but does not address the issue of hyperosmolar dehydration, which results from insufficient free water intake rather than intolerance to lactose.

B. Reposition the NG tube – Repositioning the tube is necessary if there is displacement, but it does not treat dehydration caused by hyperosmolar feedings.

C. Increase the rate of formula delivery – Increasing the rate can worsen dehydration by further increasing the solute load, leading to a greater fluid shift from intracellular to extracellular spaces.

D. Add water to the formula – This is the correct answer because hyperosmolar dehydration occurs when high-solute enteral formulas pull water into the intestines, leading to excessive fluid loss. To prevent this, the nurse should ensure the client receives adequate free water flushes alongside tube feedings.

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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

A nurse is implementing seizure precautions for a newly admitted client. Which of the following equipment should the nurse place in the client's room?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Correct Answer is D

Explanation

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