A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L.
Which of the following findings should the nurse expect?

Muscle irritability.

Constipation.

Hypoglycemia.

Increased BP.

Answer and Explanation

The Correct Answer is A

Muscle irritability. A client with a lithium level of

2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.

Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.

Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.

Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.

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Correct Answer is D

Explanation

Bleach.

According to the CDC, bleach is an effective disinfectant for environmental surfaces contaminated with blood or body fluids from a person with AIDS or other bloodborne pathogens. Bleach can kill HIV and hepatitis viruses when used in a 1:10 dilution with water.

Choice A is wrong because isopropyl alcohol is not recommended for disinfecting environmental surfaces. It can evaporate quickly and may not have enough contact time to kill the pathogens.

Choice B is wrong because chlorhexidine is an antiseptic, not a disinfectant. It is used for skin cleansing or wound irrigation, but it is not effective against spores or non-enveloped viruses.

Choice C is wrong because hydrogen peroxide is a low-level disinfectant that can be inactivated by organic matter.

It is not suitable for disinfecting surfaces contaminated with blood or body fluids.

A. Transferring the client from the bed to a chair. B. Checking the client’s surgical dressing for bleeding. C. Determining whether the client has incisional pain. D. Showing the client how to use an incentive spirometer.

Correct Answer is A

Explanation

Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.

Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.

The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.

Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.

The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.

Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.

The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.

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A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect?

Nursing Test Bank

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A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L.
Which of the following findings should the nurse expect?