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The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
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The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?
- A. playing alone, with no interaction with other children
- B. playing cooperatively in a single-sex group
- C. playing parallel to other children, but not playing together
- D. playing and interacting cooperatively in a mixed-sex group
Correct Answer: C
Rationale: Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?
- A. Obtain a crash cart
- B. Check the calcium level
- C. Assess the dressing for drainage
- D. Assess the blood pressure for hypertension
Correct Answer: B
Rationale: Tingling around the mouth and extremities suggests hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disturbance, so checking the calcium level is the next action.
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:
- A. 10 ml
- B. 11.5 ml
- C. 10 gm
- D. 12 gm
Correct Answer: B
Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).