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Question 1 of 5

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.

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.

Question 2 of 5

A critically injured woman is rushed to the ER. She needs an immediate blood transfusion, and there is no time to crossmatch blood type. The nurse anticipates the physician will call for

Correct Answer: D

Rationale: O negative blood is the universal donor, safe for emergency transfusions without crossmatching, minimizing reaction risk.

Question 3 of 5

The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

Correct Answer: D

Rationale: implementation, fixed and dilated pupil represents a neurological emergency

Question 4 of 5

The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

Correct Answer: C

Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.

Question 5 of 5

Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.

Order the Items

Source Container

Ask the client to open and close the hand until the skin blanches.
Palpate the ulnar and radial pulses and apply pressure to both arteries.
Observe the hand for color.
Release the ulnar artery while maintaining pressure on the radial artery.

Correct Answer: A,B,D,C

Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.

Similar Questions

A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
The nurse is reviewing medication orders for his clients. Which order would necessitate contacting the health care provider?

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