NCLEX Question of the Day – Sunday, March 01, 2026

Today’s question targets safe medication management and prioritization. You will spot lithium toxicity risk and choose the first nursing action. This matters because dehydration and sodium shifts can turn a routine dose into an emergency. Nurses prevent harm by recognizing early red flags and acting fast.

Clinical Scenario

A 30-year-old patient arrives to the emergency department with nausea, vomiting, and diarrhea for 2 days. History: bipolar I disorder, taking lithium carbonate 300 mg by mouth three times daily for the last year. The patient reports a new coarse hand tremor and feels “unsteady” when walking. Last lithium dose was 6 hours ago. Vital signs: BP 98/60, HR 112, RR 18, Temp 37.8 C (100.0 F). Dry mucous membranes are noted. Urine output is scant and dark. Recent labs return: sodium 130 mEq/L, creatinine 1.6 mg/dL.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Hold the next lithium dose, notify the provider, obtain a stat lithium level, and prepare to start isotonic IV fluids.
2. B. Administer the scheduled lithium dose to maintain a steady therapeutic level.
3. C. Encourage increased oral fluids at home and plan to recheck sodium and creatinine in the morning.
4. D. Give ondansetron, provide a BRAT diet handout, and discharge with return precautions.

Correct Answer

A. Hold the next lithium dose, notify the provider, obtain a stat lithium level, and prepare to start isotonic IV fluids.

Detailed Rationale

This is a pharmacology prioritization question focused on lithium toxicity. Lithium has a narrow therapeutic range (about 0.6–1.2 mEq/L for maintenance). Dehydration, hyponatremia, and impaired renal function reduce lithium clearance. The kidney reabsorbs more lithium when sodium is low, which drives the level up. The patient shows classic risk factors (GI losses, low sodium, rising creatinine) and early toxicity signs (coarse tremor, unsteady gait). Vital signs also suggest volume depletion (tachycardia, low BP).

Safety comes first. The nurse should hold lithium immediately to stop further accumulation. Notify the provider because this likely needs urgent management. A stat lithium level guides treatment. Start isotonic IV fluids (normal saline) to restore volume and sodium. Restoring volume improves renal perfusion and lithium excretion. Do not give hypotonic fluids; they can worsen hyponatremia and increase lithium reabsorption.

What else to assess, do, and monitor:

• Assess neuro status (tremor severity, confusion, ataxia, slurred speech), hydration status, and fall risk.
• Obtain ECG and continuous monitoring if available. Lithium can cause dysrhythmias at higher levels.
• Strict intake and output; monitor urine output for renal recovery.
• Trend labs: lithium level, sodium, creatinine, BUN. Repeat levels until falling into the therapeutic range.
• Anticipate antiemetics IV and seizure/fall precautions. In severe toxicity (levels often ≥2.5 with neuro changes), anticipate nephrology consult for possible hemodialysis.

Why the Other Options Are Wrong

• B. Administer the scheduled lithium dose to maintain a steady therapeutic level. Wrong because continuing lithium during dehydration and hyponatremia can push the patient into severe toxicity. The steady-state principle does not apply when clearance is impaired and toxicity signs are present.
• C. Encourage increased oral fluids at home and plan to recheck sodium and creatinine in the morning. Unsafe delay. The patient is vomiting, cannot reliably rehydrate, and already has low sodium and rising creatinine. This requires IV fluids and urgent evaluation now, not outpatient watchful waiting.
• D. Give ondansetron, provide a BRAT diet handout, and discharge with return precautions. Symptom control alone misses the cause. Discharging a patient with possible lithium toxicity, low sodium, and volume depletion risks rapid deterioration and neurologic complications.

Key Takeaways

• Lithium toxicity risk rises with dehydration, hyponatremia, kidney impairment, and interacting drugs (NSAIDs, ACE inhibitors, ARBs, and thiazide diuretics).
• Early signs: GI upset, coarse tremor, ataxia, slurred speech. Severe signs: confusion, seizures, dysrhythmias.
• First steps: hold lithium, notify provider, obtain stat lithium level, and start isotonic IV fluids.
• Correct sodium and volume to improve lithium clearance; avoid hypotonic fluids.
• Monitor ECG, neuro status, I&O, and labs. Consider dialysis for severe toxicity.

On-shift mini-checklist:

• Stop lithium; document time of last dose.
• Draw lithium level, BMP (focus on Na, BUN/Cr). Place on cardiac monitor.
• Start normal saline; reassess vitals every 15–30 min until stable.
• Implement fall and seizure precautions; frequent neuro checks.
• Review meds for interactions (NSAIDs, ACEi/ARBs, thiazides). Educate on hydration and consistent salt intake.
• Update provider with serial assessments and lab trends; prepare for possible dialysis if worsening.

Quick Practice Extension

• A patient on lithium asks about pain relief for knee arthritis. Which over-the-counter options can raise lithium levels, and what safer alternatives could you suggest?
• A stable patient on lithium starts hydrochlorothiazide. What lab changes and symptoms would make you intervene immediately?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com