22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Establish IV access.

Open the airway using a jaw-thrust maneuver.

Remove clothing for a thorough assessment.

Perform a Glasgow Coma Scale assessment..

Determine effectiveness of ventilator efforts.

Answer and Explanation

The Correct Answer is B, E, A, D, C

B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.

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Correct Answer is B

Explanation

A. Auscultate the bowel sounds: While gastrointestinal side effects such as nausea or
constipation can occur with phenytoin, auscultating bowel sounds is not a specific assessment related to its adverse effects.

B. Inspect the oral mucosa: Phenytoin is associated with gingival hyperplasia, a condition characterized by overgrowth of gum tissue. Therefore, inspecting the oral mucosa for signs of gum enlargement or other oral changes is important for evaluating adverse effects of phenytoin.

C. Check pupil reaction to light: Phenytoin does not typically affect pupil reaction to light. This assessment is more relevant for medications that act on the central nervous system or conditions affecting cranial nerve function.

D. Listen to the lung sounds: Phenytoin is not typically associated with respiratory side effects. Assessing lung sounds may be relevant in certain clinical situations, but it is not a specific assessment related to phenytoin adverse effects.

A. Patient has slight elevations in liver function test results B. Patient's most recent blood pressure is 156/92 mm Hg. C. Patient experiences an aura before seizures. D. Patient has tonic-clonic seizures.

Correct Answer is A

Explanation

A. Patient has slight elevations in liver function test results: Phenytoin is primarily metabolized by the liver, and elevated liver function tests may indicate impaired liver function, potentially affecting the metabolism and clearance of phenytoin. Consultation with the healthcare provider is warranted to assess the risk-benefit ratio of administering phenytoin in the presence of liver function abnormalities.

B. Patient's most recent blood pressure is 156/92 mm Hg: While hypertension is not a contraindication for phenytoin administration, it is important to monitor blood pressure, especially considering the potential cardiovascular side effects of the medication. However, elevated blood pressure alone does not typically warrant consultation before administering phenytoin.

C. Patient experiences an aura before seizures: Experiencing an aura before seizures is a common phenomenon in patients with epilepsy and does not necessarily contraindicate the use of phenytoin. In fact, phenytoin is commonly prescribed to prevent seizures, including those preceded by an aura.

D. Patient has tonic-clonic seizures: Phenytoin is indicated for the treatment and prevention of tonic-clonic seizures, among other seizure types. Therefore, the presence of tonic-clonic seizures would not typically warrant consultation before administering phenytoin.

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Naxlex Comprehensive Predictor Exams

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Correct Answer is B

Explanation

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Correct Answer is A

Explanation

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown