A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure 100/78 mm Hg.

Double vision.

Puffy, bleeding gums.

Chronic insomnia.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not an assessment finding that warrants immediate intervention by the nurse. Blood pressure 100/78 mm Hg is within the normal range for an adult, and it does not indicate any adverse effect of phenytoin. The nurse should monitor the blood pressure for any changes, but it is not a priority.

Choice B reason: This is an assessment finding that warrants immediate intervention by the nurse. Double vision, or diplopia, is a sign of phenytoin toxicity, which can occur due to overdose, drug interactions, or impaired metabolism. Double vision can impair the client's vision, balance, and coordination, and increase the risk of falls and injuries. The nurse should stop the phenytoin infusion, if applicable, and notify the healthcare provider. The nurse should also check the serum phenytoin level and other vital signs, and prepare to administer an antidote, such as fosphenytoin, if indicated.

Choice C reason: This is not an assessment finding that warrants immediate intervention by the nurse. Puffy, bleeding gums are a common side effect of phenytoin, which can cause gingival hyperplasia, or overgrowth of the gum tissue. Puffy, bleeding gums are not life-threatening, but they can affect the client's oral hygiene and appearance. The nurse should instruct the client to brush and floss the teeth regularly, and to visit a dentist for dental care.

Choice D reason: This is not an assessment finding that warrants immediate intervention by the nurse. Chronic insomnia is not a common or serious side effect of phenytoin, which is an anticonvulsant that can have sedative effects. Chronic insomnia may be caused by other factors, such as stress, pain, or caffeine intake. The nurse should assess the client's sleep pattern and quality, and provide education and counseling on sleep hygiene and relaxation techniques.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action for the nurse to take. Risedronate is a bisphosphonate that is used to treat osteoporosis by inhibiting bone resorption. It should be taken with a full glass of water at least 30 minutes before the first food or drink of the day, as food and beverages can reduce its absorption and effectiveness. Milk and other dairy products are especially problematic, as they contain calcium, which can bind to risedronate and prevent it from reaching the bone.

Choice B reason: This is not a correct action for the nurse to take. Assigning a UAP to bring the client a glass of low fat milk is not appropriate, as it contradicts the instruction to take risedronate with water only. Low fat milk still contains calcium, which can interfere with risedronate absorption. The nurse should educate the client and the UAP about the proper administration of risedronate and the importance of avoiding food and beverages for at least 30 minutes after taking the medication.

Choice C reason: This is not a correct action for the nurse to take. Consulting with a pharmacist about scheduling the dose one hour after the client eats is not necessary, as risedronate should be taken before the first food or drink of the day, not after. Taking risedronate one hour after eating may not ensure adequate absorption and efficacy, as food and beverages can remain in the stomach for longer periods of time. The nurse should follow the prescribed schedule and the manufacturer's guidelines for risedronate administration.

Choice D reason: This is not a correct action for the nurse to take. Withholding the medication until the client's breakfast tray is available on the unit is not advisable, as it may delay the treatment of osteoporosis and increase the risk of fractures. Risedronate should be taken as soon as possible after waking up, before the first food or drink of the day, to maximize its absorption and effectiveness. The nurse should not postpone the medication administration without consulting the healthcare provider.

A. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration of the medication. B. One hour after completion of the IV dose and one hour before the next administration of the medication. C. Two hours after completion of the IV dose and two hours before the next administration of the medication. D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.

Correct Answer is B

Explanation

Choice A reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured after the completion of the IV dose, not during the administration. The trough level should be measured just before the next administration, not 30 minutes before.

Choice B reason: This is the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, when the concentration of the medication is highest in the blood. The trough level should be measured one hour before the next administration, when the concentration of the medication is lowest in the blood.

Choice C reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not two hours after. The trough level should be measured one hour before the next administration, not two hours before.

Choice D reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not immediately after. The trough level should be measured one hour before the next administration, not 30 minutes before.

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A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

Correct Answer is A

Explanation

A client is receiving intravenous (IV) vancomycin and the nurse plans to draw blood for a peak and trough to determine the serum level of the medication. Which of the following collection times provide the best determination of these levels?

Correct Answer is B

Explanation

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