A nurse is administering phenytoin to a client. The nurse should monitor for which of the following adverse effects?

Tinnitus

Bleeding gums

Jaundice

Deep vein thrombosis

Answer and Explanation

The Correct Answer is B

A. Tinnitus. Phenytoin is not commonly associated with tinnitus. Ototoxicity is more frequently linked to medications such as aminoglycoside antibiotics, loop diuretics, or high-dose aspirin. While phenytoin affects the nervous system, it does not typically cause ringing in the ears.

B. Bleeding gums. Gingival hyperplasia, characterized by swollen and bleeding gums, is a well-known adverse effect of phenytoin, especially with long-term use. It occurs due to an overgrowth of gum tissue and can be minimized with good oral hygiene and regular dental care. Clients should be advised to brush with a soft-bristled toothbrush and visit the dentist regularly.

C. Jaundice. Although phenytoin is metabolized by the liver, hepatotoxicity and jaundice are not common side effects. However, liver function should still be monitored, particularly in clients with pre-existing liver conditions or those taking other hepatotoxic medications.

D. Deep vein thrombosis. Phenytoin does not significantly increase the risk of deep vein thrombosis (DVT). While some anticonvulsants may affect coagulation factors, phenytoin is not known to cause hypercoagulability or clot formation. Clients at risk for DVT should be monitored for other contributing factors, such as immobility or genetic predisposition.

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Correct Answer is C

Explanation

A. The client had a local reaction from a previous immunization. A mild local reaction, such as redness or swelling at the injection site, is not a contraindication to receiving the MMR vaccine. These reactions are common and typically resolve without complications. Only severe allergic reactions, such as anaphylaxis, would warrant withholding the vaccine.

B. The client reports having diarrhea this morning. Mild illnesses, such as diarrhea or the common cold, do not contraindicate vaccination. The MMR vaccine can be safely administered as long as the client does not have a moderate to severe illness with fever. Delaying immunization due to minor illnesses could lead to unnecessary gaps in vaccine coverage.

C. The client is at 9 weeks of gestation. The MMR vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal harm. Pregnant individuals should wait until after delivery to receive the vaccine. If a client of childbearing age is vaccinated, they should be advised to avoid pregnancy for at least 4 weeks following immunization to reduce the risk of congenital rubella syndrome.

D. The client reports an allergy to penicillin. A penicillin allergy is not a contraindication for the MMR vaccine. The MMR vaccine does not contain penicillin or related antibiotics. Severe allergic reactions to vaccine components, such as neomycin or gelatin, would be more relevant contraindications. Clients with a penicillin allergy can safely receive the MMR vaccine without concern.

A. Assist the client to a left lateral position. B. Insert the suppository along the posterior wall of the vaginal canal C. Apply a light coating of petroleum jelly to the suppository. D. Put on sterile gloves before handling the suppository.

Correct Answer is B

Explanation

A. Assist the client to a left lateral position. The preferred position for vaginal suppository insertion is the dorsal recumbent (lying on the back with knees bent) or the lithotomy position. The left lateral position is typically used for rectal suppository administration, not vaginal medication insertion.

B. Insert the suppository along the posterior wall of the vaginal canal. The suppository should be inserted along the posterior vaginal wall, as this allows for proper absorption and helps ensure the medication remains in place. The client should be advised to lie down for at least 10-15 minutes after insertion to prevent the suppository from slipping out.

C. Apply a light coating of petroleum jelly to the suppository. Petroleum jelly should never be used as it can interfere with medication absorption and may break down the suppository. If lubrication is needed, a small amount of water-soluble lubricant (e.g., KY Jelly) can be applied to facilitate insertion.

D. Put on sterile gloves before handling the suppository. Clean gloves (not sterile gloves) are sufficient for vaginal suppository administration. The vaginal canal is not a sterile environment, so strict aseptic technique is not required. However, proper hand hygiene and glove use are essential to prevent contamination and infection.

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A nurse is administering phenytoin to a client. The nurse should monitor for which of the following adverse effects?

Nursing Test Bank

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