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A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?

Red man syndrome

Hypotension

Hypoglycemia

Bradycardia

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Red man syndrome is typically associated with the rapid infusion of vancomycin, not phenytoin.

Choice B rationale:

Hypotension can be an adverse effect of phenytoin administration, especially if the medication is administered rapidly.

Choice C rationale:

Hypoglycemia is not commonly associated with phenytoin use.

Choice D rationale:

Bradycardia is not commonly associated with phenytoin use.

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Correct Answer is D

Explanation

A: Flushing an IV line with dextrose 5% in water before and after medication administration is a common practice to ensure that the medication is delivered properly and to prevent interactions in the IV line. This would not typically require an incident report.
B: An absolute neutrophil count of 2.500/mm3 is within the normal range for patients undergoing chemotherapy and would not typically necessitate an incident report.
C: Having chemotherapy 12 hours before the administration of filgrastim does not contraindicate its use and is within the appropriate time frame as filgrastim is often given after chemotherapy to help recover white blood cell counts.
D: According to the guidelines, filgrastim should be stored in the refrigerator and allowing it to sit at room temperature for 2 hours could compromise its effectiveness. This is a deviation from the medication's storage requirements and could potentially harm the patient, thus an incident report should be filed.

A. Remove the medication from the dispensing system. B. Compare the client's wristband to the medication administration record. C. Open the medication package. D. Document administration of the medication.

Correct Answer is A,B,C,D

Explanation

Choice A rationale:

The first step is to remove the medication from the dispensing system. This ensures that the nurse has the right medication and dose for the client. The nurse should also check the label of the medication against the medication administration record (MAR) at this point. Choice B rationale:

The second step is to compare the client's wristband to the MAR. This verifies the client's identity and prevents medication errors. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.

Choice C rationale:

The third step is to open the medication package. This prepares the medication for administration and prevents contamination. The nurse should also check the expiration date of the medication before opening it.

Choice D rationale:

The fourth step is to document administration of the medication. This completes the medication administration process and provides a record of the client's care. The nurse should document the medication name, dose, route, time, and any relevant observations or outcomes.

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A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A,B,C,D

Explanation

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