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?

Bradycardia.

Red man syndrome.

Hypotension.

Hypoglycemia.

Answer and Explanation

The Correct Answer is C

Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.

Choice A is wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.

Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.

Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.

Choice D is wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.

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Correct Answer is D

Explanation

The client will need to have blood levels drawn to monitor the therapeutic and toxic levels of theophylline, a bronchodilator that is used to treat symptoms of asthma and other lung conditions. The normal range of theophylline in the blood is 10 to 20 mcg/mL.

Choice A is wrong because the client should not sprinkle the medication in applesauce or any other food. Theophylline is a sustained-release capsule that should be swallowed whole and not crushed or chewed.

Choice B is wrong because the client should avoid caffeine while on this medication, as it can increase the side effects of theophylline, such as nausea, vomiting, headache, and irregular heart rate.

Choice C is wrong because the client should not limit fluid intake while on this medication unless instructed by the doctor.

Fluid intake helps prevent dehydration and kidney problems that can affect theophylline levels in the blood.

A. The quality improvement committee. B. The charge nurse. C. The nurse who caused the error. D. The nurse who identifies the error.

Correct Answer is D

Explanation

The nurse who caused the error is responsible for completing an incident report. An incident report is a tool for documenting any event that deviates from the standard of care or causes harm to a client, staff member, or visitor. The purpose of an incident report is to improve quality and safety, not to assign blame or punish anyone. The nurse who caused the error should fill out the report as soon as possible after the event, providing factual and objective information.

A. The quality improvement committee is not directly involved in the incident and does not complete the report. The committee may review the report later to identify trends and areas for improvement.

B. The charge nurse is not responsible for completing the report, although they may assist or supervise the nurse who caused the error.The charge nurse may also notify the provider and other relevant staff members about the incident.

C.The nurse who caused the error may be involved in providing details and information about the incident, but the nurse who discovers the error is the one responsible for completing the incident report to ensure that all relevant information is accurately documented.

D. It is crucial for the nurse who discovers the error to complete the incident report to ensure that all relevant details are accurately documented. This allows for a thorough investigation and implementation of corrective actions to prevent future errors.

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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 D

Explanation

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