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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Taking a high-ceiling diuretic predisposes this client to developing digoxin toxicity because it can cause hypokalemia (low blood potassium level), which increases the sensitivity of the heart to digoxin. Digoxin is a medicine that is used to treat heart failure or arrhythmias (abnormal heart rhythms) by increasing cardiac contractility and controlling the heart rate. Digoxin toxicity happens when there is too much digoxin in the body and it becomes harmful, causing symptoms such as nausea, vomiting, headache, confusion, vision disturbance, and irregular heartbeat.
Choice A is wrong because taking an HMG CoA reductase inhibitor (also called a statin) does not increase the risk of digoxin toxicity.
Statins are lipid-lowering medications used to prevent coronary heart disease by blocking an enzyme involved in cholesterol synthesis.
Statins do not affect the blood potassium level or the sensitivity of the heart to digoxin.
Choice B is wrong because having a 10-year history of COPD (chronic obstructive pulmonary disease) does not increase the risk of digoxin toxicity. COPD is a lung condition that causes breathing difficulties and chronic inflammation.
COPD does not affect the blood potassium level or the sensitivity of the heart to digoxin.
Choice D is wrong because having a prolapsed mitral valve does not increase the risk of digoxin toxicity.
A prolapsed mitral valve is a condition where the valve between the left atrium and left ventricle of the heart does not close properly, allowing some blood to leak back into the atrium.
A prolapsed mitral valve does not affect the blood potassium level or the sensitivity of the heart to digoxin.
Correct Answer is A
Explanation
This is because the umbilicus is a potential site of infection and should be avoided when administering subcutaneous heparin.
Choice B is wrong because massaging the site after administering the medication can cause bruising and hematoma formation.
Choice C is wrong because a 21-gauge needle is too large for subcutaneous injection and can cause tissue trauma and bleeding.
A smaller needle, such as 25- or 27-gauge, should be used.
Choice D is wrong because aspirating before injecting the medication can increase the risk of hematoma formation and is not recommended for subcutaneous heparin.
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