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 A
Explanation
The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.
Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.
It is suitable for children aged 8 to 17 years who can read and understand words.
Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.
Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.
It is suitable for infants aged 0 to 6 months who cannot communicate verbally.
Correct Answer is D
Explanation
The correct answer is d. Administer the medication over 2 hr.
Choice A reason: Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
Choice B reason: Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
Choice C reason: Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
Choice D reason: Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
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