A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?
Headache, restlessness
Decreased blood pressure, rapid pulse
Muscle cramps, chest heaviness
Pain and tingling at the access site
The Correct Answer is A
The correct answer is Choice A
Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.
Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.
Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.
Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale: Potassium is primarily excreted by the kidneys. While adequate renal function is necessary, the standard minimum urine output for adults is 30 mL/hour rather than 1 mL/kg/hour.
Choice B rationale: Low potassium levels (2.5 mEq/L) require long-term management. Educating the client on potassium-rich foods like bananas and potatoes helps prevent future depletion and supports overall electrolyte balance.
Choice C rationale: Severe hypokalemia and rapid IV replacement increase the risk of lethal cardiac dysrhythmias. Continuous ECG monitoring is vital to detect life-threatening changes in cardiac conduction and rhythm.
Choice D rationale: Following intravenous replacement, serum levels must be re-evaluated to confirm the effectiveness of the treatment and ensure the client does not develop iatrogenic hyperkalemia.
Choice E rationale: Dextrose stimulates insulin secretion, which causes an intracellular shift of potassium. This can lead to a further decrease in serum potassium levels, worsening the client's hypokalemia.
Correct Answer is D
Explanation
Choice A reason: While pain management is important for comfort, it does not directly slow the progression of PKD to ESRD.
Choice B reason: Blood glucose control is important for overall health but is not the most critical factor in slowing the progression of PKD to ESRD.
Choice C reason: Fluid restriction is not typically necessary for PKD unless there is an associated condition that requires it.
Choice D reason: Blood pressure control is crucial in PKD as hypertension can accelerate the progression to ESRD.
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