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 A
Explanation
Choice A reason: General anesthesia can impair the autonomic nervous system, which controls bladder function, leading to urinary retention. This risk is particularly high shortly after surgery.
Choice B reason: While liver failure can lead to multiple organ dysfunction, it is not directly associated with urinary retention unless there are concurrent issues affecting the urinary system.
Choice C reason: A diet high in calcium oxalate can contribute to kidney stones, which could potentially cause urinary obstruction, but it is not a direct cause of urinary retention.
Choice D reason: Antibiotics for a skin infection would not typically lead to urinary retention unless there were an allergic reaction or other rare side effects that affect the urinary system.
Correct Answer is D
Explanation
Choice A reason: An elevated creatinine level indicates reduced kidney function, which is often the reason a kidney biopsy is being performed in the first place. It is not a contraindication for the procedure.
Choice B reason: Urinary retention does not directly impact the ability to perform a kidney biopsy, as the procedure involves the kidneys and not the lower urinary tract where urine is stored.
Choice C reason: Flank pain is a common symptom in patients with kidney issues and is not a contraindication for a kidney biopsy. The procedure may help diagnose the cause of the ?ank pain.
Choice D reason: Bleeding tendencies are a significant contraindication for a kidney biopsy. Patients with a history of bleeding disorders or those on anticoagulant therapy are at increased risk of bleeding complications from the procedure.
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