A nurse is contributing to the care plan for a client who has recently been diagnosed with type 2 diabetes mellitus. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

The question is about calculating the volume of phenytoin oral solution that the nurse should administer per dose. The client is prescribed 250 mg of phenytoin and the available solution has a concentration of 25 mg/5 mL.

Let’s calculate the volume step by step:

Step 1: Identify the prescribed dose and the concentration of the available medication. The prescribed dose is 250 mg and the concentration of the available medication is 25 mg/5 mL.

Step 2: Set up the calculation. We want to find out how many mL correspond to the prescribed dose. We can set up the calculation as follows: (Prescribed dose ÷ Concentration) × Volume.

Step 3: Substitute the known values into the calculation. This gives us: (250 mg ÷ 25 mg/5 mL).

Step 4: Perform the division operation first due to the order of operations (BIDMAS/BODMAS). This gives us: (250 mg ÷ 5 mg/mL).

Step 5: Perform the final calculation. This gives us: 50 mL.

So, the nurse should administer 50 mL of the phenytoin oral solution per dose.

Please note that this calculation assumes that the prescribed dose (250 mg) is to be administered in one go. If the dose is to be split over the day, the volume to be administered would change accordingly.

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.