A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?
Administer the medication no faster than 100 mg/min.
Monitor plasma phenytoin levels to establish the therapeutic range.
Add the medication to the existing IV solution.
Monitor the client for hypertension.
The Correct Answer is A
Choice A rationale:
Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.
Choice B rationale:
Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.
Choice C rationale:
Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.
Choice D rationale:
Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.
Choice B rationale:
A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.
Choice C rationale:
A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.
Choice D rationale:
A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.
Correct Answer is B
Explanation
Choice A rationale:
The statement "If I can keep my hemoglobin A1C less than 6.5%, I will be cured of diabetes.”. is incorrect. While maintaining an A1C level below 6.5% is a recommended target for some individuals with diabetes, achieving this level does not cure diabetes. Diabetes is a chronic condition that requires ongoing management and lifestyle modifications.
Choice B rationale:
Checking blood sugar levels before exercising is an important aspect of managing type 1 diabetes. Exercise can affect blood glucose levels, and knowing the current level helps the client determine whether it is safe to engage in physical activity or if adjustments to insulin or carbohydrate intake are needed.
Choice C rationale:
Having regular eye checks every 2 years is essential for clients with diabetes, but it is not the best statement that indicates an understanding of health promotion activities for a new diagnosis of type 1 diabetes mellitus.
Choice D rationale:
Soaking feet daily in warm, soapy water is not a recommended practice for clients with diabetes. It can lead to skin dryness and increase the risk of infection. Instead, clients with diabetes should practice daily foot inspections and keep their feet moisturized to prevent complications related to peripheral neuropathy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.