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 B
Explanation
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.
Choice B rationale:
The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.
Choice C rationale:
The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.
Choice D rationale:
Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.
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