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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to managing dry mouth caused by benztropine. While fiber is essential for digestive health, it does not directly address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can be helpful in promoting saliva production, but in Parkinson's disease, it can exacerbate swallowing difficulties and increase the risk of aspiration.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the appropriate recommendation. Lemon-glycerin swabs can help lubricate the mouth and provide relief from dryness, which is a common side effect of benztropine, an anticholinergic medication.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat oral candidiasis (thrush), a fungal infection, and is not relevant to managing dry mouth caused by benztropine.

A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Metabolic acidosis.

Correct Answer is A

Explanation

Choice A rationale:

The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.

Choice B rationale:

Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.

Choice C rationale:

Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.

Choice D rationale:

Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Parkinson's disease and is taking benztropine and reports experiencing a dry mouth. Which of the following recommendations should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are pH 7.48, PCO2 30 mm Hg, HCO3 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

Correct Answer is A

Explanation

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