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 D
Explanation
Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.
Correct Answer is B
Explanation
Choice A rationale:
(Fluticasone) Fluticasone is a corticosteroid inhaler used for the long-term management of asthma symptoms and prevention of asthma attacks. It is not suitable for treating acute asthma
attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice B rationale:
(Albuterol) Albuterol is a short-acting beta-agonist bronchodilator and the preferred medication for relieving acute asthma symptoms and treating asthma attacks. It works by quickly relaxing the airway muscles, making it easier to breathe during an asthma attack. Therefore, this is the correct choice for medications to treat an acute asthma attack.
Choice C rationale:
(Salmeterol) Salmeterol is a long-acting beta-agonist bronchodilator used for the prevention of asthma symptoms but should not be used for treating acute asthma attacks. It has a slower onset of action compared to short-acting beta-agonists like albuterol. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice D rationale:
(Beclomethasone) Beclomethasone is a corticosteroid inhaler used for long-term asthma management and prevention of asthma symptoms but is not appropriate for treating acute asthma attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
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