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

C. Fever:
Fever is a classic sign of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize the fat in the IV fat emulsion properly, leading to fat accumulation in tissues and organs. This can result in fever, which is one of the primary manifestations. Other signs can include respiratory distress, liver dysfunction, and changes in laboratory values, such as elevated triglycerides.

A. Wash in a distal to proximal direction. B. Use a circular motion with the washcloth. C. Massage legs after completing the bath. D. Disconnect the IV tubing prior to performing the bath.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.

Choice B rationale:

Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.

Choice C rationale:

Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.

Choice D rationale:

There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.

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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 assessing a client who is receiving IV fat emulsion therapy. Which of the following findings should the nurse identify as a manifestation of fat overload syndrome?

Correct Answer is C

Explanation

A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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