A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

Administer the phenytoin infusion over 5 min.

Flush with 0.9% sodium chloride after administration.

Flush with 100 units/mL of heparin after administration.

Administer the phenytoin in 100 mL of D5W

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.

Choice B rationale:

Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.

Choice C rationale:

Flushing with heparin is not standard practice for administering phenytoin.

Choice D rationale:

Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.

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Correct Answer is B

Explanation

Choice A rationale:

A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.

Choice B rationale:

Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.

Choice C rationale:

Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.

Choice D rationale:

Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.

A. "I need to make sure other members of my family get immunized against the disease." B. "Since I will stay in the hospital, I should begin the process of selling my home." C. "I will need to begin hospice care immediately." D. "I would like to talk to someone about creating a living will."

Correct Answer is D

Explanation

Choice A rationale:

Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.

Choice B rationale:

Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.

Choice C rationale:

Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.

Choice D rationale:

Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.

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A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a prescription for methylergonovine. Which of the following findings should the nurse identify as a contraindication to the administration of this medication?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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