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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.
Choice B rationale:
A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.
Choice C rationale:
A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.
Choice D rationale:
An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.
Correct Answer is B
Explanation
Choice A rationale:
Understanding the relationship between food intake and the menstrual cycle is a relevant topic for individuals with anorexia nervosa.
Choice B rationale:
Rapid weight gain of 2 pounds per week can be concerning and may indicate an unhealthy pattern or behaviors related to the eating disorder.
Choice C rationale:
Recognizing that the body will never be perfect is a positive and realistic perspective that can contribute to a healthier mindset in individuals with anorexia nervosa.
Choice D rationale:
Taking a laxative for constipation is not uncommon among individuals with eating disorders, but the statement doesn't necessarily raise immediate concern compared to the rapid weight gain mentioned in choice B.
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