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 B
Explanation
Choice A rationale:
Assigning an Apgar score is important, but drying the newborn and promoting warmth are immediate priorities.
Choice B rationale:
Drying the newborn and providing warmth help prevent heat loss and maintain the newborn's body temperature, which is essential for their well-being.
Choice C rationale:
Weighing the newborn is important, but maintaining their body temperature takes precedence immediately after birth.
Choice D rationale:
Placing an identification bracelet on the newborn is important for proper identification, but ensuring the newborn's immediate well-being and comfort is the priority.
Correct Answer is B
Explanation
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
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