A nurse is preparing to administer phenytoin 50 mg IV bolus to a client Who has a seizure disorder. The medication is supplied as a 50 mg/mL vial. Which of the following actions should the nurse take?

Dilute the medication with sterile water before injecting.

Administer the medication over 1 min.

Follow the IV injection with sterile water.

Slow the injection if the medication crystallizes.

Answer and Explanation

The Correct Answer is B

A.   Diluting phenytoin with sterile water before injecting is not recommended, as phenytoin is incompatible with most used diluents. Diluting it can lead to precipitation and potentially cause adverse effects such as tissue irritation and phlebitis.
B.   Administering the medication over 1 min is recommended. Phenytoin should be administered at a rate of 50mg/min.
C.   Following the IV injection with sterile water is unnecessary and not indicated for administering phenytoin.
D. Phenytoin precipitates out of solution when mixed with certain diluents or when administered too quickly. Crystallized phenytoin can cause local irritation, tissue damage, and potentially more serious adverse effects. Therefore, it should not be administered at all.

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Correct Answer is B

Explanation

The client is exhibiting symptoms and signs of anaphylaxis. Anaphylaxis is a severe systemic allergic reaction that occurs due to allergens presenting with (itching) urticaria and sudden onset shortness of breath and/or shock. The first action should be to stop the infusion to prevent worsening the severity of the allergic reaction.

A. Important to allow for further prescription but not a priority

C. Auscultating the lungs allows the nurse to assess for the severity of the reaction but should come after stopping the infusion

D. Elevating the head can improve ventilation but is not a priority

A. Take the medication with orange juice to enhance absorption. B. Rinse the mouth before taking the iron. C. Take the medication on an empty stomach to decrease gastrointestinal irritation. D. Take the medication with milk.

Correct Answer is A

Explanation

vitamin C and other fruit juices (except grape juice) enhance the absorption of oral iron supplements in the gastrointestinal tract. Therefore, the clients are encouraged to take the supplements along with such fruit juices.

B. Rinsing the mouth should be done after to prevent staining of teeth

C. Taking the supplement on an empty stomach promotes gastrointestinal irritation

D. Dairy products inhibit iron absorption and should therefore be avoided

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A nurse is preparing to administer phenytoin 50 mg IV bolus to a client Who has a seizure disorder. The medication is supplied as a 50 mg/mL vial. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?

Correct Answer is A

Explanation

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