A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

"You can safely take this medication if you become pregnant."

"You can skip a dose of this medication if you are nauseated."

"You should expect to have blood work every 6 months while taking this medication."

"You might experience swollen gums while taking this medication."

Answer and Explanation

The Correct Answer is D

A.   Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B.   Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C.   Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D.   Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.

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Correct Answer is C

Explanation

A. Allowing a family member to stay with the body is a common practice in many cultures, but it is not specific to Islamic practices.
B. Positioning the head northward is not a specific requirement of Islamic postmortem care.
C. Correct. Positioning the client's head toward Mecca is an important aspect of Islamic postmortem care, as Muslims pray facing Mecca.
D. Allowing a family member to stay with the body for a specific duration is not a specific Islamic practice.

A. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. C. A nurse discovers that a client's family member has administered a PCA dose. D. A nurse observes a client vomiting after receiving an oral pain medication.

Correct Answer is A

Explanation

A. Correct. This situation involves a potential medication error due to the electronic IV pump delivering excessive fluid, which requires documentation and an incident report for reporting and tracking purposes.
B. While observing another nurse's practice is important, the scenario does not involve an incident that requires reporting via an incident report.
C. This situation may warrant a medication incident report, but the family member's administration of PCA might be within their scope if properly trained and authorized.
D. This scenario involves a side effect of a medication, but it is not a situation requiring an incident report unless it is a severe or unexpected reaction.

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A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an Incident report. Which of the following examples should the nurse include?

Correct Answer is A

Explanation

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