A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy.
The client begins to experience a tonic-clonic seizure.
Identify the sequence of steps the nurse should follow.
(Move the steps into the box on the right, placing them in the selected order of performance.
Use all the steps.).

Reorient and reassure the client.

Remain with the client and call for help.

Check the client for injuries.

Place the client in the lateral position.

Answer and Explanation

The Correct Answer is B

Step 1 is B. Remain with the client and call for help. This ensures the client’s safety and gets additional assistance. Step 2 is D. Place the client in the lateral position. This prevents aspiration if the client vomits. Step 3 is C. Check the client for injuries. After the seizure has ended, the nurse should assess for any injuries that may have occurred during the seizure. Step 4 is A. Reorient and reassure the client. After a seizure, the client may be confused and scared. Reorienting and reassuring the client can help them recover. So, the correct sequence is B, D, C,

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Correct Answer is D

Explanation

Choice A rationale:

Switching brands of phenytoin can lead to variations in drug absorption and serum drug levels, potentially leading to a loss of seizure control or toxicity. Therefore, this is not a correct instruction.

Choice B rationale:

Altering the phenytoin administration regimen each week can lead to fluctuations in serum drug levels, potentially leading to a loss of seizure control or toxicity. Therefore, this is not a correct instruction.

Choice C rationale:

Phenytoin does not turn urine blue. This is a side effect associated with some other medications, but not phenytoin. Therefore, this is not a correct instruction.

Choice D rationale:

Alcohol can increase serum phenytoin levels, potentially leading to toxicity. Therefore, this is a correct instruction.

So, the correct answer is D. Alcohol increases the chance of phenytoin toxicity.

Correct Answer is ["94"]

Explanation

Step 1 is to calculate the rate of infusion. The formula is total volume ÷ total time. So, (750 mL ÷ 8 hr) = 93.75 mL/hr. Rounding to the nearest whole number gives 94 mL/hr.

So, the correct answer is 94 mL/hr.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has a prescription for phenytoin.Which of the following instructions should the nurse include in the teaching?.

Correct Answer is D

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies.

Correct Answer is ["94"]

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for phenytoin.The nurse should recognize that which of the following statements by the client indicates a need for further teaching?.

A nurse is caring for a client who states, "I am not going to take my medication anymore.”. Which of the following responses should the nurse make?.

A nurse is preparing to administer phenytoin 75 mg PO. Available is phenytoin suspension 25 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is modifying the diet of a client who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet?.

A nurse is preparing to administer ofloxacin otic drops to an adult client who has otitis externa. Which of the following actions should the nurse take?.

A nurse is reinforcing discharge instructions with a client who has multiple sclerosis (MS). Which of the following instructions should the nurse include?.

A nurse is reviewing the medication administration records of a group of clients who have been newly admitted to a long-term care facility.Which of the following clients should the nurse monitor for extrapyramidal symptoms?.