A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply)

Choice A reason: Ask the client to blow his nose

Asking the client to blow his nose is not advisable in this situation. Blowing the nose can increase intracranial pressure and potentially worsen the condition by causing more cerebrospinal fluid (CSF) to leak or even lead to further complications. Therefore, this action should be avoided.

Choice B reason: Suction the nostril

Suctioning the nostril is also not recommended. This action can introduce infection and increase the risk of further complications. It is important to handle any potential CSF leak with care to prevent infection and other issues.

Choice C reason: Notify the physician

While notifying the physician is important, it is not the immediate first step. The nurse should first confirm whether the clear drainage is CSF. Once confirmed, notifying the physician would be the next appropriate step.

Choice D reason: Test the drainage for glucose

Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive glucose test would confirm that the drainage is indeed CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures. Confirming the presence of CSF will guide further medical interventions and management.

Choice A reason: Administering the medication over 1 minute is crucial for phenytoin IV administration. Phenytoin should be administered slowly to prevent severe cardiovascular reactions, including hypotension and arrhythmias. The recommended rate is not to exceed 50 mg per minute.

Choice B reason: Diluting the medication with sterile water before injecting is not recommended for phenytoin. Phenytoin should be administered undiluted or diluted with normal saline if necessary. Using sterile water can cause the medication to precipitate.

Choice C reason: Slowing the injection if the medication crystallizes is not an appropriate action. If phenytoin crystallizes, it should not be administered. The nurse should ensure the solution is clear before administration and discard any crystallized medication.

Choice D reason: Following the injection with sterile water is not necessary. Phenytoin does not require a flush with sterile water after administration. Instead, normal saline can be used to flush the IV line before and after administration to ensure the line is clear.