The client was admitted to the medical floor. Upon arrival, the client was assessed: He is difficult to arouse but follows commands. He has a peripheral IV which is infusing normal saline at 145 mL/hr. No redness or edema at the site. Breath sounds are clear and equal bilaterally. He appears pink and well-perfused.

The client had a tonic-clonic seizure that lasted for 3 minutes and 5 seconds. The client became apneic during the seizure and the oxygen saturation dropped to 48%. The client was manually ventilated at 100% oxygen and padding was placed around the vent for safety. After the seizure, the client was turned to his left for recovery.

The physician comes to the bedside following the seizure and prescribes phenytoin. The PN administers the phenytoin as prescribed.

What are the possible toxic effects of phenytoin that the PN should closely monitor the client for after administration?

Select all that apply

Choice A reason:

Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.

Choice B reason:

Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.

Choice C reason:

Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.

Choice D reason:

Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.

Gently blowing the nose helps to clear any mucus or debris from the nasal passages, allowing for better delivery and absorption of the medication. It also helps to ensure that the nasal passages are clear and open, allowing the medication to reach its intended target.
A. Deep breathing and coughing are unrelated to the administration of nasal spray and are not necessary before using the medication.
B. Checking glucose levels before and after administration is not relevant for fluticasone furoate nasal spray. Glucocorticoid nasal sprays are not typically associated with significant effects on blood glucose levels.
C. Exhaling through the mouth is not a specific action required before using the nasal spray. It may be a general instruction for some other respiratory therapies or procedures, but it is not directly related to the administration of the nasal spray.