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

During a generalized tonic-clonic seizure, it is important for the practical nurse (PN) to prioritize the safety and well-being of the child. The correct actions to implement immediately are:

A. Observe the progression of the seizure: The PN should closely observe the seizure to gather important information that can be helpful for medical professionals in assessing the seizure's characteristics and duration.

D. Pad the side rails with pillows: Padding the side rails of the bed with pillows helps to prevent the child from injuring themselves by hitting the side rails during the seizure.

E. Loosen clothing around the neck: Loosening any tight clothing around the child's neck helps to ensure adequate breathing and prevent any constriction or discomfort during the seizure.

B. Hold the extremities close to the body: This action is not recommended during a seizure as it may increase the risk of injury to the child or the PN.

C. Insert a tongue blade between the teeth: It is not recommended to insert any object, including a tongue blade, between the teeth of a person experiencing a seizure. This can cause injury to the person's mouth or teeth and is no longer considered an appropriate intervention for seizures.

The client is prescribed oxygen at 3 liters per minute, but the flowmeter shows that only 1 liter of oxygen is being delivered. This indicates an inadequate oxygen supply and immediate action is required to adjust the flow rate to meet the prescribed oxygen requirement. Failure to provide the appropriate oxygen flow rate can compromise the client's respiratory status and oxygenation. The PN should promptly increase the flow rate to the prescribed level to ensure the client receives the necessary oxygen therapy.
The other assessment findings mentioned are also important to note and address, but they do not require immediate action:
A. The client lying in a supine position in bed: While it is generally recommended for clients receiving oxygen therapy to be in an upright or semi-upright position, this finding does not require immediate action unless there are specific indications or contraindications related to the client's condition.
B. The cannula pressed snugly against the client's cheeks: The cannula should fit comfortably and securely on the client's face without causing discomfort or pressure areas. While this finding may require adjustment to ensure proper fit and comfort, it does not require immediate action unless it is causing harm or compromising oxygen delivery.
D. There is no humidifier attached to the delivery system: While a humidifier may be recommended to add moisture to the oxygen, its absence does not pose an immediate threat to the client's safety or require immediate action. The need for humidification depends on the client's condition and comfort level, and it can be addressed by attaching a humidifier if necessary.