The nurse is preparing to administer phenytoin to a patient who has a seizure disorder. The patient appears drowsy, and the nurse notes that the last random serum drug level was 18 mcg/mL. What action will the nurse take?
Administer the dose since the patient is not toxic
Contact the provider to discuss decreasing the phenytoin dose
Give the drug and monitor closely for adverse effects
Report drug toxicity to the providers
The Correct Answer is D
A. Administer the dose since the patient is not toxic.
This is not the appropriate action. With a drowsy patient and a high serum phenytoin level, there is a concern for toxicity. Administering the next dose could worsen the toxicity.
B. Contact the provider to discuss decreasing the phenytoin dose.
While adjusting the dose may be a consideration, the immediate action should be to withhold the next dose and report the elevated level to the healthcare provider. The provider can then determine the appropriate course of action.
C. Give the drug and monitor closely for adverse effects.
Giving the drug without further intervention is not appropriate when there are signs of potential toxicity, such as drowsiness. Monitoring alone is not sufficient in this case.
D. Report drug toxicity to the providers.
This is the correct choice. With a drowsy patient and a serum phenytoin level of 18 mcg/mL, which is considered high, reporting the drug toxicity to the healthcare provider is the immediate and appropriate action. The provider can then determine the next steps, such as adjusting the dose or ordering additional tests.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Before breakfast or lunch
Methylphenidate (Ritalin), a stimulant medication commonly used to treat attention deficit hyperactivity disorder (ADHD), is usually administered before breakfast or lunch for maximum effectiveness. This schedule helps align the peak concentration of the medication with the times when increased focus and attention are often needed, such as during school hours.
B. With meals
While it can be administered with meals, the goal is often to have the medication take effect before meals to help with focus and attention during activities like school or work.
C. After dinner
Administering methylphenidate after dinner may interfere with the patient's ability to fall asleep, as the medication can cause insomnia. It is generally recommended to avoid administering it in the late afternoon or evening.
D. At bedtime
Administering methylphenidate at bedtime is not appropriate due to the potential for insomnia. The stimulant effect of the medication is not aligned with the patient's sleep-wake cycle.
Correct Answer is D
Explanation
A. Aspirin has the potential to cause gastrointestinal (GI) bleeding in children.
While it is true that aspirin can cause GI bleeding, this is not the primary concern in this scenario. Reye's syndrome, a severe and potentially fatal condition, is the more significant worry when aspirin is given to children with viral infections.
B. Aspirin has the potential to cause hyperglycemia.
Hyperglycemia (high blood sugar) is not a known effect of aspirin in children. Aspirin is not typically associated with glucose metabolism issues.
C. Aspirin has the potential to cause ringing in the ears (tinnitus) in children.
Tinnitus can occur with aspirin use, but it is not the primary concern in this situation. Reye's syndrome is a more serious and immediate risk associated with aspirin use in children with viral infections.
D. Aspirin has the potential to cause Reye's syndrome in children.
This is the correct and most significant concern. Reye's syndrome is a rare but severe condition associated with aspirin use in children during or after viral infections. It affects the liver and brain and can be life-threatening.
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