The nurse prepares to administer a 1,000 mg loading dose of phenytoin IV to a client with a subarachnoid hemorrhage.
Which consideration is most important when administering this dose?

Delegation requires understanding the scope of practice for unlicensed assistive personnel versus licensed nurses. Tasks involving clinical judgment, titration of medications, or invasive monitoring must be reserved for the registered nurse, while routine, non-invasive tasks can be safely delegated.

Choice A rationale

Central venous pressure monitoring involves an invasive line and requires clinical interpretation of waveforms and readings. This task is beyond the scope of unlicensed personnel and must be performed by a nurse to ensure accuracy and safety.

Choice B rationale

Oral care is a routine hygiene task that falls within the scope of practice for unlicensed assistive personnel. Regular oral care is essential for preventing ventilator-associated pneumonia and maintaining mucosal integrity in critically ill septic patients.

Choice C rationale

While some glucose monitoring can be delegated, hourly measurements in a septic patient typically require clinical titration of insulin or close monitoring of metabolic instability. Agency policies often restrict high-frequency or critical-care monitoring to licensed staff.

Choice D rationale

Titration of vasoactive medications like norepinephrine requires advanced clinical judgment and assessment of hemodynamics. This is a complex nursing intervention that can never be delegated to unlicensed staff due to the high risk of hemodynamic instability.

Choice E rationale

Assessing vital signs in a hemodynamically unstable septic patient involves clinical evaluation. Furthermore, measuring urine output via a catheter in an intensive care setting is often combined with assessing renal perfusion, requiring professional nursing oversight.

Choice F rationale

Measuring and documenting intake and output is a standard technical task delegated to unlicensed personnel. While the nurse must interpret the clinical significance of the balance, the manual collection and recording of data are appropriate delegated duties.

Administering phenytoin requires applying knowledge of intravenous drug compatibility and cardiovascular safety profiles. The nurse must prioritize monitoring for life-threatening complications associated with rapid infusion, specifically focusing on the drug's narrow therapeutic index and its significant irritant properties.

Choice A rationale

Phenytoin is highly unstable and will precipitate if mixed with dextrose solutions. It must only be diluted with 0.9 percent sodium chloride. Incorrect dilution can lead to crystalline emboli and loss of drug efficacy during administration.

Choice B rationale

Intravenous phenytoin is a known vesicant that can cause purple glove syndrome if administered into small peripheral veins like those in the hand. Use of a large-bore catheter in a large vein or central line is preferred.

Choice C rationale

Rapid infusion of phenytoin can lead to severe cardiovascular collapse, including hypotension and fatal dysrhythmias. The infusion rate should not exceed 50 mg per minute to allow the heart to tolerate the drug's membrane-stabilizing effects safely.

Choice D rationale

The standard therapeutic range for phenytoin is 10 to 20 mcg per mL, not 20 to 30 mg per mL. Levels exceeding 20 mcg per mL often result in toxicity, characterized by nystagmus, ataxia, and decreased mental status.