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?
Dilantin should be mixed in dextrose in water before administration.
Dilantin should be administered through an IV catheter in the client's hand.
Rapid Dilantin administration can cause cardiac dysrhythmias.
Therapeutic drug levels should be maintained between 20 to 30 mg/mL.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Maintaining airway patency while managing intracranial pressure requires a balance between oxygenation and avoiding spikes in pressure. Knowledge of airway management and the physiological effects of hypoxia on cerebral edema is essential for prioritizing immediate life-saving interventions.
Choice A rationale
Elevating the head of the bed to 30 to 45 degrees promotes venous drainage and reduces intracranial pressure. While a standard nursing intervention for these patients, it does not clear an obstructed airway caused by pooled secretions.
Choice B rationale
Limiting stimulation helps prevent sudden increases in intracranial pressure caused by environmental stress. Although important for neurological stability, it is not the priority when the client's airway is compromised by secretions that prevent adequate ventilation.
Choice C rationale
Suctioning is necessary to clear the airway and maintain oxygenation. Hypoxia and hypercapnia are potent vasodilators that significantly increase intracranial pressure. Clearing the airway is the first priority, though it should be done quickly to minimize stimulation.
Choice D rationale
Sedatives may be used to reduce metabolic demand and blunt the intracranial pressure response to noxious stimuli like suctioning. However, administration takes time and does not physically remove the secretions causing the immediate airway obstruction..
Correct Answer is A
Explanation
Reporting suspected child abuse involves legal and ethical obligations of healthcare professionals. Knowledge of mandatory reporting laws, professional responsibility, and communication techniques for maintaining a professional boundary while disclosing required actions to concerned or upset parents is essential for this response.
Choice A rationale
Nurses are mandated reporters under the law. Stating this legal requirement provides a factual, non-judgmental explanation for the action. It frames the report as a professional obligation rather than a personal accusation against the upset parents.
Choice B rationale
Referring only to hospital policy is insufficient and potentially misleading. While policies exist, the primary driver for reporting suspected abuse is state law. This response lacks the necessary emphasis on the broader legal and ethical mandates of nursing.
Choice C rationale
This statement is subjective and accusatory, which can escalate a volatile situation. Nurses are required to report suspicion rather than provide a definitive belief of guilt. This phrasing undermines the objective nature of the mandatory reporting process.
Choice D rationale
Deflecting the concern to the provider is inappropriate because the nurse has an independent legal responsibility to report. Avoiding the parents question does not address the nurses role or the legal necessity of the report that was filed.
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