What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Bladder palpation.

Blood glucose monitoring.

Inspection of the mouth.

Auscultation of breath sounds.

Answer and Explanation

The Correct Answer is C

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

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Correct Answer is C

Explanation

Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.

Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.

Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.

Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.

A. Fluctuation with respiration in the water-seal chamber of the B. The dry gauze dressing over the insertion site is clean and intact. C. No bubbling in the suction chamber of the Pleura. D. Serous fluid in the drainage chamber of the Pleura.

Correct Answer is A

Explanation

Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.

Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.

Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.

Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.

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What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Correct Answer is C

Explanation

A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Correct Answer is A

Explanation

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