Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?

Hold tube feeding 1 hour before and 2 hours after to avoid clumping.

Monitor the patient for lethargy and drowsiness as these may indicate a high drug level.

Inform the patient that they may experience increased and large amounts of urinary output.

Advise the patient to use an extra soft toothbrush to avoid gum bleeding.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.

Correct Answer is ["167"]

Explanation

To calculate the rate for the infusion pump, you would divide the total volume by the total time, then multiply by the drop factor. Here’s how you can do it: Step 1 is: Calculate the total volume in mL, which is 1000 mL.

Step 2 is: Calculate the total time in minutes. Since there are 60 minutes in an hour, 2 hours is 120 minutes.

Step 3 is: Divide the total volume by the total time. So, 1000 mL ÷ 120 min = 8.33 mL/min.

Step 4 is: Multiply the result by the drop factor. If we assume a standard drop factor of 20 drops/mL, then (8.33 mL/min) × 20 drops/mL = 166.67 drops/min. So, the nurse should set the infusion pump to approximately 167 drops per minute. Vital signsVital signs Explore

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

Correct Answer is B

Explanation

The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

Correct Answer is ["167"]

Explanation

The nursing assistant is delivering patient meals. What meal should the nurse expect to be delivered to a patient who had gastric bypass surgery the day before?

Which of the following conditions could potentially lead to a gastrointestinal bleed? (Select all that apply.)

Which of the following are risk factors for Hepatitis B? Select all that apply.

A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?