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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
Choice B rationale
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
Choice C rationale
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
Choice D rationale
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.
Correct Answer is A
Explanation
A. Stop the antibiotic infusion immediately and notify the healthcare provider.
- Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.
B. Apply a cool compress to the itchy areas and monitor for further reactions.
- Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.
C. Administer diphenhydramine (Benadryl) as a first-line treatment.
- Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.
D. Assess the client’s throat for swelling and encourage them to drink water.
- Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.
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