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 C
Explanation
Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.
Correct Answer is A
Explanation
Choice A rationale
Handling the cast with the palms of the hands is recommended, especially when the cast is still wet and not fully hardened. This helps to avoid indentations and pressure points that could lead to discomfort or skin complications.
Choice B rationale
Drying the cast with a hair dryer is not typically recommended. Excessive heat can cause the cast material to weaken and can also burn the skin.
Choice C rationale
Keeping the casted leg in a dependent position is not recommended. This can lead to increased swelling and discomfort.
Choice D rationale
Covering the patient’s legs with a blanket is not specifically related to the care of a fresh cast. While it may provide comfort, it does not have a direct impact on the care or outcome of the cast.
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