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 ["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
Correct Answer is A
Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
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