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.

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Correct Answer is B

Explanation

Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.

A. A 33-year-old with burns to the back and shoulders. B. A 32-year-old with burns on the hands and face. C. A 42-year-old with burns on both legs. D. A 25-year-old with a burn on the left arm.

Correct Answer is B

Explanation

Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.

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

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Naxlex Comprehensive Predictor Exams

Which of the following clients should be seen first?

Correct Answer is B

Explanation

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area. Which patient should be attended to first?

Correct Answer is B

Explanation

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