A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?

Bradycardia.

Red man syndrome.

Hypotension.

Hypoglycemia.

Answer and Explanation

The Correct Answer is C

Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.

Choice A is wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.

Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.

Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.

Choice D is wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.

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Correct Answer is D

Explanation

A WBC count of 5,000/mm3 is low and could indicate leukopenia, a possible side effect of amitriptyline. Leukopenia increases the risk of infection and should be reported to the provider.

Choice B is wrong because a total bilirubin of 1.5 mg/dL is within the normal range of 0.3 to 1.9 mg/dL.

Choice C is wrong because a Hct of 44% is within the normal range of 37% to 48% for women and 45% to 52% for men.

Choice D is wrong because a potassium level of 4.2 mEq/L is within the normal range of 3.5 to 5.0 mEq/L.

A. A client who has a referral for social services. B. A client who is transported to radiology. C. A client who is transferred to a step-down unit. D. A client who has a consultation for physical therapy.

Correct Answer is C

Explanation

Medication reconciliation is the process of creating the most accurate list possible of all medications a client is taking and comparing that list against the physician’s orders at every transition of care. A client who is transferred to a step-down unit is at risk of medication errors due to changes in the level of care and the prescribing providers. Therefore, medication reconciliation should be performed for this client to prevent adverse drug events.

Choice A is wrong because a referral for social services does not involve a change in the client’s medications or care setting.

Choice B is wrong because transport to radiology is a temporary and short-term movement that does not require medication reconciliation.

Choice D is wrong because a consultation for physical therapy does not affect the client’s medication regimen or orders.

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A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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