A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Headache, restlessness

Decreased blood pressure, rapid pulse

Muscle cramps, chest heaviness

Pain and tingling at the access site

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A

Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.

Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.

Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.

Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.

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Correct Answer is C

Explanation

Choice A reason: Iron deficiency is not typically associated with an increased risk of renal calculi. Renal calculi, or kidney stones, are generally composed of minerals such as calcium, oxalate, urate, cystine, xanthine, and phosphate.

Choice B reason: While protein in the urine, or proteinuria, may indicate kidney disease, it is not a direct risk factor for the formation of renal calculi. However, excessive dietary protein intake can increase the risk of stone formation.

Choice C reason: Dehydration is a significant risk factor for renal calculi. Insufficient fluid intake leads to concentrated urine, which can promote the crystallization and aggregation of stone-forming substances.

Choice D reason: Obesity is associated with an increased risk of renal calculi. Higher body mass index (BMI) can lead to changes in urine that promote the formation of stones.

A. Diagnosis B. Assessment C. Implementation D. Outcomes identification

Correct Answer is B

Explanation

Choice A reason: Diagnosis is the identification of a disease or condition, which is not directly related to reviewing kidney function test data.

Choice B reason: Assessment involves collecting and analyzing data, which is what the nurse is doing when reviewing kidney function test results.

Choice C reason: Implementation refers to carrying out interventions, not reviewing test data.

Choice D reason: Outcomes identification involves setting goals and expected outcomes, not reviewing test data.

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A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

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