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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While a low-protein diet can help manage electrolyte imbalances, it is not specifically targeted at reducing the risk for hyperkalemia. Hyperkalemia is more directly managed by restricting foods high in potassium.
Choice B reason: A low-protein diet helps reduce the risk for uremia, which is the accumulation of waste products in the blood due to impaired kidney function. By consuming less protein, there is less urea and other nitrogenous wastes for the kidneys to filter, which can help delay the progression of kidney disease.
Choice C reason: Edema is related to fluid retention and not directly to protein intake. A low-protein diet does not specifically reduce the risk for edema unless it is associated with kidney dysfunction affecting fluid balance.
Choice D reason: A low-protein diet will indeed decrease the amount of nitrogenous waste in the blood because less protein breakdown means less waste for the kidneys to remove. However, this choice is less specific than Choice B, which directly addresses the condition of uremia that is a concern for patients with chronic kidney failure.
Correct Answer is C
Explanation
Choice A reason: Dizziness can be a symptom of DKA due to dehydration; however, it is not as specific as mental status changes.
Choice B reason: Nervousness is not a specific symptom of DKA and can be related to high blood glucose levels rather than DKA itself.
Choice C reason: Mental status changes such as confusion or altered consciousness are significant indicators of DKA and require immediate medical atention.
Choice D reason: Cool, clammy skin is not typically associated with DKA; instead, DKA can present with dry skin and mouth due to dehydration.
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