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: Hyperkalemia refers to high potassium levels, which may not directly cause shortness of breath and swelling.
Choice B reason: Hypervolemia, or fluid overload, is likely the cause of the client's symptoms, including shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
Choice C reason: Hypovolemia, or fluid deficit, would not typically present with swelling and crackles in the lungs.
Choice D reason: Hyponatremia refers to low sodium levels, which may not directly cause the symptoms described.
Correct Answer is B
Explanation
Choice A reason: A raised red rash is not typically indicative of venous insufficiency but could suggest an allergic reaction or infection.
Choice B reason: Coldness and numbness distal to the fistula site can indicate poor blood flow, which is a symptom of venous insufficiency.
Choice C reason: Pain proximal to the fistula site can be a sign of venous hypertension and insufficiency, as it may
indicate increased pressure in the veins.
Choice D reason: Foul-smelling drainage is not a typical sign of venous insufficiency but may indicate an infection.
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