A nurse is caring for a client in an emergency department (ED).

Which of the following medications should the nurse expect the physician to prescribe for this client?
Select All That Apply

Phenytoin is a potent antiepilepticthat requires extreme caution during intravenous administration due to its high alkalinity and potential for precipitation. It is incompatible with most intravenous solutions and must be delivered through a large-bore catheter to prevent extravasationand tissue necrosis. Close cardiovascular monitoring is mandatory during infusion to detect potential arrhythmias or severe hypotension.

Rationale:

A.Injecting sterile water after administration is not the standard protocol; instead, the line must be flushed with 0.9% sodium chloride. Phenytoin is highly unstable and will precipitate if it comes into contact with many other fluids. Using 0.9% sodium chloride ensures the vein is cleared of the medication without causing the formation of dangerous micro-crystals in the IV tubing.

B.Administering phenytoin with 5% dextrose in water (D5W) is strictly contraindicated because the medication will immediately precipitate into a solid form. Phenytoin is only compatible with 0.9% sodium chloride, and any contact with glucose-containing solutions leads to crystallization. Such precipitates can cause emboli or severe vein irritation, compromising the safety of the intravenous access site.

C.Discarding the medication if it appears cloudy is a critical safety action because cloudiness indicates that the phenytoin has precipitated. Intravenous phenytoin should be a clear, colorless solution; any presence of crystals or opaqueness means the drug is no longer safe for infusion. Injecting a precipitated solution can cause catastrophic vascular damage or pulmonary embolism in the client.

D.Administering the medication at a rate of 100 mg/min is dangerously fast and exceeds the maximum recommended safety limit. To prevent severe hypotension and cardiac arrhythmias, the infusion rate must not exceed 50 mg/min for adults. Rapid administration can lead to cardiovascular collapse, making slow, controlled delivery and continuous heart rate monitoring an essential nursing priority.

Diabetic peripheral neuropathyresults from chronic hyperglycemia-induced nerve fiber damage and microvascular impairment. The resulting pain is neuropathicrather than nociceptive, requiring medications that modulate neurotransmitter release or stabilize neuronal membranes. Standard analgesics are often ineffective for the characteristic parasthesiaand burning sensations associated with this condition.

Rationale:

A.Gabapentin is an anticonvulsant medication frequently used as a first-line treatment for neuropathic pain. It works by binding to the alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system, reducing the release of excitatory neurotransmitters. This stabilization of overactive neurons effectively alleviates the burning and tingling sensations typical of diabetic nerve damage.

B.Acetylcysteine is a mucolytic agent used primarily to thin respiratory secretions or as an antidote for acetaminophen toxicity. It does not possess analgesic properties and has no role in managing nerve-related pain. Administering this medication would not address the underlying pathophysiology of the client's peripheral neuropathy or provide any relief for their sensory symptoms in the feet.

C.Fentanyl is a potent opioid agonist used for severe, acute, or chronic nociceptive pain. While opioids can mask pain, they are generally not recommended as first-line therapy for diabetic neuropathy due to the high risk of dependence and limited efficacy for neuropathic burning. Treatment guidelines prioritize non-opioid neuromodulators like gabapentin or antidepressants over potent narcotics for this condition.

D.Hydromorphone is a strong opioid analgesic indicated for moderate to severe pain that is unresponsive to other treatments. Like fentanyl, it is not the preferred choice for managing the chronic, lancinating pain of diabetic neuropathy. Long-term use of hydromorphone carries a significant risk of tolerance and hyperalgesia without addressing the specific neuronal hyperexcitability that causes the tingling sensations.