A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

Administer the medication no faster than 100 mg/min.

Monitor plasma phenytoin levels to establish the therapeutic range.

Add the medication to the existing IV solution.

Monitor the client for hypertension.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.

Choice B rationale:

Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.

Choice C rationale:

Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.

Choice D rationale:

Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.

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Correct Answer is C

Explanation

Choice A rationale:

Taking colesevelam on an empty stomach is not necessary. This medication can be taken with food to reduce gastrointestinal side effects.

Choice B rationale:

Increasing fiber in the diet is generally beneficial for bowel health, but it is not specific to the use of colesevelam powder for oral suspension.

Choice C rationale:

This is the correct answer because if the oral suspension of colesevelam is cloudy after mixing, it indicates that the medication may have degraded or is not suitable for consumption. Discarding the cloudy suspension ensures that the client receives the appropriate dose and effectiveness of the medication.

Choice D rationale:

Avoiding grapefruit juice is important for some medications, but it is not relevant to colesevelam. Grapefruit juice can interfere with the metabolism of certain drugs, but it does not have a significant effect on colesevelam.

A. Elevated WBC Count. B. Elevated amylase level. C. Rebound tenderness. D. Ascites. E. Anorexia.

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.

Choice B rationale:

Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.

Choice C rationale:

Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.

Choice D rationale:

Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.

Choice E rationale:

Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.

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A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for colesevelam powder for oral suspension. The nurse should include which of the following instructions?

Correct Answer is C

Explanation

A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a client who has long-term liver cirrhosis and a new diagnosis of abdominal ascites. Which of the following interventions should the nurse include in the plan of care to prevent complications?

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A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

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