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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Completely irrigating one eye before irrigating the second eye is the correct action to take when a client receives a chemical splash on their face. This approach helps prevent the potential spread of the chemical from one eye to the other. Irrigation should be done immediately to flush out the chemical and minimize its harmful effects.

Choice B rationale:

Informing the client to blink their eyes rapidly during the irrigation process is not recommended. Blinking may exacerbate the dispersion of the chemical and could lead to further damage to the eyes. Instead, the client should keep their eyes open during irrigation.

Choice C rationale:

Delaying the irrigation process until the type of chemical in the eyes is identified is not appropriate. Time is critical in minimizing the impact of the chemical on the eyes. Immediate irrigation is essential, regardless of the type of chemical, to remove the substance from the eyes.

Choice D rationale:

Asking the client to count the number of fingers held up by the nurse before irrigating their eyes is not relevant in this situation. The priority is to initiate immediate irrigation to remove the chemical from the eyes. Assessing the client's visual acuity can be done later in the evaluation process after the eyes have been irrigated.

A. "When taking leflunomide, expect decreased swelling within 1 week.". B. "If acute inflammation is present, apply hot packs directly to the joint for pain relief.". C. "Take calcium and vitamin D supplements along with your steroid medication.". D. "Make sure your varicella vaccine is up to date.".

Correct Answer is C

Explanation

Choice A rationale:

Leflunomide is a disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis, but it does not typically result in decreased swelling within one week. It usually takes several weeks or even months for its full effect to be observed.

Choice B rationale:

Applying hot packs directly to the joint for pain relief is not recommended for rheumatoid arthritis, as heat can exacerbate inflammation. Cold packs or other anti-inflammatory measures are more appropriate.

Choice C rationale:

Steroid medications, such as prednisone, can lead to bone density loss and an increased risk of osteoporosis. Taking calcium and vitamin D supplements helps to mitigate this risk.

Choice D rationale:

The Varicella vaccine is not directly related to rheumatoid arthritis. It is important for immune support, but it is not specifically required for rheumatoid arthritis treatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 in the emergency department is preparing to irrigate the eyes of a client who received a chemical splash on their face. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching an adult client who has been recently diagnosed with rheumatoid arthritis. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is providing information about maintaining a special diet with a client who has irritable bowel syndrome. Which of the following information should the nurse include?

A nurse is teaching a client who has a new prescription for lovastatin. Which of the following diagnostic tests should the nurse instruct the client to complete before starting the medication?

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

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?

A nurse is assessing a client's ability to adapt to a new colostomy. Which of the following client statements indicates to the nurse the client is adapting?

A nurse is teaching an adolescent client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the instructions?

A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?