A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

Administer the phenytoin infusion over 5 min.

Flush with 0.9% sodium chloride after administration.

Flush with 100 units/mL of heparin after administration.

Administer the phenytoin in 100 mL of D5W

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.

Choice B rationale:

Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.

Choice C rationale:

Flushing with heparin is not standard practice for administering phenytoin.

Choice D rationale:

Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.

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Correct Answer is A

Explanation

Choice A rationale:

The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.

Choice B rationale:

Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.

Choice C rationale:

Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.

Choice D rationale:

Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.

A. Determine if the client is experiencing command hallucinations. B. Arrange for the client to have consistent staff assignments. C. Administer lorazepam to the client. D. Use the client's name when talking to him.

Correct Answer is A

Explanation

Choice A rationale:

Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.

Choice B rationale:

Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.

Choice C rationale:

Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.

Choice D rationale:

Using the client's name is respectful and helpful, but it is not the priority action in this scenario.

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A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

Nursing Test Bank

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