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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale:
Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.
Choice B rationale:
Administering valproic acid is not a nursing intervention for autism spectrum disorder.
Choice C rationale:
Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.
Choice D rationale:
Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.
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