A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take

Dilute the medication with dextrose 5k in water.

Administer a saline solution after injection.

Administer the medication at 100 mg/min.

Hold the injection if seizure activity is present.

Answer and Explanation

The Correct Answer is B

It is recommended that every injection of phenytoin be followed by infusion of at least 50 to 100mls of normal saline infusion. This is important to prevent local irritation that occurs as surrounding tissues react to the medication.

A. Mixing phenytoin in dextrose 5% is not recommended due risk of precipitation of the Phenytoin acid

C. Phenytoin should be given at a date of 50mg/min or less to reduce the risk of toxicity

D. The injection should not be held as it is used to manage the seizure unless it is not safe for the nurse to give it

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Correct Answer is D

Explanation

Bethanechol is a cholinergic agonist used to stimulate contraction of the bladder to help in the expulsion of urine. It is used in the management of urinary retention by promoting bladder emptying. Therefore, it should be administered when the client reports an inability to void, as this indicates urinary retention
A. Bladder spasms are treated with Oxybutynin
B. Frequent painful urination is a feature of UTI requiring antibiotics
C. Bethanechol has no analgesic property

A. Call the prescribing physician and inform her of the client's serum potassium level results. B. Omit the KCL dose and document it was not given. C. Call the lab to verify the client's results. D. Give the ordered KCL as prescribed.

Correct Answer is A

Explanation

potassium level of 5.2 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Giving potassium chloride (KCL) to a client with hyperkalemia can exacerbate the condition and lead to life- threatening cardiac arrhythmias. It is crucial to notify the physician promptly so that appropriate action can be taken, such as adjusting the dosage of potassium supplementation or discontinuing it altogether.
B. Omitting the KCL dose without consulting the physician is not appropriate as further instructions are needed.
C. Calling the lab to verify the client's results is unnecessary since the nurse already has the laboratory results. The focus should be on informing ensuring client safety.
D. Giving the ordered KCL as prescribed is not appropriate as administering potassium in the presence of hyperkalemia can be dangerous and should be avoided until further guidance is obtained from the physician.

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A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client Who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports Which of the following manifestations?

Correct Answer is D

Explanation

A nurse is caring for a client Who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/I— Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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