A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

"You can safely take this medication if you become pregnant."

"You can skip a dose of this medication if you are nauseated."

"You should expect to have blood work every 6 months while taking this medication."

"You might experience swollen gums while taking this medication."

Answer and Explanation

The Correct Answer is D

A.   Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B.   Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C.   Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D.   Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.

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Correct Answer is C

Explanation

A. Insert an oral airway into the client's mouth.Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.

B. Lower the side rails of the bed when the seizure begins.Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.

C. Measure the duration of the seizure.It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).

D. Restrain the client's arms and legs to prevent injury.Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.

A. Maintain abduction of the client's residual limb with a pillow. B. Encourage the client to use the overbed trapeze. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client's surgical site.

Correct Answer is B

Explanation

A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.

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A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Correct Answer is B

Explanation

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