The client was admitted to the medical floor. Upon arrival, the client was assessed: He is difficult to arouse but follows commands. He has a peripheral IV which is infusing normal saline at 145 mL/hr. No redness or edema at the site. Breath sounds are clear and equal bilaterally. He appears pink and well-perfused.

The client had a tonic-clonic seizure that lasted for 3 minutes and 5 seconds. The client became apneic during the seizure and the oxygen saturation dropped to 48%. The client was manually ventilated at 100% oxygen and padding was placed around the vent for safety. After the seizure, the client was turned to his left for recovery.

The physician comes to the bedside following the seizure and prescribes phenytoin. The PN administers the phenytoin as prescribed.

What are the possible toxic effects of phenytoin that the PN should closely monitor the client for after administration?

Select all that apply

The practical nurse (PN) should include the following actions when assessing a client for signs and symptoms of fluid volume excess:

• Palpate the rate and volume of the pulse: Fluid volume excess can lead to an increased pulse rate and bounding pulse due to the increased blood volume.
• Measure body weight at the same time daily: Monitoring daily weights can help identify fluid retention or weight gain, which can be indicative of fluid volume excess.
• Observe the color and amount of urine: Changes in urine color and output can provide information about kidney function and fluid balance. In fluid volume excess, urine output may be increased and urine may appear pale or diluted.

The following options are incorrect:

• Check fingernails for the presence of clubbing: Clubbing of the fingernails is not directly related to fluid volume excess. It is a finding commonly associated with chronic respiratory conditions and certain cardiac disorders.
• Compare muscle strength of both arms: Assessing muscle strength is not directly related to fluid volume excess. It is more relevant when evaluating neurological or musculoskeletal conditions.

The client is prescribed oxygen at 3 liters per minute, but the flowmeter shows that only 1 liter of oxygen is being delivered. This indicates an inadequate oxygen supply and immediate action is required to adjust the flow rate to meet the prescribed oxygen requirement. Failure to provide the appropriate oxygen flow rate can compromise the client's respiratory status and oxygenation. The PN should promptly increase the flow rate to the prescribed level to ensure the client receives the necessary oxygen therapy.
The other assessment findings mentioned are also important to note and address, but they do not require immediate action:
A. The client lying in a supine position in bed: While it is generally recommended for clients receiving oxygen therapy to be in an upright or semi-upright position, this finding does not require immediate action unless there are specific indications or contraindications related to the client's condition.
B. The cannula pressed snugly against the client's cheeks: The cannula should fit comfortably and securely on the client's face without causing discomfort or pressure areas. While this finding may require adjustment to ensure proper fit and comfort, it does not require immediate action unless it is causing harm or compromising oxygen delivery.
D. There is no humidifier attached to the delivery system: While a humidifier may be recommended to add moisture to the oxygen, its absence does not pose an immediate threat to the client's safety or require immediate action. The need for humidification depends on the client's condition and comfort level, and it can be addressed by attaching a humidifier if necessary.