The nurse is working on a neurosurgery unit. The patient calls the desk to complain that his arm is really burning and feels hot. The patient is receiving IV phenytoin for his grand mal seizures. What is the nurse's best action?

Call the health carer provider immediately to change the medication to oral.

Continue the infusion and reassure the patient.

Flush the line with 10 mL of normal saline and continue the infusion.

Discontinue the IV and restart the IV infusion in a different site

Answer and Explanation

The Correct Answer is D

A. Call the health care provider immediately to change the medication to oral.

Changing the medication to oral may not address the immediate issue of the burning sensation and feeling of heat at the IV site. This option focuses on changing the route of administration rather than addressing the current discomfort.

B. Continue the infusion and reassure the patient.

Continuing the infusion without addressing the patient's discomfort could lead to potential complications, and it is important to prioritize patient comfort and safety. Reassurance alone may not be sufficient if there is an issue with the IV site.

C. Flush the line with 10 mL of normal saline and continue the infusion.

While flushing the line with normal saline is a good practice to ensure patency, it may not resolve the issue if there is ongoing irritation or infiltration at the site. Continuing the infusion without addressing the patient's complaint might lead to further discomfort.

D. Discontinue the IV and restart the IV infusion in a different site.

This is the best action. Discontinuing the IV allows the nurse to assess the current site for signs of infiltration or irritation. Restarting the IV in a different site addresses the immediate issue, ensuring that the medication is delivered safely and effectively.

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Correct Answer is B

Explanation

A. Ask a colleague what the order says:

This option involves seeking assistance from a colleague to interpret the illegible handwriting. While collaboration among healthcare professionals is important, relying on a colleague to interpret unclear handwriting may introduce the risk of miscommunication or misinterpretation.

B. Contact the prescriber to clarify the order:

This is the recommended and safest option. Contacting the prescriber directly to seek clarification ensures accurate information and reduces the risk of misinterpretation or errors related to illegible handwriting.

C. Wait until the prescriber makes rounds again to clarify the order:

This option involves delaying clarification until the prescriber is available during rounds. Waiting may not be ideal if the patient requires prompt intervention or if there is an urgency in administering the medication. Timely communication is crucial for patient safety.

D. Ask the patient what medications he takes at home:

This option is unrelated to the issue of illegible handwriting on the prescription. While obtaining a patient's medication history is important for comprehensive care, it does not address the immediate need to clarify the unclear order.

A. "Continue taking OCPS because phenytoin is not safe during pregnancy." B. "You should use a backup method of contraception along with OCPs." C. "You should stop taking OCPs because of drug-drug interactions with phenytoin." D. "You should take low-dose aspirin while taking these medications to reduce your risk of stroke."

Correct Answer is B

Explanation

A. "Continue taking OCPS because phenytoin is not safe during pregnancy."

This statement is not accurate. While it's essential to address pregnancy risk, phenytoin can reduce the effectiveness of oral contraceptives. Women on phenytoin are often advised to use additional contraceptive measures.

B. "You should use a backup method of contraception along with OCPs."

This is the correct response. Phenytoin can accelerate the metabolism of oral contraceptives, potentially reducing their effectiveness. Using a backup method, such as condoms, is recommended to ensure adequate contraception.

C. "You should stop taking OCPs because of drug-drug interactions with phenytoin."

This advice is generally not recommended without consulting the healthcare provider. Abruptly stopping OCPs without an alternative form of contraception can increase the risk of unintended pregnancy.

D. "You should take low-dose aspirin while taking these medications to reduce your risk of stroke."

This statement is not relevant to the situation described. Low-dose aspirin is not typically recommended for contraception, and its use in this context does not address the potential interaction between phenytoin and oral contraceptives.

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The nurse is working on a neurosurgery unit. The patient calls the desk to complain that his arm is really burning and feels hot. The patient is receiving IV phenytoin for his grand mal seizures. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A 25 year-old female patient will begin taking phenytoin for epilepsy. The patient tells the nurse she is taking oral contraceptives (OCPs). Which response will the nurse give?

Correct Answer is B

Explanation

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