What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Bladder palpation.

Blood glucose monitoring.

Inspection of the mouth.

Auscultation of breath sounds.

Answer and Explanation

The Correct Answer is C

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

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Correct Answer is C

Explanation

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

A. Apply compression stockings before ambulation. B. Soak feet to soften nails before trimming. C. Keep legs dependent to promote blood flow. D. Medicate inflamed skin areas with an antibiotic ointment.

Correct Answer is A

Explanation

Choice A: Applying compression stockings before ambulation is a key aspect of self-care for a client with chronic venous insufficiency. Compression stockings help improve venous return and reduce edema.

Choice B: Soaking feet to soften nails before trimming is not a specific intervention for chronic venous insufficiency and should be done with caution in individuals with open ulcers.

Choice C: Keeping legs dependent to promote blood flow is not advisable in chronic venous insufficiency, as it can worsen venous pooling and edema.

Choice D: Medicating inflamed skin areas with an antibiotic ointment may be part of wound care but does not address the primary intervention of using compression stockings for chronic venous insufficiency.

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What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Correct Answer is C

Explanation

When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identifies bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide?

Correct Answer is A

Explanation

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