Question

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?

Answer 1

Correct Answers:

Administer a saline solution after injection.

Rationale :

🔹Phenytoin IV must be administered slowly (no faster than 50 mg/min in adults) and should not be mixed with dextrose due to precipitation risk. 🔹After IV administration, flushing the line with normal saline ensures no residual drug remains in the tubing, reducing the risk of local irritation or crystallization.

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Answer 2

Correct Answers:

Liver function tests must be monitored.

Rationale :

🔹Valproate (divalproex sodium) can cause hepatotoxicity, especially in the first 6 months of therapy. 🔹 Liver function tests (LFTs) are essential before and during treatment. 🔹This helps detect early signs of liver damage and prevent complications.

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Answer 3

Correct Answers:

"I'll take this medicine first thing in the morning

Rationale :

🔹 Fluoxetine, an SSRI, can cause CNS stimulation (e.g., insomnia), so it’s best taken in the morning to minimize sleep disturbances. 🔹Food is not required for absorption, and grapefruit juice is not contraindicated with fluoxetine.

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Answer 4

Correct Answers:

Pull the skin 1.3 cm (1/2 inch) to the side.

Rationale :

🔹The Z-track technique involves displacing the skin laterally by 1 to 1.5 inches to seal the medication deep in the muscle, preventing leakage into subcutaneous tissue and reducing irritation.

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Answer 5

Correct Answers:

Administer the morning dose of lithium.

Rationale :

🔹A lithium level of 1.0 mEq/L is within the therapeutic range (0.6–1.2 mEq/L). 🔹There is no indication of toxicity, so the dose should be administered as scheduled.

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Answer 6

Correct Answers:

Pharmacists
Published journals
Physicians’
Desk Reference

Rationale :

🔹Reliable references include pharmacists, the PDR, and peer-reviewed journals. 🔹 Pharmaceutical sales reps are not considered an evidence-based source due to potential bias.

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Answer 7

Correct Answers:

"He has so many new bruises on his body:

Rationale :

🔹Carbamazepine can cause bone marrow suppression, including thrombocytopenia, increasing the risk of bleeding. 🔹New bruises suggest this adverse effect and require immediate evaluation.

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Answer 8

Correct Answers:

Diazepam

Rationale :

🔹Benzodiazepines like diazepam are the first-line treatment for alcohol withdrawal to prevent seizures and manage agitation. 🔹Disulfiram, methadone, and buprenorphine are for long-term treatment, not acute withdrawal.

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Answer 9

Correct Answers:

Discard the medication.

Rationale :

🔹Medications past their expiration date should never be administered due to potential changes in effectiveness or safety. 🔹 Discarding ensures patient safety.

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Answer 10

Correct Answers:

Position the client in left lateral Trendelenburg.

Rationale :

🔹These symptoms suggest an air embolism—a risk with central lines. 🔹Positioning the client in the left lateral Trendelenburg traps air in the right atrium and prevents it from entering pulmonary circulation.

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QLexNursing

1 : 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?

2 : A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

3 : A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching?

4 : A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following is an appropriate action during this procedure?

5 : A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1 .O mEq/L. Which of the following actions should the nurse take?

6 : A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply.)

7 : A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client’s parent is the nurse's priority?

8 : A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which of the following medications should the nurse plan to administer?

9 : The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take?

10 : A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?