A patient with seizure activity is receiving intravenous Dilantin. Which of the following should the nurse do when caring for this patient?
1. turn and reposition every 2 hours
2. frequent monitoring of the injection site
3. assess deep tendon reflexes
4. keep blood glucose level within normal limits
2
Rationale: Nursing care for a patient with an acute onset of seizures in the acute care setting includes observing the injection site frequently during administration of Phenytoin to prevent infiltration. Additional interventions include monitoring vital signs, assess for respiratory depression, hypotension, arrhythmias, decreased level of consciousness, and signs and symptoms of an allergic reaction. Turning and repositioning every 2 hours, assessing deep tendon reflexes, and keeping the blood glucose level within normal limits are not indications associated with intravenous Dilantin.
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