The client has been started on phenytoin. He reports experiencing reddish-colored urine. What is the nurse's highest priority intervention?
a. Report this symptom to the physician; this is an adverse reaction.
b. Instruct the client to stop the medication; this is a life-threatening reaction.
c. Report this symptom to the physician; this indicates toxicity of the medication.
d. Instruct the client that this is an expected side effect of the medication.
ANS: D
Phenytoin will cause reddish-brown colored urine.
You might also like to view...
You are caring for a patient with AIDS, and the patient wants to visit with a friend of his, another patient, who you know has an active case of the flu. What are the implications?
What will be an ideal response?
A patient calls from home because of a concern about the appearance of a vial of insulin lispro. The patient reports that the solution appears cloudy. What would be the nurse's best response?
1. "Agitate the solution, and the granules should disperse." 2. "Discard the vial. The solution should be clear." 3. "Proceed with the injection. Drawing the solution into the syringe will mix the particles." 4. "Lispro is always cloudy. Proceed with the injection."
The nurse working in the role of educator with groups of clients may
a. Care for clients in acute care settings. b. Coordinate activities with staff members in community settings. c. Use learning principles to increase understanding about mental illness. d. Act as an advocate for mental health support groups.
You are asked to assist the patient into the Trendelenburg position. You know that this means
A) the patient will be having a Pap smear. B) the patient's head must be lower than the rest of his body. C) this position improves circulation to the extremities. D) the patient should lie on the left side with knees flexed.