The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse?
a. Blood pressure (BP) 138/92
b. Frequent hiccups
c. Irregular apical pulse
d. Nausea and vomiting
C
IV phenytoin can cause cardiac arrhythmias and hypotension, especially if given faster than 50 mg/min.
You might also like to view...
A child is diagnosed with attention-deficit/hyperactivity disorder (ADHD). The prescriber orders a central nervous system stimulant. Which statement by the child's parent indicates a need for further teaching?
a. "I should report insomnia and poor appe-tite to his provider." b. "I will make sure he takes his medication after breakfast every day." c. "This drug will make him less impulsive while he's at school." d. "This medication will help my child focus so he can learn new behaviors."
An Apgar score of _______ is considered normal for a newborn
a. 8–10 b. 6–10 c. 4–7 d. 0–3
The nurse is caring for a client with acute pain and uses the FLACC pain assessment. Which clinical scenario does the nurse recognize as least appropriate for use of the FLACC pain assessment?
A. Situations where clients self-report pain. B. Situations requiring rapid pain assessment. C. Clients who are asleep. D. Clients who are children.
Match the options with the patient situation that best represents it. (Each option can be used once, more than once, or not at all.)
a. Fluid volume deficit b. Fluid volume deficit with risk for metabolic acidosis c. Fluid volume deficit with risk for metabolic alkalosis d. Fluid volume excess 1. Patient experiencing diarrhea for 2 days 2. Patient with congestive heart failure (CHF) with generalized edema 3. Patient refusing oral fluids for 24 hours 4. Patient vomiting for 2 days