A nurse is caring for a client with seizure disorders who is admitted to the health care facility. The client is prescribed phenytoin. During therapy, which of the following would be most important for the nurse to include in the ongoing assessment?
A) Check the client's temperature every 3 to 4 hours.
B) Obtain serum plasma drug levels regularly.
C) Assess the client's respiratory rate.
D) Evaluate the client's pulse rate and rhythm.
Ans: B
Feedback:
Although vital signs such as temperature, pulse rate and rhythm, and respiratory rate are commonly assessed routinely, it would be most important for the nurse to obtain serum plasma drug levels to evaluate the effectiveness of the therapy and also to prevent possible toxicity. Unless the client's vital signs are not within normal parameters, the nurse would monitor them based on the facility's policy.
You might also like to view...
The nurse is conducting an assessment of a 65-year-old client who has come for an annual assessment. For which reasons should the nurse anticipate providing immunizations to the client? (Select all that apply.)
1. Promoting client health 2. Caring for the client's illness 3. Maintaining the client's health 4. Alleviating the client's suffering 5. Caring for the client's family
The nurse is assessing the patient with schizophrenia. Which will the nurse recognize as negative symptoms associated with the disorder? Select all that apply
1. The patient is withdrawn. 2. The patient has a blunted affect. 3. The patient reports auditory hallucinations. 4. The patient reports lack of motivation. 5. The patient introduces himself as Pope Francis.
A client in her first trimester of pregnancy presents with the complaint of persistent nausea throughout the day. The nurse suggests which intervention to best deal with this problem?
1. Eat large meals frequently throughout the day. 2. Consume noncarbonated beverages. 3. Increase foods with a high fat content. 4. Eat dry toast and crackers before getting out of bed.
Hypertonic dehydration occurs in which of the following conditions?
a. the vascular space loses fluid and particles in equal proportions b. with vomiting and diarrhea or in severe blood loss c. then the vascular space loses more fluid than particles d. then the vascular space loses a greater portion of particles than fluid