A patient complains of vomiting, diarrhea, and insomnia. During the assessment, the patient begins having seizures. The nurse suspects theophylline toxicity. Which of the following actions would be the nurse's priority intervention?

Question

a. Obtain a stat theophylline level.
b. Call the prescriber.
c. Administer charcoal.
d. Protect the patient from injury and monitor the airway.

Answer 1

D
When a patient is having a seizure, regardless of the potential cause, the priority of care is patient safety, along with airway, breathing, and circulation (ABCs).
Although blood should be drawn for measurement of a stat theophylline level. it should not be done until the patient's condition has stabilized.
Although the prescriber should be called, that activity can be delegated to someone else while the nurse takes care of the emergency needs of the patient.
Although the symptoms of theophylline toxicity are present (nausea, vomiting, diarrhea, sei-zures), the diagnosis of theophylline toxicity has not been confirmed by serum values, therefore administering activated charcoal at this time would be premature.