Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?
A. "You can safely take this medication if you become pregnant."
Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.
B. "You should expect to have blood work every 6 months while taking this medication."
Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary.The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.
C. "You might experience swollen gums while taking this medication."
Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.
D. “You can skip a dose of this medication if you are nauseated."
Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.
Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.
Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.
Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.
Similar Questions
A nurse is caring for a 2-year-old child who has Clostridium difficile.
Which of the following actions should the nurse take?
A. Use an N95 respirator.
Is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.
B. Instruct the parents to avoid bringing fresh flowers into the room.
Is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.
C. Initiate contact precautions.
Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.
D. Place the child in a room that has a HEPA filtration system.
Is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.
Full Explanation
Explanation
C. Initiate contact precautions
Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.
The other options are not necessary or specific to the care of a child with Clostridium difficile:
Using an N95 respirator in (option A) is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.
Instructing the parents to avoid bringing fresh flowers into the room in (option)is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.
Placing the child in a room with a HEPA filtration system in (option D) is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.
A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?
A. Locks the wheels on the client's bed
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
B. Clears furniture from the path leading to the bathroom
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
C. Assists the client to the bathroom every 2 hr
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently. It's important to promote mobility and independence for the client while ensuring their safety.
D. Raises all four side-rails on the client's bed
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Full Explanation
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.
It's important to promote mobility and independence for the client while ensuring their safety.
A nurse is reviewing laboratory findings for three clients.
Which of the following laboratory results should the nurse expect for a client who has cirrhosis?
A. Elevated amylase
It is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.
B. Decreased bilirubin
They are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.
C. Elevated lipase
It is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.
D. Elevated ammonia
Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.
Full Explanation
Explanation
D, Elevated ammonia
Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.
Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.
Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.
Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.