Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?
A. Hold tube feeding 1 hour before and 2 hours after to avoid clumping.
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
B. Monitor the patient for lethargy and drowsiness as these may indicate a high drug level.
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
C. Inform the patient that they may experience increased and large amounts of urinary output.
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
D. Advise the patient to use an extra soft toothbrush to avoid gum bleeding.
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
Similar Questions
A nurse is attending to a client who has suffered a basal skull fracture.
During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.
What should be the nurse’s immediate action?
A. Inform the charge nurse.
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
B. Apply a dressing under the client’s nose.
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
C. Check the client’s temperature.
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
D. Test the drainage for glucose.
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
Full Explanation
Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.
Which symptom should the nurse address first?
A. Fatigue
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
B. Pain
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
C. Fever
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
D. Stridor
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
Full Explanation
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
A nurse is attending to a client experiencing hypovolemic shock.
What findings should the nurse anticipate?
A. Hypertension
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
B. Purpura
Purpura, or blood spots, are not typically associated with hypovolemic shock.
C. Bradypnea
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
D. Oliguria
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.
Full Explanation
Choice A rationale
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
Choice B rationale
Purpura, or blood spots, are not typically associated with hypovolemic shock.
Choice C rationale
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
Choice D rationale
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.