The physician has ordered intravenous phenytoin (Dilantin). The ...

[dollx]

The physician has ordered intravenous phenytoin (Dilantin). The patient is also receiving 5 dextrose in water (D5W) intravenously (IV). What will the nurse plan to do before administering this medication?
 
  1. Use a large vein for the infusion.
  2. Use an intravenous (IV) line with a filter.
  3. Flush the intravenous (IV) line with saline.
  4. Monitor the patient for hypertension.
  5. Monitor the patient for Stevens-Johnson Syndrome.

Question 2

The physician has ordered intravenous (IV) diazepam (Valium) for the patient in status epilepticus. During administration, which assessment by the nurse is most important?
 
  1. Assessing respirations every 5 to 15 minutes
  2. Assessing level of consciousness
  3. Assessing pulse for bradycardia
  4. Assessing blood pressure for hypertension

[carolinefletcherr]

Answer to Question 1

Correct Answer: 1,2,3
Rationale: Intravenous lines of 5 dextrose in water (D5W) must be flushed with saline, as traces of dextrose can cause microscopic precipitate formations that become emboli, if infused. An intravenous filter will trap any precipitate that occurs. Phenytoin (Dilantin) is a soft-tissue irritant that will cause local tissue damage if extravasation occurs, so a large vein must be used for infusion. Patients receiving phenytoin (Dilantin) are at risk for hypotension, not hypertension. Stevens-Johnson syndrome is a side effect of phenytoin (Dilantin), but it takes days to occur.

Answer to Question 2

Correct Answer: 1
Rationale: Respiratory depression is common when diazepam is given intravenously (IV). Respiratory assessment is the priority. Although hypotension is an effect of intravenous diazepam (Valium), it is not the top priority. Although tachycardia is an effect of intravenous diazepam (Valium), it is not the top priority. Assessing respirations is a higher priority than assessing the level of consciousness.

[dollx]

Thanks

[carolinefletcherr]

Welcome