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One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 μmol/L). Which action by the health care provider does the nurse anticipate?
- A. Administer phenytoin as prescribed
- B. Decrease phenytoin daily dose
- C. Increase phenytoin daily dose
- D. Repeat serum phenytoin level in 2 hours
Correct Answer: B
Rationale: A phenytoin level of 32 mcg/mL is toxic (therapeutic range: 10-20 mcg/mL), so the dose should be decreased (B). Continuing (A) or increasing (C) the dose risks toxicity. Repeating the level (D) delays intervention.
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A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.
A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?
- A. The client has difficulty moving his right arm.
- B. The client did not notice a nurse who was standing on his left side.
- C. The client is having difficulty swallowing.
- D. The client is having difficulty speaking.
Correct Answer: B
Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.
An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?
- A. Increase the IV drip rate
- B. Place the client in a supine position
- C. Ask the client if this has happened before
- D. Raise the head of the bed
Correct Answer: D
Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.
A mother calls the pediatrician's office stating that her 15-month-old son received an MMR vaccination yesterday. Today, the site of the injection is red, warm, and puffy. What is the best action for the nurse to take?
- A. Report the symptoms to the physician as an adverse reaction
- B. Suggest the mother apply a warm compress every two hours
- C. Advise the mother to give her son baby aspirin
- D. Explain to the mother that this is an expected response
Correct Answer: D
Rationale: Mild redness, warmth, and swelling at the MMR injection site are expected reactions, resolving without intervention.