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The nurse is caring for a client with epilepsy who is to receive phenytoin sodium (Dilantin) 100mg IV push. The client has an IV of D51/2NS infusing at 100mL/hr. When administering the Dilantin, which is the appropriate initial nursing action?

Obtain an ambu bag and put it at bedside.
Insert a 16g IV catheter.
Flush the IV line with normal saline.
remedicate with promethiazine (phenergan) IV push.

1 Answer

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Final answer:

The appropriate nursing action when administering phenytoin sodium IV push is to flush the IV line with normal saline to avoid precipitation. In other treatments like correcting hypokalemia with KCl, an aide would prepare the IV solution by diluting a stock solution, not by taking pre-made bags. For dehydration, IV fluids tailored to the patient's needs are given.

Step-by-step explanation:

When administering phenytoin sodium (Dilantin) intravenously to a client with epilepsy, it is critical to ensure that the medication is delivered safely and correctly. The appropriate initial nursing action is to flush the IV line with normal saline before administering the medication. This step is essential because it helps to ensure that the phenytoin does not precipitate, which can occur when it mixes with dextrose-containing solutions such as D51/2NS. By flushing the line with normal saline, the nurse ensures that the vein is cleared of any potential incompatible solutions. Once the line is flushed, the nurse can then administer the phenytoin sodium IV push safely.

For patients in an emergency scenario where medications or rehydration is required, such as the administration of 0.5% KCl for hypokalemia, an aide would typically not simply grab a pre-made IV bag from a supply cabinet. Instead, they would need to prepare the proper dilution by mixing a stock solution of KCl with a sterile solution using specific calculations to achieve the desired concentration.

In a scenario where a patient is dehydrated, the healthcare provider will usually administer an IV fluid such as normal saline or a balanced electrolyte solution to rehydrate the patient. The choice of fluid and the rate of administration are tailored to the patient's specific needs.

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