An adult client who recently experienced status epilepticus is prescribed intravenous phenytoin. When administering this medication, which of the following safety interventions must the nurse implement? Select all that apply.
- Ensure the administration rate does not exceed 50 mg/min.Answer
- Flush the intravenous line with 0.9% sodium chloride before and after the dose.Answer
- CPrepare the medication as a secondary infusion mixed with 5% dextrose in water (D5W).
- Assess the client's blood pressure and electrocardiogram continuously during the infusion.Answer
- EDelegate the task of monitoring the client's vital signs during the infusion to unlicensed assistive personnel (UAP).
- Observe the intravenous insertion site closely for signs of infiltration or tissue necrosis.Answer
Answer
The nurse must ensure the administration rate does not exceed 50 mg/min, flush the IV line with 0.9% sodium chloride before and after the dose, continuously assess the client's blood pressure and ECG, and closely observe the IV insertion site for infiltration.
Intravenous phenytoin requires strict safety protocols due to its alkaline nature and cardiovascular effects. It must be administered at a maximum rate of 50 mg/min and flushed or mixed exclusively with 0.9% sodium chloride to prevent precipitation. Continuous ECG and blood pressure monitoring are essential to detect arrhythmias and hypotension. Additionally, because it is a vesicant, the IV site must be monitored for extravasation to prevent severe tissue necrosis.
Step-by-Step Solution
Key Concept
Intravenous Phenytoin Administration Safety