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Question 1 of 5

A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?

Correct Answer: B

Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention

Question 2 of 5

A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:

Correct Answer: A

Rationale: Lying prone with feet hanging over the mattress edge promotes knee extension, helping to prevent or reduce flexion contractures in rheumatoid arthritis.

Question 3 of 5

Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.

Order the Items

Source Container

Ask the client to open and close the hand until the skin blanches.
Palpate the ulnar and radial pulses and apply pressure to both arteries.
Observe the hand for color.
Release the ulnar artery while maintaining pressure on the radial artery.

Correct Answer: A,B,D,C

Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.

Question 4 of 5

A infant weighs 7 pounds at birth. The expected weight by 1 year should be:

Correct Answer: D

Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.

Question 5 of 5

A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?

Correct Answer: B

Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention

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