A female client who has a history of seizures went to a healthcare facility to ask the nurse regarding the use of birth control pills while on phenytoin therapy. The nurse correctly states to the client that:

Correct Answer: A

Rationale: Phenytoin is an antiepileptic medication that can induce hepatic enzymes, which can lead to a decrease in the effectiveness of hormonal contraceptives, including birth control pills. This interaction can increase the risk of unintended pregnancy. Therefore, it is important for the client to be advised about the decreased effectiveness of birth control pills while on phenytoin therapy and discuss alternative contraceptive options with her healthcare provider.

Correct Answer: C

Rationale: Albumin is a plasma protein that helps maintain the oncotic pressure in the blood vessels and prevents fluid from leaking out into the tissues. During an infusion of albumin, there is a risk of fluid volume overload, especially in patients with existing heart failure or kidney disease. The nurse must monitor the patient closely for signs and symptoms of fluid volume overload, such as edema, shortness of breath, crackles in the lungs, and increased blood pressure. Prompt recognition and management of fluid volume overload are essential to prevent complications such as pulmonary edema and worsening heart failure. Hypernatremia and fluid volume deficit are unlikely to occur during an albumin infusion, and a transfusion reaction is not associated with albumin administration.

Correct Answer: C

Rationale: When teaching a patient how to use sublingual nitroglycerin tablets, the nurse should include the instruction that if the chest pain is not relieved after one tablet, the patient should call 911 immediately. This is because persistent chest pain could indicate a more serious cardiac event, such as a myocardial infarction, that requires prompt medical attention. It is important for the patient to seek emergency help if the chest pain is not relieved after taking one sublingual nitroglycerin tablet. Taking multiple doses without relief of symptoms can be dangerous and delay appropriate medical intervention.

Correct Answer: D

Rationale: The patient is exhibiting signs of a transfusion reaction, specifically indicating the possibility of a febrile non-hemolytic transfusion reaction. Chills and back pain are common symptoms of this type of reaction. The nurse's priority action in this situation is to discontinue the blood transfusion immediately to prevent further complications and potential harm to the patient. It is crucial to notify the prescriber promptly so that appropriate interventions can be initiated. Observing for other symptoms and slowing the infusion rate are important actions but may not be the priority in this scenario where the patient is experiencing signs of a possible transfusion reaction. It is not appropriate to tell the patient that these symptoms are a normal reaction, as they indicate a potential complication that needs immediate attention.

Correct Answer: C

Rationale: One major side effect to monitor in a patient taking Lithium for bipolar I disorder is the risk of seizures. Lithium is known to lower the seizure threshold, increasing the likelihood of seizures occurring, especially if the patient has any pre-existing risk factors for seizures. Therefore, it is critical to closely monitor patients on Lithium for any signs or symptoms of seizures and promptly address them if they occur to prevent any complications. Monitoring lithium levels and maintaining them within the therapeutic range can also help reduce the risk of seizures.