The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?

Correct Answer: C

Rationale: Phenytoin (Dilantin) is known to be incompatible with dextrose solutions (such as dextrose 5% or dextrose 5% and half-normal saline). Therefore, the nurse would plan to use normal saline solution to dilute phenytoin in order to ensure medication effectiveness and prevent any potential adverse reactions. Lactated Ringer's solution is not commonly used for diluting phenytoin as normal saline solution is the preferred choice due to compatibility considerations.

Correct Answer: C

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.

Correct Answer: B

Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children. Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.

Correct Answer: D

Rationale: Nurse Cheryl should include in her teaching plan for Reggie's parents to avoid contact with people who have upper respiratory tract infections. Otitis media is often caused by upper respiratory infections, and exposure to individuals with such infections can increase the risk of exacerbating Reggie's condition or causing recurrent infections. Implementing measures to minimize exposure can help prevent further complications and promote faster recovery for Reggie. Placing the child in the supine position to bottle-feed may increase the likelihood of fluid entering the middle ear, worsening the otitis media. Giving amoxicillin on an empty stomach is not recommended as it can cause gastrointestinal upset and reduce absorption; instead, it should be given with food to enhance efficacy. Cleaning the inside of the ear canals with cotton swabs can be harmful and may cause damage or introduce infection, making it an inappropriate practice in managing otitis media.

Correct Answer: B

Rationale: Antibodies, also known as immunoglobulins, are proteins produced by the immune system in response to the presence of pathogens like bacteria, viruses, and other foreign substances. These proteins are specifically designed to recognize and bind to antigens, which are molecules that the immune system identifies as foreign or harmful. Antibodies play a crucial role in the immune response by marking pathogens for destruction by other immune cells and signaling the immune system to attack the invaders. Therefore, antibodies are primarily made up of proteins.