The nurse has orders to administer phenytoin (Dilantin) 100 mg IV as an anticoagulant. The priority action wh… - AIIMS Delhi NO - 2018

AIIMS Delhi NO - 2018

Medical & Surgical Nursing

Medium

Appeared in: AIIMS Delhi NO - 2018

Explanation

The question asks for the priority action when administering IV phenytoin.
Phenytoin is a vesicant, meaning it can cause severe tissue damage if it infiltrates into the surrounding tissue.
This complication, known as extravasation, can lead to tissue necrosis and 'purple glove syndrome'.
Therefore, the highest priority for patient safety is to continuously monitor the IV site for signs of infiltration, such as pain, swelling, or redness.
It is also critical to note that phenytoin is an anticonvulsant, not an anticoagulant as stated in the question.

Option A: Administering the drug immediately is unsafe. IV phenytoin must be given slowly (not exceeding 50 mg/min in adults) to prevent cardiovascular side effects like hypotension and arrhythmias, in addition to the risk of infiltration.
Option C: Assessing for the drug's effects (e.g., seizure control, side effects like nystagmus or ataxia) is an important nursing responsibility, but it is not the most immediate priority during the infusion itself. Preventing iatrogenic tissue injury from infiltration takes precedence.
Option D: While assessing for signs of overdose or toxicity is important, pupil dilation is not a primary or reliable sign of phenytoin toxicity. Nystagmus (involuntary eye movement), ataxia (unsteady gait), and confusion are more common signs. Preventing infiltration is a more immediate, infusion-related priority.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing action during intravenous administration of Phenytoin (Dilantin) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
A nurse's primary responsibility during IV medication administration is to ensure patient safety, which includes preventing complications like infiltration.
Knowing the properties of medications (e.g., vesicant, irritant) is crucial for safe practice. Always check drug administration guidelines before giving an unfamiliar IV medication.
What if? If the patient reports burning pain at the IV site during the phenytoin infusion, the nurse's first and most critical action is to immediately stop the infusion. Do not wait to finish the dose or simply slow the rate. Stop, assess, and then notify the provider.

How to Approach the Question

First, identify the core question: It asks for the 'priority action' during the administration of a specific drug (IV Phenytoin).
Recognize the significant error in the stem (phenytoin is an anticonvulsant, not an anticoagulant), but don't let it distract from the main point about administration priorities.
Recall the key safety risks associated with IV phenytoin. The most immediate and severe risk during infusion is its vesicant nature, which can cause tissue damage.
Evaluate the options based on the principle of immediate patient safety. Preventing physical harm from the infusion process (infiltration) is a higher priority than assessing the drug's systemic effects or signs of toxicity.
Select the option that directly addresses the most immediate, potentially harmful complication of the administration procedure itself.

Concept Tested & Keywords

Concept Tested: Priority nursing action during intravenous administration of Phenytoin (Dilantin).
Stem keywords: phenytoin, Dilantin, IV, priority action
Lead-in keywords: priority action
Clinical cues: IV administration of a vesicant drug.
Clinical cues: Question incorrectly identifies phenytoin as an anticoagulant; it is an anticonvulsant.

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E6 Pharmacology Nursing Lilley 11e Part 1 pp. 241-243, 247-249, 242-244