hard · NCLEX-RN pharmacology
The nurse identifies cues indicating immediate adverse reactions to the phenytoin therapy. Which findings require urgent nursing intervention? Select all that apply. Apply the response specifically to this case: intravenous phenytoin therapy complicated by hypotension, dysrhythmia, purple-glove injury, protein binding, and fosphenytoin conversion.
- Sinus bradycardia
- Hypotension
- QRS duration of 0.14 seconds
- Mottled purple skin discoloration distal to the IV site
- Post-ictal state (GCS 14 at 08:00)
- Baseline total phenytoin level < 2.0 mcg/mL
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