The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?
A) Check for blood return and compatibility prior to administration.
B) Use a new IV tubing set each time the medication is administered.
C) Document the date, time, and nurse's initials after each dose is administered.
D) Use sterile gloves when drawing up and administering the medication.

Question

Quizplus · Accepted Answer

Phenytoin (Dilantin) can cause significant irritation to blood vessels and tissues when administered via IV. For this reason, the nurse must ensure that the IV catheter is located correctly in the vein by checking for a blood return prior to administration. Dilantin may not be given with IV fluids that contain dextrose as precipitation and crystallization, so the nurse must also check compatibility with the patient's prescribed IV fluids.

The Nurse Is Caring for a Patient Who Is to Receive