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A nurse in a clinic is caring for a client.

Click to highlight the findings that require immediate follow-up as contraindications to the prescribed prescription. To deselect a finding click on the finding again.

Body System

Findings

Vital Signs/General History

Temperature 36.4° C (97.6° F), oral

Heart rate 75/min

Respiratory rate 16/min

Blood pressure 100/74mm Hg

Oxygen saturation 99% on room air

Client is a vegetarian and takes a multivitamin daily

Client reports having three to four alcoholic beverages a couple times per week

Integumentary

Skin color is consistent with genetic background. No rashes or lesions. The client varicose veins.

Cardiovascular/ Respiratory

S1 S2 auscultated. No murmurs. All peripheral pulses 2+ Lung sounds clear bilaterally

Gastrointestinal/Genitourinary

Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odourless. Last menstrual period was 3 months ago

Neurologic/Musculoskeletal

Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities

Client is a vegetarian and takes a multivitamin daily

Client reports having three to four alcoholic beverages a couple times per week

Last menstrual period was 3 months ago

Client takes diazepam as needed for anxiety

Temperature 36.4° C (97.6° F)

Respiratory rate 16/min

Blood pressure 100/74mm Hg

Oxygen saturation 99% on room air

S1 S2 auscultated

Client has full range of motion and is able to maintain flexion against resistance in all four extremities

Last bowel movement was 3 days ago.

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Client reports having three to four alcoholic beverages a couple times per week. Phenytoin metabolism is significantly affected by alcohol consumption. Chronic alcohol use increases phenytoin clearance, leading to subtherapeutic drug levels and seizure breakthrough. Conversely, acute alcohol intake inhibits phenytoin metabolism, increasing the risk of toxicity. The client should be counseled to avoid alcohol while on phenytoin therapy.
Client takes diazepam as needed for anxiety. Diazepam is a CNS depressant that interacts with phenytoin, increasing sedation and the risk of respiratory depression. Both medications can cause drowsiness, dizziness, and impaired coordination, raising the risk of falls and injury. The provider should assess whether diazepam should be discontinued or adjusted when initiating phenytoin therapy.
Last menstrual period was 3 months ago. Phenytoin is Pregnancy Category D, meaning it poses a significant teratogenic risk, including fetal hydantoin syndrome. The missed menstrual period suggests a possible pregnancy, which must be evaluated before starting phenytoin. A pregnancy test should be performed, and alternative antiseizure medications may need to be considered if pregnancy is confirmed.
Client is a vegetarian and takes a multivitamin daily. Phenytoin interferes with the absorption of folic acid and vitamin D, both of which are crucial for bone health and red blood cell production. Vegetarians are already at higher risk for folate and vitamin B12 deficiency, making supplementation essential. However, multivitamins containing calcium, magnesium, or iron can decrease phenytoin absorption, reducing its effectiveness. The provider should review the multivitamin’s composition and adjust dosing schedules to prevent interactions.
Temperature 36.4°C (97.6°F), oral. The client’s temperature is within normal range and does not indicate infection or systemic concerns that would affect phenytoin therapy.
Heart rate 75/min, Respiratory rate 16/min, Blood pressure 100/74 mm Hg, Oxygen saturation 99% on room air.
All vital signs are stable and do not indicate hemodynamic instability, respiratory depression, or cardiovascular issues that would contraindicate phenytoin administration.
Skin color is consistent with genetic background. No rashes or lesions. The client has varicose veins. There are no signs of drug hypersensitivity reactions or dermatologic conditions that would require stopping phenytoin therapy.
S1 S2 auscultated. No murmurs. All peripheral pulses 2+. Lung sounds clear bilaterally.
There are no cardiopulmonary concerns that would indicate contraindications to phenytoin.
Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odorless. Mild constipation is noted, but this is not a contraindication for phenytoin. The client should be encouraged to increase fiber and fluid intake to prevent worsening constipation, which can sometimes be a side effect of phenytoin.
Alert and oriented to person, place, and time. Client has full range of motion and is able to maintain flexion against resistance in all four extremities. There are no neurological deficits requiring immediate intervention, and the client's baseline mental status is intact.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Fluconazole. Fluconazole is an antifungal medication used to treat fungal infections, such as candidiasis. It is not related to penicillin and does not pose a risk for cross-reactivity in clients with a penicillin allergy. It can be safely administered in this scenario.

B. Tetracycline. Tetracycline is a broad-spectrum antibiotic used to treat bacterial infections, including acne and respiratory infections. It belongs to a different antibiotic class than penicillins and cephalosporins, meaning it does not pose a risk of cross-reactivity in clients with a penicillin allergy.

C. Acyclovir. Acyclovir is an antiviral medication used to treat viral infections, such as herpes simplex and varicella-zoster. Since it does not belong to the beta-lactam antibiotic class, it is not contraindicated for clients with a penicillin allergy.

D. Cephalexin. Cephalexin is a first-generation cephalosporin, which shares a similar beta-lactam ring structure with penicillins. Clients with a history of an anaphylactic reaction to penicillin are at increased risk of cross-reactivity with cephalosporins, particularly first-generation ones like cephalexin. Due to the severity of the client’s allergic reaction, cephalexin should be avoided, and an alternative non-beta-lactam antibiotic should be considered.

A. "Instruct the client's visitors not to operate the PCA pump.” B. "Check the client's pain level every 8 hours." C. "Diarrhea is an adverse effect of morphine PCA.” D. "Using morphine PCA increases the client's risk of toxicity."

Correct Answer is A

Explanation

A. "Instruct the client's visitors not to operate the PCA pump.” Only the client should press the PCA button to self-administer medication. Allowing visitors or family members to press the button ("PCA by proxy") increases the risk of over-sedation, respiratory depression, and opioid toxicity. The nurse should reinforce to visitors that only the client should control medication delivery based on their own pain level.

B. "Check the client's pain level every 8 hours." Pain assessment should be performed more frequently than every 8 hours when a client is receiving morphine PCA. Pain, sedation level, and respiratory status should be monitored every 1–2 hours initially and then at regular intervals as determined by hospital protocol to ensure effective pain management and prevent complications such as respiratory depression.

C. "Diarrhea is an adverse effect of morphine PCA." Morphine is an opioid analgesic that commonly causes constipation, not diarrhea. Opioids slow gastric motility, which can lead to delayed bowel movements, bloating, and discomfort. Clients on long-term opioid therapy often require stool softeners or laxatives to prevent opioid-induced constipation.

D. "Using morphine PCA increases the client's risk of toxicity." PCA pumps are designed with preset dose limits and lockout intervals to prevent overdose. While there is a risk of opioid toxicity if the system is misused (e.g., PCA by proxy or improper settings), PCA is actually safer than traditional opioid administration methods because it allows for precise dosing and patient-controlled pain management. Proper monitoring helps prevent complications.

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Body System	Findings
Vital Signs/General History	Temperature 36.4° C (97.6° F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74mm Hg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client varicose veins.
Cardiovascular/ Respiratory	S1 S2 auscultated. No murmurs. All peripheral pulses 2+ Lung sounds clear bilaterally
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odourless. Last menstrual period was 3 months ago
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cellulitis and is to begin antibiotic therapy. The client has a history of anaphylactic reaction to penicillin. Which of the following medications is contraindicated for this client?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving tobramycin. The nurse should monitor the client for which of the following adverse effects?

A nurse is monitoring a client's response to receiving glipizide instead of guaifenesin. Which of the following actions should the nurse take?

A nurse is preparing to insert a miconazole vaginal suppository for a client who has vulvovaginal candidiasis. Which of the following actions is appropriate for inserting this medication?

A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?

A nurse is caring for a client who is receiving heparin therapy. If the client requires a reversal of the effects of heparin, which of the following medications should the nurse expect the provider to prescribe?

A nurse is planning care for a client who has angina and a new prescription for nitroglycerin ointment. Which of the following actions should the nurse plan to take?

A nurse is reviewing a list of current medications for a client who is starting therapy with furosemide. Which of the following medications should the nurse identify as being contraindicated?