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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 C

Explanation

A. Deferoxamine. Deferoxamine is a chelating agent used to treat iron overload or toxicity. It has no role in managing an acute allergic reaction or respiratory distress caused by nafcillin, a penicillin-type antibiotic.

B. Vitamin K. Vitamin K is used to reverse the effects of warfarin-induced anticoagulation and is not indicated for treating an allergic reaction. Anaphylaxis is not related to coagulation disturbances, making this an inappropriate intervention.

C. Epinephrine. Epinephrine is the first-line treatment for anaphylaxis, which can present with difficulty breathing, bronchospasm, and hypotension. It works by stimulating alpha- and beta-adrenergic receptors, leading to bronchodilation, increased cardiac output, and vasoconstriction to counteract severe allergic reactions. Immediate administration is necessary to prevent further airway compromise and circulatory collapse.

D. Prednisone. Prednisone is a corticosteroid used to reduce inflammation and prevent delayed allergic reactions. While it may be prescribed as part of long-term management, it does not provide the rapid bronchodilation and vasoconstriction needed for emergency treatment of anaphylaxis.

A. Tinnitus B. Abdominal cramping C. Stevens-Johnson syndrome D. Insomnia

Correct Answer is C

Explanation

A. Tinnitus. Nitrofurantoin is not commonly associated with ototoxicity or tinnitus. Medications such as aminoglycosides and loop diuretics are more likely to cause this adverse effect. While nitrofurantoin can have some neurological side effects, tinnitus is not a primary concern.

B. Abdominal cramping. Gastrointestinal side effects such as nausea and vomiting can occur with nitrofurantoin, especially if taken on an empty stomach. However, abdominal cramping is usually mild and not a serious adverse effect requiring discontinuation of the medication. Taking the drug with food can help reduce gastrointestinal discomfort.

C. Stevens-Johnson syndrome. Stevens-Johnson syndrome (SJS) is a rare but serious hypersensitivity reaction that can occur with nitrofurantoin use. It presents with flu-like symptoms, followed by a painful rash, blistering, and skin peeling. Immediate discontinuation and medical intervention are required if symptoms develop, as SJS can be life-threatening.

D. Insomnia. Nitrofurantoin does not commonly cause insomnia. Some medications, such as corticosteroids and stimulants, are more likely to interfere with sleep. Nitrofurantoin’s side effects primarily affect the gastrointestinal, pulmonary, and dermatologic systems rather than sleep patterns.

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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 reports difficulty breathing during the administration of an intermittent IV bolus of nafcillin. After stopping the infusion and notifying the provider, the nurse should anticipate a prescription for which of the following medications?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a new prescription for nitrofurantoin to treat a urinary tract infection. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?

A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?

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 reinforcing teaching with a client who has a new prescription for digoxin. Which of the following herbal supplements should the nurse include as a contraindication for this medication?

A nurse is collecting data from a client who reports nausea and has vomited clear emesis. Which of the following medications should the nurse administer?

A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?

A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?

A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?