A nurse is reviewing the medical record for a client who has a new prescription for phenytoin. Which of the following statements from the medical record should the nurse identify as a contraindication for the administration of phenytoin?

The client has a history of sinus bradycardia.

The client has a history of cholecystitis.

The client takes vitamin B12 supplements.

The client takes ibuprofen.

Answer and Explanation

The Correct Answer is A

Phenytoin is a hydantoin anticonvulsant that stabilizes neuronal membranes by delaying the influx of sodium ions during action potentials. It has a narrow therapeutic index and significant effects on cardiac conduction, specifically lengthening the refractory period. Due to its potential to depress myocardial automaticity, it is strictly avoided in patients with certain pre-existing conduction system abnormalities.

Rationale:

A. Sinus bradycardia is a major contraindication for phenytoin because the drug can further depress cardiac conduction and automaticity. Phenytoin possesses class IB antiarrhythmic properties, which can lead to severe cardiovascular collapse or heart block in patients with slow heart rates. Administering this drug to a bradycardic patient poses a life-threatening risk of asystole.

B. A history of cholecystitis, or inflammation of the gallbladder, does not contraindicate the use of phenytoin for seizure management. While phenytoin is metabolized by the liver, it does not have a direct impact on gallbladder function or the formation of gallstones. The nurse would prioritize monitoring liver enzymes rather than focusing on a history of cholecystitis.

C. Taking vitamin B12 supplements does not prevent a patient from receiving phenytoin, as there is no dangerous interaction between the two. Interestingly, long-term phenytoin use is actually associated with folate deficiency rather than issues with B12. Supplements are generally safe and may be necessary for patients with concurrent nutritional deficiencies during anticonvulsant therapy.

D. Ibuprofen is a non-steroidal anti-inflammatory drug that does not have a documented clinical contraindication with the administration of phenytoin. While phenytoin has many drug-drug interactions involving the cytochrome P450 system, ibuprofen is not typically one that causes toxicity. The nurse can safely administer both medications as long as standard monitoring is performed.

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Correct Answer is C

Explanation

Phenytoin is a potent antiepilepticthat requires extreme caution during intravenous administration due to its high alkalinity and potential for precipitation. It is incompatible with most intravenous solutions and must be delivered through a large-bore catheter to prevent extravasationand tissue necrosis. Close cardiovascular monitoring is mandatory during infusion to detect potential arrhythmias or severe hypotension.

Rationale:

A.Injecting sterile water after administration is not the standard protocol; instead, the line must be flushed with 0.9% sodium chloride. Phenytoin is highly unstable and will precipitate if it comes into contact with many other fluids. Using 0.9% sodium chloride ensures the vein is cleared of the medication without causing the formation of dangerous micro-crystals in the IV tubing.

B.Administering phenytoin with 5% dextrose in water (D5W) is strictly contraindicated because the medication will immediately precipitate into a solid form. Phenytoin is only compatible with 0.9% sodium chloride, and any contact with glucose-containing solutions leads to crystallization. Such precipitates can cause emboli or severe vein irritation, compromising the safety of the intravenous access site.

C.Discarding the medication if it appears cloudy is a critical safety action because cloudiness indicates that the phenytoin has precipitated. Intravenous phenytoin should be a clear, colorless solution; any presence of crystals or opaqueness means the drug is no longer safe for infusion. Injecting a precipitated solution can cause catastrophic vascular damage or pulmonary embolism in the client.

D.Administering the medication at a rate of 100 mg/min is dangerously fast and exceeds the maximum recommended safety limit. To prevent severe hypotension and cardiac arrhythmias, the infusion rate must not exceed 50 mg/min for adults. Rapid administration can lead to cardiovascular collapse, making slow, controlled delivery and continuous heart rate monitoring an essential nursing priority.

A. Pedal edema B. Dry cough C. Fever D. Hyperglycemia

Correct Answer is C

Explanation

Amphotericin B is a potent polyene antifungalused for systemic mycoses, known for its significant toxicity. It frequently causes an acute infusion-related reactiondue to the release of pro-inflammatory cytokinessuch as TNF-alpha and interleukin-1 during the intravenous administration process.

Rationale:

A.Pedal edema is not typically a sign of an acute infusion reaction; rather, it may indicate renal impairment or fluid volume overload. While amphotericin B is notoriously nephrotoxic, which can eventually lead to fluid retention, this is a chronic complication rather than an immediate reaction. Acute reactions are characterized by systemic inflammatory signs occurring within 1 to 3 hours.

B.A dry cough is not a classic manifestation of an acute infusion reaction to amphotericin B. Respiratory symptoms like dyspnea or tachypnea can occur in severe cases, but they are usually accompanied by more prominent signs of inflammation. A dry cough would more likely be associated with other drug classes, such as ACE inhibitors or pulmonary complications.

C.Fever is a hallmark sign of an acute amphotericin B infusion reaction, often accompanied by chills, rigors, and headache. This occurs as the drug triggers a systemic inflammatory response shortly after the infusion begins. Nurses often pre-medicate clients with antipyretics and antihistamines to mitigate these distressing symptoms, which are sometimes colloquially referred to as "shake and bake."

D.Hyperglycemia is not an expected adverse effect of amphotericin B therapy. The drug primarily impacts renal function and electrolyte balance, specifically causing hypokalemia and hypomagnesemia. Glucose metabolism is not typically altered by polyene antifungals. If hyperglycemia occurs, the nurse should investigate other factors such as the client's intravenous maintenance fluids or underlying diabetic status.

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A nurse is reviewing the medical record for a client who has a new prescription for phenytoin. Which of the following statements from the medical record should the nurse identify as a contraindication for the administration of phenytoin?

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