Adverse effects, interactions and contraindications

42 NCLEX-RN practice questions on Adverse effects, interactions and contraindications, part of Pharmacological and Parenteral Therapies. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium · Select all that apply

   A client with advanced dementia cannot rate pain after a hip fracture repair. Which findings suggest that the client is in pain?

   1. AGrimacing during repositioning
   2. BGuarding the operative hip
   3. CRelaxed face while resting quietly
   4. DNoisy, laboured breathing at rest
   5. EStriking out during care
   6. FMoaning when the leg is moved

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   Answer: A, B, D, E, F

   Recognise cues (CJMM): clients who cannot self-report need a behavioural tool such as PAINAD (breathing, vocalisation, facial expression, body language, consolability). Absence of complaints never means absence of pain; treat and reassess with the same tool.

   • C: A relaxed face at rest does not indicate pain.

2. Question 2 · Hard · Matrix

   A client has been stable on warfarin for a year. For each newly started product, indicate the expected effect on the INR.

   For each row, choose: Increases INR / Decreases INR

   1. Rifampin
   2. Amiodarone
   3. Fluconazole
   4. A large daily kale smoothie
   5. St John's wort
   6. Trimethoprim-sulfamethoxazole

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   Answer:

   • Rifampin: Decreases INR
   • Amiodarone: Increases INR
   • Fluconazole: Increases INR
   • A large daily kale smoothie: Decreases INR
   • St John's wort: Decreases INR
   • Trimethoprim-sulfamethoxazole: Increases INR

   Analyse cues (CJMM): enzyme inhibitors (amiodarone, azoles, TMP-SMX, metronidazole) raise the INR and bleeding risk, while enzyme inducers (rifampin, carbamazepine, St John's wort) and extra vitamin K lower it and risk clotting. Any new drug calls for closer INR checks.

   • Rifampin: Rifampin induces liver enzymes and speeds warfarin breakdown.
   • Amiodarone: Amiodarone inhibits warfarin metabolism; the warfarin dose usually needs lowering.
   • Fluconazole: Azole antifungals inhibit warfarin metabolism.
   • A large daily kale smoothie: A sudden rise in vitamin K intake opposes warfarin.
   • St John's wort: This herb induces enzymes and lowers warfarin's effect.
   • Trimethoprim-sulfamethoxazole: It inhibits CYP2C9 and sharply raises the INR.

3. Question 3 · Medium · Matrix

   A client has taken lithium for bipolar disorder for several years with stable levels. For each change, indicate whether it increases the risk of lithium toxicity.

   For each row, choose: Increases risk / Does not increase risk

   1. Two days of vomiting and diarrhoea
   2. Starting lisinopril for blood pressure
   3. Taking acetaminophen for a headache
   4. Starting ibuprofen for a sprained ankle
   5. Starting hydrochlorothiazide for blood pressure
   6. Keeping a steady daily salt and fluid intake

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   Answer:

   • Two days of vomiting and diarrhoea: Increases risk
   • Starting lisinopril for blood pressure: Increases risk
   • Taking acetaminophen for a headache: Does not increase risk
   • Starting ibuprofen for a sprained ankle: Increases risk
   • Starting hydrochlorothiazide for blood pressure: Increases risk
   • Keeping a steady daily salt and fluid intake: Does not increase risk

   Analyse cues (CJMM): lithium is handled like sodium by the kidney, so anything that lowers sodium or renal blood flow (thiazides, NSAIDs, ACE inhibitors, dehydration) makes the kidney retain lithium. Teach a steady salt and fluid intake, and early report of vomiting, diarrhoea, coarse tremor or confusion.

   • Two days of vomiting and diarrhoea: Fluid and sodium loss concentrates lithium and reduces its excretion.
   • Starting lisinopril for blood pressure: ACE inhibitors decrease lithium clearance.
   • Taking acetaminophen for a headache: Acetaminophen does not change renal lithium handling.
   • Starting ibuprofen for a sprained ankle: NSAIDs reduce renal lithium clearance and raise serum levels.
   • Starting hydrochlorothiazide for blood pressure: Thiazides cause sodium loss, and the kidney then retains lithium.
   • Keeping a steady daily salt and fluid intake: Consistent sodium and fluid intake keeps lithium levels stable.

4. Question 4 · Medium · Matrix

   Ten minutes into an IV vancomycin infusion, a client develops flushing and itching of the face, neck and upper chest. BP is 118/74 mm Hg and breathing is unlaboured. For each action, indicate whether it is indicated or not indicated.

   For each row, choose: Indicated / Not indicated

   1. Give the prescribed diphenhydramine
   2. Stop the infusion and assess the client
   3. Record vancomycin as a severe allergy never to be given again
   4. Restart at the original rate as soon as the flushing fades
   5. Infuse later doses over at least 60 minutes or longer

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   Answer:

   • Give the prescribed diphenhydramine: Indicated
   • Stop the infusion and assess the client: Indicated
   • Record vancomycin as a severe allergy never to be given again: Not indicated
   • Restart at the original rate as soon as the flushing fades: Not indicated
   • Infuse later doses over at least 60 minutes or longer: Indicated

   Take action (CJMM): vancomycin infusion reaction (formerly red man syndrome) is a rate-related histamine release from mast cells, not a true allergy. Stop or slow the infusion, give an antihistamine as prescribed, and infuse over at least 60 minutes (often longer); watch for hypotension.

   • Give the prescribed diphenhydramine: The flushing is histamine-mediated and responds to an antihistamine.
   • Stop the infusion and assess the client: Stopping the infusion removes the trigger while the nurse assesses the reaction.
   • Record vancomycin as a severe allergy never to be given again: Infusion flushing is not an IgE allergy; vancomycin can be given again at a slower rate.
   • Restart at the original rate as soon as the flushing fades: Restarting at the same rate will reproduce the reaction.
   • Infuse later doses over at least 60 minutes or longer: The reaction is rate-related, so slowing the infusion prevents it.

5. Question 5 · Hard · Matrix

   For each drug combination, indicate the main adverse effect the nurse should monitor for.

   For each row, choose: Serotonin syndrome / Bleeding / Hyperkalaemia

   1. Clopidogrel with naproxen
   2. Lisinopril with trimethoprim
   3. Fluoxetine with tramadol
   4. Sertraline with linezolid
   5. Lisinopril with spironolactone
   6. Warfarin with aspirin

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   Answer:

   • Clopidogrel with naproxen: Bleeding
   • Lisinopril with trimethoprim: Hyperkalaemia
   • Fluoxetine with tramadol: Serotonin syndrome
   • Sertraline with linezolid: Serotonin syndrome
   • Lisinopril with spironolactone: Hyperkalaemia
   • Warfarin with aspirin: Bleeding

   Analyse cues (CJMM): grouping interactions by mechanism helps: serotonergic stacking causes serotonin syndrome, combined antiplatelet or anticoagulant drugs cause bleeding, and drugs that cut renal potassium loss cause hyperkalaemia. Each combination needs targeted monitoring rather than routine checks.

   • Clopidogrel with naproxen: NSAIDs add antiplatelet and GI-mucosal injury.
   • Lisinopril with trimethoprim: Trimethoprim acts like amiloride on the distal tubule and retains potassium.
   • Fluoxetine with tramadol: Tramadol blocks serotonin reuptake.
   • Sertraline with linezolid: Linezolid is a weak MAO inhibitor that adds to SSRI effects.
   • Lisinopril with spironolactone: Both reduce renal potassium excretion.
   • Warfarin with aspirin: Antiplatelet and anticoagulant effects add together.

6. Question 6 · Medium · Select all that apply

   A client who takes sertraline was prescribed tramadol for back pain three days ago and is now restless and sweating. Which findings are consistent with serotonin syndrome?

   1. AAgitation and pressured speech
   2. BLead-pipe rigidity with slow movements
   3. CTemperature 39.1 °C (102.4 °F)
   4. DProfuse diaphoresis
   5. EHeart rate 124/min
   6. FInducible ankle clonus

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7. Question 7 · Medium · Matrix

   The nurse is teaching a client newly prescribed levothyroxine. For each client statement, indicate whether it shows understanding or needs more teaching.

   For each row, choose: Shows understanding / Needs more teaching

   1. I will take it with water 30 to 60 minutes before breakfast.
   2. I will swallow it together with my calcium tablet.
   3. I can drink my coffee with the tablet.
   4. I will report a racing heart or trouble sleeping.
   5. I will take my iron pill at least 4 hours apart from it.

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8. Question 8 · Hard · Matrix

   The nurse reviews morning medications for six clients. For each, indicate whether the nurse should give the drug or hold it and contact the provider.

   For each row, choose: Give as prescribed / Hold and contact provider

   1. Spironolactone; potassium 5.8 mEq/L
   2. Amlodipine; BP 128/78 mm Hg
   3. Lisinopril; client is 10 weeks pregnant
   4. Metformin; eGFR 55 mL/min/1.73 m2
   5. Levothyroxine; low TSH, heart rate 118/min and new palpitations
   6. Propranolol; client has new wheezing from an asthma flare

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9. Question 9 · Medium · Select all that apply

   The provider prescribes IV ketorolac for postoperative pain. For which clients should the nurse question the prescription?

   1. AA client with a history of migraine
   2. BA client with an eGFR of 25 mL/min/1.73 m2
   3. CA client taking levothyroxine for hypothyroidism
   4. DA client with a past allergy to morphine
   5. EA client with an active duodenal ulcer
   6. FA client who is also taking naproxen

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10. Question 10 · Hard · Select all that apply

    A client on day 7 of a continuous heparin infusion for a DVT has a platelet count of 85,000/mm3 (baseline 230,000/mm3) and a new cool, pale left foot. Which actions should the nurse anticipate?

    1. ASwitch to subcutaneous enoxaparin
    2. BStop the infusion and all heparin flushes
    3. CPrepare to start an argatroban infusion as prescribed
    4. DTransfuse platelets before any further anticoagulant
    5. EStart warfarin today to prevent further clots
    6. FReport the platelet fall and the foot findings to the provider

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11. Question 11 · Hard · Select all that apply

    A client is on day 6 of IV gentamicin and IV furosemide for a complicated infection. Which findings should the nurse report?

    1. ATemperature 37.0 °C (98.6 °F)
    2. BUrine output 60 mL/hour
    3. CWBC 9,500/mm3 (admission 15,800/mm3)
    4. DNew ringing in both ears
    5. EUnsteady gait and dizziness when walking
    6. FCreatinine 1.6 mg/dL (baseline 0.9 mg/dL)

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12. Question 12 · Hard · Matrix

    A client takes oxycodone for chronic cancer pain. For each finding, indicate whether it is expected and managed routinely or requires prompt intervention.

    For each row, choose: Expected, manage routinely / Requires prompt intervention

    1. Hard stools while on a scheduled bowel regimen
    2. Unable to void with 800 mL of urine on bladder scan
    3. Mild nausea in the first days after starting
    4. Drowsy but easily roused on the first day after a dose increase
    5. Respiratory rate 8/min and hard to rouse

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13. Question 13 · Easy · Select all that apply

    A client taking warfarin asks which over-the-counter products are safe for minor aches. Which products should the nurse advise the client to avoid?

    1. AAspirin
    2. BDocusate sodium stool softener
    3. CAcetaminophen at the labelled dose
    4. DGinkgo biloba
    5. ENaproxen
    6. FSaline nasal spray

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14. Question 14 · Medium · Select all that apply

    A client who has not taken opioids before returns from surgery with morphine patient-controlled analgesia (PCA) on demand doses only. Which actions should the nurse include in the plan of care?

    1. AHave a second nurse independently check the pump programming
    2. BWithhold the PCA until the client rates pain above 7
    3. CKeep naloxone and airway equipment available
    4. DAssess sedation level and respiratory rate on a set schedule
    5. EUse continuous pulse oximetry or capnography as policy allows
    6. FAdd a basal infusion so the client sleeps through the night

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15. Question 15 · Hard · Select all that apply

    A client receiving haloperidol has a temperature of 40.2 °C (104.4 °F), BP 168/102 mm Hg, rigid limbs, confusion and a CK of 9,800 units/L. Which actions should the nurse anticipate?

    1. APrepare dantrolene or bromocriptine as prescribed
    2. BGive IV fluids as prescribed
    3. CBegin active cooling measures
    4. DGive a PRN dose of IM haloperidol for agitation
    5. EHold all further haloperidol doses
    6. FMonitor urine output and colour closely

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16. Question 16 · Easy · Select all that apply

    A client is starting phenelzine for depression. Which foods should the nurse teach the client to avoid?

    1. ACured salami
    2. BSoy sauce
    3. CFreshly cooked chicken
    4. DAged cheddar cheese
    5. ECottage cheese
    6. FDraft (tap) beer

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17. Question 17 · Hard · Select all that apply

    A postoperative client with hydromorphone PCA is snoring, cannot be kept awake when called and shaken, has a respiratory rate of 6/min and SpO2 of 85%. Which actions should the nurse take?

    1. AStop the PCA infusion
    2. BGive naloxone 2 mg undiluted by rapid IV push
    3. CStimulate the client and call for the rapid response team
    4. DLet the client sleep and recheck in one hour
    5. EGive oxygen and support the airway
    6. FGive diluted naloxone in small increments, titrated to breathing

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18. Question 18 · Medium · Select all that apply

    A client with schizophrenia has taken clozapine for six weeks. Which findings should the nurse report to the provider promptly?

    1. ANo bowel movement for four days with a swollen abdomen
    2. BFeeling sleepy for an hour after the dose
    3. CA brief generalised seizure
    4. DFever with a sore throat
    5. EChest pain with a resting heart rate of 120/min
    6. FDrooling on the pillow at night

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19. Question 19 · Medium

    The nurse reviews four new orders for ibuprofen 400 mg orally every 6 hours. For which client should the nurse question the order?

    1. AA 72-year-old with stage 4 chronic kidney disease
    2. BA 24-year-old with painful menstrual cramps
    3. CA 41-year-old with a tension-type headache
    4. DA 35-year-old with a sprained ankle from soccer

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20. Question 20 · Easy

    A client is starting oral doxycycline. The nurse teaches the client to avoid taking the dose together with:

    1. AMilk, antacids or iron tablets
    2. BAn evening dose of acetaminophen
    3. CA light meal of toast and fruit
    4. DA full glass of plain water

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21. Question 21 · Hard

    Day 1 after abdominal surgery, at night. The client has morphine PCA with a basal rate. Nurse's note: drifts off to sleep mid-sentence but opens eyes to voice; respirations 9/min and shallow; SpO2 90% on 2 L/min; BP 108/64 mm Hg; pain 3/10 when awake. What should the nurse do FIRST?

    1. AStop the PCA and keep stimulating the client
    2. BLower the oxygen and recheck in one hour
    3. CTeach the client to press the button less
    4. DGive naloxone 0.4 mg IV push undiluted

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22. Question 22 · Medium

    A client newly prescribed lisinopril says, "I'm switching to a salt substitute to cut down on sodium." The nurse explains that most salt substitutes:

    1. AContain extra sodium, which cancels the blood-pressure benefit
    2. BContain potassium, which this drug can raise to a dangerous level
    3. CContain iodine, which interferes with how the drug works
    4. DContain calcium, which blocks the absorption of the drug

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23. Question 23 · Medium

    On day 8 of trimethoprim-sulfamethoxazole, a client reports fever, sore throat and a spreading painful rash with blisters on the lips and inside the mouth. The nurse recognises these findings as a sign of:

    1. AA viral infection unrelated to the antibiotic course
    2. BOral candidiasis from changes in the normal mouth flora
    3. CStevens-Johnson syndrome needing the drug stopped at once
    4. DA mild drug rash that can be treated with an antihistamine

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24. Question 24 · Hard

    A 76-year-old client takes lisinopril and furosemide. Ten days ago the client began naproxen twice daily for knee pain. Today: creatinine 2.1 mg/dL (baseline 1.0), potassium 5.6 mEq/L, urine output 20 mL/h for 4 hours, BP 102/60 mm Hg. Which is the most likely explanation for these findings?

    1. AAcute kidney injury from the NSAID added to the other two drugs
    2. BHypovolemia caused by furosemide alone at the usual dose
    3. CDehydration-related muscle breakdown from knee pain
    4. DAllergic interstitial nephritis caused by lisinopril

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25. Question 25 · Medium

    A client is being discharged with oral metronidazole for 7 days. Which statement indicates a need for further teaching?

    1. A"I may notice a metallic taste in my mouth for a while."
    2. B"My urine might turn darker while I am on this medicine."
    3. C"I will finish all the tablets even if I feel better soon."
    4. D"I can have a glass of wine with dinner while I take this."

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