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?

• NSAID use. The client has been taking ibuprofen (an NSAID) twice daily while also receiving prednisone (a corticosteroid) for asthma exacerbation. Both NSAIDs and corticosteroids inhibit prostaglandin production, which normally protects the stomach lining. This combination increases the risk of gastric irritation, peptic ulcers, and gastrointestinal bleeding.
• Recent immunization. The client received the influenza vaccine three days ago, but this does not significantly increase the risk of infection. The flu shot contains inactivated or weakened virus, meaning it cannot cause the flu. The client’s asthma may increase their risk of complications from the flu, but the vaccine helps reduce this risk rather than increasing it.
• Weight gain. The client has gained 1.36 kg (3 lb) in one week, which is likely due to fluid retention from prednisone use. While long-term corticosteroid use can lead to Cushing syndrome, this condition develops over weeks to months of high-dose steroid therapy, not within a short period. Therefore, the client is at a higher risk of peptic ulcers rather than Cushing syndrome.
• Cushing syndrome. Cushing syndrome results from chronic corticosteroid use leading to fat redistribution, muscle weakness, skin thinning, and hyperglycemia. However, this client is on a short-term tapering dose of prednisone, making Cushing syndrome unlikely at this stage.
• Influenza. Although the client has asthma, which increases the risk of complications from respiratory infections, there is no indication that they have developed the flu. The flu shot helps prevent infection, and there are no reports of fever, body aches, or respiratory symptoms suggestive of influenza.
• Peptic ulcers. The combination of NSAIDs and corticosteroids significantly increases the risk of peptic ulcer disease by weakening the stomach lining and promoting acid production. The client should be advised to monitor for signs of gastric irritation, such as abdominal pain, black stools, or nausea, and may require a proton pump inhibitor (PPI) like omeprazole for ulcer prevention.

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.