A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?

Planning

Evaluation

Diagnosis

Implementation

Assessment

Answer and Explanation

The Correct Answer is B

A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.

B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.

C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.

D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.

E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) The client flushes the medication down the toilet: Flushing medication down the toilet is not recommended unless it is explicitly stated on the medication packaging or insert. Many medications, especially controlled substances, may be harmful to the environment if disposed of in this way. Environmental regulations discourage flushing medications unless instructed by the manufacturer, as it can contribute to water contamination. Therefore, this action indicates a need for additional education on proper medication disposal.

B) The client removes identifying information from the medication container: This is an appropriate action. Removing identifying information from the medication container before disposal helps ensure privacy and confidentiality, preventing unauthorized individuals from accessing personal health information. This is part of safe and secure medication disposal practices.

C) The client reads the medication insert to determine the disposal method: This is an appropriate action. Reading the medication insert is the best way for a client to understand the recommended disposal method for their specific medication. Many medications have detailed instructions on how to dispose of them safely and environmentally.

D) The client mixes the medication with coffee grounds: This is an appropriate action. Mixing medications with coffee grounds, cat litter, or dirt is recommended for medications that should not be flushed or thrown in the trash. This helps make the medication less appealing to children, pets, or others who may come across it and ensures safe disposal. This action is consistent with the guidance for non-hazardous medications.

A. The drugs will compete for receptor sites B. The client will have increased effects of both drugs C. The client will have decreased effects of both drugs D. Both drugs are equally bound to protein

Correct Answer is B

Explanation

A) The drugs will compete for receptor sites: While it's true that highly protein-bound drugs can compete for binding sites on proteins (like albumin), the main issue with highly protein-bound drugs interacting is not related to competition for receptor sites. The primary concern is how the drugs displace each other from the protein-binding sites, which can increase the free (active) drug levels in the bloodstream. This can lead to a higher pharmacological effect, especially if the unbound drug concentration rises to a therapeutic or toxic level.

B) The client will have increased effects of both drugs: This is the correct answer. When two highly protein-bound drugs are administered together, they can displace each other from protein-binding sites. This displacement increases the amount of free (active) drug in circulation, which may intensify the pharmacologic effects of both drugs. For example, if one drug displaces the other from its protein-binding site, more of the free drug will be available to exert its effects. This can increase the risk of side effects, toxicity, or both.

C) The client will have decreased effects of both drugs: This is incorrect. The opposite is true—when two highly protein-bound drugs are given together, the displacement of one drug increases the amount of the free drug available, leading to a stronger effect, not a weaker one. Decreased effects would occur if the drug had no access to the target receptor or if it were metabolized or eliminated too quickly, which isn't the case in this scenario.

D) Both drugs are equally bound to protein: While both drugs may bind to protein, they do not necessarily bind equally. One drug might bind more strongly or more selectively to the protein than the other, which could lead to displacement of the weaker-bound drug. The important point is that their competition for protein-binding sites can lead to an increase in free (active) drug concentrations.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is preparing a medication for administration and is disposing the remaining medication. Which action by the client indicates the need for additional education?

Correct Answer is A

Explanation

What happens if you give two drugs together that are highly protein bound?

Correct Answer is B

Explanation

Which medications are most likely to be used in a dual drug therapy program for peptic ulcer disease from H. pylori?

The client receives 200 mg of a medication on a consistent schedule. How much drug is in the body at 4 half-lives?

A client is ordered to receive a laxative by rectal suppository. How should the nurse position the client during the administration of the suppository?

A client currently prescribed a medication highly metabolized by the CYP 450 recently began smoking due to a stressful life event. True or False: The level of medication will increase in this client.

The healthcare provider decreased the ordered dose of fentanyl to 25 mcg/hr transdermal patch. The pharmacy delivers a 50 mcg/hr patch to the nurse when the next dose is scheduled. What is the best action by the nurse?

The nurse is providing discharge instructions to a female client who delivered a healthy, full-term infant. What information should the nurse provide about taking medications while breast feeding?

A client is to be started on a heparin intravenous infusion at 2,000 units per hour. On hand is an IV bag labeled 25,000 units/ 250 mL. At what rate (mL/hour) will the nurse set the pump? (Answer to the nearest whole number)

The health care provider prescribes scopolamine for a client who is planning to take cruise and is concerned about motion sickness. What information in the past medical history would serve as a contraindication for this medication?