A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours.
What patient condition should the nurse report to the healthcare provider before administering the medication?

Choice A rationale

Baclofen is a muscle relaxant used to treat muscle symptoms caused by multiple sclerosis (MS), including spasm, pain, and stiffness. It acts on the central nervous system to relieve spasticity, improving muscle movement and relieving pain from spasticity. One of the common side effects of Baclofen is drowsiness, dizziness, and weakness. Therefore, advising the patient to move slowly and cautiously when getting up and walking is an important nursing intervention to prevent falls and injuries.

Choice B rationale

While evaluating the patient’s muscle strength every 4 hours can provide valuable information about the patient’s response to treatment, it is not the most critical intervention in this context. Baclofen’s primary effect is to relieve spasticity, not necessarily to increase muscle strength.

Choice C rationale

Monitoring the patient’s intake and output every 8 hours is a standard nursing intervention for many patients, but it is not specifically related to the administration of baclofen.

Choice D rationale

While it’s important for patients to understand their medication regimen, including when to stop taking certain medications, baclofen should not be stopped abruptly. Abrupt discontinuation has resulted in serious adverse reactions including death. Therefore, ensuring the patient understands to stop taking baclofen before using other antispasmodics is not the correct intervention.

Choice A rationale

Sodium polystyrene sulfonate is a medication used to treat high levels of potassium in the blood, a condition known as hyperkalemia. Hyperkalemia is a common complication of acute kidney injury (AKI). The medication works by exchanging sodium ions for potassium ions in the intestine, which are then excreted from the body. Therefore, a decrease in serum potassium levels to within the normal range (3.5-5.0 mEq/L) would indicate that the medication has been effective.

Choice B rationale

Hemoglobin levels are not directly affected by sodium polystyrene sulfonate. Hemoglobin is a protein in red blood cells that carries oxygen. While it’s an important indicator of overall health, changes in hemoglobin levels would not indicate whether treatment for hyperkalemia is working.

Choice C rationale

Sodium polystyrene sulfonate does not directly affect glucose levels. While it’s important to monitor glucose levels in patients with kidney disease, changes in glucose would not indicate whether treatment for hyperkalemia is working.

Choice D rationale

Sodium polystyrene sulfonate does not directly affect ammonia levels. While elevated ammonia levels can occur in certain conditions, such as liver disease, changes in ammonia levels would not indicate whether treatment for hyperkalemia is working.