An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

The correct answer is 200 mL/h.

Step 1: The client has been prescribed ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour.

Step 2: The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D5W) 200 mL12. Step 3: To calculate the infusion rate, the nurse should use the formula: Infusion rate (mL/hr)

= Volume (mL) / Time (hr)3.

Step 4: In this case, the volume is 200 mL and the time is 1 hour. Step 5: Therefore, Infusion rate (mL/hr) = 200 mL ÷ 1 hr.

Step 6: Infusion rate (mL/hr) = 200 mL/hr.

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.