The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

Advise the client to move slowly and cautiously when rising and walking.

Evaluate muscle strength every 4 hours.

Monitor intake and output every 8 hours.

Ensure the client knows to stop baclofen before using other antispasmodics.

Answer and Explanation

The Correct Answer is A

Choice A reason: Baclofen is a muscle relaxant that can cause drowsiness, dizziness, and orthostatic hypotension. These side effects can increase the risk of falls and injuries for the client. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking, and to use assistive devices if needed.

Choice B reason: Evaluating muscle strength every 4 hours is not the most important intervention for the nurse to implement, as baclofen does not affect muscle strength directly. It may reduce muscle spasticity and stiffness, but it does not improve muscle function or coordination.

Choice C reason: Monitoring intake and output every 8 hours is not the most important intervention for the nurse to implement, as baclofen does not have a significant effect on fluid balance or renal function. However, the nurse should monitor the client for signs of urinary retention, which is a rare but possible adverse effect of baclofen.

Choice D reason: Ensuring the client knows to stop baclofen before using other antispasmodics is not the most important intervention for the nurse to implement, as baclofen can be used in combination with other antispasmodics under medical supervision. However, the nurse should educate the client about the potential drug interactions and contraindications of baclofen, and to consult the prescriber before taking any new medications.

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Correct Answer is A

Explanation

Choice A reason: This is the highest priority action for the nurse to take. Codeine is an opioid analgesic that can cause drowsiness, dizziness, and impaired coordination. These effects can increase the risk of falls and injuries in the client, especially when ambulating to the bathroom. The nurse should instruct the client to request assistance when getting out of bed or walking, and provide adequate support and supervision.

Choice B reason: This is not the highest priority action for the nurse to take. Administering a stool softener/laxative at the same time as the analgesic is a preventive measure that can help reduce the risk of constipation, which is a common side effect of codeine. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.

Choice C reason: This is not the highest priority action for the nurse to take. Advising the client that the medication should start to work in about 30 minutes is an informative and reassuring measure that can help the client cope with pain and anxiety. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.

Choice D reason: This is not the highest priority action for the nurse to take. Telling the client to notify the nurse if the pain is not relieved is an evaluative and responsive measure that can help the nurse monitor the effectiveness of the analgesic and adjust the dosage or frequency as needed. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.

A. Scratchy throat. B. Pupillary constriction. C. Bradycardia. D. Hypertension.

Correct Answer is A

Explanation

Choice A reason: This is the correct manifestation for the nurse to identify as a reason to stop the infusion. A scratchy throat may indicate an allergic reaction to piperacillin-tazobactam, which is a penicillin derivative. The client may also develop other signs of anaphylaxis, such as rash, itching, swelling, wheezing, or difficulty breathing. The nurse should stop the infusion immediately and notify the healthcare provider.

Choice B reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Pupillary constriction is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as light exposure, medication use, or neurological conditions. The nurse should monitor the client's pupils for any changes, but it is not a reason to stop the infusion.

Choice C reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Bradycardia, or a slow heart rate, is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as cardiac disorders, medication use, or vagal stimulation. The nurse should monitor the client's vital signs for any changes, but it is not a reason to stop the infusion.

Choice D reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Hypertension, or high blood pressure, is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as stress, pain, or renal disorders. The nurse should monitor the client's blood pressure for any changes, but it is not a reason to stop the infusion.

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The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?

Correct Answer is A

Explanation

The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?

Correct Answer is A

Explanation

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