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 D

Explanation

Choice A reason: Assessing for orthostatic hypotension is not a priority action before administering labetalol. Orthostatic hypotension is a possible side effect of the drug, but it is not an immediate concern.

Choice B reason: Administering the dose and monitoring the client's BP regularly is not the best action. The client's heart rate is below the normal range of 60 to 100 beats/minute, which indicates bradycardia. Labetalol can further lower the heart rate and cause cardiac complications.

Choice C reason: Applying a telemetry monitor before administering the dose is not necessary. Telemetry monitoring is used to detect cardiac arrhythmias, which are not a common adverse effect of labetalol. The client's heart rate and rhythm should be assessed by auscultation.

Choice D reason: Withholding the scheduled dose and notifying the health care provider is the correct action. The client's heart rate is too low to safely receive labetalol, which is a beta-blocker that can decrease the heart rate and contractility. The health care provider should be informed of the client's vital signs and the need to adjust the medication dosage or frequency.

A. Take the tablet with a daily multivitamin. B. Bedtime is the best time to take the tablet. C. Wait 2 hours after meals to take the tablet. D. Crush the tablets and mix with pudding.

Correct Answer is C

Explanation

Choice A reason: This is not a correct information for the nurse to include in the discharge instructions. Taking the tablet with a daily multivitamin is not advisable, as some vitamins and minerals, such as calcium, zinc, and vitamin C, can interfere with the absorption of iron and reduce its effectiveness. The client should take the tablet on an empty stomach or with a small amount of food that does not contain these substances.

Choice B reason: This is not a correct information for the nurse to include in the discharge instructions. Bedtime is not the best time to take the tablet, as it may cause gastrointestinal side effects, such as nausea, vomiting, constipation, or diarrhea, that can disrupt the client's sleep and comfort. The client should take the tablet at least 2 hours before or after meals, and preferably in the morning.

Choice C reason: This is a correct information for the nurse to include in the discharge instructions. Waiting 2 hours after meals to take the tablet is recommended, as it ensures that the stomach is empty and that the iron is not affected by any food or beverages that may impair its absorption. The client should also drink plenty of water with the tablet to facilitate its passage and prevent irritation of the esophagus.

Choice D reason: This is not a correct information for the nurse to include in the discharge instructions. Crushing the tablets and mixing with pudding is not appropriate, as it can damage the enteric coating of the tablets, which is designed to protect the iron from being destroyed by the stomach acid and to reduce the gastrointestinal side effects. The client should swallow the tablets whole and not chew, break, or crush them.

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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

The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99° F (37.2° C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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