The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Advise the patient to move slowly and cautiously when getting up and walking.

Evaluate the patient’s muscle strength every 4 hours.

Monitor the patient’s intake and output every 8 hours.

Ensure the patient understands to stop taking baclofen before using other antispasmodics.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is ["42"]

Explanation

To calculate the infusion rate in gtt/min, we first need to calculate the infusion rate in mL/hr. The formula for this is:

Step 1: Calculate the infusion rate in mL/hr

Infusion rate (mL/hr)=Total time (hr)Total volume (mL) Substituting the given values: Infusion rate (mL/hr)=2 hr mL=250 mL/hr

Step 2: Convert the infusion rate from mL/hr to gtt/min Infusion rate (gtt/min)=60 min/hrInfusion rate (mL/hr)×Drop factor (gtt/mL).

Substituting the given values: Infusion rate (gtt/min)=60 min/hr mL/hr×10 gtt/mL ≈42 gtt/min Therefore, the nurse should regulate the infusion to approximately 42 gtt/min.

A. Notify the healthcare provider of the carbamazepine level. B. Administer the carbamazepine as prescribed. C. Withhold this dose of the carbamazepine. D. Assess the patient for side effects of carbamazepine.

Correct Answer is A

Explanation

The correct answer is A:

Choice A reason: Notifying the healthcare provider is crucial because the patient’s carbamazepine level is significantly above the therapeutic range, which is 4-12 mcg/mL. A level of 84 mcg/mL indicates a high risk of toxicity, and the healthcare provider must be informed to take appropriate action, which may include adjusting the dose or discontinuing the medication.

Choice B reason: Administering the carbamazepine as prescribed would not be safe without addressing the elevated drug level. Continuing to administer the medication could increase the risk of severe side effects and toxicity due to the already high serum level.

Choice C reason: Withholding the dose may be a necessary immediate action, but it does not address the need for medical intervention to manage the patient’s elevated drug level. Therefore, while withholding the dose might be part of the response, it should follow notifying the healthcare provider.

Choice D reason: Assessing the patient for side effects is important, but it is not the most immediate action required. The priority is to notify the healthcare provider because of the potential for serious toxicity given the high carbamazepine level.

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The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?

Correct Answer is ["42"]

Explanation

Before administering the evening dose of carbamazepine, the nurse notes that the patient’s morning carbamazepine level was 84 mcg/mL. What action should the nurse take?

Correct Answer is A

Explanation

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