The nurse is administering the muscle relaxant baclofen PO to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Evaluate muscle strength every 4 hours.

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

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

Monitor intake and output every 8 hours.

Answer and Explanation

The Correct Answer is B

A. Evaluate muscle strength every 4 hours: While assessing muscle strength is important in clients with multiple sclerosis, it does not need to be done this frequently unless the client is unstable. Baclofen may cause weakness, but routine assessments every 4 hours are excessive for stable patients.

B. Advise the client to move slowly and cautiously when rising and walking: Baclofen can cause dizziness, sedation, decreased muscle tone and orthostatic hypotension, particularly in the early stages of treatment. Educating the client to change positions carefully helps reduce the risk of falls and injury.

C. Ensure the client knows to stop baclofen before using other antispasmodics: Baclofen should not be stopped abruptly due to the risk of withdrawal symptoms like hallucinations or seizures. Combining different antispasmodic medications can increase the risk of adverse effects such as excessive sedation or muscle weakness. Medication changes therefore should only be made under the supervision of the healthcare provider.

D. Monitor intake and output every 8 hours: Baclofen does not typically affect renal function or fluid balance significantly. Monitoring intake and output is not a standard intervention specific to baclofen administration unless there is another underlying condition.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Administer an oral analgesic and evaluate its effectiveness before applying the new patch: There is no need to switch to oral analgesics if the client is already well-managed on a fentanyl patch. The focus should be on properly managing the patch schedule rather than changing the route of administration.

B. Apply the new patch in a different location after removing the original patch: Proper protocol for transdermal patches includes removing the old patch before applying a new one to prevent overdose. The new patch should be placed on a different skin site to avoid skin irritation and ensure even drug absorption.

C. Place the patch on the client's shoulder and leave both patches in place for 12 hours: Leaving both patches in place can lead to dangerously high serum fentanyl levels and significant respiratory depression. Only one patch should be used at a time unless otherwise specifically prescribed.

D. Remove the patch and consult with the healthcare provider (HCP) about the client's pain resolution: It is unnecessary to contact the HCP immediately if the client is pain-free and the scheduled time for patch replacement has arrived. Standard procedure should be followed by simply removing the old patch and applying the new one.

A. Positive guaiac of stool. B. Hemoglobin 13 g/dL (130 g/L). C. Hematocrit 42% (0.42 volume fraction). D. Gastric pH 2.

Correct Answer is A

Explanation

A. Positive guaiac of stool: A positive guaiac test indicates the presence of blood in the stool, suggesting gastrointestinal bleeding. Given the client’s history of frequent ibuprofen use, which can cause gastric ulcers and GI bleeding, this is a critical finding that must be reported immediately to the healthcare provider.

B. Hemoglobin 13 g/dL (130 g/L): Although slightly below the normal reference range for males, a hemoglobin of 13 g/dL is not critically low. It suggests mild anemia but is not an urgent finding compared to evidence of active gastrointestinal bleeding.

C. Hematocrit 42% (0.42 volume fraction): A hematocrit of 42% falls within the normal reference range for a male client. Therefore, this finding is stable and does not require immediate reporting in the context of the client's current symptoms.

D. Gastric pH 2: A gastric pH of 2 is within the normal range for stomach acid levels (1.5 to 3.5). The current gastric pH suggests that their acid production is within expected limits and is not the immediate concern. This value does not indicate any acute problem by itself and would not require immediate notification of the healthcare provider.

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The nurse is administering the muscle relaxant baclofen PO to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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