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

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

Monitor intake and output every 8 hours.

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

Evaluate muscle strength every 4 hours.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Baclofen is a muscle relaxant used to reduce muscle spasticity in conditions such as multiple sclerosis. One of the common side effects of baclofen is dizziness or orthostatic hypotension, which can increase the risk of falls. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking to prevent falls and injury.

Choice B rationale: Monitoring intake and output every 8 hours is not directly related to the administration of baclofen.

Choice C rationale: Ensuring the client knows to stop baclofen before using other antispasmodics is not the correct intervention. Baclofen should not be abruptly discontinued without medical advice, and its use should be discussed with the healthcare provider.

Choice D rationale: Evaluating muscle strength every 4 hours may be part of the client's overall care plan, but it is not directly related to the administration of baclofen. Muscle strength evaluation is more pertinent for assessing the progression of multiple sclerosis and its effects on muscle function.

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Correct Answer is B

Explanation

Choice A rationale: Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

Choice B rationale: Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.

Choice C rationale: Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

Choice D rationale: Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

A. Monitor skin for excessive bruising. B. Replace salt with a salt substitute. C. Cover your skin before going outside. D. Limit intake of high-potassium foods.

Correct Answer is D

Explanation

Choice A rationale: This instruction is not directly related to spironolactone use or hyperaldosteronism. Excessive bruising may be relevant in some situations but not specifically for this scenario.
Choice B rationale: While heart failure patients are often advised to reduce their sodium intake, the use of a salt substitute (potassium-based) would be contraindicated in this case due to the risk of hyperkalemia.
Choice C rationale: This instruction is not directly related to spironolactone use or
hyperaldosteronism. It may be relevant for sun protection, but it is not a priority in this context.
Choice D rationale: Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium while excreting sodium and water. Since the client has heart failure (HF), there is a risk of hyperkalemia (high potassium levels) associated with spironolactone use. To prevent this, the nurse should instruct the client to limit their intake of high-potassium foods, such as bananas, oranges, tomatoes, spinach, and other potassium-rich foods.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client's plan of care?

Correct Answer is D

Explanation

A male client with a history of heart failure (HF) complains of heartburn when he lies down after dinner. The home health nurse should encourage the client to talk to the healthcare provider about using which over-the-counter medication to relieve this problem?

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take?

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Find information about a client below. Exhibits What should the nurse double-check with a second nurse? Select all that apply.

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