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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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"D"}

Explanation

0845: The peak action of insulin lispro occurs about 1 to 2 hours after injection. Since it was administered at 0745, the nurse should expect a peak effect beginning around 0845, when the insulin will have its strongest blood glucose-lowering action.

0745: 0745 is the time when the insulin lispro was administered, not when it starts working. Since lispro usually takes about 15 to 30 minutes to begin acting, 0745 is too early to expect therapeutic action.

0815: Lispro insulin begins to work approximately 15 to 30 minutes after subcutaneous administration. Since it was given at 0745, the nurse should expect it to start lowering blood glucose around 0815, consistent with its pharmacologic profile.

0915: Given that insulin lispro peaks 1 to 2 hours after administration, the later part of the peak window would occur around 0915. This timing ensures the nurse monitors for potential hypoglycemia at the height of insulin activity.

A. Review most recent coagulation laboratory values. B. Report findings to healthcare provider (HCP). C. Complete a medication variance report. D. Obtain a soft bristle toothbrush for client. E. Provide a PRN nonsteroidal antiinflammatory drug (NSAID) for gum discomfort.

Correct Answer is ["A","B","D"]

Explanation

A. Review most recent coagulation laboratory values: Checking coagulation studies like INR, PT, or aPTT is essential to assess the client's bleeding risk and determine if the anticoagulant effect is too strong, helping guide further medical management.

B. Report findings to healthcare provider (HCP): Bleeding gums and easy bruising are signs of excessive anticoagulation, which could become life-threatening. Promptly notifying the HCP allows for immediate evaluation and possible adjustment of the medication.

C. Complete a medication variance report: A medication variance report is appropriate when there is an error in prescribing, dispensing, or administering. Since this appears to be a medication side effect rather than an error, a variance report is not needed at this stage.

D. Obtain a soft bristle toothbrush for client: Using a soft toothbrush minimizes trauma to the gums, helping to reduce the risk of further bleeding while still maintaining oral hygiene, an important supportive intervention for clients on anticoagulants.

E. Provide a PRN nonsteroidal antiinflammatory drug (NSAID) for gum discomfort: NSAIDs increase the risk of bleeding and should be avoided in clients taking anticoagulants. Treating discomfort with NSAIDs could worsen bleeding complications rather than relieve them safely.

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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

Patient Data Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse should expect for the insulin lispro to start working at dropdown and to peak at dropdown to dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"D"}

Explanation

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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