What happens if you give two drugs together that are highly protein bound?

A) "If you do not take it now, it will put you behind schedule.": While the nurse might be concerned about the medication schedule, this response dismisses the client's concern and doesn’t prioritize safety. The nurse should not pressure the client to take the medication before verifying that it is correct.
B) "Let me check the original order before you take it.": This is the best response because it demonstrates a commitment to patient safety. If the client is concerned about the medication, the nurse should take the time to verify the order directly from the original source to ensure the right medication is being given. This approach reassures the client and promotes trust.

C) "It wouldn't be listed here if it were not ordered for you!": This response can come across as dismissive and unprofessional. While it is important that the medication appears on the record, the nurse should still verify it to address the client's concern. Simply relying on the medication record without confirmation is not the best course of action.

D) "It's listed here on the medication sheet, so you should take it.": Similar to option C, this response dismisses the client’s concern and does not prioritize verifying the medication’s accuracy. It could lead to the client feeling their concerns were not taken seriously, which could negatively impact their trust in the care provided.

A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.

B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.

C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.

D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.

E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.