Question

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

Answer 1

Correct Answers:

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

Rationale :

◆ Baclofen, a central muscle relaxant, may cause drowsiness, dizziness, and hypotension, especially when initiating therapy.

◆ Clients with multiple sclerosis are already at risk for mobility issues and falls, so it's essential to reinforce fall precautions.

◆ Moving slowly when rising helps prevent orthostatic hypotension and potential injury.

◆ This safety measure ensures that the therapeutic benefit of baclofen does not result in adverse outcomes.

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Answer 2

Correct Answers:

Advise the client that the healthcare provider needs to be made aware of her current diet

Rationale :

◇ Warfarin's effectiveness is directly impacted by vitamin K, which is high in leafy green vegetables.

◇ Consistency is key—clients do not need to eliminate these vegetables but should maintain a stable intake and notify the provider.

◇ The provider may adjust the warfarin dose or increase monitoring of INR levels accordingly.

◇ Providing accurate dietary disclosure ensures safe anticoagulation management.

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Answer 3

Correct Answers:

Wort can decrease plasma concentrations of cyclosporine.

Rationale :

◈ St. John’s Wort is a known CYP3A4 inducer, which can decrease plasma levels of cyclosporine, increasing the risk of organ rejection.

◈ This interaction is especially dangerous in post-transplant clients who depend on stable immunosuppression.

◈ Nurses must assess all herbal supplement use and inform providers of any potential contraindicated interactions.

◈ Educating clients to avoid unverified herbal advice is critical for transplant outcomes.

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Answer 4

Correct Answers:

Ask the client to rate the current level of pain using a pain scale.

Rationale :

⋄ Pain assessment using a standardized scale (0–10 or FACES) is always the first step in pain management.

⋄ Without establishing the intensity, the nurse cannot determine the appropriate dose or need for analgesia.

⋄ This approach ensures that opioids or other medications are given safely and appropriately.

⋄ It also opens communication with the client, validating their concern while ensuring safe medication practice.

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Answer 5

Correct Answers:

Recent use of other antidepressants.

Rationale :

♦ Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI), and combining it with other antidepressants (especially MAOIs or SSRIs) can lead to serotonin syndrome.

♦ The nurse must ensure a sufficient washout period has occurred between antidepressants.

♦ Assessing recent psychiatric medication use helps prevent life-threatening interactions.

♦ Clients should be informed to avoid self-medicating or abrupt switching between antidepressants.

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Answer 6

Correct Answers:

Hold both medications until contacting the healthcare provider.

Rationale :

❖ A serum calcium level of 14 mg/dL indicates hypercalcemia, which is above the normal reference range.

❖ Administering calcitriol or calcium carbonate in this situation could worsen the hypercalcemia, leading to cardiac or renal complications.

❖ The nurse must hold both medications and promptly inform the healthcare provider for further guidance.

❖ Clients with hypoparathyroidism require frequent monitoring of calcium to avoid overtreatment.

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Answer 7

Correct Answers:

Involuntary movements.

Rationale :

✦ Metoclopramide can cause extrapyramidal symptoms (EPS) such as tardive dyskinesia, especially with prolonged or high-dose use.

✦ Involuntary movements like lip smacking, jerking, or restlessness should be immediately reported, as they may become permanent.

✦ The nurse should stop the medication and notify the provider for alternative antiemetic therapy.

✦ Early detection of EPS is key to preventing irreversible neurological damage.

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Answer 8

Correct Answers:

Protect the skin from sunlight while taking the drug.

Rationale :

✧ Tetracycline increases photosensitivity, putting clients at risk for severe sunburns and phototoxic reactions.

✧ The nurse should teach the client to use broad-spectrum sunscreen, wear protective clothing, and avoid direct sun exposure.

✧ Clients should also avoid taking this medication with milk or antacids, which interfere with absorption.

✧ Preventing photosensitive reactions is part of essential client safety education.

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Answer 9

Correct Answers:

Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.

Rationale :

💠 Peak and trough levels are drawn to monitor therapeutic dosing and toxicity of vancomycin.

💠 The peak is drawn immediately after infusion, when the drug concentration is highest, and the trough is drawn just before the next dose.

💠 This timing helps adjust dosing to avoid renal toxicity and ensure antimicrobial effectiveness.

💠 Nurses must coordinate with lab staff and accurately time collections for valid results.

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Answer 10

Correct Answers:

Low sodium antacid.

Rationale :

🔶 Clients with heart failure should avoid sodium-containing medications, as they can worsen fluid retention and edema.

🔶 Low sodium antacids are safer choices for managing reflux or heartburn without contributing to volume overload.

🔶 The nurse should also assess for dietary contributors and positioning habits that might exacerbate reflux.

🔶 Medications like diphenhydramine or NSAIDs may worsen fluid retention or have unwanted side effects in heart failure patients.

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QLexNursing

1 :
The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

2 :
A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

4 :
A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

5 :
The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

7 :
A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

8 :
The healthcare provider prescribes the antibiotic tetracycline HCI for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

9 :
A client is receiving intravenous (IV) vancomycin and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times provide the best determination of these levels?

10 :
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?

QLexNursing

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

2 : A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

4 : A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

5 : The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

7 : A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

8 : The healthcare provider prescribes the antibiotic tetracycline HCI for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

9 : A client is receiving intravenous (IV) vancomycin and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times provide the best determination of these levels?

10 : 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?

1 :
The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

2 :
A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

4 :
A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

5 :
The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

7 :
A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

8 :
The healthcare provider prescribes the antibiotic tetracycline HCI for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

9 :
A client is receiving intravenous (IV) vancomycin and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times provide the best determination of these levels?

10 :
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?