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The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?
- A. Advise the patient to move slowly and cautiously when getting up and walking.
- B. Evaluate the patient’s muscle strength every 4 hours.
- C. Monitor the patient’s intake and output every 8 hours.
- D. Ensure the patient understands to stop taking baclofen before using other antispasmodics.
Correct Answer: A
Rationale: Baclofen causes drowsiness and weakness, increasing fall risk. Advising slow, cautious movement (A) enhances safety. Muscle strength checks (B) and intake/output (C) are less critical. Abruptly stopping baclofen (D) risks withdrawal (e.g., seizures), not advised.
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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.
An adult patient at an outpatient clinic has been prescribed the antibiotic tetracycline HCl. What instructions should the nurse include in the patient’s teaching plan?
- A. Consume with milk or antacids to prevent gastrointestinal irritation.
- B. Protect your skin from sunlight while on this medication.
- C. Enhance gastrointestinal absorption by taking with orange juice.
- D. Return to the clinic weekly for serum drug level checks.
Correct Answer: B
Rationale: This question is identical to Question 9. Tetracycline increases photosensitivity, requiring sun protection (B). Milk/antacids (A) and orange juice (C) impair absorption. Weekly drug checks (D) are unnecessary. Note: Duplicate question; consider removing.
An older adult with iron deficiency anemia is being discharged with a prescription for ferrous sulfate enteric-coated tablets. To promote the best absorption of the medication, what information should the nurse include in the discharge instructions?
- A. The best time to take the tablet is at bedtime.
- B. Crush the tablets and mix with pudding.
- C. Wait 2 hours after meals to take the tablet.
- D. Take the tablet with a daily multivitamin.
Correct Answer: C
Rationale: Ferrous sulfate is best absorbed on an empty stomach, 2 hours after meals (C). Bedtime dosing (A) isn’t specific to absorption. Crushing enteric-coated tablets (B) disrupts their protective coating. Multivitamins (D) may contain minerals that reduce iron absorption.
An adult patient at an outpatient clinic has been prescribed the antibiotic tetracycline HCI. What should the nurse include in the patient’s teaching plan?
- A. Consume with milk or antacids to prevent gastrointestinal irritation.
- B. Protect your skin from sunlight while on this medication.
- C. Enhance gastrointestinal absorption by taking with orange juice.
- D. Return to the clinic weekly for serum drug level checks.
Correct Answer: B
Rationale: Tetracycline causes photosensitivity, increasing sunburn risk, so sun protection (B) is essential. Milk/antacids (A) reduce absorption by chelating tetracycline. Orange juice (C) contains calcium, impairing absorption. Weekly drug level checks (D) are not required for tetracycline.
A patient with osteoporosis is administered risedronate at 0700 and requests a glass of milk to take with the medication. What should the nurse’s response be?
- A. Advise the patient to only consume water with the medication.
- B. Delay the medication until the patient’s breakfast tray arrives.
- C. Consult with a pharmacist about administering the dose one hour post-meal.
- D. Assign an unlicensed assistive personnel to bring the patient a glass of low-fat milk.
Correct Answer: A
Rationale: This question is identical to Question 1. Risedronate requires plain water on an empty stomach (A) to ensure absorption. Milk (D) reduces efficacy. Delaying for breakfast (B) or post-meal dosing (C) violates guidelines. Note: Duplicate question; consider removing.