A male client with dementia is admitted to the emergency department (ED) because he accidentally self-administered several doses of diltiazem. Which intervention is most important for the nurse to implement?
Frequently assess the patient's blood pressure.
Observe the client for signs of gastric irritation.
Monitor electrocardiogram (ECG) continuously.
Assess for changes in level of consciousness.
The Correct Answer is C
A. Frequently assess the client’s blood pressure: While monitoring blood pressure is important, it is not as critical as monitoring the ECG in cases of diltiazem overdose. Diltiazem is a calcium channel blocker that can lead to significant cardiac effects.
B. Observe the client for signs of gastric irritation: This is relevant for some medications, but in the case of diltiazem overdose, the primary concern is the potential for severe cardiac effects rather than gastric irritation.
C. Monitor electrocardiogram (ECG) continuously: Diltiazem overdose can lead to serious cardiac arrhythmias, such as bradycardia, AV block, or other conduction disturbances. Continuous ECG monitoring is crucial to detect these potentially life-threatening complications.
D. Assess for changes in level of consciousness: While important, changes in level of consciousness are secondary to the immediate need to monitor cardiac function closely in the context of diltiazem overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Platelet count of 100,000/mm³ (100 x 10^9/L): Enoxaparin is a low molecular weight heparin used to prevent deep vein thrombosis (DVT), and a low platelet count (thrombocytopenia) can be a serious adverse effect of anticoagulant therapy. A platelet count of 100,000/mm³ is below the normal range (150,000 to 400,000/mm³) and indicates potential thrombocytopenia, which could increase the risk of bleeding and may warrant immediate action.
B. Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L): This BUN level is at the upper limit of normal but does not typically require immediate action unless there are other symptoms or significant changes in kidney function.
C. Serum creatinine 1.0 mg/dL (88.4 μmol/L): This value is within the normal range for serum creatinine and does not indicate an immediate concern related to enoxaparin.
D. Hematocrit 45% (0.45 volume fraction): This hematocrit level is within the normal range and does not typically require immediate action.
Correct Answer is A
Explanation
A. Leave the patch in place and administer a PRN dose of sublingual nitroglycerin: It is appropriate to administer a PRN dose of sublingual nitroglycerin for immediate relief of acute angina while leaving the transdermal patch in place. The sublingual nitroglycerin acts quickly to relieve chest pain, while the transdermal patch provides a longer, more sustained effect.
B. Reassure the client that the patch will begin to take effect within a few minutes: The transdermal patch generally takes 30 to 60 minutes to reach therapeutic levels, which is not suitable for immediate relief of acute chest pain. Therefore, reassurance alone may not address the current symptoms effectively.
C. Withhold further doses of nitroglycerin until contacting the healthcare provider: Withholding further doses of nitroglycerin without assessing the situation can delay appropriate relief of chest pain. Immediate intervention is necessary, and it is appropriate to use sublingual nitroglycerin as needed.
D. Obtain another transdermal patch and position it on the patient's left upper chest: Applying an additional transdermal patch is not necessary and could lead to excessive nitroglycerin exposure. The current patch should be left in place, and sublingual nitroglycerin can be used for acute symptoms.
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