A nurse inadvertently administered 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?
Evaluate the client for orthostatic hypotension.
Check the client for nasal congestion.
Obtain the client's laboratory results.
Monitor the client's urine output.
The Correct Answer is A
A. Correct. The priority is to assess the client for any adverse effects of the medication, such as a drop in blood pressure, which can result in orthostatic hypotension.
B. Incorrect. Nasal congestion is not typically associated with an overdose of valsartan.
C. Incorrect. While obtaining laboratory results might be necessary, it is not the priority action in this situation.
D. Incorrect. Monitoring urine output is important, but assessing for potential complications related to the overdose takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.
B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.
C. Incorrect. Most facilities require more frequent password changes (e.g., every 90 days) to enhance security. Therefore, this statement may be inaccurate depending on the facility's policy.
D. Correct. Firewalls are security systems that are used to protect computer networks from unauthorized access. They are an important component of any computerized documentation system.
Correct Answer is D
Explanation
A. Incorrect. Clamping the catheter tubing might not be necessary in this situation and could potentially cause urinary retention.
B. Incorrect. While obtaining a urine specimen might be necessary if there's suspicion of infection, the immediate concern in this case is the low urine output rather than infection. Therefore, this may not be the first action taken.
C. Incorrect. Continuous bladder irrigation might be indicated for specific situations, such as after certain surgeries, but it is not the first-line intervention based solely on the description provided.
D. Incorrect. Administering a fluid bolus might not be necessary unless there are other signs of dehydration or fluid imbalance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.