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.
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Related Questions
Correct Answer is B
Explanation
A. Incorrect. Sitting on the bed next to the client may infringe on the client's personal space and comfort.
B. Correct. Sitting in a chair next to the bed at the client's eye level helps establish a more comfortable and empathetic interaction.
C. Incorrect. Standing at the side of the bed may be perceived as less engaging and could create a power dynamic.
D. Incorrect. Standing at the foot of the bed may be uncomfortable for the client and may impede effective communication.
Correct Answer is ["A","C","E"]
Explanation
A. Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B. Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C. Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D. Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E. Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.
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