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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Administering the medication 30 minutes earlier may not be appropriate without specific orders from the provider.
B. Infusing the medication at a faster rate is not a solution for adjusting the timing of the dose.
C. Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.

D. Adjusting the medication schedule solely for the convenience of the client without consulting the provider is not recommended.

A. The client is unable to obey commands. B. The client is oriented times three. C. The client opens eyes to sound. D. The client withdraws from pain.

Correct Answer is B

Explanation

A. Incorrect. A Glasgow coma scale (GCS) rating of 15 indicates that the client is able to obey commands.
B. Correct. A GCS rating of 15 indicates that the client is fully conscious and oriented to person, place, and time.
C. Incorrect. Opening eyes to sound is a response associated with the eye-opening component of the GCS score, but this response does not provide information about the client's orientation.
D. Incorrect. Withdrawing from pain is a response associated with the motor component of the GCS score, but this response does not provide information about the client's orientation.

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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?

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