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 D
Explanation
A. Instruct the client that since the hematocrit remains low, the daily injections are still necessary: A hematocrit of 43% is within the normal range, suggesting the client’s anemia is improving. If the hematocrit were still low, continuing daily injections would be appropriate, but this is not the case here.
B. Notify the healthcare provider of the client’s hematocrit level so the frequency of injections can be reduced: Since the hematocrit is normal, there is no need to notify the healthcare provider specifically for changing the injection frequency based solely on the hematocrit level. Reducing injection frequency should be based on the overall treatment plan and not just the current hematocrit.
C. Advise the client that the medication is having the desired effect, but daily injections will continue to be needed for life for this chronic condition: While the medication may be effective, informing the client about the potential for less frequent injections could improve adherence and reduce discomfort, if the healthcare provider approves.
D. Offer to instruct the client in self-administration techniques to improve the client's sense of control over the painful daily injections: Teaching self-administration can empower the client and potentially reduce discomfort by allowing the client to become more comfortable with the process. It also offers the opportunity for the client to manage their injections more conveniently and with greater control.
Correct Answer is D
Explanation
A. Determine if there is a decrease in serum potassium due to renal compromise: Acetaminophen is not commonly associated with significant renal impairment or changes in serum potassium levels, making this a less relevant consideration.
B. Expect to find an increase in today's activated partial thromboplastin time (APTT) as compared to last quarter's due to bleeding: Acetaminophen does not significantly affect APTT or bleeding risk, so changes in APTT would not be expected due to acetaminophen use.
C. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due to dehydration: Acetaminophen is not known to cause changes in hemoglobin and hematocrit levels or dehydration-related increases in these values.
D. Look for an increase in today's lactic dehydrogenase (LDH) compared to the previous one to assess for possible liver damage: Acetaminophen overdose or chronic high use can lead to liver damage, which would be indicated by elevated LDH levels. Monitoring LDH is appropriate to assess for potential liver damage related to acetaminophen use.
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