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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Maintain a cool, calm room environment: While a calm environment can be beneficial for overall patient well-being, it is not specifically related to the care of a client on clopidogrel. This instruction does not address the direct needs or precautions associated with clopidogrel use.
B) Provide the client with a soft toothbrush: Clopidogrel is an antiplatelet medication that increases the risk of bleeding. To minimize gum bleeding and oral mucosal damage, it is crucial to use a soft toothbrush to prevent injury. This measure helps to reduce the risk of bleeding complications associated with the medication.
C) Allow the client ample rest periods: While rest is important for overall health, it is not specifically related to the precautions needed for a client on clopidogrel. The primary concern with clopidogrel is managing bleeding risks rather than providing rest.
D) Keep the head of the bed elevated: Elevating the head of the bed is generally useful for managing certain conditions like respiratory issues or gastrointestinal reflux but does not directly relate to the specific needs of a client taking clopidogrel. The focus for clients on clopidogrel should be on preventing bleeding complications.

A. Alternate the use of each nostril when administering the nasal spray each day. B. Do not lie down within thirty minutes of use of the nasal spray. C. Use an nonsteroidal anti-inflammatory drug (NSAID) PRN to reduce any inflammation that may occur. D. Take an over-the-counter antihistamine with each dally dose of nasal spray.

Correct Answer is A

Explanation

A. Alternate the use of each nostril when administering the nasal spray each day: Alternating nostrils can help reduce local irritation and rhinitis associated with the use of nasal spray medications. This practice allows each nostril to recover and reduces the risk of continuous irritation from the spray.
B. Do not lie down within thirty minutes of use of the nasal spray: While this can help ensure the medication is absorbed properly, it is not specifically aimed at reducing rhinitis. It is more important to manage irritation by alternating nostrils.
C. Use a nonsteroidal anti-inflammatory drug (NSAID) PRN to reduce any inflammation that may occur: NSAIDs might not be suitable for everyone, and using them could mask symptoms or lead to additional side effects. They are not a primary strategy for managing rhinitis caused by nasal spray use.
D. Take an over-the-counter antihistamine with each daily dose of nasal spray: Antihistamines are not typically used to manage rhinitis caused by nasal sprays. Additionally, combining medications should be done cautiously and usually under medical advice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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