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 B

Explanation

A. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner. The sacrum is not reliable especially in the dark colored individuals.
B. Palms of the hand is reliable site for assessing for cyanosis.
C. Incorrect. Shoulders are not a common location to assess for cyanosis. Areas with thinner skin, such as the lips, oral mucosa, and nail beds, are usually observed for cyanosis.
D. Incorrect. Areas of trauma are not specifically used to assess for cyanosis. Cyanosis is a clinical sign that indicates inadequate oxygenation of the blood.

A. "Participate in range-of-motion exercises." B. "Place a pillow under your knees while in bed." C. "Remain on bed rest for 24 hours following the procedure." D. "Use an incentive spirometer every 4 hours."

Correct Answer is A

Explanation

A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.

B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.

C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).

D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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