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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Alcohol-based mouthwashes can exacerbate dry mouth (xerostomia) and should be avoided.
B. Correct. Providing humidification of the room air can help alleviate the symptoms of xerostomia.
C. Saltine crackers may not significantly help with xerostomia.
D. Esophageal speech is unrelated to xerostomia.
Correct Answer is D
Explanation
A. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Reverse Trendelenburg involves tilting the bed so that the head is elevated and the feet are lower. While this position may help with respiratory difficulties (by allowing the diaphragm to expand), it does not address the concern of aortocaval compression, which is critical during pregnancy.
C. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. The wedge position helps maintain blood flow to the placenta by relieving aortocaval compression, thereby improving venous return and placental perfusion. This is particularly important in pregnant clients, where the uterus can exert significant pressure on these blood vessels in the supine position.
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