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?

A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

• A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
• A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
• A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia

Choice A rationale:

Overweight is not applicable in this situation as the client's BMI indicates a weight status below the normal range.

Choice B rationale:

Obesity class 1 is not applicable in this situation as the client's BMI indicates a weight status below the normal range.

Choice C rationale:

Underweight is the correct choice. A BMI of less than 18.5 is considered underweight according to the World Health Organization (WHO) classification. A BMI of 17.2 falls below this threshold, indicating that the client is underweight. This is a cause for concern, as individuals with Crohn's disease often struggle with maintaining a healthy weight due to malabsorption issues and reduced appetite.

Choice D rationale:

Healthy weight is not applicable in this situation as the client's BMI is below the normal range, indicating an underweight status.