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 A

Explanation

The correct answer is Choice A.

Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.

Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.

Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.

Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.

A. INR B. Fibrinogen level C. aPTT D. Platelet count

Correct Answer is A

Explanation

A. Correct. The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value.
B. Fibrinogen level measures clotting potential but is not directly related to warfarin therapy monitoring.
C. Activated Partial Thromboplastin Time (aPTT) is used to monitor other anticoagulants like heparin, not warfarin.
D. Platelet count measures the number of platelets in the blood and is not specifically related to warfarin therapy monitoring.

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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?

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Naxlex Comprehensive Predictor Exams

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