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 C

Explanation

Choice A rationale:

Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.

Choice B rationale:

Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.

Choice C rationale:

Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.

Choice D rationale:

Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.

A. Beneficence B. Autonomy C. Fidelity D. Veracity

Correct Answer is A

Explanation

A. Correct. Beneficence refers to the ethical principle of doing good and taking actions that promote the well-being and best interests of the client. Sitting with the client to provide comfort aligns with this principle.

B. Incorrect. Autonomy relates to respecting the client's right to make decisions about their own care and treatment.

C. Incorrect. Fidelity pertains to keeping promises and maintaining trust in the nurse-client relationship.

D. Incorrect. Veracity involves truthfulness and honesty in communication with clients, particularly in providing accurate information about their care and condition.

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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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