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.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
A. Correct. Having regular interdisciplinary team meetings allows healthcare professionals from various disciplines to collaborate, share information, and ensure coordinated care for the client with complex needs.
B. Noting changes in the treatment plan in the client's medical record is important, but it may not directly promote effective communication among staff.
C. Recording the client's progress in the nurses' notes is essential but may not address the need for communication among the entire care team.
D. Posting swallowing precautions at the head of the client's bed is important for the client's safety but does not directly address communication among staff members.
Correct Answer is D
Explanation
A. Incorrect. Rubella is not transmitted via airborne routes. Droplet precautions are typically not required for rubella.
B. Incorrect. Koplik spots are a characteristic of measles, not rubella.
C. Incorrect. Aspirin administration is contraindicated in adolescents with viral infections due to the risk of Reye's syndrome.
D. Correct. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.
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