A nurse inadvertently administers 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?
Monitor the client’s urine output
Check the client for nasal congestion
Evaluate the client for orthostatic hypotension
Obtain the client’s laboratory results
The Correct Answer is C

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct first action for the charge nurse to take in response to an increase in facility-acquired catheter infections is toidentify possible precipitating factors related to the infections. This is because understanding the root cause of the problem is crucial before implementing any changes or interventions. By identifying the factors contributing to the increase in infections, the nurse can then develop targeted strategies to address these specific issues.
Now, let’s discuss why the other options are not the first actions to take:
-
Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.
-
Meet with providers to discuss measures to decrease the infections: This could be a subsequent step after identifying the precipitating factors. Meeting with providers without concrete data or understanding of the problem may lead to ineffective solutions.
-
Revise the current policy for catheter care: Policy revision should be based on evidence and identified needs. It would be premature to revise policies without first understanding what factors are contributing to the increase in infections.
In summary, the first step in addressing a problem is always to understand its causes. Only then can effective solutions be developed and implemented.
Correct Answer is D
Explanation

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
