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?

Choice A reason

Abdomen area is not appropriate: Assessing skin turgor on the abdomen is not commonly performed. The abdomen may not be the most accurate site for assessing skin turgor, especially in older adults, as it can be influenced by factors such as body fat distribution.

Choice B reason:

Shoulder are is not appropriate: The shoulder is not a typical site for assessing skin turgor. It is generally not used for this purpose, as it may not provide reliable results

Choice C reason:

Stomach is not the correct answer.: Assessing skin turgor on the stomach is also not commonly performed. The abdomen or stomach may not be the most accurate site for assessing skin turgor, especially in older adults.

Choice D reason

When assessing skin turgor in an older adult client, the nurse should lift the skin on the neck to evaluate its elasticity and hydration status. Skin turgor is a measure of skin's elasticity and is commonly used as an indicator of hydration in both adults and older adults.

To assess skin turgor, the nurse will gently pinch a small amount of skin on the back of the client's hand or the front of the chest (sternum). However, since the options listed do not include these areas, the closest alternative for an older adult would be the neck.

The correct answer is choice D, spotting.

Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.

This can cause painless, bright red vaginal bleeding, usually in the third trimester.

Spotting is a sign of placenta previa and should be reported to the provider immediately.

Choice A is wrong because nausea is not a specific finding of placenta previa.

Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.

Choice B is wrong because polyhydramnios is not a finding of placenta previa.

Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.

Choice C is wrong because uterine tenderness is not a finding of placenta previa.

Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.

This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.