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?
A.
Evaluate the client for orthostatic hypotension.
B.
Check the client for nasal congestion.
C.
Obtain the client’s laboratory results.
D.
Monitor the client’s urine output.
The Correct answer and Explanation is:
The correct answer is A. Evaluate the client for orthostatic hypotension.
Explanation:
Valsartan is an angiotensin II receptor blocker (ARB) used primarily to manage hypertension and heart failure. Administering a dose that is double the prescribed amount, in this case, 160 mg instead of 80 mg, poses a significant risk of severe hypotension (low blood pressure). The priority action in this scenario is to evaluate the client for orthostatic hypotension.
Orthostatic hypotension occurs when a person experiences a significant drop in blood pressure upon standing up from a sitting or lying position. This is particularly important to assess in the context of an overdose of antihypertensive medication like valsartan. When a patient receives an excessive dose of valsartan, it can lead to a more pronounced lowering of blood pressure, increasing the risk of symptoms such as dizziness, lightheadedness, or fainting, especially when changing positions.
The other options, while important, are not as immediate in addressing the acute risk associated with the overdose:
- B. Check the client for nasal congestion: This is a less immediate concern compared to the risk of hypotension. Nasal congestion is not a common side effect or concern associated with valsartan overdose.
- C. Obtain the client’s laboratory results: While important for assessing overall health and organ function, laboratory results will not provide immediate information about the client’s acute response to the overdose. Monitoring for symptoms is more critical initially.
- D. Monitor the client’s urine output: This is important for assessing kidney function, particularly in patients with chronic hypertension or heart failure, but it does not address the immediate risk of severe hypotension resulting from the overdose.
In summary, evaluating the client for orthostatic hypotension is the priority because it directly addresses the immediate risk of severe hypotension that can result from the valsartan overdose. Ensuring the patient’s safety by monitoring blood pressure and preventing or managing symptoms related to hypotension is crucial in this situation.