The nurse is caring for a client who experienced a severe headache. When the prescribed dose of analgesics did not cause relief, the client took double the dosage 1 hour later. The nurse should assess the client for what adverse effect?
An allergic reaction
Anaphylactic reaction
Poisoning
Sedative effects
The Correct Answer is C
A. An allergic reaction is a possible response to medication, but it is not directly related to doubling the dosage.
B. Anaphylactic reaction is a severe and rapid allergic response; while possible, it is not the most likely consequence of an overdose in this context.
C. Poisoning is a likely concern when a client takes double the prescribed dosage of analgesics, especially if the medication has a narrow therapeutic index or is known to cause toxicity at high doses.
D. Sedative effects could occur depending on the analgesic used, but poisoning is a more pressing concern following an overdose.
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Correct Answer is A
Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
Correct Answer is B
Explanation
A. Administer the insulin to the client is incorrect as the nurse should first verify the dosage for safety before administration.
B. Check the dosage with another nurse is correct because double-checking the insulin dosage with another licensed nurse is a critical safety step to prevent medication errors.
C. Check the client's blood sugar again is incorrect; while monitoring blood sugar is important, it is not the immediate next action after preparing the insulin.
D. Ensure a meal tray is available is incorrect; although the client should have a meal ready after insulin administration, the priority action before administering the medication is to confirm the dosage.