A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation. Which of the following assessments is the nurse's priority?

Temperature

Level of consciousness

Heart rate

Oxygen saturation

Answer and Explanation

The Correct Answer is D

A. Temperature: Monitoring temperature is important for detecting infection or hypothermia, but it is not an immediate concern after receiving midazolam, which primarily affects the central nervous and respiratory systems.

B. Level of consciousness: Assessing consciousness is essential after sedation to determine recovery, but airway and breathing take priority over neurologic status in immediate post-sedation care.

C. Heart rate: Monitoring heart rate helps assess cardiovascular stability, yet it is secondary to ensuring adequate oxygenation and ventilation following administration of a sedative.

D. Oxygen saturation: Midazolam can cause respiratory depression and hypoxia. Continuous pulse oximetry is the top priority to detect decreased oxygen levels early, allowing prompt intervention to maintain airway patency and oxygenation.

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Correct Answer is B

Explanation

A. Provide a long-acting NSAID: Long-acting NSAIDs are not appropriate for breakthrough pain because they take time to achieve therapeutic effect and are insufficient for managing acute pain episodes in clients already on opioid therapy.

B. Administer a short-acting opioid: Short-acting opioids are indicated for breakthrough pain in clients using long-acting opioid patches like fentanyl. They provide rapid analgesia without altering the baseline opioid regimen.

C. Apply heat to the patch: Applying heat to a fentanyl patch increases drug absorption and can lead to overdose or serious adverse effects. Heat should be avoided to maintain safe dosing.

D. Replace the patch with a new one: Replacing the patch before the scheduled time can cause excessive opioid dosing and increase the risk of toxicity. Fentanyl patches are typically changed every 72 hours.

A. Naloxone B. Acetylcysteine C. Baclofen D. Dantrolene

Correct Answer is D

Explanation

A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose or respiratory depression. It has no effect on the pathophysiology of malignant hyperthermia.

B. Acetylcysteine: Acetylcysteine is the antidote for acetaminophen toxicity and works by replenishing glutathione. It does not treat malignant hyperthermia.

C. Baclofen: Baclofen is a muscle relaxant used to manage spasticity in conditions such as multiple sclerosis. It is not indicated for malignant hyperthermia.

D. Dantrolene: Dantrolene is the drug of choice for malignant hyperthermia. It acts by reducing calcium release from the sarcoplasmic reticulum in skeletal muscle, which decreases muscle rigidity, hypermetabolism, and prevents life-threatening hyperthermia.

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A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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