A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation.
Which of the following assessments is the nurse's priority?
Heart rate
Oxygen saturation
Level of consciousness
Temperature
None
None
The Correct Answer is C
A. Monitoring heart rate is important, but it is not the priority after midazolam administration.
B. Oxygen saturation is essential, but respiratory depression typically follows changes in consciousness.
C. Level of consciousness is the priority assessment because midazolam is a benzodiazepine that causes sedation, and monitoring for excessive sedation or delayed awakening is crucial.
D. Temperature monitoring is not an immediate priority following moderate sedation.
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Related Questions
Correct Answer is A
Explanation
A. This statement indicates correct understanding. Remaining upright after taking ferrous gluconate reduces the risk of esophageal irritation or discomfort, which can occur if the medication refluxes into the esophagus. This is an important teaching point for clients taking iron supplements.
B. This statement is incorrect. Antacids can interfere with the absorption of ferrous gluconate by altering stomach acidity, which is necessary for optimal iron absorption. Clients should avoid taking antacids within two hours of iron supplements.
C. This statement is incorrect. Milk and other calcium-containing products inhibit the absorption of iron. It is recommended to take ferrous gluconate with water or a source of vitamin C, such as orange juice, to enhance absorption.
D. This statement is incorrect. Black stools are a common and harmless side effect of taking iron supplements and do not typically require notifying the provider unless accompanied by other symptoms like abdominal pain or blood in the stool.
Correct Answer is C
Explanation
A. Epoetin alfa is not administered intranasally.
B. Epoetin alfa is not administered orally because it would be destroyed by digestive enzymes and have poor absorption.
C. Epoetin alfa is typically administered subcutaneously, as it is a recombinant human erythropoietin that stimulates red blood cell production.
D. Epoetin alfa is not administered trans dermally.
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