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 B
A. Heart rate is important to monitor, but it is not the most immediate indicator of a life-threatening complication from midazolam. Changes in heart rate can occur, but they are usually secondary to respiratory issues.
B. Oxygen saturation is the priority because midazolam, a benzodiazepine, can cause respiratory depression and airway compromise. Monitoring oxygenation allows for rapid detection of hypoxia, which is the most immediate risk during moderate sedation.
C. Level of consciousness should be assessed, as midazolam causes sedation and can lead to oversedation. However, airway and breathing take priority over neurological assessment in this situation.
D. Temperature is not significantly affected by midazolam and is not an immediate concern during moderate sedation. It is therefore the lowest priority among the options provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose": This statement is not necessary for the administration of nasal cyanocobalamin. Nasal decongestants are not routinely recommended before administering nasal medications.
B. "Plan to self-administer this medication for the next 6 months": While the duration of treatment for pernicious anemia may vary, specifying a timeframe of 6 months for self- administration is not appropriate without considering individualized treatment plans.
C. "Lie down for 1 hour after administering the medication": There is no need for the client to lie down after administering nasal cyanocobalamin. This instruction is not necessary and may not be practical.
D. "Administer the medication into one nostril once per week": This is the correct instruction for administering nasal cyanocobalamin. It is typically given once weekly into one nostril. This
method provides a convenient and effective route for vitamin B12 supplementation in clients with pernicious anemia.
Correct Answer is ["A","B"]
Explanation
A. Advise the client to change positions slowly: The client's symptoms of dizziness and light- headedness upon standing suggest orthostatic hypotension, which can be managed by advising the client to change positions slowly to minimize blood pressure drops upon standing.
B. Check the client for orthostatic hypotension. Monitor the client for dysrhythmias: The client's symptoms, along with the report of waking up at night to void, are suggestive of orthostatic hypotension, a drop in blood pressure upon standing. Checking for orthostatic hypotension and monitoring for dysrhythmias are appropriate nursing actions to assess and manage this condition.
C. Advise the client to restrict potassium intake: Restricting potassium intake is not indicated based on the client's symptoms of dizziness and light-headedness. This action is not relevant to the situation described.
D. Advise the client to take the medication before bedtime: There is no indication in the scenario provided that medication timing is related to the client's symptoms. This action is not relevant to addressing the client's reported symptoms.
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