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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?

A.

Heart rate

B.

Oxygen saturation

C.

Level of consciousness

D.

Temperature

E.

None

F.

None

Answer and Explanation

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 C

Explanation

  1. Nausea is a common side effect of lisinopril but does not typically require immediate reporting unless severe or persistent.
  2. Dry cough is a common side effect of lisinopril but does not typically require immediate reporting unless severe or persistent.
  3. Eyelid edema can indicate angioedema, a serious adverse reaction to lisinopril that requires immediate medical attention.
  4. Insomnia is not a common side effect of lisinopril and does not typically require immediate reporting.

Correct Answer is C

Explanation

A. "You will be weighed twice a week while receiving TPN": While weight monitoring may be part of the client's overall care plan, it is not specifically related to TPN administration.
Therefore, this statement is not a priority for inclusion in the teaching.

B. "Your blood sugar will be checked once a day": Blood sugar monitoring may be necessary for clients receiving TPN, especially if they have diabetes or are at risk of hyperglycemia. However, the frequency of monitoring may vary depending on individual factors and is not universally applicable. Therefore, this statement may or may not be accurate for this client and should not be included in the teaching.
C. "You will have a central line placed to receive TPN": TPN solutions are administered through a central venous catheter to ensure adequate and safe delivery of nutrients directly into the bloodstream. Therefore, informing the client about the need for a central line is essential for TPN administration and should be included in the teaching.
D. "Your intake and output will be measured every 2 days": While monitoring intake and output is important for assessing fluid balance and renal function, the frequency of measurement may vary depending on the client's condition and institutional protocols. Therefore, this statement
may or may not be accurate for this client and should not be a priority for inclusion in the teaching.

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