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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dobutamine: Dobutamine is a sympathomimetic medication used to increase cardiac output in conditions such as heart failure or cardiogenic shock. It is not indicated for the management of severe hypertension.
B. Epinephrine: Epinephrine is a sympathomimetic medication used for the management of severe allergic reactions (anaphylaxis), cardiac arrest, and severe asthma exacerbations. It is not indicated for the management of severe hypertension.
C. Dexamethasone: Dexamethasone is a corticosteroid medication used for a variety of
conditions, including inflammation, allergic reactions, and certain cancers. It is not indicated for the management of severe hypertension.
D. Nitroprusside: Nitroprusside is a potent vasodilator used for the rapid reduction of blood pressure in hypertensive emergencies, such as hypertensive crises or malignant hypertension. It acts quickly to dilate both arterial and venous vessels, leading to a rapid decrease in blood pressure. Therefore, it is the appropriate choice for this client with severe hypertension and a severe headache.
Correct Answer is C
Explanation
A. “I can cut the patches in half to save money": Cutting nitroglycerin patches is not recommended as it can alter the medication's release rate and efficacy. Therefore, this statement indicates a misunderstanding and should be corrected.
B. “I will apply a new patch to the same site whenever I replace it": Rotating patch sites is essential to prevent skin irritation and tolerance development. Therefore, this statement indicates a misunderstanding and should be corrected.
C. “I will take the patch off after dinner every night": This statement demonstrates understanding because nitroglycerin patches are typically worn for a certain number of hours (e.g., 12-14 hours) and then removed for a drug-free interval to prevent tolerance development.
D. "I can put a second patch on if I have chest pain": Applying multiple nitroglycerin patches simultaneously can lead to excessive vasodilation and hypotension, which can be dangerous. Therefore, this statement indicates a misunderstanding and should be corrected.
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