A nurse is caring for a client who is receiving diazepam for moderate (conscious) sedation. Which of the following actions should the nurse take to assess for an adverse reaction to the medication?

Monitor the client for seizure activity.

Auscultate the client's bowel sounds.

Monitor the client's oxygen saturation.

Check the client's urinary output.

Answer and Explanation

The Correct Answer is C

Diazepam is a benzodiazepine with potential for respiratory depression. It is, therefore, important for the nurse to cautiously monitor the respiratory rate and respond appropriately at each review.

A-Diazepam is an anticonvulsant

B, D- Diazepam has no effect on bowel habits and urinary output

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Correct Answer is D

Explanation

Melena means that the stool has a dark discoloration. This is a sign of gastrointestinal bleeding and should be reported immediately as it can be a serious complication of warfarin therapy.

A,B,C- Are not related to use of warfarin

A. Administer epinephrine 1M. B. Replace the infusion with 0.9% sodium chloride. C. Give diphenhydramine 1M, D. Elevate the client's legs and feet.

Correct Answer is A

Explanation

Epinephrine is administered as a priority in anaphylactic reaction to counter the mechanism of the reaction. Epinephrine helps to reverse the severe allergic response by constricting blood vessels, relaxing smooth muscles in the lungs to improve breathing, and reducing swelling and hives. It is typically administered intramuscularly (IM) into the thigh.

B-Replacing the infusion is important to maintain intravascular volume and blood pressure in the event of hypotension associated with the anaphylactic reaction but not a priority

C-Diphenhydramine helps in managing the cutaneous allergic manifestations but does not address the life-threatening effects

D-Elevation of the client’s feet and legs is not necessary

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A nurse is caring for a client who is receiving diazepam for moderate (conscious) sedation. Which of the following actions should the nurse take to assess for an adverse reaction to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking warfarin. Which of the following findings should the nurse identify as the priority to report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client's respiratory status and stopping the medication infusion. Which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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