A nurse is caring for a postoperative client who received Midazolam as part of the anesthesia. The client is now in the recovery room. While assessing the client, the nurse observes respiratory depression and decreased oxygen saturation. What immediate actions should the nurse take to address this situation?

increase the infusion rate of Midazolam

Administer supplemental oxygen via nasal cannula

Administer naloxone.

Perform a thorough neurological assessment

Answer and Explanation

The Correct Answer is C

A. Increasing the infusion would worsen respiratory depression.

B. Supplemental oxygen is supportive but does not address the cause of respiratory depression.

C. Midazolam can cause respiratory depression, and flumazenil (a benzodiazepine antagonist) is the antidote; however, if naloxone is available, it may reverse sedation quickly in emergency scenarios.

D. While neurological assessment is vital, it does not address the immediate issue of respiratory compromise.

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Correct Answer is ["B","C"]

Explanation

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

A. Administer prescribed analgesic medication B. Administer oxygen at 2 L/min. C. Raise the head of the bed. D. Encourage coughing and deep breathing

Correct Answer is C

Explanation

A. Administering analgesics is not a priority in managing low oxygen saturation.

B. Administering oxygen is important but should follow positioning to improve oxygenation.

C. Raising the head of the bed improves lung expansion and is the priority intervention.

D. Coughing and deep breathing can follow after oxygenation is stabilized.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

The nurse is caring for a client who reports experiencing oral itching and swelling after consuming bananas and kiwis. Which allergy should the nurse suspect the client is at risk for?

A nurse is educating a client on patient-controlled analgesia (PCA) pump. Which statement made by the client is correct?

A client is receiving diazepam prior to a procedure. Which side effect should the nurse be most concerned about?

What type of procedural information should be given to a client in preparation for ambulatory surgery? (Select All that Apply)

A nurse is working in a preoperative unit. Which task is most appropriate to be delegated to unlicensed assistive personnel (UAP)?

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

A nurse is caring for a client who has provided informed consent in preparation for a procedure. The client states, "I have decided not to have the procedure." Which action should the nurse take?