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

Explanation

A. While discussing alternatives may be beneficial later, it is not the priority action when consent is withdrawn.

B. Informing the provider ensures the client’s right to withdraw consent is respected and initiates appropriate communication.

C. Explaining why the procedure is necessary may feel coercive and does not prioritize the client’s autonomy.

D. Reminding the client about the signed consent form undermines their right to change their decision.

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

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?

Correct Answer is B

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

A nurse is caring for a client experiencing malignant hyperthermia. Which intervention(s) is/are appropriate for this client? [Select All That Apply]

A client asks the nurse why they cannot consume food or liquids before surgery. Which response is most appropriate?

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 scheduling an older client for a surgical clearance appointment. Which intervention is best to reduce the risk of drug interactions for the client?

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

A nurse is caring for a client who is scheduled for a surgical procedure. 3 Exhibits The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication? Select all that apply.

The nurse is providing preoperative teaching. The client states, "I'm so nervous about my surgery". What is the best response by the nurse?

A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)