A nurse is planning care for a client who is on droplet precautions. Which of the following actions should the nurse take for this client?

Choice A reason: Protamine sulfate reverses heparin, not midazolam, a benzodiazepine requiring flumazenil for reversal. Assuming protamine is needed risks ineffective response to oversedation, critical to avoid in ensuring rapid reversal and safety in clients post-moderate sedation with midazolam in surgical settings.

Choice B reason: Acetylcysteine treats acetaminophen overdose, not midazolam, reversed by flumazenil. Assuming acetylcysteine is appropriate risks delayed reversal of sedation, potentially causing respiratory depression, critical to prevent in ensuring safe recovery for clients post-moderate sedation with midazolam in postoperative care.

Choice C reason: Flumazenil reverses midazolam’s benzodiazepine effects, critical for managing oversedation or respiratory depression post-moderate sedation. Having it on hand ensures rapid response, essential for client safety, preventing complications, and supporting recovery in surgical settings using midazolam for procedural sedation.

Choice D reason: Naloxone reverses opioids, not midazolam, a benzodiazepine requiring flumazenil. Assuming naloxone is needed risks ineffective treatment of sedation, potentially prolonging respiratory risks, critical to avoid in ensuring proper reversal and safety in clients post-moderate sedation with midazolam.

Choice A reason: Discussing preferences for repositioning schedules is secondary to assessing physical ability in stroke clients, who may have hemiplegia. Evaluating ability ensures safety. Assuming preferences are priority risks unsafe repositioning, potentially causing falls, critical to avoid in ensuring safe mobility and care for stroke patients.

Choice B reason: Evaluating the client’s ability to assist with repositioning is critical post-stroke to assess motor function, ensuring safe technique and preventing injury. This informs whether assistive devices or additional staff are needed, essential for reducing fall risk, promoting recovery, and tailoring care to the client’s physical capacity.

Choice C reason: Repositioning without assistive devices is unsafe for stroke clients with potential weakness or paralysis, risking falls or strain. Evaluating ability is priority. Assuming no devices are needed risks injury, critical to prevent in ensuring safe handling, supporting recovery, and maintaining safety in stroke rehabilitation care.

Choice D reason: Raising side rails ensures safety but is secondary to evaluating the client’s ability to assist, which guides repositioning technique. Assuming rails are the first step risks overlooking physical capacity, potentially leading to unsafe repositioning, critical to avoid in preventing falls and ensuring safe care for stroke clients.