The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Drug dependence

Cardiac rhythm

Pulse oximetry

Pain level

Answer and Explanation

The Correct Answer is C

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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Correct Answer is D

Explanation

A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.

B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.

C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.

D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.

A. "I should discuss all over the counter drugs with my healthcare provider." B. "I cannot discontinue medication abruptly." C. "If I miss a dose, I can double up on the next dose." D. "I should take my medications exactly as ordered."

Correct Answer is C

Explanation

A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.

B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.

C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.

D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which situation should be reported to the nursing supervisor as an exposure for the nurse caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS)? The nurse

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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