A client is receiving diazepam IV, a benzodiazepine anticonvulsant, for status epilepticus. Which intervention is most important for the practical nurse (PN) to implement?
Record hourly blood pressures for the next 4 hours
Measure hourly urinary output for the next 8 hours
Monitor the client’s respiratory rate and effort
Observe the client’s eyes for deviation to the side
The Correct Answer is C
Choice A reason: Recording blood pressures is relevant, as diazepam may cause hypotension, but it is less critical than respiratory monitoring. Status epilepticus requires rapid seizure control, and diazepam’s respiratory depression risk is more immediate, as it can lead to life-threatening hypoxia if not addressed promptly.
Choice B reason: Measuring urinary output monitors renal function but is not urgent in status epilepticus. Diazepam’s primary risk is respiratory depression, not renal effects. Ensuring airway and breathing stability is more critical, as seizures and the drug both threaten respiratory function, making this choice secondary.
Choice C reason: Monitoring respiratory rate and effort is critical, as diazepam, a CNS depressant, can cause respiratory depression, especially in status epilepticus, where seizures already compromise breathing. Hypoventilation risks hypoxia, potentially leading to brain damage or death, making this the most urgent intervention to ensure airway safety.
Choice D reason: Observing eye deviation may indicate ongoing seizures but is less urgent than respiratory monitoring. Diazepam controls seizures, but its side effect of respiratory depression poses an immediate threat. Ensuring adequate ventilation is the priority to prevent hypoxia during acute seizure management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Explaining the medication’s purpose is important but does not address the inappropriate bedtime dosing. Diuretics increase urination, causing nocturia and sleep disruption. Administering as scheduled without review risks client discomfort, making this choice less appropriate than verifying timing.
Choice B reason: Reviewing the prescription with the charge nurse is critical, as bedtime diuretic administration causes nocturia, disrupting sleep. Diuretics, like hydrochlorothiazide, increase urine production, and morning dosing aligns with daily activity, minimizing nighttime disturbance, ensuring safe and effective administration timing.
Choice C reason: Withholding the medication until the next day delays treatment, risking conditions like edema or hypertension. Consulting the charge nurse allows timely clarification of dosing time, ensuring therapeutic benefits without sleep disruption, making this choice overly cautious and unnecessary.
Choice D reason: Administering the diuretic early without confirmation violates protocol, as the prescription specifies bedtime. Unilateral changes risk errors, and morning dosing requires provider approval. Reviewing with the charge nurse is safer, ensuring alignment with clinical intent while addressing sleep concerns.
Correct Answer is B
Explanation
Choice A reason: Observing the client’s ability to open the pill box ensures accessibility but does not address nitroglycerin’s stability. Nitroglycerin degrades when exposed to air, light, or plastic, reducing potency. The original container is critical for maintaining efficacy, making this choice secondary.
Choice B reason: Nitroglycerin must be stored in its original amber glass container to protect it from light, air, and moisture, which degrade its potency. Plastic pill boxes allow exposure, reducing effectiveness for angina relief. Explaining this ensures the client maintains the drug’s therapeutic integrity.
Choice C reason: Reminding the client to refresh nitroglycerin every 30 days is relevant due to its short shelf life, but the priority is proper storage. Without the original container, even fresh pills lose potency, making this choice less critical than ensuring correct storage conditions.
Choice D reason: Labeling the pill box improves usability but does not address nitroglycerin’s stability. Plastic containers expose the drug to air and light, reducing efficacy. Proper storage in the original container is more critical to ensure the drug remains effective for emergency use.
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