A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation.
Which of the following assessments is the nurse's priority?
Heart rate
Oxygen saturation
Level of consciousness
Temperature
None
None
The Correct Answer is C
A. Monitoring heart rate is important, but it is not the priority after midazolam administration.
B. Oxygen saturation is essential, but respiratory depression typically follows changes in consciousness.
C. Level of consciousness is the priority assessment because midazolam is a benzodiazepine that causes sedation, and monitoring for excessive sedation or delayed awakening is crucial.
D. Temperature monitoring is not an immediate priority following moderate sedation.
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Related Questions
Correct Answer is B
Explanation
A. Increase in serum sodium: Desmopressin, a synthetic form of vasopressin, works to decrease urine output and increase water reabsorption in the kidneys. Therefore, a therapeutic response to desmopressin would not result in an increase in serum sodium; rather, it would aim to normalize serum sodium levels by reducing excessive urine output.
B. Decrease in urine output: The primary therapeutic goal of desmopressin in the treatment of diabetes insipidus is to decrease urine output by increasing water reabsorption in the kidneys. Therefore, a decrease in urine output would indicate a positive response to the medication.
C. Increase in heart rate: Desmopressin primarily affects kidney function by increasing water reabsorption and does not typically have a direct effect on heart rate. Therefore, an increase in heart rate would not be a manifestation of a therapeutic response to desmopressin.
D. Decrease in blood pressure: Desmopressin works to increase water reabsorption in the kidneys and does not typically cause significant changes in blood pressure. Therefore, a decrease in blood pressure would not be a manifestation of a therapeutic response to desmopressin.
Correct Answer is C
Explanation
A. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
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