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

Answer and Explanation

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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Correct Answer is D

Explanation

A. This statment appeasr to challenge the patient's autonomy hence it is not appropriate.

B. This response may induce fear or guilt in the client, which is not conducive to addressing the underlying reasons for medication refusal.
C. This response may minimize the client's concerns and does not address the root cause of their refusal.
D. It is important to notify the provider so that additional interventions can be sought

A. The client had a decreased neutrophil count before the medication was administered. B. The client had chemotherapy 12 hr before the medication was administered. C. The vial was out of the refrigerator for 2 hr before the medication was administered. D. The client reported feeling nauseous after the medication was administered.

Correct Answer is C

Explanation

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.

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A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who refuses to take their prescribed medications. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

Correct Answer is C

Explanation

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A nurse is assessing a client who received midazolam IV for moderate (conscious) sedation.
Which of the following assessments is the nurse's priority?