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 A
Explanation
A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.
Correct Answer is A
Explanation
A. Leg tenderness: Leg tenderness can be a sign of deep vein thrombosis (DVT), a rare but serious complication associated with oral contraceptives. Therefore, the nurse should report this finding immediately for further evaluation and management to prevent complications such as pulmonary embolism.
B. Cramps: Mild cramps are a common side effect of oral contraceptives and do not typically require immediate reporting unless they are severe or persistent.
C. Nausea: Nausea is a common side effect of oral contraceptives, especially during the initial weeks of use. It usually improves over time and does not typically require immediate reporting unless it is severe or persistent.
D. Abdominal bloating: Abdominal bloating is a common side effect of oral contraceptives and is usually mild and self-limiting. It does not typically require immediate reporting unless it is severe or persistent.
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