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 D
Explanation
A. Dobutamine: Dobutamine is a sympathomimetic medication used to increase cardiac output in conditions such as heart failure or cardiogenic shock. It is not indicated for the management of severe hypertension.
B. Epinephrine: Epinephrine is a sympathomimetic medication used for the management of severe allergic reactions (anaphylaxis), cardiac arrest, and severe asthma exacerbations. It is not indicated for the management of severe hypertension.
C. Dexamethasone: Dexamethasone is a corticosteroid medication used for a variety of
conditions, including inflammation, allergic reactions, and certain cancers. It is not indicated for the management of severe hypertension.
D. Nitroprusside: Nitroprusside is a potent vasodilator used for the rapid reduction of blood pressure in hypertensive emergencies, such as hypertensive crises or malignant hypertension. It acts quickly to dilate both arterial and venous vessels, leading to a rapid decrease in blood pressure. Therefore, it is the appropriate choice for this client with severe hypertension and a severe headache.
Correct Answer is A
Explanation
A. Hypotension: Hypotension can occur as an adverse effect of fentanyl, particularly if the client experiences excessive sedation or respiratory depression. Fentanyl is a potent opioid analgesic
that can cause vasodilation and a decrease in blood pressure, especially when used in high doses or in susceptible individuals.
B. Tachycardia: Tachycardia is not a typical adverse effect of fentanyl. Opioids like fentanyl typically cause bradycardia or have minimal effects on heart rate.
C. Diarrhea: Diarrhea is not a common adverse effect of fentanyl. Opioids more commonly cause constipation due to their effects on gastrointestinal motility.
D. Insomnia: Insomnia is not a typical adverse effect of fentanyl. Opioids typically cause sedation and can lead to drowsiness or somnolence, especially during initial use or when administered in high doses.
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