A nurse is caring for a client who is postoperative following a procedure that required moderate sedation using midazolam. Which of the following should the nurse have on hand?

Protamine sulfate.

Acetylcysteine.

Flumazenil.

Naloxone.

Answer and Explanation

The Correct Answer is C

Choice A reason: Protamine sulfate reverses heparin, not midazolam, a benzodiazepine requiring flumazenil for reversal. Assuming protamine is needed risks ineffective response to oversedation, critical to avoid in ensuring rapid reversal and safety in clients post-moderate sedation with midazolam in surgical settings.

Choice B reason: Acetylcysteine treats acetaminophen overdose, not midazolam, reversed by flumazenil. Assuming acetylcysteine is appropriate risks delayed reversal of sedation, potentially causing respiratory depression, critical to prevent in ensuring safe recovery for clients post-moderate sedation with midazolam in postoperative care.

Choice C reason: Flumazenil reverses midazolam’s benzodiazepine effects, critical for managing oversedation or respiratory depression post-moderate sedation. Having it on hand ensures rapid response, essential for client safety, preventing complications, and supporting recovery in surgical settings using midazolam for procedural sedation.

Choice D reason: Naloxone reverses opioids, not midazolam, a benzodiazepine requiring flumazenil. Assuming naloxone is needed risks ineffective treatment of sedation, potentially prolonging respiratory risks, critical to avoid in ensuring proper reversal and safety in clients post-moderate sedation with midazolam.

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Correct Answer is D

Explanation

Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.

Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.

Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.

Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.

A. The client has decreased bowel sounds in all four quadrants. B. The client’s total urinary output is 75 mL in the last 3 hours. C. The client reports a pain level of 4 on a scale of 0 to 10. D. The client’s dressing has a scant amount of dark red drainage. E. None F. None

Correct Answer is B

Explanation

Choice A reason: Decreased bowel sounds 6 hours post-hysterectomy are expected due to anesthesia and surgical manipulation, typically resolving within 24-48 hours. Urinary output of 75 mL in 3 hours is more urgent. Assuming bowel sounds require reporting risks overlooking critical renal issues, potentially delaying intervention in postoperative care.

Choice B reason: Urinary output of 75 mL in 3 hours (25 mL/hour) is below the expected 30-50 mL/hour, indicating potential renal compromise or obstruction post-hysterectomy, requiring immediate reporting. This ensures timely intervention, critical for preventing acute kidney injury, ensuring fluid balance, and supporting recovery in postoperative clients.

Choice C reason: A pain level of 4 is moderate and manageable with routine analgesics, not requiring immediate provider reporting compared to low urinary output. Assuming pain is urgent risks misprioritizing, potentially delaying critical interventions for renal issues, essential for ensuring comprehensive postoperative care and client stability.

Choice D reason: Scant dark red drainage is expected 6 hours post-hysterectomy, indicating minor surgical oozing, not requiring immediate reporting. Low urinary output is priority. Assuming drainage is concerning risks diverting focus from renal complications, critical for preventing kidney injury and ensuring safe recovery in postoperative clients.

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A nurse is caring for a client who is postoperative following a procedure that required moderate sedation using midazolam. Which of the following should the nurse have on hand?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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