A nurse is caring for a postoperative client who received Midazolam as part of the anesthesia. The client is now in the recovery room. While assessing the client, the nurse observes respiratory depression and decreased oxygen saturation. What immediate actions should the nurse take to address this situation?

increase the infusion rate of Midazolam

Administer supplemental oxygen via nasal cannula

Administer naloxone.

Perform a thorough neurological assessment

Answer and Explanation

The Correct Answer is C

A. Increasing the infusion would worsen respiratory depression.

B. Supplemental oxygen is supportive but does not address the cause of respiratory depression.

C. Midazolam can cause respiratory depression, and flumazenil (a benzodiazepine antagonist) is the antidote; however, if naloxone is available, it may reverse sedation quickly in emergency scenarios.

D. While neurological assessment is vital, it does not address the immediate issue of respiratory compromise.

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Correct Answer is ["B","C"]

Explanation

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

A. Blood pressure of 120/84 mm Hg B. Hypoactive bowel sounds. C. Respiratory rate of 9 breaths per minute. D. Urine output 90 mL over the last 2 hours.

Correct Answer is C

Explanation

A. A blood pressure of 120/84 mm Hg is within normal limits and does not require immediate intervention.

B. Hypoactive bowel sounds are a common side effect of sedation and not an immediate concern.

C. A respiratory rate of 9 breaths per minute indicates respiratory depression, which is a life-threatening side effect of Propofol. Immediate intervention is required to maintain oxygenation.

D. Urine output of 90 mL over 2 hours is adequate and does not indicate acute distress.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client receiving Propofol for sedation during a medical procedure. Which assessment finding should the nurse prioritize when monitoring the client's response to Propofol?

Correct Answer is C

Explanation

A nurse is scheduling an older client for a surgical clearance appointment. Which intervention is best to reduce the risk of drug interactions for the client?

A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

A client asks the nurse why they cannot consume food or liquids before surgery. Which response is most appropriate?

During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?

A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

What type of procedural information should be given to a client in preparation for ambulatory surgery? (Select All that Apply)

A nurse is educating a client on patient-controlled analgesia (PCA) pump. Which statement made by the client is correct?