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 A

Explanation

A. Reviewing all current medications and supplements allows the healthcare team to identify potential drug interactions and adjust treatment.

B. While a medication schedule is helpful, it does not address the risk of interactions during pre-surgical planning.

C. Instructing the client to avoid OTC medications is overly broad and may lead to unnecessary medication omission.

D. Filling prescriptions locally does not address the risk of interactions directly.

A. Client with oxygen saturation of 8996 B. Client with a blood pressure of 8.8/58 mm Hg C. Client with temperature of 102 F D. Client with respiratory rate of 12 breaths/min

Correct Answer is A

Explanation

A. An oxygen saturation of 89% indicates hypoxemia, which poses an immediate threat to oxygenation and requires urgent intervention.

B. Hypotension is concerning but less critical than hypoxemia in this scenario.

C. A fever of 102°F requires monitoring and management but is not an immediate life threat.

D. A respiratory rate of 12 breaths/min is normal for an adult and does not require immediate action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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

Correct Answer is A

Explanation

A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

A nurse is caring for a client experiencing malignant hyperthermia. Which intervention(s) is/are appropriate for this client? [Select All That Apply]

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.)

The nurse is providing preoperative teaching. The client states, "I'm so nervous about my surgery". What is the best response by the nurse?

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 caring for a client who has provided informed consent in preparation for a procedure. The client states, "I have decided not to have the procedure." Which action should the nurse take?