The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?
Drug dependence
Cardiac rhythm
Pulse oximetry
Pain level
The Correct Answer is C
A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.
B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.
C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.
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Related Questions
Correct Answer is D
Explanation
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
Correct Answer is C
Explanation
A. Penicillins are generally safe but are not specific for ototoxicity considerations.
B. Aminoglycosides are avoided in cases of tympanic membrane rupture due to their ototoxic potential, which can lead to hearing loss.
C. Fluoroquinolones, particularly those formulated for otic use, are preferred for tympanic membrane ruptures as they are not ototoxic and are safe for middle ear exposure.
D. Cephalosporins are not typically ototoxic but are less commonly used for tympanic membrane ruptures compared to fluoroquinolones.
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