The nurse is performing an ongoing assessment on a client admitted to the post-anesthesia care unit at 1655 following abdominal surgery. The nurse documents vital signs every five minutes, as noted in the Vital Signs Record. After reviewing the vital sign trends and notifying the provider, the nurse should anticipate administering what medication?
Midazolam (Versed)
Naloxone (Narcan)
Atropine (Atropen)
Dantrolene (Dantrium)
The correct answer is B.
The Correct Answer is B
A. Midazolam (Versed): This is a benzodiazepine used for sedation. It is not typically used in the post-anesthesia care unit unless there is a need for additional sedation or anxiolysis, which is not indicated based on the scenario.
B. Naloxone (Narcan): This is the correct choice. Naloxone is used to reverse opioid-induced respiratory depression. If the vital signs indicate respiratory depression or decreased oxygen saturation potentially due to opioid medications used during surgery, naloxone would be administered.
C. Atropine (Atropen): This medication is used to treat bradycardia (slow heart rate) and is not typically indicated based on vital signs trends without specific symptoms.
D. Dantrolene (Dantrium): This medication is used to treat malignant hyperthermia, a rare but serious condition often triggered by certain anesthetics. It would be indicated if there were signs of this condition, such as a high fever and muscle rigidity, which is not mentioned in the scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Abdomen soft, surgical dressing has scant amount of old drainage: A soft abdomen and minimal old drainage from the surgical dressing are expected findings postoperatively. They do not indicate an immediate concern that requires prompt action.
B. Client ambulating with minimal assistance, complaints of occasional nausea: Ambulation and occasional nausea are common and generally expected postoperatively. These findings do not require urgent collaboration with the healthcare provider.
C. Crackles bilaterally in bases of lungs, has incisional pain: Crackles in the lungs can indicate fluid accumulation or atelectasis, which may lead to pneumonia or other respiratory complications. This finding, especially combined with recent surgery, requires prompt evaluation and intervention.
D. Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present: A slightly elevated temperature and increased pulse are common after surgery. The presence of bowel sounds is a positive sign indicating the return of gastrointestinal function. These findings are not immediately concerning.
Correct Answer is C
Explanation
A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.
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