The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? A)Administer midazolam per protocol B)Check the client's pulse oximeter C)Give more morphine per protocol D)Open the airway with head tilt-chin lift

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Quizplus · Accepted Answer

When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command. (Option A) Adequate oxygenation should be established first before administering additional benzodiazepine for sedation. (Option C) Oxygenation should be assessed before administering additional narcotics for pain. Change in the level of consciousness (restlessness/agitation or lethargy/sedation) can be an indication of excess medication and should be assessed before administering additional drugs. (Option D) If the client is speaking, the airway is open. Opening the airway would be an initial response if there is new onset of snoring respirations (the tongue falling back due to relaxation and blocking the airway). Normal respirations should be effortless and quiet. Educational objective: When new-onset restlessness occurs during procedural sedation, oxygenation should be considered first before administering additional medications. If the client is snoring, opening the airway should be considered.

The Client Has a Dislocated Shoulder and the Nurse Is