Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?
a. Assist the patient to the bathroom and stay with the patient to prevent falls.
b. Offer a urinal or bedpan and position the patient in bed to promote voiding.
c. Allow the patient up to the bathroom because medication onset is 10 minutes.
d. Ask the patient to wait because catheterization is performed just before the surgery.
ANS: B
The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.
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