A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
a. Assess the client's gag reflex.
b. Begin providing discharge instructions.
c. Document findings and continue to monitor.
d. Increase oxygen and notify the provider.
ANS: C
An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.
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