hard · NCLEX-RN risk-reduction

A nurse is reviewing the electronic health record (EHR) of a 29-year-old female client scheduled for moderate procedural sedation in an outpatient clinic. Which of the following findings are critical safety cues that the nurse must escalate to the performing provider before sedation begins? Select all that apply.

  1. A serum potassium level of 3.9 mEq/L reported on a lab panel drawn 24 hours ago.
  2. The client reports having a cup of black coffee and a slice of buttered toast 2 hours ago.
  3. A positive urine human chorionic gonadotropin (hCG) test indicating pregnancy.
  4. A documented history of mild nausea after taking oral codeine for a dental procedure five years ago.
  5. A pre-procedure blood pressure of 86/48 mm Hg and a heart rate of 114/min in a client who is actively vomiting.

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