A post-anesthesia patient received diazepam for sedation. Family offers grapefruit juice. What is the priority nursing action?

• A. Administer an additional sedative to calm the patient.
• B. Assess sedation level, respiratory effort, and vital signs.
• C. Encourage more fluids to prevent dehydration.
• D. Notify the physician immediately of grapefruit ingestion.

Answer: (B)

Grapefruit juice can inhibit the metabolism of diazepam, increasing its sedative effect and the risk of respiratory depression, which is especially dangerous in a patient who has just undergone anesthesia. The most important first step is to assess how sedated the patient is and how their breathing and vital signs are holding up. Check level of consciousness, respiratory rate and effort, airway patency, oxygen saturation, blood pressure, and heart rate. This assessment tells you whether the patient is tolerating the sedative or if there is airway or breathing compromise that requires immediate intervention or escalation of care.

Administering more sedation would worsen potential respiratory depression. Encouraging more fluids doesn’t address the immediate safety concern. Notifying the physician is important if problems are found, but the priority action is to evaluate the patient’s current sedation and respiratory status first.