What requires nursing action when a patient is receiving cisatracurium (Nimbex) and has no sedative ordered?

When a patient is receiving cisatracurium, a neuromuscular blocker that causes paralysis by blocking neuromuscular transmission, it is crucial to ensure the patient is adequately sedated. Without sedatives, the patient may be unable to communicate discomfort or distress, though they may still be aware of their surroundings and experience pain. Administering sedation is necessary to prevent potential psychological distress and provide comfort since the drug prevents voluntary movement and can lead to a state of awareness without the ability to respond.

In this context, the absence of a sedative order is particularly critical. The other options reflect physiological responses that may require attention, but the fundamental issue is that without sedation, the patient's well-being and comfort while being paralyzed cannot be assured. Therefore, nursing intervention is warranted to secure proper sedation in conjunction with the administration of cisatracurium.