A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?

Call the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support.

Determine if prescribed antibiotics were administered preoperatively.

Hold a prescription for dantrolene until fever is reduced.

Prepare ice packs for placement in the client's axillary area.

Answer and Explanation

The Correct Answer is D

Choice A reason: Calling the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support is important in certain situations. However, in this case, the client's immediate concern is the extremely high temperature, which needs to be addressed urgently.

Choice B reason: Determining if prescribed antibiotics were administered preoperatively is a standard procedure, but it is not relevant to the acute situation of muscle rigidity and extremely high temperature caused by succinylcholine. The nurse should focus on immediate cooling measures.

Choice C reason: Holding a prescription for dantrolene until the fever is reduced is not appropriate. Dantrolene is actually used to treat malignant hyperthermia, which is characterized by muscle rigidity and a high temperature. It should be administered immediately in such cases.

Choice D reason: Preparing ice packs for placement in the client's axillary area is a direct and immediate action to help reduce the client's extremely high temperature. Cooling measures are crucial to manage hyperthermia and prevent further complications.

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Correct Answer is C

Explanation

Choice A reason: Tachycardia, or a rapid heart rate, can be a symptom associated with COPD, especially during exacerbations or due to medication effects. However, it is not the primary symptom used to evaluate the effectiveness of COPD treatment.

Choice B reason: Edem of the ankles can occur in COPD patients due to right-sided heart failure (cur pulmonale) associated with chronic lung disease. While it is an important symptom to monitor, it is not the primary indicator of COPD treatment effectiveness.

Choice C reason: Dyspneal, or difficulty breathing, is the most significant and primary symptom of COPD. The primary goal of COPD treatment is to improve the client's breathing and reduce dyspneal. Assessing the client's level of breathlessness provides direct insight into how well the treatment is managing the condition.

Choice D reason: Unilateral diminished breath sounds can indicate localized issues such as pneumothorax or pleural effusion rather than the overall effectiveness of COPD treatment. Bilateral lung sounds and general respiratory status are more relevant to evaluating COPD management.

A. "You will feel drowsy for several hours after surgery." B. "You will need to get out of bed the day after surgery." C. "Your clear liquid diet will include gelatine and tea." D. "Your bowel sounds will be assessed every four hours."

Correct Answer is B

Explanation

Choice A reason: Informing the client that they will feel drowsy for several hours after surgery is important for setting realistic expectations about the immediate postoperative period. However, it is not the most critical information to ensure adherence to the postoperative regimen.

Choice B reason: It is essential to inform the client about the importance of early mobilization, which involves getting out of bed the day after surgery. Early mobilization helps prevent complications such as deep vein thrombosis (DVT), pulmonary embolism, and pneumonia. Emphasizing this information preoperatively ensures that the client understands the necessity of moving and participating in their recovery process, which is vital for successful postoperative outcomes.

Choice C reason: Explaining the components of a clear liquid diet, including gelatine and tea, is helpful for the client to know what to expect in terms of dietary modifications. However, it is not as critical as informing the client about early mobilization, which has a direct impact on their recovery and prevention of complications.

Choice D reason: Informing the client that their bowel sounds will be assessed every four hours is part of routine postoperative care. While it is important for the client to understand the monitoring process, it is not the most crucial aspect to ensure adherence to the postoperative regimen. Early mobilization has a more significant impact on the client’s overall recovery.

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A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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