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: Cold intolerance is a common symptom of hypothyroidism due to the reduced metabolic rate. While it is important to address this symptom, it does not require immediate intervention compared to respiratory issues.

Choice B reason: Weight gain is also a common symptom of hypothyroidism because of the decreased metabolism. It is significant but not immediately life-threatening, so it does not take priority over more urgent conditions.

Choice C reason: Hypoventilation is the most critical finding because it indicates respiratory depression. This can lead to severe hypoxia and carbon dioxide retention, potentially causing life-threatening complications. Immediate intervention is required to support the client's breathing and prevent respiratory failure.

Choice D reason: Lethargy is a common symptom of hypothyroidism due to the overall slowing of the body's functions. While concerning, it is not as immediately dangerous as hypoventilation, which directly affects the client's ability to breathe effectively.

A. Pain in lower legs when walking. B. Black eschar over ankle ulcer. C. Absent pedal pulses by Doppler. D. Dependent rubor of lower extremities.

Correct Answer is C

Explanation

Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.

Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.

Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.

Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.

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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

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Correct Answer is C

Explanation

The nurse is assessing a client who was admitted yesterday with peripheral artery disease (PAD) and an ulcer on the lateral malleolus. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

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