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: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.

Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.

Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.

Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

A. Describe the use of an elimination diet to find trigger foods. B. Instruct the client to avoid foods with gluten, such as wheat bread. C. Advise the client to limit foods that are high in calcium and iron. D. Explain that the need to restrict fluids is the primary limitation.

Correct Answer is A

Explanation

Choice A reason: Describing the use of an elimination diet to find trigger foods is appropriate for clients with Crohn's disease. This approach helps identify specific foods that may cause or exacerbate symptoms, allowing the client to avoid them and manage their condition more effectively.

Choice B reason: Instructing the client to avoid foods with gluten is not necessary unless they have a confirmed gluten intolerance or celiac disease. Gluten avoidance is not a standard dietary restriction for Crohn's disease.

Choice C reason: Advising the client to limit foods that are high in calcium and iron is not appropriate, as these nutrients are important for overall health. Crohn's disease patients may need to adjust their diet based on individual needs and deficiencies, but blanket limitations on calcium and iron are not recommended.

Choice D reason: Explaining that the need to restrict fluids is the primary limitation is incorrect. In fact, staying well-hydrated is crucial for managing Crohn's disease. Fluid restriction may be necessary in specific cases, but it is not a general guideline.

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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

Correct Answer is C

Explanation

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is A

Explanation

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