A nurse in a post anesthesia care unit is caring for a client who is recovering from general anesthesia and is experiencing malignant hyperthermia. Which of the following actions should the nurse take?
Administer dantrolene sodium IV.
Monitor client for rapid decrease in heart rate.
Infuse chilled lactated Ringer's IV.
Provide oxygen at 12 L/min via Venturi mask.
The Correct Answer is A
A) Administer dantrolene sodium IV: Dantrolene sodium is the treatment of choice for malignant hyperthermia. It acts as a muscle relaxant by inhibiting calcium release from the sarcoplasmic reticulum in skeletal muscles, which helps to halt the hypermetabolic crisis.
B) Monitor client for rapid decrease in heart rate: While monitoring vital signs is essential, a rapid decrease in heart rate is not a typical manifestation of malignant hyperthermia. The nurse should primarily focus on interventions to reduce hyperthermia and stabilize the client's condition.
C) Infuse chilled lactated Ringer's IV: Infusing chilled IV fluids can help lower the body temperature in malignant hyperthermia. However, this intervention is supportive and secondary to the administration of dantrolene sodium, which directly addresses the underlying pathophysiology.
D) Provide oxygen at 12 L/min via Venturi mask: Providing high-flow oxygen is necessary to manage hypoxia and metabolic acidosis associated with malignant hyperthermia. Nonetheless, this action is secondary to administering dantrolene sodium, which is crucial to stopping the hyperthermic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Cleanse the client's finger with an antiseptic swab: The first step in performing a capillary blood glucose test is to cleanse the client’s finger with an antiseptic swab. This reduces the risk of infection and ensures that any contaminants on the skin do not affect the accuracy of the blood glucose reading.
B) Hold the client's finger in a dependent position: Holding the finger in a dependent position can help increase blood flow, but this step is taken after cleansing the finger. The priority is to first clean the area to minimize the risk of infection.
C) Wipe away the first drop of blood: Wiping away the first drop of blood is done to avoid contamination from interstitial fluid and to ensure a more accurate reading. However, this action occurs after the blood sample is obtained, not before the test begins.
D) Place the lancet on the side of the selected finger: While placing the lancet on the side of the finger is important for minimizing discomfort and obtaining an adequate blood sample, it follows the initial steps of cleaning the finger and preparing for the blood draw.
Correct Answer is A
Explanation
A) "I can add lean turkey to a salad.": Lean turkey is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based sources. Including iron-rich foods like lean turkey in the diet helps address iron-deficiency anemia effectively.
B) "I should choose apples over strawberries.": Apples are not particularly high in iron compared to strawberries. While apples provide some nutrients, strawberries contain more vitamin C, which enhances iron absorption from other foods.
C) "I can take an iron supplement with milk to enhance the effect.": Milk and other dairy products can inhibit iron absorption due to their calcium content. It is recommended to take iron supplements with vitamin C-rich beverages like orange juice to enhance absorption.
D) "I should consume coffee or tea with my meals.": Coffee and tea contain compounds like polyphenols that can inhibit iron absorption when consumed with meals. It's better to avoid these beverages around meal times to improve iron absorption.
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