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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Talking with the client's family to determine how the condition affects the client role:
Understanding the client's role within the family is important for comprehensive care, but it is not the most immediate priority in discharge planning. This information can be gathered once the client has the tools to manage their condition effectively.
B) Assessing the impact of the client's body image changes:
While body image is a significant concern for many clients with chronic conditions, it does not directly affect the immediate physical ability to manage daily activities and pain, which is crucial for someone with osteoarthritis.
C) Giving the client printed information about when to use hot and cold therapy:
Providing education on managing symptoms is essential, but simply giving printed information might not address the client's immediate need for practical assistance and adaptations necessary for self-care at home.
D) Consulting occupational therapy to provide assistive devices for self-care:
Ensuring the client has access to assistive devices through occupational therapy is the priority because it directly addresses their ability to perform activities of daily living independently and safely. This intervention can significantly improve the client’s quality of life and reduce the risk of complications.
Correct Answer is D
Explanation
A) Expect optimum visual acuity to return in 4 to 6 weeks: While some improvement in vision can be noted soon after cataract surgery, optimal visual acuity typically returns within 1 to 2 months. It's important to set realistic expectations for recovery. Telling the patient to expect optimum visual acuity to return in 4 to 6 weeks provides a more accurate timeframe for complete visual recovery.
B) Notify the provider if new floaters persist for more than 3 days: The presence of new floaters can be a sign of complications such as retinal detachment or vitreous hemorrhage. However, patients are generally advised to notify their provider immediately if they notice any new floaters, flashes of light, or a sudden decrease in vision, rather than waiting for three days. Immediate notification can lead to prompt evaluation and treatment if necessary.
C) Take aspirin every 4 to 6 hr for mild discomfort: Aspirin is generally avoided postoperatively due to its blood-thinning properties, which can increase the risk of bleeding. Instead, non-aspirin pain relievers like acetaminophen are usually recommended to manage mild discomfort after cataract surgery, as they do not carry the same risk of bleeding complications.
D) Avoid lifting objects that weigh 9.07 kg (20 lb) or more: Patients are advised to avoid lifting heavy objects and engaging in strenuous activities after cataract surgery to prevent increased intraocular pressure, which can interfere with healing and potentially cause complications such as bleeding or dislocation of the intraocular lens. This instruction helps ensure the safety and proper healing of the surgical site.
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