A nurse is assisting with the care of a postoperative client who has developed malignant hyperthermia. Which of the following actions should the nurse take?
Administer meperidine IM.
Instill a warm enema solution.
Apply a cooling blanket.
Ventilate client with 50% oxygen.
The Correct Answer is C
Choice A Reason:
Administer meperidine IM is incorrect. Reason why it's not the answer: Meperidine (Demerol) is not recommended in cases of malignant hyperthermia. It can potentially exacerbate the situation by further increasing muscle rigidity and potentially contributing to the hypermetabolic state. Meperidine can trigger additional release of calcium from the sarcoplasmic reticulum in muscles, worsening the symptoms.
Choice B Reason:
Instill a warm enema solution is incorrect. Reason why it's not the answer: Introducing warm solutions can exacerbate the client's condition by further increasing body temperature. Malignant hyperthermia is characterized by a dangerous increase in body temperature, and adding heat through an enema would only make the situation worse.
Choice C Reason:
Applying a cooling blanket is recommendable. Reason why it's the answer: A cooling blanket is a recommended intervention for managing malignant hyperthermia. Lowering the body temperature is crucial in preventing further complications associated with the high fever. Cooling blankets help dissipate heat from the body, aiding in rapidly reducing the dangerously elevated temperature associated with malignant hyperthermia.
Choice D Reason:
Ventilate client with 50% oxygen is incorrect. Reason why it's not the answer: While providing oxygen support might be necessary as part of managing the overall condition, ventilating with 50% oxygen specifically may not directly address the core issue of rapidly cooling the body during a malignant hyperthermia crisis. Ventilation may be required, but the immediate concern is to cool the body to prevent complications arising from the elevated body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.
Correct Answer is A
Explanation
Choice A Reason:
"The organism that causes TB becomes resistant to antituberculotic medications when you only take one medication." This statement is appropriate.
Tuberculosis bacteria tend to develop resistance to single medications when used alone. Using multiple medications simultaneously helps prevent the bacteria from becoming resistant to any single drug. This strategy, known as combination therapy, is crucial in treating TB effectively and reducing the risk of drug resistance.
When TB bacteria are exposed to just one medication, they can mutate and become resistant to that specific drug. However, using a combination of medications helps ensure that if one medication fails to eliminate some bacteria due to resistance, the other drugs can still work against the resistant strains.
Preventing drug resistance is essential for successful TB treatment and to avoid the need for more complex and less effective medications if resistance develops.
Choice B Reason:
"Taking several antituberculotic medications will protect your liver from toxic effects." This statement is incorrect. While it's true that some antituberculotic medications can have hepatotoxic effects (adverse effects on the liver), the primary reason for using multiple medications in TB treatment isn't solely to protect the liver. The main goal of using multiple medications is to prevent the development of drug-resistant strains of TB bacteria. Protecting the liver is an important consideration in medication selection and monitoring but isn't the primary rationale for multiple medications.
Choice C Reason:
"People who have a severe form of TB need several antituberculotic medications, but those who have less severe TB need just one medication." This statement is incorrect. The severity of TB doesn't determine the number of medications required. The standard treatment approach for TB involves multiple medications, regardless of the severity. This approach aims to prevent the development of drug resistance, ensure effective treatment, and reduce the risk of treatment failure. Using a combination of medications is a fundamental strategy to combat TB effectively.
Choice D Reason:
"Adverse effects occur more often and are more severe when you take only one antituberculotic medication." This statement is incorrect. While it's true that adverse effects can occur with antituberculotic medications, the primary reason for using multiple medications isn't solely to reduce adverse effects. The main concern addressed by using multiple drugs is preventing the development of drug-resistant TB strains. Using a combination of medications reduces the likelihood of resistance developing and increases the effectiveness of treatment, rather than solely minimizing adverse effects.
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