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:
Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.
Choice B Reason:
Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.
Choice C Reason:
Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.
Choice D Reason:
Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.
Correct Answer is A
Explanation
Choice A Reason:
Older adults are at increased risk for falls due to decreased vision, balance issues, and decreased reaction time. Placing white or brightly colored tape on the edges of stairs enhances visibility, reducing the risk of missteps and falls.
Choice B Reason:
Placing area rugs on wooden floors is not appropriate. Area rugs on wooden floors can pose a tripping hazard, especially for older adults who might have mobility issues. They can easily slip or trip on loose rugs. Securing rugs with non-slip backing or removing them entirely is a better safety measure.
Choice C Reason:
Running wires and cords under carpeting is not appropriate. Running wires and cords under carpeting can create tripping hazards and increase the risk of electrical issues, including potential overheating and fire hazards. It's safer to secure cords along walls or use cord covers to prevent tripping and reduce potential electrical hazards
Choice D Reason:
Heating systems should be inspected annually to prevent carbon monoxide poisoning and fire hazards. An annual inspection is recommended, especially for older adults who may have impaired smell or cognition, making them less likely to detect gas leaks or heating malfunctions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.