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A nurse is caring for a client who is postoperative following administration of general anesthesia.

Exhibits

Select from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Malignant Hyperthermia

The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
Incorrect choices:
- Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
- Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
- Hypercapnia (C): The client is hyperventilating, not hypoventilating.
- Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

Administer dantrolene (C)
- Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
Monitor muscle rigidity (E)
- Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

Incorrect choices:
- Obtain the latex-free cart (A): There is no indication of a latex allergy.
- Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
- Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

Bowel sounds (C)
- Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.
Muscle rigidity (E)
- Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

Incorrect choices:
- Blood pressure (A): While important, it is not a specific marker for MH progression.
- Urine output (B): Useful for assessing kidney function but not directly related to MH management.
- Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

Condition Most Likely Experiencing: Malignant hyperthermia
Two Actions to Take: Administer dantrolene, Monitor muscle rigidity
Two Parameters to Monitor: Bowel sounds, Muscle rigidity

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Correct Answer is B

Explanation

A. Frequency that the problem occurs is important for understanding the issue but does not ensure that the evidence gathered is relevant to the specific clinical question.
B. Relevance to the situation is the most critical factor in evidence-based practice. The evidence must directly apply to the client’s condition, treatment, or intervention to support sound decision-making.
C. Past experience with similar problems can guide nursing judgment but is not a substitute for current, research-based evidence.
D. Related personal values may influence decision-making but should not be prioritized over scientifically validated evidence.

A. Anti-cyclic citrullinated peptide (anti-CCP) antibodies B. C-reactive protein C. Sedimentation rate D. D-Dimer. E. White blood bell count

Correct Answer is ["A","B","C"]

Explanation

A. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis (RA). A positive result supports the diagnosis of RA.
B. C-reactive protein is an inflammatory marker that is elevated in active RA, reflecting inflammation in the body.
C. Sedimentation rate (ESR) is also an inflammatory marker and is often elevated in RA, indicating active inflammation.
D. D-Dimer is a test that assesses for the presence of clot formation and breakdown. It is not used for diagnosing RA.
E. White blood cell count may be slightly elevated in RA due to inflammation, but it is not specific for RA and is less helpful in the diagnosis compared to the other tests.

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Summary of Correct Answers:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is ["A","B","C"]

Explanation

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