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

Vital Signs 0830:

Temperature 36.9° C (98.5° F) Heart rate 134/min

Respiratory rate 28/min

Blood pressure 92/52 mm Hg Pulse oximetry 89% on room air

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.

Select:

Condition Most Likely Experiencing

2 Actions to Take

2 Parameters to Monitor

Obtain the latex free cart

Paralytic ileus

Nausea and vomiting

Hypercapnia

Nasogastric (NG) tube

Malignant hyperthermia

Administer ondansetron

Administer dantrolene

Latex allergy

Urticaria

Muscle rigidity

Bowel sounds

Answer and Explanation

Correct Answer : F,H,K,M

A: Obtain the latex free cart is incorrect. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.
B: Paralytic ileus is incorrect. Paralytic ileus is not the primary condition that the client is experiencing, but a possible secondary complication of malignant hyperthermia.
C: Nausea and vomiting is incorrect. Nausea and vomiting are common postoperative symptoms that may or may not be related to malignant hyperthermia.
D: Hypercapnia is incorrect. Hypercapnia is a condition of elevated carbon dioxide levels in the blood that can result from hypoventilation or respiratory failure. The client's respiratory rate is high, not low, indicating hyperventilation rather than hypoventilation.
E: Nasogastric (NG) tube is incorrect. An NG tube may be indicated for paralytic ileus or bowel obstruction, but not for malignant hyperthermia.
F: Malignant hyperthermia is correct. The client's vital signs indicate a possible malignant hypertermia reaction, which is a rare but life-threatening complication of general anesthesia that causes a rapid rise in body temperature, muscle rigidity, tachycardia, tachypnea, and hypoxia.
G: Administer ondansetron is incorrect. Ondansetron is an antiemetic medication that can help with nausea and vomiting, but it does not address the underlying cause of malignant hyperthermia.
H: Administer dantrolene is correct. Dantrolene is the antidote for malignant hyperthermia and should be given as soon as possible to stop the metabolic crisis and lower the body temperature.
I: Latex allergy is incorrect. Latex allergy is a hypersensitivity reaction to latex products that can cause urticaria, angioedema, bronchospasm, or anaphylaxis. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.
J: Urticaria is incorrect. Urticaria is a skin rash that can be caused by allergic reactions, infections, or other factors. There is no evidence that the client has urticaria or that it is related to malignant hyperthermia.
K: Muscle rigidity is correct. Muscle rigidity is one of the signs of malignant hyperthermia and should be monitored closely by the nurse.
L: Bowel sounds is correct. Bowel sounds should be assessed regularly by the nurse to detect any signs of paralytic ileus, which is a potential complication of malignant hyperthermia that causes intestinal obstruction and abdominal distension.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

A. Clean the mouthpiece with warm water every 2 weeks B. Wait 10 seconds between inhalations C. Take a quick inhalation when pressing the dispenser D. Take the medication 15 min before playing sports

Correct Answer is D

Explanation

Take the medication 15 min before playing sports.

A. Clean the mouthpiece with warm water every 2 weeks. This is incorrect because the mouthpiece should be cleaned with warm water at least once a week, or more often if used frequently, to prevent bacterial growth and contamination.
B. Wait 10 seconds between inhalations. This is incorrect because the recommended time interval between inhalations is 1 minute, not 10 seconds, to allow adequate absorption of the medication and prevent overdose or side effects.
C. Take a quick inhalation when pressing the dispenser. This is incorrect because a quick inhalation can cause poor coordination of hand-mouth movement and result in less medication reaching the lungs. The nurse should instruct the child to take a slow, deep inhalation when pressing the dispenser, hold their breath for 10 seconds, and exhale slowly.
D. Take the medication 15 min before playing sports. This is correct because albuterol is a short-acting bronchodilator that can prevent exercise-induced bronchospasm. The nurse should teach the child to take the medication before engaging in physical activity that can trigger asthma symptoms, such as sports, cold weather, or allergens.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy.Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

A nurse is providing phone advice for a client who is pregnant. Exhibits here Complete the following sentence by using the copy pasting from the list of options. The client is at risk for experiencingelectrolyte imbalancedue to the

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds.Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor.Which of the following findings is a contraindication for administration of this medication?

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?