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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.

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Correct Answer is D

Explanation

Choice A rationale:

The provider does not choose a client's healthcare surrogate. Advance directives, including the appointment of a healthcare surrogate, allow individuals to make their own decisions about their medical treatment if they become unable to communicate their wishes. Clients have the right to designate their healthcare surrogate based on their preferences and values. This statement is incorrect as it misrepresents the purpose of advance directives.

Choice B rationale:

A healthcare surrogate does not need to be a family member. The choice of a healthcare surrogate is a personal decision made by the individual. It can be a family member, friend, or any other person whom the individual trusts to make medical decisions on their behalf. There is no requirement that the surrogate must be a family member.

Choice C rationale:

The provider cannot go against the client's wishes regarding advance directives. Advance directives are legally binding documents that outline the individual's preferences for medical treatment, including decisions to withhold or withdraw life-sustaining interventions. Healthcare providers are ethically and legally obligated to respect and follow the directives outlined by the client. Going against the client's wishes would be a violation of their autonomy and legal rights.

Choice D rationale:

The client can resume control of healthcare decisions after a temporary loss of competency if specified in the advance directives. Advance directives often include provisions stating that the individual's decision-making capacity should be

A. Select a 1-inch needle B. Use a 45° angle when inserting the needle C. Use the ventrogluteal site D. Pinch the skin up during injection

Correct Answer is C

Explanation

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.
B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.
C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.
D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about advance directives.Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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