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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 C

Explanation

A. Recording wound drainage is important, but fluid management takes priority due to the risk of dehydration and electrolyte imbalances.

B. Turning the client every 2 hours is helpful for preventing pressure ulcers, but fluid replacement takes precedence.

C. Clients with ulcerative colitis, especially after surgery, are at high risk for fluid and electrolyte imbalances due to diarrhea and fistula drainage. Ensuring appropriate fluid replacement is vital to maintaining hemodynamic stability.

D. Assessing skin condition is important, but it is secondary to managing fluid and electrolyte balance in this situation.

A. Client's bladder. B. Catheter tubing. C. The client's bed. D. Urinary meatus.

Correct Answer is B

Explanation

A. Client's bladder: The bladder is typically sterile. Infection is most likely introduced from external sources such as the catheter or tubing.
B. Catheter tubing: The catheter and its tubing can harbor bacteria, which increases the risk of a urinary tract infection.
C. The client's bed: Although the bed should be kept clean, it is unlikely to be the direct source of infection.
D. Urinary meatus: The meatus is usually sterile, and infection is more likely to arise from the catheter or tubing.

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Summary of Correct Answers:

Nursing Test Bank

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