A nurse is caring for a client who is postoperative following the 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 []

Rationale:

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: Malignant hyperthermia (MH) itself does not inherently include hypercapnia as a defining characteristic. However, during an episode of malignant hyperthermia, metabolic acidosis can occur due to the increased production of lactic acid and carbon dioxide as byproducts of the hypermetabolic state. This acidosis can potentially lead to respiratory compensation mechanisms, such as increased respiratory rate and depth, to attempt to eliminate excess carbon dioxide from the body. In some cases, if the compensatory respiratory efforts are insufficient to adequately remove carbon dioxide, hypercapnia can develop as a secondary complication of malignant hyperthermia.

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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Free Nursing Study Resources

Correct Answer is B

Explanation

A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.

A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities.

When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may aﬀect the client's bowel function.

A. Encourage the client to take a cool sponge bath each morning. B. Administer opioid analgesia. C. Increase the client's dietary iron intake. D. Restrict the client's intake of foods high in purines.

Correct Answer is C

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Correct Answer is B

Explanation

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Correct Answer is C

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