A nurse is caring for a client who is postoperative following the administration of general anesthesia.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.
Choice B reason
Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.
Choice C reason:
Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.
Choice D reason:
Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.
Correct Answer is D
Explanation
A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.