A nurse working in the PACU (post-anesthesia care unit)/recovery room unit is monitoring a patient whose vital signs were stable upon arrival from the operating room. The patient’s temperature began to rise steadily the past 20 minutes and continues to rise, the heart monitor shows sinus tachycardia with a rate of 122, the patient’s blood pressure is 86/42, and pulse ox is 88% on 2 L O2 via nasal cannula.
The nurse suspects which genetic condition?

Alpha-1 antitrypsin deficiency.

Malignant hypothermia.

Thalassemia.

Malignant hyperthermia.

Answer and Explanation

The Correct Answer is D

Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.

Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.

It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.

Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.

It does not cause a rise in body temperature or muscle rigidity.

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Correct Answer is D

Explanation

This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.

Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.

Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.

Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.

Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.

A. Patient will exhibit O2 saturation > 92% by discharge. B. Teach pursed-lip breathing prior to discharge. C. Patient will state 2 ways to decrease chance of reinfection by the end of shift. D. Patient will demonstrate pursed-lip breathing.

Correct Answer is C

Explanation

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is D

Explanation

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Correct Answer is C

Explanation

A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?

A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?