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 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.

A. The teenager is probably difficult for a single mother to manage, so the family will be referred to social services. B. Further assessment needs to be done to determine if the family needs assistance. C. The mother needs assistance to cope with the stress of raising a teenager on her own. D. The mother will need financial support while she takes off work to care for her son.

Correct Answer is B

Explanation

This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.

Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.

Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.

Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own. How should the nurse interpret this family’s functionality?

Correct Answer is B

Explanation

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

The nurse educator is presenting information to a group of nursing students regarding uninsured and underinsured clients. The nurse educator emphasizes that a lack of insurance or lack of sufficient insurance is:

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

A new nurse is working in a hospital. Which of the following actions by the nurse is NOT related to one of the National Patient Safety Goals?

An elderly man fell during his hospitalization and has died from a head injury sustained in the fall. What is the role of the risk manager in this situation?

The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?