A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?

Call the PACU nurse to prepare for prolonged ventilatory support.

Hold a prescription for dantrolene until the fever is reduced.

Prepare ice packs for placement in the patient’s axillary area.

Determine if prescribed antibiotics were administered preoperatively.

None

Answer and Explanation

The Correct Answer is C

C. Prepare ice packs for placement in the patient’s axillary area.This response is crucial because the symptoms described—muscle rigidity and hyperthermia—are indicative of malignant hyperthermia, a serious reaction that can occur after the administration of succinylcholine, especially in conjunction with certain anesthetics. Immediate cooling measures, such as applying ice packs, are essential to help reduce the patient's elevated body temperature.

Rationale for Other Options:

A. Call the PACU nurse to prepare for prolonged ventilatory support.: While preparing for ventilatory support may be necessary later, immediate action to address hyperthermia is critical.
B. Hold a prescription for dantrolene until the fever is reduced.: Dantrolene is the antidote for malignant hyperthermia and should be administered as soon as possible rather than held.
D. Determine if prescribed antibiotics were administered preoperatively.: This action is not relevant to the immediate management of malignant hyperthermia.

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Correct Answer is D

Explanation

Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.

A. Blood pH level B. Hematocrit C. White blood cell (WBC) count D. Platelet count

Correct Answer is C

Explanation

Choice A rationale
Blood pH level is a measure of the acidity or alkalinity of the blood. While it’s an important measure in many medical situations, it’s not directly related to the presence of purulent drainage at a burn wound site.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
The White Blood Cell (WBC) count is a key indicator of infection or inflammation in the body. An elevated WBC count can indicate an infection, which could be the cause of the purulent drainage observed at the burn wound site.
Choice D rationale
Platelet count is a measure of the number of platelets in the blood. Platelets are involved in clotting and wound healing, but they do not directly indicate the presence of an infection that could cause purulent drainage.

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A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?

Rationale for Other Options:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Correct Answer is D

Explanation

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

Correct Answer is C

Explanation

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