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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Huff coughing is a method that forces mucus up your throat by breathing it in, holding it, and actively exhaling. It’s different from a typical cough and more effective in clearing mucus from the lungs. Pursed-lip breathing, which the patient is doing, is not part of the huff coughing technique.
Choice B rationale
Taking several shallow breaths before the next exhalation is not part of the huff coughing technique. The technique involves taking a slow and deep breath until your lungs are about 75% full, holding your breath for two to three seconds, and then exhaling slowly but strongly.
Choice C rationale
Instructing the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times is the correct method for huff coughing. This technique helps to move mucus from the smaller airways to the larger ones, making it easier to cough up and out.
Choice D rationale
Positioning the patient in the semi-Fowler’s position and applying oxygen is not part of the huff coughing technique. While oxygen therapy can be beneficial for patients with COPD, it does not directly aid in the huff coughing technique.
Correct Answer is A
Explanation
Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
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