During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

Surgical site infection

Hypercapnia

Malignant hyperthermia

Hypertensive crisis

Answer and Explanation

The Correct Answer is C

Choice A reason: Surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place.

Choice B reason: Hypercapnia is the presence of higher-than-normal levels of carbon dioxide in the blood.

Choice C reason: Malignant hyperthermia is a life-threatening pharmacogenetic reaction to certain general anesthesia, characterized by hypermetabolism resulting in high body temperature, rigid muscles, and rapid heart rate.

Choice D reason: Hypertensive crisis is a severe elevation in blood pressure, often requiring immediate medical attention.

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Correct Answer is B

Explanation

Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.

Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.

Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.

Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.

A. "I start to use the incentive spirometer when I can get out of bed." B. "I breathe deeply and cough every 4 hours." C. "I splint my incision with a pillow to cough." D. "I lie flat in bed to cough and deep breathe."

Correct Answer is C

Explanation

Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.

Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.

Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.

Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.

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During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

Correct Answer is C

Explanation

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We encourage the patient to cough and deep breathe after surgery to prevent:

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