Exhibits

Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.

Drag from the Word Choices to complete the sentence.

The client demonstrates effective epidural anesthesia by

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A. Measuring vital signs before the walk is not specifically necessary unless the client exhibits symptoms of orthostatic hypotension or other concerns.

B. Reporting dizziness or lightheadedness is essential for ensuring the client's safety during ambulation.

C. Teaching the client about orthostatic hypotension helps them understand the risks and manage symptoms during activity.

D. Offering assistance to void before ambulating helps reduce the risk of falls and ensures comfort during the walk.

E. Applying a gait belt is crucial to ensure the client's safety and provide support during ambulation.

Condition Most Likely Experiencing: Malignant Hyperthermia

• The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
• While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
• Incorrect choices:
  • Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
  • Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
  • Hypercapnia (C): The client is hyperventilating, not hypoventilating.
  • Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

1. Administer dantrolene (C)
   • Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
2. Monitor muscle rigidity (E)
   • Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

• Incorrect choices:
  • Obtain the latex-free cart (A): There is no indication of a latex allergy.
  • Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
  • Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

1. Bowel sounds (C)

   • Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.

2. Muscle rigidity (E)

   • Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

• Incorrect choices:
  • Blood pressure (A): While important, it is not a specific marker for MH progression.
  • Urine output (B): Useful for assessing kidney function but not directly related to MH management.
  • Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

• Condition Most Likely Experiencing: Malignant hyperthermia
• Two Actions to Take:Administer dantrolene, Monitor muscle rigidity
• Two Parameters to Monitor: Bowel sounds, Muscle rigidity