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

A. Severe abdominal pain in the right lower quadrant: This could indicate appendicitis, a surgical emergency, or another acute abdominal condition requiring immediate intervention. The sudden onset and severe nature of pain are concerning.
B. Blood pressure 115/76 mm Hg: This is within normal limits and does not indicate immediate instability.
C. Capillary refill 2 seconds: This indicates adequate peripheral perfusion and is not an urgent concern.
D. Radial and pedal pulses 2+: Normal peripheral pulses do not require immediate follow-up.
E. Temperature 100.8° F (38.2° C): Fever suggests an inflammatory or infectious process, such as appendicitis or another intra-abdominal infection.
F. Respirations 28 breaths/minute with shallow breathing: Increased respiratory rate and shallow breathing may indicate pain-related distress or developing peritonitis, a life-threatening complication of appendicitis.
G. Feels anxious: Anxiety may be a response to pain but is not an immediate concern requiring urgent intervention.
H. Heart rate 121 beats/minute: Tachycardia could be a response to pain, infection, or developing sepsis, which requires urgent evaluation.
I. Vomiting small amounts of green bile: While bile-stained emesis can indicate an obstruction, other findings (pain, fever, tachycardia, and respiratory distress) are higher priority.

Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.

Appendicitis is the most likely diagnosis, given the right lower quadrant (RLQ) pain, fever, nausea, vomiting, and CT findings of a dilated appendix with fat stranding. CT scan results confirming appendix dilation and fat stranding indicate inflammation, which is characteristic of appendicitis. WBC count is often elevated in appendicitis due to the inflammatory response and potential infection. Gastroenteritis is unlikely since there is no history of diarrhea or recent illness, and pneumonia is not relevant given the primary abdominal symptoms.

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume. Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.
F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Administering pain medication after activity helps manage pain more effectively and encourages the client to engage in necessary postoperative activities.

Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.

Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.

Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.

Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.

Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.

Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.

A. Frequency that the problem occurs is important for understanding the issue but does not ensure that the evidence gathered is relevant to the specific clinical question.
B. Relevance to the situation is the most critical factor in evidence-based practice. The evidence must directly apply to the client’s condition, treatment, or intervention to support sound decision-making.
C. Past experience with similar problems can guide nursing judgment but is not a substitute for current, research-based evidence.
D. Related personal values may influence decision-making but should not be prioritized over scientifically validated evidence.

A. Obtaining a history of recent bleeding and anticoagulant use is essential but should not delay immediate stabilization.
B. Elevating the head of the bed to 30 degrees helps reduce intracranial pressure and promotes cerebral perfusion, which is a priority in stroke management.
C. Sequential compression devices (SCDs) are useful for preventing deep vein thrombosis (DVT) but are not an immediate intervention.
D. Elevating dependent joints on the affected side does not have immediate benefits for stroke management.

A. Obtaining a 12-lead ECG is done after return of spontaneous circulation (ROSC), not during defibrillation.
B. Interrogating the pacemaker is important but is not the immediate priority during resuscitation.
C. Defibrillator pads should be placed at least 1 inch away from the pacemaker to prevent damage to the device and ensure effective defibrillation.
D. A doughnut magnet is used to deactivate pacemaker functions in cases like pacemaker-mediated tachycardia but is not relevant in ventricular fibrillation.