A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?

Call the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support.

Determine if prescribed antibiotics were administered preoperatively.

Hold a prescription for dantrolene until fever is reduced.

Prepare ice packs for placement in the client's axillary area.

Answer and Explanation

The Correct Answer is D

Choice A reason: Calling the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support is important in certain situations. However, in this case, the client's immediate concern is the extremely high temperature, which needs to be addressed urgently.

Choice B reason: Determining if prescribed antibiotics were administered preoperatively is a standard procedure, but it is not relevant to the acute situation of muscle rigidity and extremely high temperature caused by succinylcholine. The nurse should focus on immediate cooling measures.

Choice C reason: Holding a prescription for dantrolene until the fever is reduced is not appropriate. Dantrolene is actually used to treat malignant hyperthermia, which is characterized by muscle rigidity and a high temperature. It should be administered immediately in such cases.

Choice D reason: Preparing ice packs for placement in the client's axillary area is a direct and immediate action to help reduce the client's extremely high temperature. Cooling measures are crucial to manage hyperthermia and prevent further complications.

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Correct Answer is B

Explanation

Choice A reason: Asking about the consumption of milk or dairy products is not directly related to the client's serum sodium level. Dairy intake does not typically cause significant changes in sodium levels. Therefore, this question would not help in identifying the cause of the hyponatremia.

Choice B reason: This question is most relevant because excessive water or ice chip intake can lead to dilutional hyponatremia. Ingestion of large amounts of water can dilute the sodium concentration in the blood, resulting in a low serum sodium level. Identifying excessive fluid intake is critical in determining if this is the cause of the client's hyponatremia.

Choice C reason: Inquiring about the number of fresh vegetables in the client's diet is more related to overall nutrition rather than directly linked to sodium levels. While vegetables can be part of a healthy diet, this question would not specifically address the cause of a low serum sodium level.

Choice D reason: The frequency of consuming processed or canned foods, which are typically high in sodium, would generally be expected to increase serum sodium levels rather than decrease them. Therefore, this question does not directly address the issue of a low sodium level.

A. Review the client's fluid intake prior to bedtime. B. Obtain a fingerstick blood glucose level. C. Collect a urine specimen for culture analysis. D. Palpate the bladder above the symphysis pubis.

Correct Answer is D

Explanation

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

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The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

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