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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fluid volume excess is not related to the therapeutic use of galantamine hydrobromide. This medication is used to improve cognitive function in clients with Alzheimer's disease, which is more closely associated with disturbed thought processes.
Choice B reason: Disturbed thought processes are directly related to the therapeutic use of galantamine hydrobromide. This medication helps enhance cognitive function by increasing the levels of acetylcholine in the brain, which is crucial for memory and thinking. Clients with Alzheimer's disease often experience cognitive decline, and this medication aims to mitigate those symptoms.
Choice C reason: Altered breathing pattern is not addressed by the therapeutic use of galantamine hydrobromide. This medication is specifically used to treat cognitive symptoms associated with Alzheimer's disease, rather than respiratory issues.
Correct Answer is A
Explanation
Choice A reason: Starting pelvic floor exercises might be beneficial in the long term for improving urinary control after TURP. However, immediately following the surgery and while the indwelling catheter is in place, it may not be the appropriate time to begin these exercises. The nurse should clarify when and how to start pelvic floor exercises.
Choice B reason: Reporting fever or chills is crucial because these symptoms could indicate an infection, which requires prompt medical attention. This statement reflects an understanding of important post-operative care instructions and does not need clarification.
Choice C reason: Increasing fluid intake to help with hydration is important for clients with a urinary catheter. Adequate hydration helps flush the urinary system and prevent complications such as urinary tract infections. This statement does not need clarification.
Choice D reason: Taping the urinary catheter securely to the thigh helps prevent tension on the catheter and reduces the risk of accidental dislodgement or trauma. This instruction is correct and does not need clarification.
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