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: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

A. "I should apply drying agents on my draining lesions every day." B. "I need to make sure no one else comes in contact with my skin rash." C. "Tanning booths are okay to use, but I need to stay out of direct sunlight." D. "If I'm out in the sun, I need to use a very strong sunblock."

Correct Answer is D

Explanation

Choice A reason: Applying drying agents on draining lesions every day is not recommended for clients with SLE. This approach can lead to excessive dryness and irritation of the skin, which can worsen the condition and cause additional discomfort. Moisturizing and protecting the skin are more appropriate measures.

Choice B reason: While avoiding contact with others can help prevent the spread of infections, it is not the most important aspect of skin care for SLE. SLE is an autoimmune condition, and managing skin care focuses more on protecting the skin from external triggers and minimizing inflammation.

Choice C reason: Tanning booths are not safe for clients with SLE. Exposure to UV light, whether from the sun or artificial sources, can exacerbate SLE symptoms and trigger flares. Therefore, it is important to avoid both direct sunlight and tanning booths.

Choice D reason: Using a very strong sunblock when out in the sun is crucial for clients with SLE. Sun exposure can worsen skin lesions and trigger flares, so it is essential to protect the skin with a high SPF sunblock, wear protective clothing, and seek shade whenever possible.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Correct Answer is B

Explanation

Which statement by a client with systemic lupus erythematosus (SLE) indicates the best understanding of proper skin care?

Correct Answer is D

Explanation

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