A nurse in a post anesthesia care unit is caring for a client who is recovering from general anesthesia and is experiencing malignant hyperthermia. Which of the following actions should the nurse take?
Administer dantrolene sodium IV.
Monitor client for rapid decrease in heart rate.
Infuse chilled lactated Ringer's IV.
Provide oxygen at 12 L/min via Venturi mask.
The Correct Answer is A
A) Administer dantrolene sodium IV: Dantrolene sodium is the treatment of choice for malignant hyperthermia. It acts as a muscle relaxant by inhibiting calcium release from the sarcoplasmic reticulum in skeletal muscles, which helps to halt the hypermetabolic crisis.
B) Monitor client for rapid decrease in heart rate: While monitoring vital signs is essential, a rapid decrease in heart rate is not a typical manifestation of malignant hyperthermia. The nurse should primarily focus on interventions to reduce hyperthermia and stabilize the client's condition.
C) Infuse chilled lactated Ringer's IV: Infusing chilled IV fluids can help lower the body temperature in malignant hyperthermia. However, this intervention is supportive and secondary to the administration of dantrolene sodium, which directly addresses the underlying pathophysiology.
D) Provide oxygen at 12 L/min via Venturi mask: Providing high-flow oxygen is necessary to manage hypoxia and metabolic acidosis associated with malignant hyperthermia. Nonetheless, this action is secondary to administering dantrolene sodium, which is crucial to stopping the hyperthermic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) It manifests as a sense of relief upon the loved one's death: This describes a possible outcome of anticipatory grief but does not define anticipatory grief itself. While relief can be a reaction, it is not the core characteristic of anticipatory grief.
B) It causes a prolonged grief response to occur: Anticipatory grief involves experiencing grief before the actual loss occurs. This process can sometimes lead to a prolonged grief response, as individuals might go through stages of grief before and after the loss.
C) It occurs when the loss of a loved one cannot be shared openly: This describes disenfranchised grief, which happens when the loss is not socially acknowledged or supported. Anticipatory grief occurs prior to the loss, not due to a lack of social support.
D) It remains difficult to process due to a lack of finality: While anticipatory grief can be challenging due to ongoing uncertainties and emotional strain, it is not primarily defined by a lack of finality. The grief occurs as individuals anticipate the impending loss.
Correct Answer is B
Explanation
A) Maintain the client on bed rest for 48 hr following surgery: While some bed rest is recommended initially post-surgery, maintaining bed rest for 48 hours is excessive and can increase the risk of complications like deep vein thrombosis. Early mobilization is generally encouraged to enhance recovery.
B) Check the tubing for kinks and blood clots at least every 2 hr: Regularly checking the catheter tubing for kinks and blood clots is essential to ensure the continuous flow of urine and prevent catheter blockage. This can help in reducing the risk of complications such as bladder distension and urinary retention.
C) Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate: Continuous bladder irrigation is often done post-TURP to prevent clot formation, but 5% dextrose in Ringer's lactate is not the recommended solution. Typically, normal saline is used to minimize the risk of electrolyte imbalance and maintain the correct osmolarity.
D) Remove the catheter if the client reports severe bladder spasms: Severe bladder spasms can occur post-TURP, but removing the catheter is not the immediate solution. The catheter is necessary for drainage and should be managed with antispasmodic medications or adjusting the irrigation flow rather than removal.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.