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 C
Explanation
A) Apples:
Apples are generally considered safe for individuals with gastroesophageal reflux disease (GERD). They are low in acid and do not typically contribute to reflux symptoms, making them a suitable fruit choice.
B) Potatoes:
Potatoes are bland and non-acidic, making them a good option for individuals with GERD. They do not typically trigger reflux symptoms and can be included in a reflux-friendly diet.
C) Tomatoes:
Tomatoes are highly acidic and can significantly aggravate GERD symptoms. Their acidity can weaken the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus, causing discomfort and heartburn.
D) Bananas:
Bananas are low in acid and often recommended for people with GERD. They are gentle on the stomach and do not usually cause reflux symptoms, making them a good dietary choice for managing GERD.
Correct Answer is D
Explanation
A) A potassium supplement: Administering a potassium supplement would be inappropriate for a client with a potassium level of 6.4 mEq/L. This level is above the normal range (3.5-5.0 mEq/L) and indicates hyperkalemia, which can have serious effects on cardiac function. Increasing potassium intake could exacerbate the condition.
B) A fiber supplement: While fiber supplements can be beneficial for overall digestive health, they do not directly address or correct an electrolyte imbalance like hyperkalemia. They are not relevant in managing elevated potassium levels.
C) An anticonvulsant: Anticonvulsants are used to manage seizure activity and are not indicated for treating hyperkalemia. They do not have any role in the regulation or management of potassium levels in the body.
D) A diuretic: Diuretics, particularly loop diuretics, are often used to help manage hyperkalemia by promoting the excretion of potassium through urine. This helps lower the elevated potassium levels in the blood and reduce the risk of complications such as cardiac arrhythmias. Therefore, administering a diuretic is an appropriate intervention for a client with a potassium level of 6.4 mEq/L.
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