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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Place the child in a tub bath of tepid water: While tepid water can help in some situations of hyperthermia, it is not suitable for hypothermia. A more controlled and gradual rewarming method is necessary to prevent further complications such as rewarming shock.

B) Cover the child's head with a hat: Covering the child's head with a hat is an important step in rewarming because a significant amount of body heat is lost through the head. This helps in retaining body heat and stabilizing the child’s temperature.

C) Administer acetaminophen every 4 hr: Acetaminophen is typically used for reducing fever and managing pain. It is not indicated for treating hypothermia, as it does not aid in rewarming the body or addressing the underlying hypothermic condition.

D) Obtain a specimen for blood cultures: While obtaining blood cultures might be necessary if there is a suspicion of infection, it is not a primary intervention for treating hypothermia. Immediate focus should be on rewarming and stabilizing the child.

A. Request a prescription for levothyroxine IV. B. Administer supplemental oxygen to the client. C. Cover the client with warm blankets. D. Implement measures to increase the client's pulse rate.

Correct Answer is D

Explanation

A) "Limit sodium intake to 3,500 milligrams per day.":
Limiting sodium intake is crucial for managing heart failure to prevent fluid retention and exacerbation of symptoms. However, the recommended limit is typically much lower, around 1,500 to 2,000 milligrams per day, not 3,500 milligrams.

B) "Take ibuprofen for discomfort.":
Ibuprofen and other NSAIDs are not recommended for clients with heart failure as they can cause fluid retention, worsen heart failure symptoms, and increase the risk of kidney problems. Alternatives such as acetaminophen are generally safer for pain relief.

C) "Increase the distance you walk by 100 feet daily, even if you feel fatigued.":
While regular exercise is important, clients with heart failure should not push through fatigue, as overexertion can lead to worsening symptoms. Exercise recommendations should be tailored to the individual's tolerance and should be adjusted based on their energy levels.

D) "Include no more than 2,000 milliliters of fluid intake in 24 hours.":
Restricting fluid intake to 2,000 milliliters per day helps prevent fluid overload, which is critical for managing heart failure. Monitoring and limiting fluid intake can help control symptoms such as edema and shortness of breath.

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