A nurse in a postanesthesia 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.

Infuse chilled lactated Ringer's IV.

Provide oxygen at 12 L/min via Venturi mask.

Monitor client for rapid decrease in heart rate.

Answer and Explanation

The Correct Answer is A

A. Administer dantrolene sodium IV: Dantrolene sodium is the specific treatment for malignant hyperthermia. It works by reducing muscle rigidity and decreasing the hypermetabolic state associated with the condition.

B. Infuse chilled lactated Ringer's IV: Uusing chilled fluids is not the primary treatment. The key intervention is administering dantrolene. Cooling measures, such as ice packs or cooling blankets, may also be used but are not the first-line treatment.

C. Provide oxygen at 12 L/min via Venturi mask: While oxygen should be provided, the Venturi mask is typically used for delivering a precise oxygen concentration. In a case of malignant hyperthermia, high-flow oxygen via a non-rebreather mask is recommended.

D. Monitor client for rapid decrease in heart rate: Malignant hyperthermia typically causes tachycardia not bradycardia. The nurse should be monitoring for tachycardia, increased temperature, and other signs of the condition, rather than a decrease in heart rate.

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Correct Answer is D

Explanation

A. RBC 4.4: A red blood cell (RBC) count of 4.4 million is within the normal range for females, and it does not specifically indicate recovery from mononucleosis. RBC count is more related to anemia or overall blood volume rather than viral infection recovery.

B. Hgb 14 g/dL: Hemoglobin (Hgb) of 14 g/dL is within the normal range for females, and while it reflects adequate oxygen-carrying capacity, it does not directly indicate recovery from mononucleosis.

C. Hct 42%: Hematocrit (Hct) of 42% is within the normal range for females and shows appropriate blood volume. It does not indicate viral recovery specifically, as mononucleosis affects other components of the blood, particularly white blood cells.

D. Lymphocytes 30%: During mononucleosis, lymphocyte levels are typically elevated. As the client recovers from the virus, the lymphocyte count decreases. A decrease to 30% indicates that the client is likely in the recovery phase of mononucleosis.

A. "Plan to include high doses of Vitamin E in your diet." B. "Remove glasses before performing the Amsler grid test at home." C. "Straining during a bowel movement can increase the progression of the disease." D. "Central vision loss is affected first."

Correct Answer is D

Explanation

A. "Plan to include high doses of Vitamin E in your diet.": A balanced diet rich in vitamins and nutrients, including vitamin C, vitamin E, and zinc, may be beneficial, but high doses should be avoided unless prescribed.

B. "Remove glasses before performing the Amsler grid test at home.": Glasses should be worn while performing the Amsler grid test if the client normally wears them for reading. Removing glasses could distort the test results, so the client should use the grid with their regular corrective lenses if they wear them.

C. "Straining during a bowel movement can increase the progression of the disease.": Straining during bowel movements doesn’t cause progression of macular degeneration. The condition primarily affects the retina and is not related to pressure changes in the body from straining.

D. "Central vision loss is affected first.": In macular degeneration, the central part of the retina (the macula) is affected first, leading to central vision loss. This results in difficulty with activities like reading while peripheral vision is usually preserved longer.

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A nurse in a postanesthesia 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?

Nursing Test Bank

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