A nurse is assisting with the induction of general anesthesia for a client who is undergoing a cholecystectomy. The nurse monitors the client for signs of malignant hyperthermia, which include:

Hypothermia, bradycardia, and hypotension.

Hyperthermia, tachycardia, and hypertension.

Hypothermia, tachypnea, and hypertension.

Hyperthermia, bradypnea, and hypotension.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Hypothermia, bradycardia, and hypotension are not signs of malignant hyperthermia, but rather signs of hypovolemia, shock, or anesthesia overdose. Malignant hyperthermia is a rare but life-threatening condition that occurs when a patient is exposed to certain anesthetic agents and develops a hypermetabolic response that leads to high fever, muscle rigidity, tachycardia, hypertension, acidosis, and rhabdomyolysis.

Choice B reason:

Hyperthermia, tachycardia, and hypertension are the classic signs of malignant hyperthermia. The patient may also experience increased carbon dioxide production, decreased oxygen saturation, dysrhythmias, cyanosis, muscle breakdown, and organ failure. The nurse should monitor the patient's vital signs, temperature, blood gases, electrolytes, and urine output closely and notify the anesthesia care provider immediately if malignant hyperthermia is suspected. The treatment involves stopping the anesthetic agent, administering 100% oxygen, cooling the patient with ice packs and cold intravenous fluids, and giving dantrolene sodium intravenously to relax the muscles.

Choice C reason:

Hypothermia, tachypnea, and hypertension are not consistent with malignant hyperthermia. Hypothermia may occur due to exposure to cold operating room environment or intravenous fluids. Tachypnea may be caused by pain, anxiety, hypoxia, or acidosis. Hypertension may be related to stress, pain, or sympathetic stimulation. These signs are not specific to malignant hyperthermia and do not indicate a hypermetabolic state.

Choice D reason:

Hyperthermia, bradypnea, and hypotension are not typical of malignant hyperthermia. Hyperthermia may occur due to infection, inflammation, or dehydration. Bradypnea may be a result of oversedation, opioid administration, or respiratory depression. Hypotension may be due to blood loss, dehydration, or vasodilation. These signs do not reflect a hypermetabolic state or muscle rigidity that are characteristic of malignant hyperthermia.

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Correct Answer is A

Explanation

Choice A reason:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped”. or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B reason:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C reason:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D reason:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.

A. "I will not be able to move or feel anything below my waist.” B. "I will have to stay awake during the surgery.” C. "I will need someone to drive me home after the surgery.” D. "I will have less risk of nausea and vomiting than with general anesthesia.” E. "I will have to fast for at least 8 hours before the surgery.".

Correct Answer is ["B","C"]

Explanation

Choice A reason:

This statement is correct. Regional anesthesia blocks the sensation of pain and other sensations from a specific part of the body, such as below the waist for spinal or epidural anesthesia. The client will not be able to move or feel anything in the affected area during the surgery.

Choice B reason:

This statement is incorrect. Regional anesthesia does not require the client to stay awake during the surgery, unless the client prefers to do so. The client can also receive sedation or general anesthesia along with regional anesthesia, depending on the type and duration of the surgery and the client's preference.

Choice C reason:

This statement is incorrect. Regional anesthesia can have residual effects on the client's motor and sensory function, as well as blood pressure and heart rate, for several hours after the surgery. The client will need someone to drive them home after the surgery and monitor them for any signs of complications.

Choice D reason:

This statement is correct. Regional anesthesia has some advantages over general anesthesia, such as less risk of nausea and vomiting, less blood loss, less stress response, and better postoperative pain control.

Choice E reason:

This statement is correct. Regional anesthesia does not affect the client's ability to swallow or protect their airway, unlike general anesthesia. However, the client will still have to fast for at least 8 hours before the surgery to prevent aspiration of stomach contents in case general anesthesia or sedation is needed or administered.

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A nurse is assisting with the induction of general anesthesia for a client who is undergoing a cholecystectomy. The nurse monitors the client for signs of malignant hyperthermia, which include:

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Naxlex Comprehensive Predictor Exams

A client who had abdominal surgery reports feeling "a pop”. in his incisional area followed by severe pain when he turned in bed earlier in his shift; he now reports feeling "wet”. in his abdominal area under his gown and dressing. The nurse should:

Correct Answer is A

Explanation

The nurse is reviewing the informed consent form with a client who is scheduled for surgery with regional anesthesia. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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