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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:

Double gloving is a recommended precaution for health care workers who are exposed to blood or body fluids of clients who have a positive HIV test result. Double gloving can reduce the risk of needlestick injuries and transmission of HIV or other bloodborne pathogens.

Choice B reason:

Placing instruments in closed containers at completion of surgery is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Placing instruments in closed containers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice C reason:

Wearing shoe covers in addition to personal protective equipment is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Wearing shoe covers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice D reason:

Using instruments only from specially marked trays is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Using instruments only from specially marked trays does not protect the health care workers from exposure to blood or body fluids during surgery.

A. Wearing tight-fitting clothing or jewelry on the affected arm. B. Elevating the affected arm above the level of the heart. C. Applying moisturizer or sunscreen to the affected arm. D. Having blood pressure or blood draws on the affected arm. E. Performing range-of-motion exercises on the affected arm.

Correct Answer is D

Explanation

Choice A reason:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B reason:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C reason:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D reason:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E reason:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

View Question and Answer

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

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The scrub nurse is preparing for an emergency cesarean section for a client who has a positive HIV test result. The nurse plans care knowing that which of these precautions will be implemented?

Correct Answer is A

Explanation

A nurse is evaluating the discharge instructions for a client who had a mastectomy with lymph node dissection. The nurse instructs the client to avoid:

Correct Answer is D

Explanation

A nurse is evaluating a client's understanding of postoperative instructions after a total hip replacement surgery. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

A nurse is assessing a client who had an appendectomy 24 hours ago. The nurse observes redness, warmth, swelling, and purulent drainage at the incision site. The nurse suspects that the client has developed:

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.)

A nurse is reviewing the preoperative checklist of a client who is going to have a laparoscopic cholecystectomy. Which of the following items should be completed before transferring the client to the operating room?

A nurse is monitoring a patient who had general anesthesia for a hernia repair. Which of the following findings indicate that the patient is at risk for hypothermia? (Select all that apply.)

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:

A nurse is reviewing discharge instructions with a client who had a laparoscopic cholecystectomy. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

The circulating nurse notices that an incorrect sponge count has been reported by the scrub nurse during an abdominal surgery. What action should be taken by the circulating nurse?