A nurse working in the PACU (post-anesthesia care unit)/recovery room unit is monitoring a patient whose vital signs were stable upon arrival from the operating room. The patient’s temperature began to rise steadily the past 20 minutes and continues to rise, the heart monitor shows sinus tachycardia with a rate of 122, the patient’s blood pressure is 86/42, and pulse ox is 88% on 2 L O2 via nasal cannula.
The nurse suspects which genetic condition?

Alpha-1 antitrypsin deficiency.

Malignant hypothermia.

Thalassemia.

Malignant hyperthermia.

Answer and Explanation

The Correct Answer is D

Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.

Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.

It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.

Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.

It does not cause a rise in body temperature or muscle rigidity.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.

A. Do you have spiritual practices that are helpful to you? B. What makes you feel that your belief is correct? C. Are you part of a religious or spiritual community? D. What sustains you and keeps you going?.

Correct Answer is B

Explanation

The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.

Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.

Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.

Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.

Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.

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Naxlex Comprehensive Predictor Exams

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The nurse knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE. This acronym means:

The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

The nurse identifies chronic pain as an appropriate nursing priority (or problem/diagnosis) for a client with fibromyalgia. Which manifestation did the client most likely report that caused the nurse to select this priority?