During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

Surgical site infection

Hypercapnia

Malignant hyperthermia

Hypertensive crisis

Answer and Explanation

The Correct Answer is C

Choice A reason: Surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place.

Choice B reason: Hypercapnia is the presence of higher-than-normal levels of carbon dioxide in the blood.

Choice C reason: Malignant hyperthermia is a life-threatening pharmacogenetic reaction to certain general anesthesia, characterized by hypermetabolism resulting in high body temperature, rigid muscles, and rapid heart rate.

Choice D reason: Hypertensive crisis is a severe elevation in blood pressure, often requiring immediate medical attention.

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Correct Answer is C

Explanation

Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

A. Urine output 18 mL/hr. B. Blood pressure 88/50 mmHg. C. Lethargy. D. Pulse 110 bpm.

Correct Answer is A

Explanation

Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.

Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.

Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.

Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.

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During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Correct Answer is C

Explanation

The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?

Correct Answer is A

Explanation

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