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Review H and P and nurses’ notes.

Exhibits

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.

heart rate 128 beats/minute

rhythm sinus tachycardia

respiratory rate 14 breaths/minute

oxygen saturation 100% on 40% fraction of inspired oxygen

temperature 96.9° F (36.1° C)

blood pressure 90/79 mm Hg

surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing

Answer and Explanation

The Correct Answer is ["A","B","E","F","H"]

Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion.

Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock.

Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets).

Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury.

Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.

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

Explanation

A: The nurse’s signature as a witness indicates that the client voluntarily signed the consent form, free from coercion.

B: The nurse is not responsible for explaining the risks and benefits of the surgery; that is the surgeon's role.

C: The nurse’s signature also affirms that the client appears competent to sign the consent and is not under any impairment or duress at the time of signing.

D: The nurse does not verify that the client understands the procedure, but simply observes that the consent is signed willingly.

E: The surgeon, not the nurse, is responsible for explaining the procedure and its necessity to the client.

Correct Answer is []

Explanation

Condition Most Likely Experiencing: Malignant Hyperthermia

The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
Incorrect choices:
- Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
- Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
- Hypercapnia (C): The client is hyperventilating, not hypoventilating.
- Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

Administer dantrolene (C)
- Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
Monitor muscle rigidity (E)
- Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

Incorrect choices:
- Obtain the latex-free cart (A): There is no indication of a latex allergy.
- Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
- Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

Bowel sounds (C)
- Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.
Muscle rigidity (E)
- Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

Incorrect choices:
- Blood pressure (A): While important, it is not a specific marker for MH progression.
- Urine output (B): Useful for assessing kidney function but not directly related to MH management.
- Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

Condition Most Likely Experiencing: Malignant hyperthermia
Two Actions to Take:Administer dantrolene, Monitor muscle rigidity
Two Parameters to Monitor: Bowel sounds, Muscle rigidity

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is (are) the legal implication(s) of the nurse's signature on the client's surgical consent form? Select all that apply.

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

Explanation

Correct Answer is []

Explanation

Summary of Correct Answers:

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