The new post op client in PACU suddenly develops a temperature of 103 degrees F. What would you suspect?

The development of malignant hyperthermia

The development of fluid volume excess

The development of an allergic response to the pain medication

The development of an infection.

Answer and Explanation

The Correct Answer is A

A. The development of malignant hyperthermia: Malignant hyperthermia (MH) is a life-threatening reaction to certain anesthetics (e.g., succinylcholine, halothane). It causes rapid muscle breakdown, severe hyperthermia, tachycardia, muscle rigidity, and metabolic acidosis. Immediate treatment with IV dantrolene and cooling measures is required.

B. The development of fluid volume excess: Fluid overload may cause hypertension and pulmonary edema but does not cause sudden high fever.

C. The development of an allergic response to the pain medication: Drug allergies typically present with rash, itching, or anaphylaxis, not extreme fever.

D. The development of an infection. Post-op infections usually develop over several days, not immediately in PACU.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assess the fistula with a large bore needle: Large bore needles are used during dialysis sessions, not for routine assessment. Inappropriate needling can damage the fistula.

B. Auscultate the fistula site for a bruit: A functional AV fistula should have a palpable thrill (vibration) and an audible bruit (whooshing sound) when auscultated with a stethoscope. These findings confirm adequate blood flow and patency.

C. Measure the blood pressure in the affected arm: Blood pressure measurements should never be taken on the fistula arm to prevent compression and potential fistula failure.

D. Assess the rate and quality of the radial pulse on the affected arm: The radial pulse does not accurately assess AV fistula patency; the focus should be on the thrill and bruit.

A. Discard the client's last void at the end of the collection time period. B. Refrigerate the urine during the collection time period. C. Save the first void at the start of the collection time period. D. Include toilet paper with the collected urine

Correct Answer is B

Explanation

A. Discard the client's last void at the end of the collection time period. The last void must be included for complete data.

B. Refrigerate the urine during the collection time period: Refrigerating the urine prevents bacterial growth and chemical breakdown, ensuring accurate lab results. Some tests may require urine to be kept on ice instead.

C. Save the first void at the start of the collection time period. The first void is discarded because it may contain residual metabolites from the previous period.

D. Include toilet paper with the collected urine. Toilet paper can contaminate the sample and alter test results.

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The new post op client in PACU suddenly develops a temperature of 103 degrees F. What would you suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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