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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Correct Answer is A

Explanation

A. Prepare the client for dialysis: A potassium level of 8.3 mEq/L is critically high (normal range: 3.5–5.3 mEq/L), putting the client at immediate risk for life-threatening cardiac arrhythmias (e.g., ventricular fibrillation). Emergency dialysis is needed to remove excess potassium if other interventions (e.g., insulin, calcium gluconate) fail.

B. Start an IV and run normal saline at 50mL/hour: Fluid administration alone does not lower potassium quickly enough in a life-threatening situation.

C. Repeat the electrolyte values later in the day: Delaying treatment would increase the risk of cardiac arrest.

D. Monitor urine output: Although important, monitoring alone does not treat the emergency. Clients with acute renal failure often have little to no urine output.

A. 0.45% sodium chloride B. 0.9% sodium chloride C. Lactated Ringers D. Albumin

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

Solutions	Hypotonic	Isotonic	Hypertonic
0.45% sodium chloride	✅
0.9% sodium chloride		✅
Lactated Ringers		✅
Albumin			✅

0.45% Sodium Chloride (Hypotonic): Has lower osmolarity than blood, causing fluid to shift into cells, making them swell. Used for dehydration and intracellular rehydration.

0.9% Sodium Chloride (Isotonic): Has the same osmolarity as blood, so it stays in the intravascular space. Used for fluid resuscitation (hypovolemia, dehydration, shock).

Lactated Ringers (Isotonic): Contains electrolytes (Na+, K+, Ca2+, lactate), making it ideal for burns, surgery, and trauma patients. Maintains intravascular volume without fluid shifts.

Albumin (Hypertonic): Large protein that pulls fluid into the intravascular space (colloid osmotic pressure). Used for hypovolemia, burns, or severe hypoalbuminemia.

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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

The nurse is caring for a client diagnosed with acute renal failure and has a potassium level of 8.3 mEq/L. What collaborative intervention would be a priority for this client?

Correct Answer is A

Explanation

The nurse is reviewing IV solutions to identify which solution falls under which category.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

The client receiving hemodialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?

What type of electrolyte imbalance would most likely occur following the administration of three tap water enemas?

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which intervention should the nurse perform?

What happens when a hypertonic IV solution is administered to a client?

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

What medication would the nurse prepare to give to reduce shivering in a hyperthermic client?

A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect?

A nurse is preparing to obtain a 24-hr urine collection from a client. Which of the following actions should the nurse plan to take?