You are the circulating nurse in the OR. The surgery began at 0700. The vital signs at 0700 were BP 120/80, RR 16, HR 88. At 0708, you notice that the patient's heart rate is 136 and the monitor is alarming.
The anesthesiologist stops the anesthesia and suspects that the patient is experiencing Malignant Hyperthermia. Which of the following interventions would be inappropriate in this situation?
Placing a cooling blanket on the patient.
Applying oxygen therapy.
Initiating warmed IV fluids.
Administering Dantrolene Sodium (Dantrium).
The Correct Answer is C
Choice A rationale
Hyperthermia represents a hypermetabolic state where the body temperature can rise rapidly, sometimes exceeding 44 degrees Celsius. Internal cooling measures are vital to prevent cellular damage and multi-organ failure. A cooling blanket facilitates conductive heat loss through the skin. Reducing the core temperature is a priority to stabilize the metabolic rate and prevent the denaturation of critical proteins and enzymes within the systemic circulation during a crisis.
Choice B rationale
Malignant hyperthermia causes a massive increase in oxygen consumption and carbon dioxide production due to sustained muscle contractions. Normal respiration rates of 12 to 20 breaths per minute are insufficient. Providing high-flow 100 percent oxygen helps meet the increased metabolic demands of the tissues and assists in the elimination of excess carbon dioxide. This intervention is necessary to prevent severe respiratory and metabolic acidosis during the intraoperative emergency.
Choice C rationale
Administering warmed intravenous fluids is contraindicated because the primary goal in malignant hyperthermia is to lower the body temperature rapidly. Warmed fluids would further elevate the core temperature, exacerbating the hypermetabolic state and worsening the clinical outcome. Instead, chilled or cold intravenous saline is typically administered to help cool the patient from the inside out. This choice represents an inappropriate action that could harm the patient.
Choice D rationale
Dantrolene sodium is the specific pharmacological treatment for malignant hyperthermia. It acts as a muscle relaxant by abolishing the excitation-contraction coupling in muscle cells. Specifically, it inhibits the release of calcium ions from the sarcoplasmic reticulum. By lowering intracellular calcium levels, it stops the uncontrolled muscle contractions and the resulting heat production. Prompt administration is the most effective way to reverse the life-threatening symptoms and stabilize the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Allowing a patient to walk independently after receiving antianxiety preoperative medications, such as benzodiazepines, is a major safety risk. These medications frequently cause drowsiness, ataxia, and orthostatic hypotension, which significantly increase the risk of falls and related injuries. The nurse must prioritize physical safety by ensuring the patient remains in bed or is assisted by staff if movement is absolutely necessary. Independent ambulation is strictly contraindicated once these central nervous system depressants are administered.
Choice B rationale
Informed consent must be obtained before the administration of any mind-altering or sedative medications. Antianxiety drugs impair the client's cognitive function, judgment, and ability to process complex information, rendering them legally unable to provide truly informed consent. If the nurse allows the client to sign after medication administration, the consent is considered invalid and unethical. All legal documentation regarding the procedure must be finalized while the client is fully alert, oriented, and mentally competent.
Choice C rationale
Education regarding the surgical procedure should ideally occur during the preoperative phase before any sedative medications are given. Antianxiety medications interfere with memory consolidation and the ability to focus, meaning the client is unlikely to retain or understand the information provided. Effective patient teaching requires an alert mind. Attempting to educate the client at this stage is ineffective and could lead to post-operative confusion or non-compliance because the patient cannot recall the instructions or risks explained.
Choice D rationale
Placing side rails in an upright position is a standard safety intervention after a patient receives preoperative sedation or antianxiety medication. These drugs cause altered levels of consciousness and decreased coordination, which makes the patient vulnerable to accidentally falling out of bed. Ensuring the side rails are up provides a physical barrier and serves as a reminder for the patient to stay in bed. This action is a direct nursing responsibility aimed at maintaining a safe environment.
Correct Answer is D
Explanation
Choice A rationale
A history of deep vein thrombosis increases a patient's risk for future venous thromboembolism and pulmonary embolism during the sedentary postoperative period. However, it is not a direct physiological risk factor for the development of a surgical site infection. Infection risk is primarily driven by factors that impair the immune response, decrease tissue perfusion, or introduce pathogens. While DVT is a significant surgical concern, it does not mechanically or biologically compromise the primary wound healing process.
Choice B rationale
A body mass index of 19 falls within the normal and healthy range of 18.5 to 24.9. Patients who are significantly underweight or morbidly obese are at higher risk for surgical site infections due to poor nutrition or poor vascularity of adipose tissue, respectively. Because this patient's BMI is within the expected parameters, they do not have the specific risks associated with malnourishment or excessive subcutaneous fat that often complicate the healing of surgical incisions and increase infection rates.
Choice C rationale
While advanced age can be a factor in slowed wound healing due to naturally declining physiological reserves, a 55-year-old individual is generally not considered to be at a significantly increased risk for infection based on age alone. Generally, the risk becomes much more pronounced in the very elderly, such as those over 75 or 80, where the immune system is significantly senescent. At 55, most individuals still possess adequate immune function and tissue regenerative capacity to heal.
Choice D rationale
Type 2 diabetes mellitus is a major risk factor for surgical site infections. Elevated blood glucose levels impair leukocyte function, specifically neutrophilic phagocytosis, which is the body's primary defense against invading bacteria. Chronic hyperglycemia also damages microvasculature, leading to decreased oxygen and nutrient delivery to the surgical site. This environment hinders the inflammatory and proliferative phases of wound healing, providing a fertile ground for bacterial growth and significantly increasing the likelihood of postoperative infection.
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