Nokea
A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse is most appropriate?
- A. Administer insulin and glucose.
- B. Administer dantrolene sodium (Dantrium).
- C. Increase intravenous fluids.
- D. Monitor the client's electrocardiogram.
Correct Answer: B
Rationale: Malignant hyperthermia is a medical emergency, and dantrolene sodium (Dantrium) is the drug of choice to treat it. Hyperkalemia (potassium 6.5 mEq/L) may occur, but the priority is to administer dantrolene to reverse the malignant hyperthermia. Administering insulin and glucose or increasing fluids may be part of the treatment protocol, but dantrolene is the most critical. Monitoring the ECG is important but not the priority action.
You may also like to solve these questions
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is more appropriate?
- A. Ask the surgeon to change the sterile gown.
- B. Do nothing, this is acceptable sterile procedure.
- C. Do the nurse surgeon more quickly and has been broken.
- D. Obtain a new part of sterile gloves for the surgeon to put on.
Correct Answer: C
Rationale: The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach; changing only the gloves or only the gown does not restore the sterile sections of the gown. Doing nothing is unacceptable.
A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?
- A. Administer an anxiolytic.
- B. Provide warm blankets.
- C. Introduce the surgical staff.
- D. Remain with the client.
Correct Answer: D
Rationale: The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An anxious client may need an anxiolytic, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.
A client is in stage 2 of general anesthesia. What action by the nurse is more important?
- A. Being prepared to suction the airway
- B. Being prepared to suction the airway
- C. Positioning the client correctly
- D. Positioning the client correctly
Correct Answer: A
Rationale: During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client correctly is important throughout to prevent hypothermia, but it is not the priority during this stage.
A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
- A. Facilitate marking the site with the client and surgeon.
- B. Have the client mark the operative site.
- C. Have the client mark the operative site.
- D. Tell the surgeon it is time to mark the surgical site.
Correct Answer: A
Rationale: The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
- A. Allow the client to keep hearing aids in until anesthesia begins.
- B. Pad the table as appropriate for the surgical procedure.
- C. Position the client for maximum visualization of the site.
- D. Stay with the client, providing emotional comfort and support.
Correct Answer: A
Rationale: Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.