a nurse in the pacu is caring for a client who has received ga and has a manifestation of malignant hyperthermia the nurse should expect to administer
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse in the PACU is caring for a client who has received general anesthesia and has a manifestation of malignant hyperthermia. The nurse should expect to administer which of the following medications?

Correct answer: C

Rationale: Corrected Rationale: Dantrolene is the medication of choice to treat malignant hyperthermia, a life-threatening reaction to general anesthesia. It works by inhibiting the release of calcium ions in skeletal muscle cells, preventing muscle contracture and hypermetabolism. Acetaminophen (Choice A) and ibuprofen (Choice B) are not indicated for treating malignant hyperthermia. Diazepam (Choice D) may be used to control muscle spasms but is not the first-line treatment for malignant hyperthermia.

2. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

3. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

4. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

5. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

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