[DOCUMENT TITLE]
,01 A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly
after respiratory status has been stabilized, the client becomes flushed, profusely diaphoretic, and
has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button
for more information.
1. IM epinephrine
2. IV atropine
3. IV dantrolene
4. IV glucagon
Explanation:
Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by general
anesthetics (eg, succinylcholine). Skeletal muscles become unable to control calcium levels, leading
to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH
include tachypnea, tachycardia, and rigid jaw or generalized rigidity. As the condition progresses,
the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac
dysrhythmias, and myoglobinuria.
MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism.
Succinylcholine should be discontinued. Other interventions include applying cooling blankets to
reduce temperature and treating high potassium levels.
(Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe
asthma attacks; it is not appropriate for MH.
(Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen
tachycardia in this client.
(Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously,
or intravenously for severe hypoglycemia. IV glucose is preferred for its immediate effect; however, if
it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood
glucose.
Educational objective:
Malignant hyperthermia (MH) is a life-threatening hypermetabolic condition triggered by general
anesthetics. Administration of IV dantrolene slows metabolism and is the priority nursing action for a
client with MH. Other interventions include cooling the client and treating high potassium levels.
02 The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When
collecting data to develop a plan of care for the client, the nurse should give priority to which of the
following items?
1. Orthostatic blood pressure changes
2. Presence or absence of knee reflexes
3. Pupil size and reaction to light
4. Rate and depth of respirations
,Explanation:
Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often
accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity
weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs).
Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of
the respirations should be monitored (Option 4). Measurement of serial bedside forced vital
capacity (spirometry) is the gold standard for assessing early ventilation failure.
(Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension,
paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are
not a priority.
(Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending
nature of the disease. Absence of gag reflex indicates GBS progression.
(Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses
CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are
involved due to the ascending nature of GBS.
Educational objective:
The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory
compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of
respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the
disease course.
03 The nurse performs admission assessments on 4 clients. Which client assessment information is
most concerning and needs priority care?
17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4
1. C), headache with photophobia, and stiff neck
36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and
2. foul-smelling drainage from self-injection sites
45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F
3. (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L)
76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive
4. cough of thick green mucus
Explanation:
Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial
infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct
contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is
prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs
include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in
mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and
initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening
medical emergency.
(Option 2) Although this client has an infection, is at increased risk for septicemia, and needs to be
treated with antibiotics and antipyretics, this situation is not immediately life-threatening.
, (Option 3) Fever and hyperglycemia are expected responses to infection, and this client needs to be
treated with antibiotics and insulin. However, this situation is not immediately life-threatening.
(Option 4) This client is at increased risk for pneumonia and needs to be treated with antibiotics,
antipyretics, bronchodilators, and expectorants. This situation is not immediately life-threatening.
Educational objective:
Meningococcal meningitis is a highly contagious bacterial infection. Classic signs include fever,
nuchal rigidity, headache, photophobia, nausea, vomiting, and changes in mental status. If
meningococcal meningitis is suspected, diagnostic testing and immediate treatment with antibiotics
are critical as it is a life-threatening medical emergency.
04 A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse
notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly
identify? Click the exhibit button for more information.
1. Metabolic alkalosis, compensated
2. Metabolic alkalosis, uncompensated
3. Respiratory alkalosis, compensated
4. Respiratory alkalosis, uncompensated
Explanation:
This client's ABG analysis shows uncompensated metabolic alkalosis. The most likely cause of this
alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning. Metabolic
imbalances affect the bicarbonate level. This client's ABG is high in pH (alkalosis) and bicarbonate.
,01 A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly
after respiratory status has been stabilized, the client becomes flushed, profusely diaphoretic, and
has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button
for more information.
1. IM epinephrine
2. IV atropine
3. IV dantrolene
4. IV glucagon
Explanation:
Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by general
anesthetics (eg, succinylcholine). Skeletal muscles become unable to control calcium levels, leading
to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH
include tachypnea, tachycardia, and rigid jaw or generalized rigidity. As the condition progresses,
the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac
dysrhythmias, and myoglobinuria.
MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism.
Succinylcholine should be discontinued. Other interventions include applying cooling blankets to
reduce temperature and treating high potassium levels.
(Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe
asthma attacks; it is not appropriate for MH.
(Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen
tachycardia in this client.
(Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously,
or intravenously for severe hypoglycemia. IV glucose is preferred for its immediate effect; however, if
it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood
glucose.
Educational objective:
Malignant hyperthermia (MH) is a life-threatening hypermetabolic condition triggered by general
anesthetics. Administration of IV dantrolene slows metabolism and is the priority nursing action for a
client with MH. Other interventions include cooling the client and treating high potassium levels.
02 The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When
collecting data to develop a plan of care for the client, the nurse should give priority to which of the
following items?
1. Orthostatic blood pressure changes
2. Presence or absence of knee reflexes
3. Pupil size and reaction to light
4. Rate and depth of respirations
,Explanation:
Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often
accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity
weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs).
Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of
the respirations should be monitored (Option 4). Measurement of serial bedside forced vital
capacity (spirometry) is the gold standard for assessing early ventilation failure.
(Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension,
paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are
not a priority.
(Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending
nature of the disease. Absence of gag reflex indicates GBS progression.
(Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses
CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are
involved due to the ascending nature of GBS.
Educational objective:
The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory
compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of
respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the
disease course.
03 The nurse performs admission assessments on 4 clients. Which client assessment information is
most concerning and needs priority care?
17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4
1. C), headache with photophobia, and stiff neck
36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and
2. foul-smelling drainage from self-injection sites
45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F
3. (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L)
76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive
4. cough of thick green mucus
Explanation:
Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial
infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct
contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is
prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs
include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in
mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and
initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening
medical emergency.
(Option 2) Although this client has an infection, is at increased risk for septicemia, and needs to be
treated with antibiotics and antipyretics, this situation is not immediately life-threatening.
, (Option 3) Fever and hyperglycemia are expected responses to infection, and this client needs to be
treated with antibiotics and insulin. However, this situation is not immediately life-threatening.
(Option 4) This client is at increased risk for pneumonia and needs to be treated with antibiotics,
antipyretics, bronchodilators, and expectorants. This situation is not immediately life-threatening.
Educational objective:
Meningococcal meningitis is a highly contagious bacterial infection. Classic signs include fever,
nuchal rigidity, headache, photophobia, nausea, vomiting, and changes in mental status. If
meningococcal meningitis is suspected, diagnostic testing and immediate treatment with antibiotics
are critical as it is a life-threatening medical emergency.
04 A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse
notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly
identify? Click the exhibit button for more information.
1. Metabolic alkalosis, compensated
2. Metabolic alkalosis, uncompensated
3. Respiratory alkalosis, compensated
4. Respiratory alkalosis, uncompensated
Explanation:
This client's ABG analysis shows uncompensated metabolic alkalosis. The most likely cause of this
alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning. Metabolic
imbalances affect the bicarbonate level. This client's ABG is high in pH (alkalosis) and bicarbonate.
