NUR 02 CRITICAL CARE 01
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.
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.
