You are a nurse in the postanesthesia care unit (PACU), and you note that your client has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?
1. Infection: Notify surgeon and anticipate administration of antibiotics.
2. Pneumonia: Listen to breath sounds, notify surgeon, and
anticipate order for chest radiography.
3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives.
4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.
2. Teaching the client and family
A nurse should determine the learning needs preoperatively and teach both the client and the family before surgery. Teaching the family helps them to participate in client care postoperatively. Teaching only the client limits learning preoperatively because the client can be anxious and not receptive to new information. Brief verbal instructions are often forgotten. Using only written instructions does not provide the opportunity for learning evaluation. Other means of preoperative teaching include telephone calls, mailings, printed guidelines and checklists, and videotapes.
TEST-TAKING TIP:
Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by:" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer. For this question, teaching the client and family includes teaching the client, and is also more effective.
Text Reference
- p. 1267
Nursing Care Plan Deficient Knowledge Regarding Preoperative and Postoperative Care Requirements Related to Lack of Exposure to Information
1. The client with a history of spina bifida
4. The client who has a spinal cord injury
5. The client who has urogenital abnormality
The client with spina bifida, the client who has a spinal cord injury, and the client with urogenital abnormality should be assessed for latex allergy. Clients with spina bifida, spinal cord injuries, and urogenital abnormalities have had repeated exposure to latex products throughout their lives. These clients have been exposed to latex urinary catheters and examination gloves. This repeated exposure may lead to the development of a latex allergy. Clients who have diabetes mellitus do not use latex products for managing their disease, so they do not have an increased risk. Clients who have allergies to bananas, chestnuts, kiwi fruit, avocados, and tomatoes may have a cross-sensitivity to latex.
STUDY TIP: A mnemonic for the allergies that show cross-sensitivity to latex is "T-BACK": Tomatoes, Bananas, Avocados, Chestnuts, and Kiwi. Think of a silly visual to accompany the mnemonic, such as a latex bandage on the BACK of a T-shirt.
Text Reference - p. 1261