A client is having surgery. The circulating nurse notes the ...

[kfurse]

A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90 and the heart rate is 110 beats/min. What action by the nurse is best?
 
  a. Assess the client's end-tidal carbon dioxide level.
  b. Document the findings in the client's chart.
  c. Inform the anesthesia provider of these values.
  d. Prepare to administer dantrolene sodium (Dantrium).

Question 2

A client is in stage 2 of general anesthesia. What action by the nurse is most important?
 
  a. Keeping the room quiet and calm
  b. Being prepared to suction the airway
  c. Positioning the client correctly
  d. Warming the client with blankets

[mk6555]

Answer to Question 1

ANS: A
Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.

Answer to Question 2

ANS: B
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 usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.