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).
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.
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