A patient who received an inhalation anesthetic is received into the recovery room. A nurse obtains vital signs during the immediate postoperative assessment
The patient's muscles are tense, and her body temperature is 104? F. The nurse's best action is to
a. administer acetaminophen (Tylenol) as ordered and recheck the temperature in 1 hour.
b. apply a cooling blanket per the agency's protocol.
c. collaborate with the prescriber regarding the risk of malignant hyperthermia.
d. administer diazepam (Valium) for the muscle rigidity.
ANS: C
Malignant hyperthermia is characterized by muscle rigidity and a profound elevation in temperature. The prescriber should be notified, because malignant hyperthermia is rare but potentially fatal.
Administration of Tylenol may not be sufficient and disregards the muscle rigidity that also is present.
A cooling blanket may not be sufficient and disregards the muscle rigidity that also is present.
Administration of diazepam does not address the hyperthermia that is present.
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