CH 18 EAQ Intraoperative Care and Anesthesia

The perioperative nurse is caring for a patient during surgery after receiving dissociative anesthesia. The patient begins having hallucinations and agitation. What anesthetic agent does the nurse determine has been administered by the anesthesia care provider? a. Ketamine b. Halothane c. Thiopental d. Nitrous oxide

ANS: A A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.

A patient is administered a benzodiazepine as an adjunct to general anesthesia. For what should the nurse monitor in this patient? Select all that apply. a. Insomnia b. Hypotension c. Tachycardia d. Pulse oximetry e. Abdominal distention

ANS: B C Benzodiazepines can cause hypotension, tachycardia, and respiratory depression. Therefore the nurse should monitor for hypotension and tachycardia in this patient. Insomnia and abdominal distention are monitored in the case of dexamethasone administration. Pulse oximetry is monitored in the case of opioid drug administration.

The circulating nurse is providing orientation to a group of nurses who are new to the perioperative setting. What should the nurse emphasize to the nurses that the role of the circulating nurse is? a. Ongoing assessment of the patient during the surgical procedure b. Implementing specific tasks related to surgical policies and procedures c. Ensuring that the patient has been assessed for safe administration of anesthesia d. Performing a preoperative history and physical assessment to identify patient needs

ANS: A A primary role of the circulating nurse when caring for the patient undergoing surgery is to provide ongoing assessment of the patient. This activity is essential because the patient's condition may change quickly. Implementing specific tasks related to surgical policy and procedures is not within the scope of practice. It is also not within the nurse's scope of practice to assess for safe administration of anesthesia; the anesthesia care provider will perform this task. The health care provider will perform a preoperative history and physical assessment to identify patient needs.

The nurse is preparing to administer medication to a patient during a minor surgical procedure. What type of anesthesia is the nurse able to administer without the presence of an anesthesia care provider? a. Moderate sedation b. General anesthesia c. Regional anesthesia d. Monitored anesthesia care

ANS: A An anesthesia care provider (ACP) is responsible for administering anesthesia. An ACP can be an anesthesiologist, nurse anesthetist, or anesthesiologist assistant. Moderate sedation involves administering sedatives, anxiolytics, or analgesics. It is used for procedures performed outside the operating room and does not require the presence of an ACP. A registered nurse who is educated in moderate sedation and is permitted by institution protocols and state nurse acts can perform this. However, general anesthesia, regional anesthesia, and monitored anesthesia care require the presence of an ACP.

A nurse anesthetist is giving information about the different adjuncts to general anesthesia. To prevent respiratory depression caused by a drug interaction with midazolam, the nurse should avoid administering what medication? a. Methadone b. Vecuronium c. Ondansetron d. Metoclopramide

ANS: A Benzodiazepines and opioids have a synergistic effect; therefore, they should not be used together because they may cause respiratory depression. Administration of methadone is avoided to prevent respiratory depression caused by drug interaction. Midazolam is a benzodiazepine and methadone is an opioid; hence, they should not be given together. Vecuronium is a neuromuscular blocking agent, whereas, ondansetron and metoclopramide are antiemetics.

A patient is scheduled for a surgery that will be performed under epidural anesthesia. When reviewing the patient's medical record, the nurse notes a surgical history of postoperative immobility following epidural anesthesia. To prevent the postoperative complication, the nurse expects what revision to the anesthesia plan? a. A decrease in the dose of the epidural anesthesia b. An increase in the dose of the epidural anesthesia c. The addition of an opioid drug to the epidural anesthesia d. The addition of a benzodiazepine to the epidural anesthesia

ANS: A In epidural anesthesia, a local anesthetic is injected into the epidural space. Lower concentrations of anesthetic lead to blockage of only sensory pathways, whereas, in higher doses both sensory and motor pathways are blocked. Therefore decreasing the dose will help this patient. Increasing the dose of epidural anesthesia would block both sensory and motor pathways. Adding adjunct drugs like opioid or benzodiazepine will not help.

A patient is scheduled for a gastrectomy. After reviewing the medical reports, the nurse finds that the patient has bone marrow depression. What precaution should be taken with regard to using nitrous oxide as an anesthetic agent? a. Avoid the administration of nitrous oxide. b. Observe for myoclonus, which is a side effect of nitrous oxide. c. Avoid administering nitrous oxide when the patient is receiving oxygen. d. Bone marrow depression has no effect on the administration of nitrous oxide.

ANS: A In the case of a bone-marrow depressed patient, it is advisable to avoid the administration of nitrous oxide due to potential side effects. Nitrous oxide, a weak anesthetic, is always administered with oxygen to prevent hypoxemia. Myclonus is not a side effect of nitrous oxide; myoclonus can occur with administration of etomidate.

The nurse is positioning a patient for laminectomy. Which position should the nurse place the patient in? a. Prone b. Supine c. Lateral d. Lithotomy

ANS: A Many positions are used in surgery; the choice is based on the type of surgery to be performed. For laminectomy, the patient should be placed in the prone position because it gives easy access to the back. The supine position is suited for surgery involving the abdomen, the heart, and the breast. The lateral position is best for surgery that involves one side of the body or the other. The lithotomy position is used for some types of pelvic organ surgery.

A child is brought to the emergency room for the surgical reduction of a displaced shoulder. The parents ask the nurse if the child will undergo anesthesia. Which is the most appropriate response by the nurse? a. "Your child will most likely be moderately sedated for the procedure." b. "There is no need for anesthesia because the reduction does not involve an incision." c. "Due to your child's age, your child will likely be given a general anesthetic before reduction." d. "The primary care provider will most likely use an epidural or spinal block to numb the area for the procedure."

ANS: A Moderate to deep sedation (previously referred to as conscious sedation) is generally used for minor therapeutic procedures such as fractures in the emergency room. General anesthetics are usually neither necessary nor appropriate in this situation. Despite the lack of an incision, the child will need some type of sedation for the procedure, which can be painful. An epidural or spinal block would not provide the necessary numbness needed in this situation.

The anesthesia care provider administers isoflurane and succinylcholine for induction. The nurse observes muscle rigidity in the front and back of the patient's thighs, a heart rate of 130 beats/minute, and skin that feels extremely hot. Which intervention is the priority in this scenario? a. Administering dantrolene b. Obtaining blood samples for testing c. Placing patient in Trendelenburg position d. Inserting a urinary catheter to monitor output

ANS: A Patients who have been anesthetized with a volatile inhalation agent, such as isoflurane and the adjunct succinylcholine, are at increased risk of malignant hyperthermia, which is characterized by muscle rigidity, hypercarbia, tachycardia, and tachypnea immediately following induction with an inhalation agent. Dantrolene is a skeletal muscle relaxant that must be administered immediately to treat malignant hyperthermia. Obtaining blood samples may be done to provide follow-up lab results, but the highest priority is to administer the dantrolene. Placing the patient in the Trendelenburg position would not address the symptoms or treat malignant hyperthermia. Inserting a urinary catheter to monitor urinary output is not necessary at this time.

The circulating nurse is observing the area around the patient for continuity of sterility. What event observed by the nurse requires immediate intervention? a. A glove contacts the leg of the table that supports the sterile field. b. The cuff of the scrub nurse's sterile gown contacts the sterile field. c. The sterile field was established at 0650 and the current time is 0900. d. Bacteria are present in the nares and upper respiratory passages of the nurse.

ANS: A Tables sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point of 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.

The nurse is caring for a patient postoperatively after major abdominal trauma sustained during a motor vehicle crash. The patient begins to pick at the air and asks the nurse why there are so many bugs in the room. Which nursing actions are a priority at this time? Select all that apply. a. Provide a calm, quiet environment. b. Obtain an order for a benzodiazepine. c. Monitor the patient for increased heart rate and blood pressure. d. Assess the patient for cardiopulmonary and respiratory depression. e. Observe the patient for transient skeletal muscle movements (myoclonia).

ANS: A B C Hallucinations and nightmares are common side effects of ketamine, a dissociative anesthetic given to trauma patients to increase their heart rate and maintain cardiac output. Based upon the patient diagnosis and symptomology, the nurse would determine that ketamine was likely used as an anesthetic agent and the patient is experiencing adverse effects. A calm, quite environment and the administration of benzodiazepines will help address the patient's hallucinations. Because ketamine can also cause an increased heart rate and blood pressure, the nurse should also monitor the patient's heart rate and blood pressure. Cardiopulmonary and respiratory depression are adverse reactions of volatile inhalational agents, not ketamine. Transient skeletal muscle movements are adverse effects of nonbarbiturate hypnotics, not ketamine.

To ensure patient safety and reduce risks associated with surgical procedures, the circulating nurse calls a surgical timeout prior to surgery. Which activities should be included in the timeout? Select all that apply. a. Verify patient identification. b. Complete a fire risk assessment. c. Verify surgical site and procedure. d. Ensure that consent for the specific procedure was obtained. e. Ensure that a significant other is available if needed for consultation.

ANS: A B C D Just before a surgical procedure, all surgical team members complete a surgical timeout to prevent risk of fire, wrong patient, wrong site, and wrong procedure. The team must also ensure that consent was obtained. Although a significant other may be present for a consultation if needed, this action is not an aspect of the surgical timeout process.

A patient has been given spinal anesthesia for knee replacement surgery. The nurse should monitor the patient for which indicators of autonomic nervous system blockade? Select all that apply. a. Nausea b. Vomiting c. Bradycardia d. Hypotension e. Hyperglycemia

ANS: A B C D Spinal anesthesia involves administration of an anesthetic agent into the cerebrospinal fluid. It may produce an autonomic, sensory, or motor blockade. The signs of autonomic blockade include nausea, bradycardia, hypotension, and vomiting. Hyperglycemia is not a sign of autonomic blockade.

The circulating nurse is preparing the surgical team for a time out. Which activities should the circulating nurse perform during this time? Select all that apply. a. Ask the patient to confirm name and date of birth. b. Assist the surgical team in putting on surgical attire. c. Teach the patient how to do deep-breathing exercises. d. Compare the hospital identity (ID) number with the patient's own ID band. e. Ask the patient to confirm the operative procedure and site and to give consent.

ANS: A D E During a surgical time-out all members of the surgical team stop what they are doing, just before the procedure starts, to verify patient identification, surgical procedure, and surgical site. The patient is asked to confirm the name and date of birth, operative procedure site, and consent. The hospital ID number is compared with the patient's own ID band. Helping with surgical attire and teaching patients how to do deep-breathing exercises are important activities, but they do not occur during a surgical time-out.

A patient undergoing abdominal surgery requires a blood transfusion. Which nurse will inform the blood bank regarding the need for a blood transfusion? a. Scrub nurse b. Circulating nurse c. Nurse anesthetist d. Anesthesiologist assistant

ANS: B A circulating nurse remains in an unsterile environment and performs activities involving touching unsterile equipment and patients. The nurse also forms an important link between anesthetic care providers and other departments like a blood bank. The scrub nurse, nurse anesthetist, and anesthesiologist assistant remain in a sterile environment.

The nurse is preparing to administer flumazenil to a patient having respiratory depression. What is the reason the nurse is administering this antidote? a. Morphine overdose b. Lorazepam overdose c. Ondansetron overdose d. Promethazine overdose

ANS: B Flumazenil is an antidote for benzodiazepines. Lorazepam is a benzodiazepine. An overdose causes respiratory depression. To reverse the action the antidote is required. Morphine is an opioid drug, whereas ondansetron and promethazine are antiemetics.

During surgery, a patient is administered ketamine hydrochloride, 60 mg, intravenously. Which is an important nursing intervention during recovery? a. Monitor the patient for hyperthermia. b. Maintain a calm and quiet environment. c. Assess the patient's ability to move limbs. d. Monitor blood sugar levels for hypoglycemia.

ANS: B Ketamine can cause hallucinations, nightmares, and agitation; therefore it is important to maintain a calm and quiet environment. Ketamine does not cause hyperthermia or changes in blood sugar levels. It does not have a musculoskeletal effect that requires monitoring of musculoskeletal strength.

An asthmatic patient underwent a splenectomy. During surgery, the patient is administered ketamine as an anesthetic, with ranitidine. Postoperatively, the patient's family members report that the patient is behaving strangely and talking to people who are not present. The patient has a history of depression. The nurse suspects that what is the most probable reason for this behavior? a. Exacerbation of asthma b. Administration of ketamine c. Administration of ranitidine d. Manifestation of depression

ANS: B Ketamine is usually used for asthmatic patients undergoing surgery because it promotes bronchodilation. However, ketamine administration can cause hallucinations and nightmares. This patient is most probably having hallucinations because of ketamine administration. Hallucination is not a symptom of depression or an exacerbation of asthma. It is not caused by administration of ranitidine, because ranitidine it is an H 2 receptor blocker.

An anesthesia care provider gives a regional block to a patient. The patient was administered ranitidine and metoclopramide IV preoperatively. While receiving the lidocaine injection for the block, the patient's blood pressure drops, and the patient experiences a seizure. The nurse recognizes that the probable cause of the patient's response is what? a. Side effect of lidocaine b. Accidental vascular injury c. Adverse effect of ranitidine d. Side effect of metoclopramide

ANS: B Lidocaine is a local anesthetic agent used for regional and local anesthesia. While administering a local anesthetic, accidental vascular injury can occur, which may lead to hypotension, seizures, or dysrhythmias. Lidocaine as such does not cause these symptoms. Ranitidine is an H 2 receptor blocker and does not cause hypotension or seizures. Metoclopramide is a gastric motility agent and does not cause a decrease in blood pressure or seizures.

The nurse is to administer ranitidine to a patient scheduled for a cholecystectomy. What would be the best time for the nurse to administer the drug? a. After surgery b. Before surgery c. During surgery d. Immediately after surgery

ANS: B Ranitidine is an H 2 receptor blocker used for aspiration prophylaxis. It should be given in the preinduction stage to avoid aspiration of secretions during anesthesia. Therefore the nurse should clarify the order from the primary health care provider and administer it before surgery. Administration of ranitidine after surgery, during surgery, and just after surgery does not serve the purpose of preventing aspiration of secretions during anesthesia.

A patient is about to have a surgical procedure with general anesthesia. What does the nurse anticipate will be the initial stage? a. The patient is intubated immediately. b. Induction is performed with an intravenous (IV) agent. c. The patient is given an oral tablet before the procedure. d. Induction is performed by delivering an inhalation agent via a face mask.

ANS: B Routine general anesthesia usually begins with an IV induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable. The patient is immediately intubated. An oral tablet would be contraindicated before surgery. Agents delivered via face mask are used, but not during initial stage.

Which member of the intraoperative team remains in the unsterile field? a. Scrub nurse b. Circulating nurse c. Surgeon's assistant d. Registered nurse first assistant

ANS: B The circulating nurse is not gowned and gloved and handles unsterile activities in the unsterile field during the intraoperative period. The scrub nurse is gowned and gloved and remains in the sterile field. The surgeon's assistant and registered nurse first assistant may handle and prepare surgical instruments and therefore remain in the sterile field during the intraoperative period.

The nurse observes a new graduate nurse wearing protective attire when working in the operating room for surgery. The nurse should intervene when the new graduate performs what action? a. Applies the cap and mask before applying the gloves b. After surgery, removes the gown before removing the gloves c. Gently pinches the upper metal band of the mask around the bridge of the nose d. When removing the mask, unties the bottom strings before untying the top strings

ANS: B The nurse should remove the gloves first to prevent contamination of hair, neck, and facial hair. Gently pinching the metal band prevents microorganisms from escaping around the nose and keeps the eyeglasses from steaming up. Applying gloves should be done after all other attire/equipment has been applied. Untying the bottom strings first prevents the top part of the mask from falling down over the uniform. If the mask falls and touches the uniform, the uniform will be contaminated.

A patient was administered propofol, ranitidine, and metoclopramide during a tubal ligation. Postoperatively, the nurse assesses the patient's blood pressure is 80/50 mm Hg. What does the nurse correlate with the present blood pressure? a. Bleeding during surgery b. Administration of propofol c. Administration of ranitidine d. Nerve injury during surgery

ANS: B The patient has low blood pressure or hypotension. It may be caused by propofol. It is ideal as an anesthetic used for short outpatient procedures like tubal ligation. This may cause hypotension, bradycardia, apnea, transient phlebitis, nausea and vomiting, and hiccups. The nurse should monitor for hypotension and bradycardia in this patient. Rantidine is an H 2 receptor blocker and does not cause hypotension. Bleeding and nerve injury are highly unlikely to occur during tubectomy.

A patient scheduled for surgery asks the nurse where their family can be in the surgical suite. What is the best response by the nurse? a. The family is not allowed to talk to the nurse at the nursing station. b. The family can be with the patient in the preoperative holding area. c. The family cannot be with the patient until the postanesthesia care unit. d. The family only is allowed in the conference room for preoperative teaching.

ANS: B The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They also are taken to the conference room for preoperative and postoperative meetings, including teaching, with the staff.

A patient is scheduled for laparoscopic cholecystectomy. When educating regarding the advantages of minimally invasive surgery over conventional surgery to the patient, what information should the nurse include? Select all that apply. a. Robotics is used. b. Incisions are smaller. c. Blood loss is reduced. d. Recovery time is prolonged. e. Postoperative pain is decreased.

ANS: B C E In a minimally invasive surgery such as laparoscopic cholecystectomy, incisions are smaller, there is less blood loss, and postoperative pain is lesser than in traditional surgeries. The recovery time is also shortened. Robotics is used in robotic-assisted surgeries.

A nurse educator discusses career options with a group of nursing students and describes the intraoperative activities of the perioperative nurses. What are the duties of a scrub nurse? Select all that apply. a. Monitor the draping procedure. b. Assist in the draping procedure. c. Assist in induction of anesthesia. d. Assist in preparing the operating room. e. Provide a hand-off report to the postanesthesia care unit (PACU) nurse.

ANS: B D A scrub nurse always remains in a sterile environment. The scrub nurse has many duties, some of which include assisting in the draping procedure, assisting in preparing the operating room, and passing instruments to surgeons and assistants by anticipating their needs. Preparing the instrument table and maintaining a sterile environment are also the responsibilities of a scrub nurse. Assisting in induction of anesthesia, monitoring the draping procedure, and providing a hand-off report to the PACU nurse are the duties of a circulating nurse.

A certified registered nurse anesthetist would be responsible for which functions related to surgery? Select all that apply. a. Passing instruments to surgeons and assistants b. Managing a patient's airway and pulmonary status c. Preparing the operating room and the instrument table d. Selecting and initiating the planned anesthetic technique e. Monitoring the patient's emergence and recovery from the anesthesia

ANS: B D E A certified registered nurse anesthetist is responsible for maintaining a patient's airway and pulmonary status, managing the emergence and recovery from anesthesia, and selecting and initiating the planned anesthetic technique. Passing instruments to the surgeon and preparing the instrument table are responsibilities of the scrub nurse.

When preparing for a surgical procedure for a patient, what intraoperative nursing responsibilities should be performed by the scrub nurse? Select all that apply. a. Documenting intraoperative care b. Keeping track of irrigation solutions for monitoring of blood loss c. Coordinating the flow and activities of members of the surgical team in the surgical suite d. Passing instruments and supplies to the health care provider by anticipating his or her needs e. Performing the count of sponges, needles, and instruments used during the surgical procedure

ANS: B D E Both scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

The nurse is preparing in the role of circulator for a surgical procedure. What activities should the nurse prepare for? Select all that apply. a. Preparing the instrument table. b. Documenting intraoperative care. c. Passing instruments to the surgeon and assistants. d. Monitoring practices of aseptic technique in self and others. e. Maintaining accurate counts of sponges, needles, and instruments.

ANS: B D E Documenting intraoperative care is a responsibility of the circulating nurse during surgery. Monitoring practices of aseptic technique in self and others, and maintaining accurate counts of sponges, needles, and instruments, is also a responsibility of the circulating nurse and is shared by the scrub nurse as well. Preparing the instruments and passing the instruments to the surgeon are responsibilities of the scrub nurse.

A patient is given dexamethasone to counteract emetic effects of morphine. The nurse should monitor for which medication side effects? Select all that apply. a. Dizziness b. Insomnia c. Tachycardia d. Dysrhythmia e. Abdominal distention

ANS: B E Dexamethasone is usually used to counteract the emetic effects of opioid drugs and inhalation agents. The nurse should monitor for side effects like insomnia, nervousness, and abdominal distension. Dexamethasone does not cause dizziness, tachycardia, or dysrhythmia.

The nurse is preparing to admit a patient to the operating room. According to the National Patient Safety Goals, what documents must be in the chart prior to the surgery beginning? Select all that apply. a. Electrocardiogram b. Signed consent form c. Functional status evaluation d. Renal and liver function tests e. A history and physical report

ANS: B E The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the health care provider and other members of the surgical team. An electrocardiogram, functional status evaluation, and renal and liver function tests are not necessary.

The scrub nurse is performing a surgical scrub before a procedure. Which of these actions should the nurse be sure to use to promote infection control? Select all that apply. Scrub from elbows to hands. Scrub the fingers and hands first. Scrub without mechanical friction. Scrub for a minimum of 10 minutes. Hold the hands higher than the elbows.

ANS: B E To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers. Scrubbing from the elbows to the hands, without mechanical friction, and for a minimum of 10 minutes are not correct actions.

The circulating nurse observes the scrub nurse washing hands prior to a surgical procedure and sees that the scrub nurse washes the fingers and hands before scrubbing the forearms and elbows, and then hands are placed lower than the level of the elbows. What should the circulator state to the scrub nurse? a. "You have followed the correct procedure." b. "You should have held your hands at the level of your elbows." c. "You should have held your hands above the level of your elbows." d. "You should have scrubbed your elbows before your fingers and hands."

ANS: C After scrubbing hands, they should always be held away from the surgical attire and above the level of elbows to prevent draining of water from the unclean area above the elbows to the hands and fingers, which have been cleaned previously. It also prevents contamination from clothing. To hold hands at the level of elbows and to scrub elbows before fingers and hands are incorrect procedure because these increase the chances of the contamination.

The nurse is caring for a patient receiving epidural anesthesia. The patient reports nausea. Upon assessment, the nurse notes a blood pressure of 80/60 mm Hg and a heart rate of 52. Which condition does the nurse expect the patient is experiencing? a. Onset of hypoxemia b. Increased intracranial pressure c. Autonomic nervous system blockade d. Development of emergence delirium

ANS: C Autonomic nervous system blockade is characterized by hypotension, bradycardia, and nausea and vomiting. This condition can occur secondary to spinal and epidural anesthesia. Hypoxemia can occur secondary to many general anesthetics. Increased cranial pressure can occur with the use of ketamine for anesthesia, not epidural anesthesia. Emergence delirium is a disadvantage of inhalation agents used for general anesthesia, not epidural anesthesia.

The perioperative nurse is assisting with the induction of anesthesia. What is an appropriate nursing action during the induction stage? a. Administer appropriate drugs. b. Secure the airway of the patient. c. Assist with the application of monitors. d. Position the patient for surgical procedure.

ANS: C General anesthesia has four different phases, including preinduction, induction, maintenance, and emergence phases. In each stage the anesthesia care provider and perioperative nurse have different roles. In the induction stage, the duty of the perioperative nurse is to assist with the application of monitors. Securing the airway, administering appropriate drugs, and positioning the patient for the surgical procedure are the duties of the anesthesia care provider.

A patient undergoing a surgical procedure with general anesthesia exhibits muscle rigidity, temperature of 103° F (39.4° C), pulse 100 beats per minute (beats/minute), and a respiratory rate of 26 breaths per minute. The symptoms subside with the administration of dantrolene. What should the nurse include in the patient's postoperative instructions? a. Taking antipyretics will bring your body temperature down. b. Do not have any future surgeries under general anesthesia. c. Consider getting genetic testing for malignant hyperthermia. d. You should refrain from using any products that may contain latex.

ANS: C Hyperthermia, tachycardia, and tachypnea, along with skeletal muscle rigidity induced by general anesthesia, are indications of malignant hyperthermia. The patient should undergo genetic testing to confirm the condition. These tests can help in taking preventive action in the future. Antipyretics may not help in bringing the body temperature down, because the temperature is increased because of an imbalance in intracellular calcium in the skeletal muscles. The patient can receive general anesthesia with appropriate precautions in future surgeries. The manifestations of latex allergy may range from urticaria to anaphylactic reaction, but that is not a factor for this patient.

The nurse is providing orientation to new surgical staff employees. What does the nurse inform the employee that proper attire for the restricted area of the surgery department would include? a. Street clothing b. Surgical attire and head cover c. Surgical attire, head cover, and mask d. Surgical attire, with the addition of shoe covers

ANS: C In the surgical suite, in the restricted area, masks are required to supplement surgical attire. The restricted area can include the operating room (OR), scrub sink area, and clean core. The unrestricted area is where people in street clothes can interact with those in surgical attire. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station or control desk). The semirestricted area includes the surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair.

A circulating nurse is preparing to scrub the skin of a patient who is scheduled for an appendectomy. What technique is appropriate for the nurse to use to ensure proper cleansing? a. Use a zigzag motion from the area distal to the incision to the site of incision. b. Use a zigzag motion from the site of the incision to the site distal to the incision. c. Use a circular motion from the site of the incision to the area distal to the incision. d. Use a circular motion from the area distal to the incision to the site of the incision.

ANS: C It is important to scrub the skin appropriately in the process of skin preparation. It is done by a circulating nurse. The principle used here is to scrub a liberal area of skin using a circular motion from the clean area (i.e., the site of the incision) to the dirty area (i.e., the site distal to the incision) with an antimicrobial agent. This should be done in this way to reduce the microorganism migration to the surgical wound. Using a zigzag motion from the site of the incision to the area distal to the incision is not appropriate. Using a zigzag motion from the area distal to the incision to the site of the incision may contaminate the incision site. Using a circular motion from the area distal to the incision to the site of the incision may contaminate the incision site.

The nurse is caring for a patient who requires emergency surgery following a motor vehicle crash. Which anesthetic drug combination is most appropriate for this patient? a. Ketamine and fentanyl b. Midazolam and fentanyl c. Ketamine and midazolam d. Metaclopramide and ondansetron

ANS: C Ketamine is the preferred anesthetic drug used in trauma patients requiring surgery because it increases the heart rate and helps in improving cardiac output. When used alone it can cause hallucinations, and therefore, it is used with midazolam. Midazolam can reduce or eliminate hallucinations associated with ketamine. Fentanyl is an opioid and has no advantages over ketamine. Midazolam and fentanyl should not be administered together because they may precipitate respiratory depression. Metaclopramide and ondansetron are antiemetics.

A patient is having general anesthesia, and the anesthesia care provider administers succinylcholine. The patient begins exhibiting signs of malignant hyperthermia. What indication does the surgical team have that this is occurring? a. The patient is having hypocapnia. b. The patient has a temperature of 97°F. c. The patient is experiencing muscle rigidity. d. The patient has a heart rate of 46 beats per minute.

ANS: C Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias also may be seen with this disorder. Since the patient is in a hypermetabolic state, the heart rate will be elevated and not bradycardic.

The nurse is administering midazolam to a patient during a closed reduction of a shoulder. What outcome does the nurse anticipate achieving from the administration of the medication? a. Analgesia and antiemetic b. Analgesic and antianxiety c. Provided conscious sedation d. Relaxation of skeletal muscles and facilitation of endotracheal intubation

ANS: C Midazolam is a benzodiazepine that is used widely for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

A nurse is providing immediate postoperative care for a patient who has undergone a thymectomy. What is the primary reason the anesthesia care provider prescribes naloxone for the nurse to administer postoperatively? a. To decrease postoperative pain b. To maintain normal blood pressures c. To reverse opioid-induced respiratory depression d. To reduce the incidence of postoperative infection

ANS: C Narcan is the antidote of opioids. It contains naloxone. Opioid overdose induces respiratory depression. Narcan is prescribed to reverse this. Narcan is not useful in reducing postoperative pain or postoperative infection, or in maintaining blood pressure.

In which phase of general anesthesia are H 2 blockers used? a. Induction phase b. Emergence phase c. Preinduction phase d. Maintenance phase

ANS: C To prevent aspiration of gastric contents during surgery, the surgeon administers H 2 blockers in the preinduction phase of anesthesia. The induction phase is the period in which medications are given to render the patient unconscious. Benzodiazepines, opioids, and barbiturates are administered in the induction phase of anesthesia. The emergence phase is the period of completion of surgical procedure. The patient is prepared to be brought back to the preoperative state. Sympathomimetics, anticholinergics, and anticholinesterases are given during the emergence phase of anesthesia. The maintenance phase is the period of ongoing surgical procedure. Benzodiazepines, opioids, and barbiturates are administered in the maintenance phase.

The nurse is caring for a patient undergoing surgery for a below-the-knee amputation. What is critical to the patient's safety before and during the procedure? Select all that apply. a. The patient has adequate health insurance. b. The anesthesia care provider is an anesthesiologist. c. The patient's allergies are conveyed to the surgical team. d. The surgeon marks the surgical site with the patient's involvement. e. The surgical team confirms the patient's identity before anesthesia is administered.

ANS: C D E Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. Preventing wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative. A surgical time-out is performed before the induction of anesthesia during which the patient is asked to confirm name, birth date, operative procedure and site, and consent, and the patient's hospital ID number is compared with the patient's own ID band and chart. Determining if the patient has health coverage and identifying that the anesthesia care provider is an anesthesiologist does not apply to patient safety.

An older adult patient is admitted to the hospital for hip replacement surgery. What special considerations should be followed during the surgery to prevent complications? Select all that apply. a. Teach the patient about postoperative care. b. Ask the patient about a family history of bone diseases. c. Take greater care in preparing and positioning the patient. d. Maintain clear and concise communication with the patient. e. Use warming devices to prevent perioperative hypothermia.

ANS: C D E Some older adults are at a greater risk of perioperative hypothermia, and warming devices should be considered. The care and vigilance of the entire surgical team are needed in preparing and positioning the older patient. Some older adults may have difficulty communicating and following directions as a result of alterations in hearing or vision. These factors increase the need for clear and concise communication in the operating room. Asking the patient about a family history and teaching postoperative care are not appropriate activities to be done in the operating room. These activities should be done during the preoperative assessment.

A nurse has opened a suturing package in an operating room. The nurse places it in a pocket below the waist level of the gown. What is true about the suturing package? a. It is contaminated because the nurse opens it. b. It is sterile because it is placed in a sterile gown. c. It is sterile because it is still in the suture packet. d. It is contaminated because it is placed below the level of the table.

ANS: D A nurse should be aware that the only sterile parts of a gown are in front from the chest up to the level of the table; therefore, the nurse's pocket is contaminated. If a sterile suture package is placed in a contaminated area, it will be considered contaminated. Once a sterile package is opened, its edges are considered contaminated unless it is placed in a sterile environment. It is not contaminated because it is opened by the nurse. It is contaminated because it is placed below the level of the table. It is not sterile because it is placed in a sterile gown and is still in the suture packet.

The perioperative nurse is explaining legal considerations regarding surgical team performance. The nurse tells the team that to whom or what does the surgical technologist need access at all times? a. Surgeon b. Computer c. Anesthesiologist d. Registered nurse

ANS: D Depending on individual state rules and regulations, if surgical technologists are permitted to perform duties in the operating room, there must be access to a registered nurse (RN) at all times. The RN is responsible for supervising the surgical technologist in performance of all delegated nursing tasks. The surgeon performs the surgical procedure and is responsible for medical management of the patient and safety in the operating room. The anesthesiologist is responsible for administering anesthetic agents and monitoring patient responses before surgery, during surgery, and in the immediate postoperative period. The computer is used to document patient information in the surgical department, but it is not a mandated piece of equipment. Some facilities continue to use paper and pen documentation in the operating room.

The circulating nurse is preparing the patient for a surgical procedure. Prior to beginning, what National Patient Safety Goal (NPSG) requirement is enacted with a surgical time-out? a. Prevention of infection b. Improved staff communication c. Identify patients at risk for suicide d. Patient, surgical procedure, and site checked

ANS: D During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide usually is not vital before surgery and does not occur during the time out.

A patient with diabetes is admitted for a prostatectomy. The patient will receive an antibiotic 60 minutes prior to the surgery, their usual dose of insulin, and etomidate IV for anesthesia. Considering the patient's diabetes, the nurse expects that which component of the preoperative plan will be revised? a. The route of administration of etomidate b. The administration of the preoperative antibiotic c. The type of drug used to regulate the patient's glucose levels d. The dosage of insulin used to regulate the patient's glucose levels

ANS: D Etomidate is an intravenous anesthetic agent. It is a nonbarbiturate hypnotic and can cause hypoglycemia. Therefore the nurse should consider revising the dosage of insulin with the surgeon to prevent hypoglycemia. It is not appropriate to change the route of administration of etomidate, because it is an IV drug. Changing the drug or omitting administration of the antibiotic is not advised. Antibiotics are administered 30 to 60 minutes prior to surgery to reduce the incidence of postoperative infections.

A nurse is preparing a patient for an appendectomy. Shortly after the patient receives fentanyl for anesthesia, the patient experiences severe respiratory depression. What should be the next primary action? a. Provide artificial ventilation. b. Decrease the dose of fentanyl. c. Administer oxygen to the patient. d. Administer naloxone to the patient.

ANS: D Fentanyl is an opioid drug, which can cause respiratory depression. Naloxone is the antidote for opioid drugs, and it can reverse respiratory depression. Therefore it should be given to this patient. Increasing or decreasing the dose of fentanyl will not help. Oxygen can be administered once naloxone is administered. Artificial ventilation may be needed if the respiratory depression is severe.

The anesthesia care provider is preparing to administer spinal anesthesia. When assisting with the procedure, where does the nurse determine the anesthetic injection will be administered? a. Pleural space b. Subdural space c. Subpleural space d. Subarachnoid space

ANS: D In spinal anesthesia, local anesthetic injection is given into the cerebrospinal fluid in the subarachnoid space. It is mostly injected below the level of L2. As a result of mixing the anesthetic with cerebrospinal fluid, autonomic, sensory, and motor nerves are blocked. Spinal anesthesia is usually used for procedures on extremities, lower gastrointestinal, prostate, and gynecologic surgeries. Local anesthetics are not administered in the pleural space, subdural space, or subpleural space.

The nursing student is discussing anesthetic agents with the nursing instructor. Which statement by the nursing student indicates a need for further teaching? a. "Brevital can be used for short procedures and has minimal postoperative effects." b. "Propofol has a very quick impact and can cause a slow heart rate and low blood pressure." c. "Volatile inhalation agents all cause respiratory depression, and I should monitor the breathing of patients on such drugs." d. "Although nitrous oxide is an old anesthetic agent, it is the best choice for patients who have problems with nausea and vomiting."

ANS: D Nitrous oxide is a weak anesthetic that is rarely used alone and should not be used for patients with a history of nausea and vomiting. Thus this statement indicates a need for further education. Brevital has an immediate impact and a brief duration of less than five minutes; this drug causes few postoperative effects. Propofol is a nonbarbiturate hypnotic with a rapid onset; side effects include bradycardia and hypotension. All volatile inhalation agents can cause respiratory depression; nurses should monitor for these effects.

A patient being prepared for surgery asks if he or she will be given anything to help avoid nausea and vomiting postoperatively. Which medication does the nurse know can decrease the likelihood of nausea and vomiting? a. Diazepam b. Sublimaze c. Pancuronium d. Ondansetron

ANS: D Ondansetron (Zofran) is an antiemetic used to prevent nausea and vomiting in the intraoperative period. Sublimaze (Fentanyl) is an opioid used to induce and maintain anesthesia. Diazepam (Valium) is used to reduce anxiety in the intraoperative period. Pancuronium (Pavulon) is a neuromuscular blocking agent used to promote skeletal muscle relaxation.

The nurse is caring for a patient after having an exploratory laparotomy that is experiencing postoperative nausea and vomiting. What medication does the nurse prepare to administer to the patient to alleviate these symptoms? a. Fentanyl b. Midazolam c. Meperidine d. Ondansetron

ANS: D Ondansetron is an antiemetic, whereas midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics.

A patient has been administered pancuronium during a surgical procedure. The nurse determines that what medication is administered at the end of surgery to reverse the action of pancuronium? a. Methadone b. Dolasetron c. Remifentanil d. Neostigmine

ANS: D Pancuronium is a neuromuscular blocking agent that causes muscle paralysis. To reverse its action towards the end of surgery, an anticholinergic drug like neostigmine is administered. Methadone and remifentanil are opioid drugs. Dolasetron is an antiemetic.

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. Because the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is related directly to the type of anesthesia being used? a. Apply grounding pad to unaffected leg. b. Assess peripheral pulses and skin color. c. Verify the last oral intake before surgery. d. Ensure a smooth surface under the patient.

ANS: D Regional anesthesia decreases sensation to the anesthetized area without impairing the level of consciousness, which means the affected leg will have a decrease in sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient has a decrease in sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. Applying a grounding pad to the unaffected leg, assessing peripheral pulses and skin color, and verifying the last oral intake before surgery will be occurring but are not related directly to the regional anesthesia.

An older adult patient is scheduled to have a hip replacement. Of what risk areas will the nurse especially need to be aware for this patient during surgery? a. Sterility b. Paralysis c. Urine output d. Skin integrity

ANS: D Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery, but would not have an impact on any patient's skin integrity.

The nurse is preparing to prep the patient's skin for surgery. In which surgical area will the patient's skin be prepped for surgery and what clothing will the person doing the prepping be wearing? a. Surgical suite, wearing a lab coat b. Preoperative holding area, wearing street clothes c. Postanesthesia care unit (PACU), wearing scrubs d. Operating room, wearing surgical attire and masks

ANS: D Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. Lab coats are usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family might. The holding area and PACU will not include prepping the patient for surgery.

The nurse is preparing the patient for a colonoscopy. Which type of anesthesia should the nurse expect to be used? a. Local anesthesia b. Moderate sedation c. General anesthesia d. Monitored anesthesia care

ANS: D The nurse should expect monitored anesthesia care to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.