Medical-Surgical Nursing Chapter 19 Intraoperative Care

4 Ondansetron is an antiemetic, whereas midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence. Text Reference - p. 344

A 71-year-old male patient who currently is undergoing coronary artery bypass graft (CABG) surgery just has experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? 1 Midazolam 2 Fentanyl 3 Meperidine 4 Ondansetron

3 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 ondensetron and promethazine are antiemetics. Text Reference - p. 344

An anesthesia care provider has prescribed flumazenil for a patient. The nurse recognizes that the flumazenil is an antidote for what medication overdose? 1 Morphine overdose 2 Ondensetron overdose 3 Lorazepam overdose 4 Promethazine overdose

1 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. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be. Text Reference - p. 344

A surgical patient's premedication regimen includes midazolam. What are the most likely desired effects of this medication? 1 Provided conscious sedation 2 Analgesic and antianxiety 3 Analgesia and antiemetic 4 Relaxation of skeletal muscles and facilitation of endotracheal intubation

1, 2, 4 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. Test-Taking Tip: Try putting questions and answers in your own words to test your understanding. Text Reference - p. 345

A 75-year-old patient is admitted to the hospital for hip replacement surgery. What special considerations or practices should be followed during the surgery? Select all that apply. 1 Use warming devices to prevent perioperative hypothermia. 2 Take greater care in preparing and positioning the patient. 3 Ask the patient about a family history of bone diseases. 4 Maintain clear and concise communication with the patient. 5 Teach the patient about postoperative care.

4 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. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes. Text Reference - p. 345

A 78-year-old patient is having a bilateral hip replacement. Of what risk areas will the nurse especially need to be aware for this patient during surgery? 1 Sterility 2 Paralysis 3 Urine output 4 Skin integrity

2 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. Text Reference - p. 344

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? 1 Vecuronium. 2 Methadone. 3 Ondansetron. 4 Metoclopramide.

1, 4 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 handoff report to the PACU nurse are the duties of a circulating nurse. Text Reference - p. 335

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. 1 Assist in the draping procedure. 2 Assist in induction of anesthesia. 3 Monitor the draping procedure. 4 Assist in preparing the operating room. 5 Provide a hand-off report to the postanesthesia care unit (PACU) nurse.

3, 4, 5 Transesophageal echocardiography (TEE) is used intraoperatively to assess ventricular function and competency of heart valves, and to recognize venous air embolism. The electrical activity of the heart is assessed by electrocardiogram. Ultrasonic-guided regional anesthesia is used for visualizing plexus of nerves. Text Reference - p. 346

A nurse is explaining new developments in surgery to the nursing staff. About what should the nurse inform the staff in regard to the uses of transesophageal echocardiography (TEE)? Select all that apply. 1 It determines the electrical activity of the heart intraoperatively. 2 It assesses the plexus of nerve supplying the heart. 3 It assesses ventricular function intraoperatively. 4 It assesses competency of heart valves intraoperatively. 5 It recognizes venous air embolism intraoperatively.

1 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. Text Reference - p. 344

A nurse is providing immediate postoperative care for a patient who has undergone a thymectomy. An anesthesia care provider has prescribed Naloxone. What is the primary reason the medication is being given? 1 To reverse opioid-induced respiratory depression 2 To decrease postoperative pain 3 To reduce the incidence of postoperative infection 4 To maintain normal blood pressures

2 Ranitidine is an H2-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. Text Reference - p. 342

A nurse is reviewing the plan of care for a patient scheduled for a cholecystectomy. The plan includes the administration of ranitidine. The nurse is aware that the medication will be given at what time? 1 After surgery 2 Before surgery 3 During surgery 4 Immediately after surgery

1, 2, 3, 4 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. Text Reference - p. 345

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. 1 Nausea 2 Bradycardia 3 Hypotension 4 Vomiting 5 Hyperglycemia

1 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 H2-receptor blocker and does not cause hypotension. Bleeding and nerve injury are highly unlikely to occur during tubectomy. Text Reference - p. 343

A patient has undergone a tubal ligation. The patient was administered propofol, ranitidine, and metoclopramide. Postoperatively, the nurse finds the patient's blood pressure is 80/50 mm Hg. What could be the reason for the hypotension? 1 Administration of propofol 2 Administration of ranitidine 3 Bleeding during surgery 4 Nerve injury during surgery

2, 3 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. Text Reference - p. 344

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. 1 Insomnia 2 Hypotension 3 Tachycardia 4 Pulse oximetry 5 Abdominal distention

2, 5 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. Text Reference - p. 344

A patient is given dexamethasone to counteract emetic effects of morphine. The nurse should monitor for which medication side effects? Select all that apply. 1 Dizziness 2 Insomnia 3 Tachycardia 4 Dysrhythmia 5 Abdominal distention

1 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. Text Reference - p. 343

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? 1 Avoid the administration of nitrous oxide. 2 Bone marrow depression has no effect on the administration of nitrous oxide. 3 Avoid administering nitrous oxide when the patient is receiving oxygen. 4 Observe for myoclonus, which is a side effect of nitrous oxide.

2 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. Text Reference - p. 338

A patient is undergoing total knee replacement surgery and during the operation, the patient requires a blood transfusion. Which nurse will inform the blood bank regarding the need for a blood transfusion? 1 Scrub nurse 2 Circulating nurse 3 Nurse anesthetist 4 Anesthesiologist assistant

3 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. Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the question stem that are the same or similar in nature to those in one or two of the options. Text Reference - p. 14

A patient undergoing a surgical procedure with general anesthesia exhibits muscle rigidity, body temperature (T) of 103° F (39.4° C), pulse (P) of 100 beats per minute (bpm), and a respiratory rate (RR) of 26 breaths per minute. The symptoms subside with the administration of dantrolene. What should the nurse include in the patient's postoperative instructions? 1 Taking antipyretics will bring your body temperature down. 2 Do not have any future surgeries under general anesthesia. 3 Consider getting genetic testing for malignant hyperthermia. 4 You should refrain from using any products that may contain latex.

1 These symptoms indicate that the patient has malignant hyperthermia triggered by succinylcholine. Its definitive treatment is immediate administration of dantrolene. It slows down the metabolism, reduces muscle contraction, and mediates the catabolic process associated with malignant hyperthermia. It is very important to diagnose this condition promptly and administer medication; otherwise, it may cause cardiac arrest and death. Propofol and morphine are anesthetics and are not useful in this case. Naloxone is an antidote for opioid drugs. Text Reference - p. 346

A patient was administered succinylcholine for thyroid surgery. A nurse finds that the patient has hyperthermia, tachycardia, tachypnea, and hypercarbia. Which drug will most likely help the patient? 1 Dantrolene 2 Propofol 3 Morphine 4 Naloxone

3 A nurse should have knowledge about aseptic technique in an operating room. Any sterile item which comes in contact with an unsterile item becomes contaminated. All the contaminated items should be immediately removed from the sterile field. However, if the unsterile item is small, such as an unopened suture, it should be removed and the area can be marked off by covering with a sterile drape. If the contaminated area is large, then the whole room should be set up again. If the contaminated area is small, there is no need to set up the whole room again. It is inappropriate to let a circulating nurse touch the sterile field. The suture is small but it may cause contamination, so it is inappropriate to ignore it. Text Reference - p. 339

A perioperative nurse has prepared an operating room for surgery. Just before leaving the room, the nurse discovers a small, unused, unsterile suture on the operating table. What is the most appropriate action? 1 Set up the whole room again. 2 Ask a circulating nurse to remove it. 3 Remove the suture and cover the area with a sterile drape. 4 Because the suture is small, the nurse need not do anything.

1 Many organizations use alcohol-based waterless surgical hand scrub instead of traditional soap and water. Before applying alcohol-based product to hands, the hands and forearms should be washed with soap. Forearms and hands should be dried thoroughly and then hand scrub should be applied. Wiping hands and forearms with hand tissue does not ensure proper cleaning. Washing hands and forearms with normal water may not cleanse all dirt from the hands. Washing hands and forearms with normal saline is not required, because it does not ensure removal of dirt. Text Reference - p. 338

Before applying alcohol-based surgical hand scrub, what action should the nurse take? 1 Wash hands and forearms with soap. 2 Wipe hands and forearms with hand tissue. 3 Rinse hands and forearms with tap water. 4 Wash hands and forearms with normal saline.

1, 4, 5 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. Text Reference - p. 339

Before starting the surgery, the team takes a surgical time-out. Which activities should the circulating nurse perform during a surgical time-out? Select all that apply. 1 Ask the patient to confirm name and date of birth. 2 Assist the surgical team in putting on surgical attire. 3 Teach the patient how to do deep-breathing exercises. 4 Ask the patient to confirm the operative procedure and site and to give consent. 5 Compare the hospital identity (ID) number with the patient's own ID band.

1 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. Text Reference - p. 342

During surgery, a patient is administered ketamine hydrochloride, 60 mg, intravenously. Which is an important nursing intervention during recovery? 1 Maintain a calm and quiet environment. 2 Monitor the patient for hyperthermia. 3 Assess the patient's ability to move limbs. 4 Monitor blood sugar levels for hypoglycemia.

3 To prevent aspiration of gastric contents during surgery, the surgeon administers H2 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. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 342

In which phase of general anesthesia are H2 blockers used? 1 Induction phase 2 Emergence phase 3 Pre-induction phase 4 Maintenance phase

4 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. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Text Reference - p. 338

In which surgical area will the patient's skin be prepped for surgery and what clothing will the person doing the prepping be wearing? 1 Surgical suite, wearing a lab coat 2 Preoperative holding area, wearing street clothes 3 Postanesthesia care unit (PACU), wearing scrubs 4 Operating room, wearing surgical attire and masks

4 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. Text Reference - p. 344

The nurse is aware that which medication is administered at the end of surgery to reverse the action of pancuronium? 1 Methadone 2 Dolasetron 3 Remifentanil 4 Neostigmine

3 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. Text Reference - p. 342

The nurse is caring for a patient who needs surgery following a motor vehicle accident. Which anesthetic drug combination is most appropriate for this patient? 1 Ketamine and fentanyl 2 Midazolam and fentanyl 3 Ketamine and midazolam 4 Metaclopramide and ondansetron

2 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 lithotomy position is used for some types of pelvic organ surgery. Text Reference - p. 340

The nurse is positioning a patient for laminectomy. Which position should the nurse place the patient in? 1 Supine 2 Prone 3 Lithotomy 4 Lateral

1 When scrubbing for surgical hand antisepsis, the fingers and the hands should be scrubbed first with progression to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all the times to prevent contamination from clothing or detergent suds and to prevent water from draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. Text Reference - p. 338

When scrubbing for surgical hand antisepsis, what is the most appropriate action? 1 Fingers and hands should be scrubbed first. 2 The hands should be held close to the surgical attire. 3 The scrubbing should progress from the forearms down. 4 The hands should be held lower than the elbows at all times.

2, 3, 5 Both the 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. Text Reference - p. 335

Which intraoperative nursing responsibilities should be performed by the scrub nurse? Select all that apply. 1 Documenting intraoperative care 2 Keeping track of irrigation solutions for monitoring of blood loss 3 Passing instruments and supplies to the health care provider by anticipating his or her needs 4 Coordinating the flow and activities of members of the surgical team in the surgical suite 5 Performing the count of sponges, needles, and instruments used during the surgical procedure

1, 5 During surgery, a physician and a registered nurse first assistant work with the surgeon to produce an optimal surgical outcome for the patient. The anesthesiologist, nurse anesthetist, and anesthesiologist assistant play roles administering anesthesia before surgery. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 336

Who assists the surgeon during surgery? Select all that apply. 1 Physician 2 Anesthesiologist 3 Nurse anesthetist 4 Anesthesiologist assistant 5 Registered nurse first assistant (RNFA