Chapter 18 Intraoperative Nursing Management

A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?

The Sims' or lateral position as shown in Option D would be used for renal surgery. The dorsal recumbent position (Option A) is used for most abdominal surgeries, except those for the gallbladder or pelvis. The Trendelenburg position (Option B) is used for surgery on the lower abdomen and pelvis. The lithotomy position (Option C) is used for nearly all perineal, rectal, and vaginal surgical procedures.

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? Malignant hyperthermia occurs in the operating room only. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. The client can develop malignant hyperthermia up to 24 hours after surgery. The client will need to be discharged with special instructions.

The client can develop malignant hyperthermia up to 24 hours after surgery. Although malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery. Malignant hyperthermia can be triggered by inhalant anesthesia with muscle relaxants.

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? oxygen alfentanil rocuronium lidocaine

oxygen Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? Temporarily set the OR temperature to 30°C. Place warm damp drapes on the client, replacing them every 5 minutes. Administer IV fluids warmed to room temperature. Apply a warm air blanket, gradually increasing body temperature.

Apply a warm air blanket, gradually increasing body temperature.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Circulating nurse Scrub nurse Surgeon

Circulating nurse

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Circulating nurse Scrub nurse Surgeon

Circulating nurse The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? Unresponsive to verbal or tactile stimuli Denies sensation to perineum and lower abdomen Yelling and pulling at equipment No movement in right lower leg

Denies sensation to perineum and lower abdomen A transsacral block anesthetizes the perineum and occasionally the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Lack of response to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.

Which drug is a nondepolarizing muscle relaxant? Pancuronium Fentanyl Succinylcholine Morphine sulfate

Pancuronium Pavulon is a nondepolarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents. Succinylcholine is a depolarizing muscle relaxant.

The anesthesiologist is administering a stable and safe nondepolarizing muscle relaxant. What medication does the nurse anticipate will be administered? Anectine (succinylcholine chloride) Norcuron (vecuronium bromide) Pavulon (pancuronium bromide) Syncurine (decamethonium)

Pavulon (pancuronium bromide) Pancuronium (Pavulon) is a nondepolarizing muscle relaxant with a longer onset and duration. Succinylcholine (Anectine) and decamethonium (Syncurine) are depolarizing muscle relaxants. Vercuronium (Norcuron) is a nondepolarizing muscle relaxant that requires mixing.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: beginning anesthesia Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression

Stage II: excitement

The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel. maintain the safety of the client.

maintain the safety of the client.

The nurse positions the client in the lithotomy position in preparation for Renal surgery Pelvic surgery Perineal surgery Abdominal surgery

Perineal surgery The client undergoing perineal surgery will be placed in the lithotomy position.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? malignant hyperthermia hypothermia infection fluid volume excess

malignant hyperthermia Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I won't feel it, but I'll have a tube to help me breathe." "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions."

"I'll be sleepy but able to respond to your questions." With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply. "The client can be involved in marking the knee, the site for the surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." "The surgeon on the team has never been involved in such a mix-up." "The client will be involved in the verification process prior to surgery." "Our surgical team would never make that mistake."

"The client can be involved in marking the knee, the site for the surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." "The client will be involved in the verification process prior to surgery." There is an increased emphasis on making sure that the right client has the right procedure at the right site. To prevent "wrong site, wrong procedure, wrong person surgery," The Joint Commission (2019) established a universal protocol to achieve this goal. Included in this checklist are steps to verify the preoperative process, mark the operative site, and perform a "time-out." Telling the client that the surgeon has not been involved in such a mix-up or would never make that mistake is false reassurance.

The nurse would intervene when making which of the following observations in the surgical environment? A staff member dressed in street clothes enters the semirestricted zone. A staff member is wearing scrub clothes in the semirestricted zone. A staff member is wearing a surgical mask and shoe covers in the restricted zone. A staff member fails to wear a mask in the semirestricted zone.

A staff member dressed in street clothes enters the semirestricted zone. Street clothes are permitted in the unrestricted zone only.

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate? Monitor for faulty electrical equipment. Alert personnel who break sterile technique. Allow unnecessary personnel to enter the OR environment. Maintain the positive pressure OR environment.

Allow unnecessary personnel to enter the OR environment. The circulating nurse restricts the admittance of unnecessary personnel in the OR environment.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? Temporarily set the OR temperature to 30°C. Place warm damp drapes on the client, replacing them every 5 minutes. Administer IV fluids warmed to room temperature. Apply a warm air blanket, gradually increasing body temperature.

Apply a warm air blanket, gradually increasing body temperature. A warm air blanket can be used to treat hypothermia. The body temperature should be increased gradually. A sudden increase in body temperature could cause complications. The OR temperature should not exceed 26.6°C to prevent pathogen growth. Only dry materials should be placed on the client because wet materials promote heat loss. IV fluids should be warmed to body temperature, not room temperature.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments

Coordinating the surgical team The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Fentanyl citrate Naloxone Thiopental sodium

Dantrolene sodium Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Increased anxiety level Increased tissue elasticity Decreased lean tissue mass Impaired thermoregulation

Decreased lean tissue mass

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Increased anxiety level Increased tissue elasticity Decreased lean tissue mass Impaired thermoregulation

Decreased lean tissue mass Elderly patients require lower doses of anesthetic agents because of decreased tissue elasticity and reduced lean tissue mass. An increased amount of anesthetic would be needed with an increased anxiety level. Impaired thermoregulation increases the patient's susceptibility to hypothermia.

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? Unresponsive to verbal or tactile stimuli Denies sensation to perineum and lower abdomen Yelling and pulling at equipment No movement in right lower leg

Denies sensation to perineum and lower abdomen

A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate? Notify the anesthesiologist immediately. Position the patient on the side. Turn on the television for distraction. Encourage increased fluid intake.

Encourage increased fluid intake. Headache may be an after-effect of spinal anesthesia. To aid in relieving the headache, the nurse would maintain a quiet environment and keep the patient flat and well-hydrated. There is no need to notify the anesthesiologist because this report is not unexpected.

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Halothane Fentanyl Succinylcholine Propofol

Halothane Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate? Leading the surgical team in a debriefing session Keeping all records and adjusting lights Handing instruments to the surgeon and assistants Coordinating activities of other personnel

Handing instruments to the surgeon and assistants The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include leading the surgical team in a debriefing session, keeping records, adjusting lights, and coordinating activities of other personnel.

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? Sore throat Itching Seizures Headache

Headache

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? Sore throat Itching Seizures Headache

Headache Headache is a common effect following spinal anesthesia.

Which stage of surgical anesthesia is also known as excitement? I II III IV

II Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? I II III IV

II Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? Ignore the comment. Report the resident to the attending surgeon. Discuss concerns regarding the comments with the charge nurse. Inform the resident that all communication needs to remain professional.

Inform the resident that all communication needs to remain professional. The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in? Left lateral Sim's Prone position Lithotomy position Trendelenburg

Lithotomy position The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures (see Fig. 18-5C). The patient is positioned on the back with the legs and thighs flexed. The position is maintained by placing the feet in stirrups.

The client received ketamine during a surgical procedure. What intervention by the nurse will assist with an optimal recovery period? Make sure that the client is stimulated frequently. Place the client in a darkened, quiet part of the recovery area. The client does not require a recovery period and may go back to the hospital room. Speak to the client in a loud, clear voice.

Place the client in a darkened, quiet part of the recovery area.

The client received ketamine during a surgical procedure. What intervention by the nurse will assist with an optimal recovery period? Make sure that the client is stimulated frequently. Place the client in a darkened, quiet part of the recovery area. The client does not require a recovery period and may go back to the hospital room. Speak to the client in a loud, clear voice.

Place the client in a darkened, quiet part of the recovery area. The client received ketamine during a surgical procedure. What intervention by the nurse will assist with an optimal recovery period? Make sure that the client is stimulated frequently. Place the client in a darkened, quiet part of the recovery area. The client does not require a recovery period and may go back to the hospital room. Speak to the client in a loud, clear voice.

A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? Dizziness and a feeling of detachment Pupillary dilation and rapid pulse Unconsciousness and regular respirations Weak, thready pulse and cyanosis

Pupillary dilation and rapid pulse During stage II, or the excitement stage, of general anesthesia, the pupils dilate and the pulse rate is rapid. During stage I, warmth, dizziness, and a feeling of detachment may be experienced. During stage III, the patient is unconscious, respirations are regular, and the pulse rate and volume are normal. During stage IV, respirations become shallow, the pulse is weak and thready, the pupils become widely dilated, and cyanosis develops.

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? Remove the item from the sterile field. Mark the client's chart for future review of infections. Remove the entire sterile field from use. Ask another nurse to review the technique used.

Remove the item from the sterile field. If any doubt exists about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the entire field was potentially contaminated. Reviewing the client's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not resolve the immediate concern.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse.

Report the infection to an immediate supervisor. The infection needs to be reported immediately because of the aseptic environment of the operating room. The usual barriers may not protect the client when an infection is present. The employee needs to follow the policy of the operating room regarding infections. Covering the infected area with a dressing may be necessary, but the infection must be reported first. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must be reported first.

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? Risk for perioperative positioning injury related to positioning in the OR Risk of latex allergy response related to possible exposure in the OR environment Disturbed sensory perception related to the effects of general anesthesia Anxiety related to ineffective coping with surgical concerns

Risk for perioperative positioning injury related to positioning in the OR Pressure ulcers, nerve and blood vessel damage, impeded respiration, hyperextended joints, and discomfort are risks associated with the prolonged, awkward positioning required for some surgical procedures. The other choices are also potential nursing diagnoses or concerns related to surgery, but they are not related to the duration of the surgery.

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first? Roll the client onto his or her side. Suction the mouth. Provide a basin. Administer an antiemetic medication.

Roll the client onto his or her side. The client must be rolled to the side to prevent aspiration. All the other interventions are correct for a sedated client who is vomiting, but the highest priority is preventing aspiration.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: beginning anesthesia Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression

Stage II: excitement The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if the anesthetic is administered smoothly and quickly. Because of the possibility of uncontrolled movements, the patient should not be touched except for purposes of restraint.

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage II Stage III Stage IV

Stage IV Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.

Which of the following techniques least exhibits surgical asepsis? Adding only sterile items to a sterile field Keeping sterile gloved hands above the waist Suctioning the nasopharyngeal cavity of a client Placing the sterile field at least one foot away from personnel

Suctioning the nasopharyngeal cavity of a client To maintain surgical asepsis, only sterile items should touch sterile items. Basic guidelines ensuring that all materials in contact with the surgical wound or used within the sterile field are sterile and maintaining at least a 1-foot distance from the sterile field. Surgical gowns are considered sterile in front from the chest to the level of the sterile field, and sleeves are considered sterile from 2 inches above the elbow to the stockinette cuff; therefore, sterile gloved hands should be kept above the sterile field to prevent contamination. Nasopharyngeal suction is an aerosol-generating procedure.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? Beginning anesthesia Excitement Surgical anesthesia Medullary depression

Surgical anesthesia Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. In beginning anesthesia, as the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Medullary depression is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light.

Which of the following is an inappropriate nursing action by the surgical nurse? Covering the hair with a surgical cap Wearing a surgical jacket with knitted cuffs on the sleeves Wearing sterile gloves over artificial nails Changing shoe covers that become torn

Wearing sterile gloves over artificial nails Artificial nails are prohibited in the clinical setting, because they can cause nosocomial infections.