CH 18
A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply. a) Caps b) Street clothes c) Scrub clothes d) Shoe covers e) Masks
• Scrub clothes • Caps Explanation: Scrub clothes and caps are worn in the semi-restricted area. Street clothes are worn in the unrestricted area. Scrub clothes, caps, shoe covers, and masks are worn in the restricted area.
Which statement by the client indicates further teaching about epidural anesthesia is necessary? a) "A needle will deliver the anesthetic into the area around my spinal cord." b) "I will become unconscious." c) "I will lose the ability to move my legs." d) "I will be able to hear the surgeon during the surgery."
"I will become unconscious." Explanation: The client receiving epidural anesthesia will remain conscious during the procedure.
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? a) "I'll be sleepy but able to respond to your questions." b) "Only the surgical area will be numb." c) "I'm so glad that I will be unconscious during the surgery." d) "I won't feel it, but I'll have a tube to help me breathe."
"I'll be sleepy but able to respond to your questions." Explanation: With moderate sedation, the patient can maintain a patent airway (ie, 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.
The client asks the nurse about possible ill effects from general anesthesia. Which of the following is the best response by the nurse? a) "Few negative effects occur with general anesthesia." b) "Clients can experience pain and loss of consciousness." c) "Some possible negative effects include oversedation and bradycardia." d) "Amnesia and analgesia are some of the negative effects of anesthesia."
"Some possible negative effects include oversedation and bradycardia." Explanation: Oversedation, allergic reaction, and bradycardia are potential adverse effects of surgery and anesthesia.
A new scrub technician is being orientated to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the last 10 years." What is the best response by the nurse?
"The operating room has some unique circumstances that increases the chances of fire." Explanation: The operating room environment has some unique characteristics that do increase the chance of fires, such as drapes that allow oxygen concentration. By engaging the new employee to understand the underlying reason for fire safety in the operating room, the new employee will develop a greater understanding and appreciation for fire safety. If fire safety is only presented as a requirement for the job then the employee may not understand the importance of fire safety. The hospital's policy for fire safety is broad; the employee would need to review the fire safety policies specifically for the operating room
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery? a) (Pic) Pt laying supine with arm strapped perpendicular to the side b) (Pic) Pt laying supine with head of bed lower than heart and arm strapped perpendicular to side. c) (Pic) Pt laying supine with both feet suspended in air. Knees bent. d) (Pic) Pt laying on side with head and feet lower than hip. (like your bent in half )
(Pic) Pt laying on side with head and feet lower than hip. (like your bent in half ) 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 patient undergoes induction for general anesthesia at 8:30 a.m. and is being assessed continuously for the development of malignant hyperthermia. At which time would the patient be most likely to exhibit manifestations of this condition? a) 9:00 to 9:10 a.m. b) 9:30 to 9:40 a.m. c) 10:00 to 10:10 a.m. d) 8:40 to 8:50 a.m.
8:40 to 8:50 a.m. Explanation: Malignant hyperthermia usually manifests about 10 to 20 minutes after the induction of anesthesia, which in this case would 8:40 to 8:50 a.m.
The nurse would intervene when making which of the following observations in the surgical environment? a) A staff member fails to wear a mask in the semirestricted zone. b) A staff member dressed in street clothes enters the semirestricted zone. c) A staff member is wearing a surgical mask and shoe covers in the restricted zone. d) A staff member is wearing scrub clothes in the semirestricted zone.
A staff member dressed in street clothes enters the semirestricted zone. Explanation: Street clothes are permitted in the unrestricted zone only.
Which of the following characteristics should the nurse include when teaching the client about moderate sedation? a) Paralysis of the lower extremities b) Loss of consciousness c) Unable to maintain airway d) Ability to respond to verbal commands
Ability to respond to verbal commands Explanation: The client receiving moderate sedation will be able to respond to verbal commands.
A patient undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The patient is ready for rewarming procedures. Which of the following actions by the nurse is appropriate? a) Administer IV fluids warmed to room temperature. b) Apply a warm air blanket, gradually increasing body temperature. c) Place warm damp drapes on the patient, replacing them every 5 minutes. d) Temporarily set the OR temperature to 30°C.
Apply a warm air blanket, gradually increasing body temperature. Explanation: A warm air blanket can be used to treat hypothermia. The body temperature should gradually be increased. 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 patient because wet materials promote heat loss. IV fluids should be warmed to body temperature, not room temperature.
A 78-year-old woman is undergoing right hip surgery to repair a hip fracture. What nursing action is appropriate during the intraoperative phase? a) Appropriately position the patient using adequate padding and support. b) Discuss the need for higher doses of anesthetic agents with the anesthesiologist. c) Withhold pain medication due to decreased renal functioning. d) Maintain an operating room temperature of 18°C to prevent hypothermia.
Appropriately position the patient using adequate padding and support. Explanation: Adequate padding and support should be used to prevent positioning injuries. The older adult is has lower bone mass, which increases the risk of intraoperative positioning injuries. Pain medication can still be used, just in smaller doses, due to decreased liver and kidney functioning. For the same reason as pain medication, lower doses of anesthetic agents are used with the older adult. The operating room is usually maintained from 20°C to 24°C; 18°C is lower than the recommended temperature and can promote hypothermia in the older adult who already has impaired thermoregulation and is prone to hypothermia.
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? a) Surgeon b) Circulating nurse c) Registered nurse first assistant d) Scrub nurse
Circulating nurse Explanation: The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.
The anesthesiologist administered a transsacral conduction block. Which of the following documentation by the nurse is consistent with the anesthesia being administered? a) Unresponsive to verbal or tactile stimuli b) Yelling and pulling at equipment c) Denies sensation to perineum and lower abdomen d) No movement in right lower leg
Denies sensation to perineum and lower abdomen Explanation: A transsacral block produces anesthesia of the perineum, and occasionally, the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Unresponsive to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? a) Positioning the sterile drape on a table from back to front b) Considering the gown sterile from mid-thigh to neck c) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff d) Allowing circulating nurses to contact sterile equipment
Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff Explanation: In the operating room, the sleeves of a gown are considered sterile from 2 inches above the elbow to the stockinette cuff. In addition, the gown is considered sterile in front from the chest to the level of the sterile field. When draping a table or patient, the sterile drape is held well above the surface to be covered and positioned from front to back. Circulating nurses and unsterile items contact only unsterile areas.
A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? a) Etomidate b) Nitrous oxide c) Isoflurane d) Tetracaine
Etomidate Explanation: Anesthesia induction begins with IV anesthesia, such as etomidate, and then is maintained at the desired stage by inhalation methods, such as isoflurane or nitrous oxide. Tetracaine is used for local or regional anesthesia.
The circulating nurse is documenting all medications administered during a surgical procedure. The anesthesiologist administers an opioid analgesic. What medication would the nurse check as having being administered? a) Mivacurium (Mivacron) b) Metocurine (Metubine) c) Etomidate (Amidate) d) Fentanyl (Sublimaze)
Fentanyl (Sublimaze) Explanation: Fentanyl is an opioid analgesic. Mivacurium and metocurine are muscle relaxants. Etomidate is an anesthetic agent.
A patient has been administered ketamine (Ketalar) for moderate sedation. What is the priority nursing intervention? a) Providing a quiet dark room b) Assessing for hallucinations c) Frequent monitoring of vital signs d) Administering oxygen
Frequent monitoring of vital signs Explanation: Vital signs must be monitored frequently to assess for respiratory depression and intervene quickly. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the patient is recovering. Hallucinations may be experienced as a side effect of the medication.
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? a) Itching b) Headache c) Seizures d) Sore throat
Headache Explanation: Headache is a common effect following spinal anesthesia.
A patient develops malignant hyperthermia. Which of the following most likely would be the first indicator of this complication? a) Generalized muscle rigidity b) Body temperature rise of 2 degrees F c) Tentanus-like jaw movements d) Heart rate over 150 beats per minute
Heart rate over 150 beats per minute Explanation: With malignant hyperthermia, tachycardia with a heart rate greater than 150 beats per minute is often the earliest sign. Generalized muscle rigidity is also an early sign. Rigidity or tetanus-like movement occurs often in the jaw. The rise in body temperature is a late sign that develops rapidly.
Which stage of anesthesia is termed surgical anesthesia? a) I b) II c) III d) IV
III Explanation: Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the patient breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a stage of medullary depression and is reached when too much anesthesia has been administered.
Which position is used for perineal surgical procedures? a) Dorsal recumbent b) Sim's c) Trendelenburg d) Lithotomy
Lithotomy Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. The Sim's or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.
Which of the following is the most common cause of anaphylaxis? a) Plastic b) Fibrin sealants c) Medications d) Latex
Medications Explanation: Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. Latex, fibrin sealants, and plastic are not the most common cause of anaphylaxis.
A patient is administered succinylcholine and propofol (Diprivan) for induction of anesthesia. One hour after administration, the patient is demonstrating muscle rigidity with a heart rate of 180. What should the nurse do first? a) Administer dantrolene sodium (Dantrium). b) Obtain cooling blankets. c) Notify the surgical team. d) Document the assessment findings.
Notify the surgical team. Explanation: Tachycardia and muscle rigidity is often the earliest sign of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, administer dantrolene sodium (Dantrium), obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.
Fentanyl (Sublimaze) is categorized as which type of intravenous anesthetic agent? a) Opioid b) Neuroleptanalgesic c) Tranquilizer d) Dissociative agent
Opioid Explanation: Fentanyl is 75 to 100 times more potent than morphine and has about 25% of the duration of morphine (IV). Examples of tranquilizers include midazolam (Versed) and diazepam (Valium). Ketamine is a dissociative agent.
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? a) Oxygen saturation (SaO2) of 85% b) Blood-tinged stools c) Heart rate of 84 beats/minute d) Decreased cough and gag reflexes
Oxygen saturation (SaO2) of 85% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.
A list of commonly used medications for a particular surgical procedure is provided to the nurse. The anesthesiologist announces the administration of a nondepolarizing muscle relaxant. Which of the following medications should the nurse document as having been administered? a) Fentanyl (Sublimaze) b) Succinylcholine (Anectine) c) Morphine sulfate d) Pancuronium (Pavulon)
Pancuronium (Pavulon) Explanation: Pavulon is a nondepolarizing muscle relaxant. Succinylcholine is a polarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents.
The nurse positions the client in the lithotomy position in preparation for a) Renal surgery b) Perineal surgery c) Abdominal surgery d) Pelvic surgery
Perineal surgery Explanation: The client undergoing perineal surgery will be placed in the lithotomy position.
During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? a) Remove wet gowns and drapes. b) Warm IV and irrigating fluids. c) Increase the temperature of the OR environment. d) Place a cooling blanket under the client.
Place a cooling blanket under the client. Explanation: The nurse would not apply a cooling blanket to a client with hypothermia. All other nursing actions are appropriate.
A patient is undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate? a) Place the patient in the Trendelenburg position. b) Place the patient in Sims' position. c) Place the patient in lithotomy position. d) Place the patient in a dorsal recumbent position.
Place the patient in lithotomy position. Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. Sims' or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.
The scrub nurse is responsible for: a) Monitoring the administration of the anesthesia b) Monitoring the operating-room personnel for breaks in sterile technique c) Calling the "time-out" to verify the surgical site and procedure d) Preparing the sterile instruments for the surgical procedure
Preparing the sterile instruments for the surgical procedure Explanation: The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.
The circulating nurse is unsure if proper technique was followed when placing an object in the sterile field during a surgical procedure. What is the best action by the nurse? a) Remove the item from the sterile field. b) Mark the patient's chart for future review of infections. c) Remove the entire sterile field from use. d) Ask another nurse to review the technique used.
Remove the entire sterile field from use. Explanation: If there is any doubt 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 field was potentially contaminated. Reviewing the patient'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 solve the immediate concern.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a) Return to work after being on antibiotics for 24 hours. b) Report the infection to an immediate supervisor. c) Ensure the infection is covered with a dressing. d) Request role change to circulating nurse.
Report the infection to an immediate supervisor. Explanation: The infection needs to be reported immediately because of the asepsis environment of the operating room. The usual barriers may not protect the patient when an infection is present. The employee will need to follow the policy of the operating room regarding infections. Covering the infections with a dressing may be necessary but the infection must first be reported. 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 first be reported.
The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: a) Need pain control throughout the procedure b) Need an endotracheal tube c) Respond verbally during the procedure d) Be anxious throughout the procedure
Respond verbally during the procedure Explanation: Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.
The physician, concerned about aspiration during a surgical procedure, orders a medication to increase gastric pH. Which of the following medications would the nurse document as given? a) Vecuronium (Norcuron) b) Famotadine (Pepcid) c) Sodium citrate (Bicitria) d) Midazolam (Versed)
Sodium citrate (Bicitria) Explanation: Sodium citrate increases the gastric pH therefore reducing the damage to the respiratory tract if aspiration should occur. Vecuronium is a muscle relaxant, famotidine decreases gastric acid production, and midazolam is an anesthetic agent.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? a) Scrub nurse b) Surgeon c) Circulating nurse d) Anesthetist
Surgeon Explanation: The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.
Which of the following clinical manifestations is often the earliest sign of malignant hyperthermia? a) Tachycardia (heart rate above 150 beats per minute) b) Oliguria c) Elevated temperature d) Hypotension
Tachycardia (heart rate above 150 beats per minute) Explanation: Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops rapidly. Scant urinary output is a later sign of malignant hyperthermia.
A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed. Lower the head of the surgical table. Provide a basin for collection. Turn the patient to the side. Suction to remove saliva.
Turn the patient to the side. Lower the head of the surgical table. Provide a basin for collection. Suction to remove saliva. Explanation: If a patient gags or begins to vomit, the patient is turned to the side, the head of the table is lowered, and a basin is provided to collect the vomitus. Suction is used to remove saliva and vomited gastric contents.
A patient is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? a) Document start of surgery. b) Obtain a sponge and syringe count. c) Acquire ordered blood products. d) Verify consent.
Verify consent. Explanation: Without consent, surgery cannot be performed. Documentation of the start of surgery can only happen once the surgery has started. Blood products must be administered within an allotted time frame and therefore should not be acquired unless needed. The sponge and syringe count is a safety issue that should be completed before surgery and while the wound is being sutured, but the patient has not consented, the surgery should not take place.
A registered nurse who is responsible for coordinating and documenting patient care in the operating room is a a) scrub nurse. b) anesthesiologist. c) circulating nurse. d) anesthetist.
circulating nurse. Explanation: A circulating nurse is a registered nurse who coordinates and documents patient care. The scrub nurse prepares instruments and supplies, and hands instruments to the surgeon during the procedure. The anesthetist is trained to deliver anesthesia and to monitor the patient's condition during surgery. The anesthesiologist is a physician trained to deliver anesthesia and to monitor the patient's condition during surgery.
The nurse recognizes older adults require lower doses of anesthetic agents due to: a) increased liver mass. b) increased tissue elasticity. c) decreased lean tissue mass. d) decreased bone mass.
decreased lean tissue mass. Explanation: Lower doses of anesthetic agents are required in older adults, as they have decreased lean tissue mass, decreased tissue elasticity, and decreased liver mass. Bone mass is unrelated to doses of anesthesia.
In which zone of the surgical area are street clothes allowed? a) Restricted b) Limited c) Semi-restricted d) Unrestricted
Unrestricted Explanation: Street clothes are allowed in the unrestricted zone. Scrubs must be worn in the semi-restricted. Scrub clothes, shoe covers, caps, and masks are worn in the restricted zone.
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: a) dantrolene sodium (Dantrium) b) potassium chloride c) an acetaminophen suppository d) verapamil (Isoptin)
dantrolene sodium (Dantrium) Explanation: The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.
The nurse recognizes that the older adult is at risk for surgical complications due to: a) decreased adipose tissue b) decreased renal function c) increased cardiac output d) increased skeletal mass
decreased renal function Explanation: Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.
Hypothermia may occur as a result of a) being young. b) increased muscle activity. c) the infusion of warm fluids. d) open body wounds.
open body wounds. Explanation: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used.
Which of the following is a duty of the registered nurse first assistant? Select all that apply. a) Providing exposure at the operative field b) Suturing c) Maintaining hemostasis d) Specimen management e) Handling tissue
• Handling tissue • Suturing • Maintaining hemostasis • Providing exposure at the operative field Explanation: Handling tissue, suturing, maintaining hemostasis, and providing exposure at the operative field are responsibilities of the registered nurse first assistant. Specimen management is a duty of the circulating nurse.
The nurse is educating new employees regarding the wearing of masks in the operating room. What information should the nurse provide? Select all that apply. a) Masks can be worn outside the surgical department if the surgery is less than 5 minutes away. b) You must change masks between treating patients. c) Masks should be tight fitting. d) Masks must be worn at all times in the semirestricted zone. e) Masks should cover the nose and mouth completely. f) When not using the mask, you can wear it around your neck.
• Masks should cover the nose and mouth completely. • You must change masks between treating patients. • Masks should be tight fitting. Explanation: Masks are changed between patients. Regardless of time, the masks should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck. Masks must be worn at all times in the restricted zone. The semirestricted zone requires scrubs and cap.
The client asks the nurse how the spinal anesthesia will be administered. The best response by the nurse is: a) "The medication will be injected into the muscle by the anesthesiologist." b) "The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." c) "The anesthesiologist will inject the anesthetic through your IV." d) "You will inhale the medication through a mask the anesthesiologist will place over your face."
"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." Explanation: The L4-L5 subarachnoid space is the usual location for the administration of spinal anesthesia.
A patient is undergoing a lumbar puncture. The nurse educates the patient about surgical positioning. Which of the following statements by the nurse is appropriate? a) "You will be on your back with the head of the bed at 30 degrees." b) "You will be lying on your side with your knees to your chest." c) "You will be placed flat on the table, face down." d) "You will be flat on your back with the table slanted so your head is below your feet."
"You will be lying on your side with your knees to your chest." Explanation: For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the patient lie on their back does not allow for access to the surgical site.
A patient has received general anesthesia and is progressing through the stages. Using the manifestations below, place them in the proper sequence from stage I to stage IV. Pupil dilation Unconsciousness Shallow respirations Ringing in the ears
1.Ringing in the ears 2.Pupil dilation 3.Unconsciousness 4.Shallow respirations Explanation: In stage I of general anesthesia, the paitent may have a ringing in the ears. During stage II, excitement occurs along with pupil dilation. During stage III, the patient is unconscious. Stage IV is marked by too much anesthesia and manifested by shallow respirations.
The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate? a) Alert personnel who break sterile technique. b) Maintain the positive pressure OR environment. c) Monitor for faulty electrical equipment. d) Allow unnecessary personnel to enter the OR environment.
Allow unnecessary personnel to enter the OR environment. Explanation: The circulating nurse restricts the admittance of unnecessary personnel in the OR environment.
Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? a) Keep the family informed of the client's status. b) Allow the client to verbalize fears. c) Verify the client's preoperative vital signs. d) Assess the client for allergies.
Assess the client for allergies. Explanation: The nurse must be aware of the client's allergies to prevent exposure to the client.
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: a) Anesthesiologist b) Surgeon c) Scrub nurse d) Circulating nurse
Circulating nurse Explanation: The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.
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? a) Decreased lean tissue mass b) Increased anxiety level c) Impaired thermoregulation d) Increased tissue elasticity
Decreased lean tissue mass Explanation: 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.
Which of the following actions by the nurse is appropriate? a) Touching sterile items with a clean-gloved hand b) Reaching over the sterile field c) Touching the edges of an open sterile package d) Discarding an object that comes in contact with the 1-inch border
Discarding an object that comes in contact with the 1-inch border Explanation: The 1-inch border of a sterile field is considered unsterile.
The nurse is assisting with positioning the patient on the operating table. The nurse understands that the most commonly used position is which of the following? a) Trendelenburg b) Dorsal recumbent c) Sims d) Lithotomy
Dorsal recumbent Explanation: The usual position for surgery is the dorsal recumbent position. The Trendelenburg position is used for surgery on the lower abdomen and pelvis. The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery.
A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate? a) Turn on the television for distraction. b) Encourage increased fluid intake. c) Position the patient on the side. d) Notify the anesthesiologist immediately.
Encourage increased fluid intake. Explanation: 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? a) Halothane b) Propofol c) Succinylcholine d) Fentanyl
Halothane Explanation: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.
Which of the following would be included as a responsibility of the scrub nurse? a) Keeping all records and adjusting lights b) Handing instruments to the surgeon and assistants c) Coordinating activities of other personnel d) Obtaining and opening wrapped sterile equipment
Handing instruments to the surgeon and assistants Explanation: 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 obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.
A patient is undergoing general anesthesia. The nurse anesthetist starts to administer the anesthesia. The patient starts giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a) III b) II c) I d) IV
II Explanation: Stage II is the excitement stage that is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia during which the patient 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 reached by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.
Which stage of surgical anesthesia is also known as excitement? a) IV b) II c) I d) III
II Explanation: Stage II is the excitement stage that 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 patient breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia. Surgical anesthesia is reached by continued administration of anesthetic vapor and gas. Stage IV is medullary depression. The patient is unconscious and lies quietly on the table.
A nurse who works in the OR is required to assess the patient continuously and protect the patient from potential complications. Which of the following would not be included as a symptom of malignant hyperthermia? a) Increased urine output b) Mottled skin c) Cardiac arrest d) Cyanosis
Increased urine output Explanation: Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.
An obese patient is undergoing abdominal surgery. A surgical resident states, "The amount of fat we have to cut through is disgusting" during the procedure. What is the best response by the nurse? a) Inform the resident that all communication needs to remain professional. b) Ignore the comment. c) Discuss concerns regarding the comments with the charge nurse. d) Report the resident to the attending surgeon.
Inform the resident that all communication needs to remain professional. Explanation: The nurse must advocate for the patient, especially when the patient 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 patient. 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 is happening.
As a circulating nurse, what task are you solely responsible for? a) Counting sponges and needles. b) Handing instruments to the surgeon. c) Keeping records. d) Estimating the client's blood loss.
Keeping records. Explanation: The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.
Which of the following should not be allowed with regards to the wearing of masks in the operating room? a) Let masks hang around the neck b) The mask should be tight fitting c) Cover the nose and mouth completely d) Change masks between treating patients
Let masks hang around the neck Explanation: Masks are changed between patients and should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck.
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? a) Stage I b) Stage IV c) Stage II d) Stage III
Stage IV Explanation: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.
What is the priority action by the scrub nurse when the surgeon is starting to close the surgical wound? a) Prepare the needed sutures. b) Obtain a sponge count. c) Handing needed equipment to the surgeon. d) Label the tissue specimen.
Obtain a sponge count. Explanation: Standards call for the scrub nurse and the circulating nurse to obtain a sponge count at the beginning of the surgery when the surgical wound is being sutured and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready prior to the surgeon needing them. While the scrub nurse hands equipment to the surgeon, the sponge count is a higher priority action.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? a) Ask the surgeon if the marked surgical site is correct. b) Review the complications and allergies with the anesthesiologist. c) Obtain the attention of all members of the surgical team. d) Discuss the surgical procedure and surgical site with the patient.
Obtain the attention of all members of the surgical team. Explanation: The second verification of the surgical procedure and surgical site should include all members of the surgical team. This verification should be done at one time with all members of the team involved. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or patient. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.
A patient is to receive general anesthesia with sevoflurane. The nurse anticipates the need for which of the following? a) Oxygen b) Rocuronium c) Alfentanil d) Lidocaine
Oxygen Explanation: Sevoflurane is an inhalation anesthetic always combined with oxygen. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.
A patient is scheduled for surgery with spinal anesthesia. When explaining this type of anesthesia to the patient, which body area would the nurse describe as being affected first? a) Abdomen b) Legs c) Chest d) Perineum
Perineum Explanation: After induction of spinal anesthesia, anesthesia and paralysis affect the toes and perineum, then gradually the legs and abdomen. If the anesthetic reaches the upper thoracic and cervical spinal cord in high concentrations, a temporary or complete respiratory paralysis occurs.
The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury? a) Pulse oximetry 98% b) Peripheral pulses palpable c) Vital signs within normal limits for client d) Absence of itching
Peripheral pulses palpable Explanation: Surgical clients are at risk for pressure ulcers and damage to nerves and blood vessels as a result of awkward positioning required for surgical procedures. Palpable peripheral pulses indicate integrity of the blood vessels.
A patient is to receive local anesthesia in combination with epinephrine. The nurse understands that epinephrine is used for which reason? a) Prolongs the local action b) Reduces the amount of anesthetic needed c) Enhances the anesthetic's absorption d) Prevents anaphylaxis
Prolongs the local action Explanation: Epinephrine is added to a local anesthetic to constrict the blood vessels, which prevents rapid absorption of the local anesthetic agent and thus prolongs its local action. Rapid absorption of the anesthetic into the blood stream could cause seizures. Epinephrine does not reduce the amount of anesthetic needed. It also does not prevent anaphylaxis.
A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? a) Pupillary dilation and rapid pulse b) Weak, thready pulse and cyanosis c) Dizziness and a feeling of detachment d) Unconsciousness and regular respirations
Pupillary dilation and rapid pulse Explanation: 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.
A nurse suspects malignant hyperthermia in a patient who underwent surgery approximately 18 hours ago. Which of the following would the nurse identify as a late, ominous sign? a) Tachycardia b) Muscle rigidity c) Rapid rise in body temperature d) Oliguria
Rapid rise in body temperature Explanation: A rise in body temperature is a late sign that develops rapidly, with the temperature possibly increasing 1 degree to 2 degrees C every 5 minutes and body core temperature exceeding 42 degrees C (107 degrees F). Tachycardia is often the earliest sign; muscle rigidity also is an early sign. Oliguria occurs with sympathetic nervous system stimulation.
A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient? a) Risk for injury related to effects of anesthetic agents b) Disturbed sensory perception related to sedation c) Risk for perioperative positioning injury related to operative position d) Anxiety related to the surgical experience
Risk for perioperative positioning injury related to operative position Explanation: Although any of the nursing diagnoses might apply for this patient, the priority would be risk for perioperative positioning injury related to the patient's history of osteoporosis. The bone loss associated with this condition necessitates careful manipulation and positioning during surgery.
Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours? a) Anxiety related to ineffective coping with surgical concerns b) Risk for perioperative positioning injury related to positioning in the OR c) Risk of latex allergy response related to possible exposure in the OR environment d) Disturbed sensory perception related to the effects of general anesthesia
Risk for perioperative positioning injury related to positioning in the OR Explanation: Pressure ulcers, nerve and blood vessel damage, and discomfort are risks associated with prolonged, awkward positioning required for surgical procedures.
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? a) Registered nurse first assistant b) Scrub role c) Circulating nurse d) Anesthetist
Scrub role Explanation: The scrub role includes performing a surgical hand scrub, setting up the sterile tables, and preparing sutures, ligatures, and special equipment. The circulating nurse manages the operating room and protects patient safety. The registered nurse first assistant functions under the direct supervision of the surgeon. Responsibilities may include handling tissue, providing exposure of the operative field, suturing, and maintaining hemostasis. The anesthetist administers the anesthetic medications.
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? a) Trendelenburg position b) Sims position c) Lithotomy position d) Supine position
Sims position Explanation: The client undergoing renal surgery will be placed in the Sims position.
The client vomits during the surgical procedure. The best action by the nurse is: a) Suction the client to remove saliva and gastric secretions. b) Lower the head of the operating table to promote circulation to the brain. c) Increase the IV infusion rate to compensate for lost fluids. d) Administer an anti-emetic to alleviate nausea.
Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.
Which of the following techniques least exhibits surgical asepsis? a) Suctioning the nasopharyngeal cavity of a client b) Placing the sterile field at least one foot away from personnel c) Adding only sterile items to a sterile field d) Keeping sterile gloved hands above the waist
Suctioning the nasopharyngeal cavity of a client Explanation: To maintain surgical asepsis, only sterile items should touch sterile items.
Which of the following is often the earliest sign of malignant hyperthermia? a) Hypotension b) Tachycardia c) Oliguria d) Decreased cardiac output
Tachycardia Explanation: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate >150 bpm) is often the first sign. In addition to tachycardia, sympathetic nervous system stimulation leads to ventricular arrhythmia, hypotension, decreased cardiac output, oliguria, and later, cardiac arrest.
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? a) If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. b) The edges of a sterile package, once opened, are considered unsterile. c) Circulating nurses may come in contact with the sterile field without contaminating it. d) A distance of 3 feet must be maintained when moving around a sterile field.
The edges of a sterile package, once opened, are considered unsterile. Explanation: To maintain surgical asepsis, the edges of a sterile package, once opened, are considered unsterile. When moving around a sterile field, individuals must maintain a distance of at least 1 foot from the sterile field. If a tear occurs in a sterile drape, it must be replaced. Only scrubbed personnel and sterile items may come in contact with sterile areas. Circulating nurses can only contact unsterile areas.
What action during a surgical procedure requires immediate intervention by the circulating nurse? a) The anesthesiologist monitoring blood gas levels b) The surgeon reaching within the sterile field to obtain equipment c) The scrub nurse calling the blood bank to obtain blood products d) The registered nurse's first assistant suturing the surgical wound
The scrub nurse calling the blood bank to obtain blood products Explanation: The scrub nurse is "scrubbed" in and should only come in contact with sterile equipment. Using the phone to call the blood bank is the responsibility of the circulating nurse and it would break the sterility of the scrub nurse. The surgeon has "scrubbed" and should only touch within sterile fields. The anesthesiologist should monitor blood gas levels as needed, and it is appropriate for the registered nurse first assistant to suture the surgical wound.
Which of the following is an inappropriate nursing action by the surgical nurse? a) Changing shoe covers that become torn b) Wearing a surgical jacket with knitted cuffs on the sleeves c) Covering the hair with a surgical cap d) Wearing sterile gloves over artificial nails
Wearing sterile gloves over artificial nails Explanation: Artificial nails are prohibited in the clinical setting, because they can cause nosocomial infections.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60 g I.V. After ketamine administration, the nurse should monitor the client for: a) extrapyramidal reactions and hiccups. b) respiratory depression. c) extrapyramidal reactions. d) hallucinations and respiratory depression. e) hallucinations. f) hiccups.
hallucinations and respiratory depression. Explanation: The nurse should monitor for hallucinations, which may follow administration of several of the injection anesthetics, including ketamine and the opioids; the reaction seems to be directly proportional to the infusion rate. Extrapyramidal manifestations are the most prominent adverse reactions to droperidol. Thiopental, etomidate, and propofol can produce airway reflex hyperactivity with hiccups, coughing, and muscle twitching and jerking. The barbiturates and propofol cause respiratory depression.
A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that: a) it may be necessary to raise the head of this client's bed. b) administering I.V. antibiotics can prevent pneumonia. c) inserting a Foley catheter can decrease fluid retention. d) this client may need intubation.
it may be necessary to raise the head of this client's bed. Explanation: The nurse should consider positioning when caring for a client who has COPD and difficulty breathing. Elevating the head of the bed assists these clients in breathing. There's no indication that it's necessary to intubate the client. A Foley catheter isn't indicated. Prophylactic I.V. antibiotics aren't administered with moderate sedation.
The nurse understands that the purpose of the "time out" is to: a) maintain the safety of the client. b) clarify the roles of the OR personnel. c) identify the client's allergies. d) verify all necessary supplies are available.
maintain the safety of the client. Explanation: Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.
Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care:
may result in the administration of general anesthesia. Explanation: Monitored anesthesia care may require the anesthsiologist to convert to general anesthesia.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all needed attire to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? a) Scrub top and drawstring are tucked into pants. b) Shoe covers are used. c) Hair is pulled back and covered by a cap. d) Mask is placed over nose and extends to bottom lip.
Mask is placed over nose and extends to bottom lip. Explanation: The mask should be tight fitting covering the nose and mouth. The mask should be extended down past the chin. The mask may not effectively cover the mouth if only extended to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.
