Med-Surg 3 Ch. 18 Prep U
A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed.
Answer: Turn the patient to the side. Lower the head of the surgical table. Provide a basin for collection. Suction to remove saliva. Why? 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.
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?
Answer: "Remain supine for the time specified by the physician." Why?The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.
The client asks the nurse about possible ill effects from general anesthesia. Which of the following is the best response by the nurse?
Answer: "Some possible negative effects include oversedation and bradycardia." Why? Oversedation, allergic reaction, and bradycardia are potential adverse effects of surgery and anesthesia.
Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"?
Answer: "You seem nervous about your surgery." Why? Use of the communication technique of "restating" is recommended as a way to encourage the patient to expand his or her thoughts and feelings.
The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?
Answer: Allow unnecessary personnel to enter the OR environment. Why? 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?
Answer: Assess the client for allergies. Why? The nurse must be aware of the client's allergies to prevent exposure to the client.
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?
Answer: Count the sponges. Why? Standards call for the scrub nurse and the circulating nurse to count the sponges 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 before the surgeon needs them. Although the scrub nurse does hand equipment to the surgeon, the sponge count is a higher priority action.
The nurse is caring for a client undergoing conscious sedation. The nurse knows the client is at risk for ineffective breathing patterns. What nursing intervention will help the client demonstrate a normal breathing pattern?
Answer: Encourage the client to take deep breaths and cough at least every hour. Why? The nurse should encourage the client to take deep breaths and cough at least every hour. Deep breathing and coughing improve oxygenation and assist in clearing the effects of anesthesia. Drinking plenty of fluids and progressive activity will not help the client to demonstrate a normal breathing pattern. Use of incentive spirometer is not required until indicated.
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate?
Answer: Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff Why? 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 client has been administered ketamine for moderate sedation. What is the priority nursing intervention?
Answer: Frequently monitoring vital signs Why? Vital signs must be monitored frequently to assess for respiratory depression and to enable quick intervention. 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 client is recovering. Hallucinations may occur as a side effect of the medication.
Which stage of anesthesia is referred to as surgical anesthesia?
Answer: III Why? Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client 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 state of medullary depression and is reached when too much anesthesia has been administered.
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?
Answer: Instruct the client to remain flat for 6 to 12 hours. Why? The client who has received spinal anesthesia should remain flat for 6 to 12 hours unless ordered otherwise. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit. It is not required to monitor the vital signs every 2 hours.
The operating nurse is caring for a patient who is receiving general anesthesia. Organize the nursing interventions in chronological order of the stages of general anesthesia, beginning with Stage I (1) and ending with Stage IV (4).
Answer: Keep discussions about the client to a minimum. Avoid auditory and physical stimuli. Place client into operative position. Prepare for and assist in treatment of cardiac and/or respiratory arrest. Why? In Stage I, the client is still conscious and aware of the environment. Therefore, discussions about the client should be kept to a minimum. Stage II is an excitement stage, whereby the client may present with varying behaviors and is susceptible to external stimuli. The nurse should avoid auditory and physical stimuli to facilitate smooth induction of the anesthesia. During Stage III, the client is unconscious and placed into the operative position. Stage IV is characterized by medullary depression and is a life-threatening situation. The nurse prepared for and assists in treatment of cardiac and/or respiratory arrest.
A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?
Answer: Notify the surgical team. Why? Tachycardia and muscle rigidity are often the earliest signs of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, and administer dantrolene sodium, 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.
A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?
Answer: Notify the surgical team. Why? Tachycardia and muscle rigidity are often the earliest signs of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, and administer dantrolene sodium, 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.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?
Answer: Obtain the attention of all members of the surgical team. Why? The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.
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? Pulse oximetry 98% , Vital signs within normal limits for client , Peripheral pulses palpabl,e Absence of itching
Answer: Peripheral pulses palpable Why? 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.
The scrub nurse is responsible for:
Answer: Preparing the sterile instruments for the surgical procedure. Why? The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.
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?
Answer: Risk for perioperative positioning injury related to operative position Why? 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?
Answer: Risk for perioperative positioning injury related to positioning in the OR Why? Pressure ulcers, nerve and blood vessel damage, and discomfort are risks associated with prolonged, awkward positioning required for surgical procedures.
Which of the following consequences may result if tranquilizers are withdrawn suddenly?
Answer: Seizures Why? Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery?
Answer: Sims
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?
Answer: Stage IV Why? Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.
An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia?
Answer: Surgical anesthesia Why? 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.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Answer: Temperature of 102.5°F (39°C) Why? Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
The patient asks the nurse how long the local infiltration anesthetic will last. What is the nurse's best response?
Answer: The anesthetic may last for 3 hours." Why? Local anesthesia is the injection of a solution containing the anesthetic agent into the tissues at the planned incision site. Often it is combined with a local regional block by injecting around the nerves immediately supplying the area. It is ideal for short (3 hours) and minor surgical procedures.
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?
Answer: The edges of a sterile package, once opened, are considered unsterile. Why? 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.
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:
Answer: dantrolene sodium (Dantrium) Why? The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.
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:
Answer: it may be necessary to raise the head of this client's bed. Why? 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.
Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care:
Answer: may result in the administration of general anesthesia. Why? Monitored anesthesia care may require the anesthesiologist to convert to general anesthesia.