nursing 6 unit 5 med surg Chapter 18: Intraoperative Nursing Management

The nurse should know that, postoperatively, a general anesthetic is primarily eliminated via what organ(s)?

The lungs Explanation: When anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs.

A patient is undergoing surgery with a brachial plexus block to the right wrist. The patient voices concerns about anesthesia awareness. What is the best response by the nurse?

"Because of the type of anesthesia used, you may be aware of what is going on around you." Explanation: Anesthesia awareness is a complication of general anesthesia. The patient is undergoing surgery with a local conduction block, not general surgery. Honest discussion of awareness is needed so patients know what to expect while they are in the operating room. Although the entire surgical team should be monitoring for anesthesia awareness, it is not relevant to the surgical procedure being performed. Telling the patient that anesthesia awareness is not a concern is dismissive of the patient's feelings.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function Explanation: Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border Explanation: The 1-inch border of a sterile field is considered unsterile.

When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate?

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.

Which of the following is a duty of the registered nurse first assistant? Select all that apply.

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.

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

I will become unconscious." Explanation: The client receiving epidural anesthesia will remain conscious during the procedure.

Which stage of anesthesia is termed surgical anesthesia?

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.

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?

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 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?

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 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. 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.

Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours?

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.

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 II: excitement Explanation: 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.

Which of the following techniques least exhibits surgical asepsis?

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?

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.

An example of an intravenous anesthetic that is a hypnotic and produces excellent amnesia is:

Versed Explanation: Versed, an excellent hypnotic, is often used as an adjunct to induction. Refer to Table 5-6 in the text.

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 patient is undergoing a lumbar puncture. The nurse educates the patient about surgical positioning. Which of the following statements by the nurse is appropriate?

"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 is scheduled to have a heart valve replacement with a porcine valve. Which patient does the nurse understand may refuse the use of any porcine-based product?

A patient of Jewish faith Explanation: Cultural, ethnic, and religious diversity are important considerations for all health care professionals. Nurses in the perioperative area should be aware of medications that may be prohibited by certain groups (e.g., Muslims and those of the Jewish faith cannot use porcine-based products [heparin (porcine or bovine)], Buddhists may choose not to use bovine products). The other faiths listed would not object to porcine-based products.

Which of the following medications would the nurse expect to be used to facilitate intubation of the client?

attacurium (Tracrium) Explanation: Attacurium (Tracrium) is commonly used to facilitate intubation of the surgical client.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium) Explanation: The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

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?

"Remain supine for the time specified by the physician." Explanation: 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.

You are working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks you why these medications are needed. What would be your best answer?

"These medications decrease gastric acidity and volume." Explanation: The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.

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?

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.

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system Explanation: Depolarizing muscle relaxants can cause cardiac dysrhythmias.

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?

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.

Which of the following interventions would be most appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

Cover the client with a light blanket. Explanation: When the client is shivering, the nurse should cover the client with a light blanket. This will prevent the client from shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105ºF. The room temperature need not be below 70°F.

A medical student, scheduled to observe surgery, enters the unrestricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse?

Educate the medical student on required attire for each surgical zone. Explanation: It would be best to educate the medical student on the required attire for each surgical zone. Since the student will be observing a surgery, the student will need to dress appropriately in each zone to decrease the risk of introducing pathogens. The unrestricted zone allows for street clothes; therefore, the student does not need to be removed. If no action is taken by the nurse, the student could enter the semirestricted or restricted zone without appropriate attire. Providing a cap and mask does not address the need to change out of the street clothes to observe the surgery.

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?

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?

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.

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

The nurse recognizes the client has reached stage III of general anesthesia when the client:

Has small pupils that react to light Explanation: Stage III of general anesthesia is characterized by dilation and reaction of pupils. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed.

As a circulating nurse, what task are you solely responsible for?

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.

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 can you tell this client to help alleviate his concerns?

He can be involved in marking his 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. Explanation: 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 (2012) 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."

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?

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.

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.)

Leakage of spinal fluid from the subarachnoid space Size of the spinal needle used Degree of patient hydration Explanation: Headache may be an aftereffect of spinal anesthesia. Several factors are related to the incidence of headache: the size of the spinal needle used, the leakage of fluid from the subarachnoid space through the puncture site, and the patient's hydration status. Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. A headache is not likely to occur as the result of the patient lying in the supine position or of an allergic reaction to the medication.

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?

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.

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.

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.

Fentanyl (Sublimaze) is categorized as which type of intravenous anesthetic 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 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?

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 zone of the surgical area only allows for attire in the form of scrub clothes and caps?

Semirestricted zone Explanation: The semirestricted zone is where attire consists of scrub clothes and caps. The unrestricted zone is where street clothes are allowed. The restricted zone is where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during the operation.

In which zone of the surgical area are street clothes allowed?

Unrestricted 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.

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed. Explanation: To protect the client from injury, the nurse needs to verify the procedure scheduled, assess for allergies, and confirm the consent form has been signed. Anti-anxiety medications reduce anxiety but do not protect the client from injury. Covering the client with warm blankets promotes comfort and prevents hypothermia, a potential complication of anesthesia.

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:

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:

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:

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.