CH 18 - Intraoperative

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? Select all that apply.

Turn the client from side to side at least every 2 hours, if permitted. Assist the client to a sitting position at the side of the bed. Instruct the client to stay in bed until sensation and movement returns. Monitor respiratory rate and sensation every 2 hours or as per ordered. The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. 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. If client complains of a headache, the client should not be encouraged to increase activity. The client may have to remain lying flat for a longer period of time.

The nurse recognizes that the older adult is at risk for surgical complications due to: increased cardiac output decreased renal function decreased adipose tissue increased skeletal mass

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

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: verapamil (Isoptin) dantrolene sodium (Dantrium) potassium chloride an acetaminophen suppository

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

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse? "Some possible negative effects include difficulty waking up and slow heart rate." "Amnesia and analgesia are some of the negative effects of anesthesia." "Clients can experience pain and loss of consciousness." "Few negative effects occur with general anesthesia."

"Some possible negative effects include difficulty waking up and slow heart rate." Explanation: Difficulty waking up (oversedation), allergic reaction, and slow heart rate (bradycardia) are potential adverse effects of surgery and anesthesia. There are a number of effects from general anesthesia. Analgesia is not an adverse effect of general anesthesia. Clients should not experience pain.

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? "The kidneys will eliminate the inhalant with urination." "The liver will eliminate the inhalant anesthesia." "The skin will eliminate the anesthesia through evaporation." "The lungs primarily eliminate the anesthesia."

"The lungs primarily eliminate the anesthesia." Explanation: When inhalant anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs.

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment.

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? Endocrine system Gastrointestinal system Genitourinary system Cardiovascular 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? Scrub nurse Registered nurse first assistant Circulating nurse Surgeon

Circulating nurse 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.

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? Frequently monitoring vital signs Providing a quiet dark room for recovery Assessing for hallucinations Administering oxygen

Frequently monitoring vital signs Explanation: 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.

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 Propofol Succinylcholine Fentanyl

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

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

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

An example of an intravenous anesthetic that is a hypnotic and produces excellent amnesia is: Amidate Midazolam Diprivan Ketalar

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

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 Pulse oximetry 98% Vital signs within normal limits for client Absence of itching

Peripheral pulses palpable 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 undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate? Place the patient in the Trendelenburg position. Place the patient in lithotomy position. Place the patient in a dorsal recumbent position. Place the patient in Sims' 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.

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. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse. Ensure the infection is covered with a dressing.

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

The client vomits during the surgical procedure. The best action by the nurse is: Increase the IV infusion rate to compensate for lost fluids. Lower the head of the operating table to promote circulation to the brain. Administer an anti-emetic to alleviate nausea. Suction the client to remove saliva and gastric secretions.

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

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? Lithotomy Supine Trendelenburg Sims

Supine Explanation: The usual position for surgery is the supine 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.Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.

What intravenous anesthetic administered by the anesthesiologist has a powerful respiratory depressant effect sufficient to cause apnea and cardiovascular depression? Etomidate Thiopental sodium Midazolam

Thiopental sodium Explanation: Thiopental sodium (Pentothal) is an intravenous anesthetic agent that in large doses may cause apnea and cardiovascular depression. The other medications listed are also intravenous anesthetic agents, but none causes apnea and cardiovascular 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. administering I.V. antibiotics can prevent pneumonia. this client may need intubation. inserting a Foley catheter can decrease fluid retention.

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

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

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

When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? Considering the gown sterile from mid-thigh to neck Allowing circulating nurses to contact sterile equipment Positioning the sterile drape on a table from back to front Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff

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 4 centimetres 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 nurse is teaching a client about airway control with inhalant anesthesia. What does the nurse include in the client teaching? Propofol will be used as an inhalant through a laryngeal mask airway. Halothane will be used with a endotracheal tube for a rapid smooth induction. Fentanyl will be used as an inhalant through an endotracheal tube. Oxygen at high concentrations are used for rapid induction.

Halothane will be used with a endotracheal tube for a rapid smooth induction. Explanation: Halothane is an example of an inhalation anesthetic. Fentanyl and propofol are commonly used intravenous agents for anesthesia. High concentrations of oxygen are not used because of the danger of oxygen toxicity.

Which of the following is a duty of the registered nurse first assistant? Select all that apply. Maintaining hemostasis Suturing Providing exposure at the operative field Specimen management Handling tissue

Handling tissue Suturing Maintaining hemostasis Providing exposure at the operative field 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 stage of anesthesia is referred to as surgical anesthesia? IV III II I

III Explanation: 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.

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

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

As a circulating nurse, what task are you solely responsible for? Estimating the client's blood loss. Handing instruments to the surgeon. Keeping records. Counting sponges and needles.

Keeping records. 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 positions would the nurse expect the client to be positioned on the operating table for renal surgery? Lithotomy position Supine position Lateral (Sims) position Trendelenburg position

Lateral (Sims) position Explanation: The client undergoing renal surgery will be placed in the Lateral, also known as the Sims position.

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

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

Surgical asepsis is a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the operating room? Masks covering the nose and mouth Goggles Gown Gloves

Masks covering the nose and mouth Explanation: Restricted zone personnel are required to wear scrub clothes, caps, shoe covers, and masks. The nurse is not required to wear a gown, goggles, or gloves in the restricted zone of the operating suite.

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? Notify the surgical team. Obtain cooling blankets. Document the assessment findings. Administer dantrolene sodium.

Notify the surgical team. Explanation: 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.

How would the operating room nurse place a patient in the Trendelenburg position? Flat on his back with his arms next to his sides On his side with his uppermost leg adducted and flexed at the knee On his back with his head lowered so that the plane of his body meets the horizontal on an angle On his back with his legs and thighs flexed at right angles

On his back with his head lowered so that the plane of his body meets the horizontal on an angle The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is supported in position by padded shoulder braces (see Fig. 18-5B), bean bags, and foam padding.

The scrub nurse is responsible for: Monitoring the administration of the anesthesia Preparing the sterile instruments for the surgical procedure Monitoring the operating-room personnel for breaks in sterile technique Calling the "time-out" to verify the surgical site and procedureHandling tissue Suturing Maintaining hemostasis Providing exposure at the operative field

Preparing the sterile instruments for the surgical procedure Explanation: The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: Need pain control throughout the procedure Respond verbally during the procedure Need an endotracheal tube 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.

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 injury related to effects of anesthetic agents Risk for perioperative positioning injury related to operative position Anxiety related to the surgical experience Disturbed sensory perception related to sedation

Risk for perioperative positioning injury related to operative position 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.

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? Anesthetist Surgeon Scrub nurse Circulating nurse

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 clinical manifestation is often the earliest sign of malignant hyperthermia? Hypotension Tachycardia (heart rate >150 beats per minute) Elevated temperature Oliguria

Tachycardia (heart rate >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 quickly. Scant urinary output is a later sign of malignant hyperthermia.

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Temperature of 102.5°F (39°C) Respiratory rate of 18 breaths/min Blood pressure of 104/62 mm Hg Pulse rate of 110 beats/min

Temperature of 102.5°F (39°C) Explanation: Intraoperative 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.

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? The edges of a sterile package, once opened, are considered unsterile. Circulating nurses may come in contact with the sterile field without contaminating it. A distance of 3 feet must be maintained when moving around a sterile field. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it.

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.

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? Acquire ordered blood products. Verify consent. Count sponges and syringes. Document the start of surgery.

Verify consent. Explanation: Surgery cannot be performed without consent. 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 if the client has not consented, the surgery should not take place.

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply. Administer anti-anxiety medication. Confirm the consent form is signed. Verify scheduled procedure with client. Assess the client for allergies. Cover the client with warm blankets.

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. Reference:

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

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

The nurse recognizes the client has reached stage III of general anesthesia when the client: lies quietly on the table exhibits shallow respirations and a weak, thready pulse shouts, talks, or sings displays agitation due to noise

lies quietly on the table Explanation: Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death.