Chapter 18, Intraop

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

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

A client 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." "Few negative effects occur with general anesthesia." "Amnesia and analgesia are some of the negative effects of anesthesia." "Clients can experience pain and loss of consciousness."

"Some possible negative effects include difficulty waking up and slow heart rate." 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 lungs primarily eliminate the anesthesia." "The skin will eliminate the anesthesia through evaporation." "The liver will eliminate the inhalant anesthesia."

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

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

2 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.

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? 8:40 to 8:50 a.m. 9:00 to 9:10 a.m. 9:30 to 9:40 a.m. 10:00 to 10:10 a.m.

8:40 to 8:50 a.m. 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 surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature? A client with gastrointestinal surgery and general anesthesia A client having a knee replacement and regional anesthesia A client having lower extremity muscle repair and spinal anesthesia A client with spinal stenosis and a regional nerve blockade

A client with gastrointestinal surgery and general anesthesia

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

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

Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? Allow the client to verbalize fears. Assess the client for allergies. Verify the client's preoperative vital signs. Keep the family informed of the client's status.

Assess the client for allergies. The nurse must be aware of the client's allergies to prevent exposure to the client.

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

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

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

Dantrolene sodium

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

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

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

Denies sensation to perineum and lower abdomen

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 Positioning the sterile drape on a table from back to front Allowing circulating nurses to contact sterile equipment Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff

Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff 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? Assessing for hallucinations Frequently monitoring vital signs Administering oxygen Providing a quiet dark room for recovery

Frequently monitoring vital signs 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 Fentanyl Succinylcholine Propofol

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

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

Handing instruments to the surgeon and assistants

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

II

Which stage of anesthesia is referred to as surgical anesthesia? II I III IV

III 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.

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 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 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 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.

Fentanyl is categorized as which type of intravenous anesthetic agent? Tranquilizer Opioid Dissociative agent Neuroleptanalgesic

Opioid

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Heart rate of 84 beats/minute Oxygen saturation (SaO2) of 85% Decreased cough and gag reflexes Blood-tinged stools

Oxygen saturation (SaO2) of 85%

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

Perineal surgery

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

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

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

Remove the entire sterile field from use.

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

Respond verbally during the procedure Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.

nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? Registered nurse first assistant Scrub role Circulating nurse Anesthetist

Scrub role 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? Trendelenburg position Lithotomy position Supine position Sims position

Sims position

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

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

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

Surgical anesthesia

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

Tachycardia (heart rate >150 beats per minute) 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.

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

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

A 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. 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. Circulating nurses may come in contact with the sterile field without contaminating it.

The edges of a sterile package, once opened, are considered unsterile. 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? Verify consent. Document the start of surgery. Acquire ordered blood products. Count sponges and syringes.

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

Wearing sterile gloves over artificial nails

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.

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

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

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder? body temperature increase of 1 °C to 2 °C (2 °F to 4 °F) tetanus-like jaw movements generalized muscle rigidity heart rate over 150 beats per minute

heart rate over 150 beats per minute With malignant hyperthermia, tachycardia with a heart rate greater than 150 beats per minute is often the earliest sign because of an increase in end-tidal carbon dioxide. Generalized muscle rigidity and tetanus-like movement occurs often in the jaw are not the first signs for health care providers to note with malignant hyperthermia. The rise in body temperature is a late sign that develops rapidly.

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

lies quietly on the table 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.

Hypothermia may occur as a result of the infusion of warm fluids. increased muscle activity. open body wounds. being young.

open body wounds. 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 particular pharmaceutical agents.

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

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

A circulating nurse is preparing a client for a surgical procedure. What are the primary responsibilities of the circulating nurse in the perioperative experience? Select all that apply. verifying informed consent ensuring proper lighting coordinating the efforts of the surgical team marking the surgical site passing the surgical instruments

verifying informed consent ensuring proper lighting coordinating the efforts of the surgical team