Chapter 18: Intraoperative Nursing Management
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). 1 Place client into operative position. 2 Prepare for and assist in treatment of cardiac and/or respiratory arrest. 3 Avoid auditory and physical stimuli. 4 Keep discussions about the client to a minimum.
4) Keep discussions about the client to a minimum. 3) Avoid auditory and physical stimuli. 1) Place client into operative position. 2) Prepare for and assist in treatment of cardiac and/or respiratory arrest. Explanation: 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.
An instructor is developing for a class a teaching plan about agents used for intravenous (IV) anesthesia. Which of the following would the instructor include in this plan about these agents and this type of anesthesia? Select all that apply. a) More pleasant onset of anesthesia b) Long duration of action c) Associated with more nausea d) Need for little equipment e) Ease of administration
a) More pleasant onset of anesthesia e) Ease of administration d) Need for little equipment Explanation: With IV anesthesia, the onset is pleasant. Agents have a brief duration of action, and the patient awakens with little nausea and vomiting. The agents also are nonexplosive, require little equipment, and are easy to administer.
The nurse positions the client in the lithotomy position in preparation for a) Perineal surgery b) Pelvic surgery c) Renal surgery d) Abdominal surgery
a) Perineal surgery Explanation: The client undergoing perineal surgery will be placed in the lithotomy position.
Which of the following should not be allowed with regards to the wearing of masks in the operating room? a) The mask should be tight fitting b) Let masks hang around the neck c) Cover the nose and mouth completely d) Change masks between treating patients
b) 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.
What is the priority action by the scrub nurse when the surgeon is starting to close the surgical wound? a) Handing needed equipment to the surgeon. b) Prepare the needed sutures. c) Obtain a sponge count. d) Label the tissue specimen.
c) 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.
A patient receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first? a) Provide a basin. b) Suction the mouth. c) Roll the patient on his or her side. d) Administer an antiemetic medication.
c) Roll the patient on his or her side. Explanation: The patient must be rolled to the side to prevent aspiration. All the other interventions are correct for a vomiting sedated patient, but the highest priority is in preventing aspiration.
Which of the following techniques least exhibits surgical asepsis? a) Adding only sterile items to a sterile field b) Placing the sterile field at least one foot away from personnel c) Suctioning the nasopharyngeal cavity of a client d) Keeping sterile gloved hands above the waist
c) Suctioning the nasopharyngeal cavity of a client Explanation: To maintain surgical asepsis, only sterile items should touch sterile items.
Which of the following clinical manifestations is often the earliest sign of malignant hyperthermia? a) Oliguria b) Elevated temperature c) Tachycardia (heart rate above 150 beats per minute) d) Hypotension
c) 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.
Which of the following medications would the nurse expect to be used to facilitate intubation of the client? a) pancuronium (Pavulon) b) fentanyl (Sublimaze) c) attacurium (Tracrium) d) diazepam (Valium)
c) attacurium (Tracrium) Explanation: Attacurium (Tracrium) is commonly used to facilitate intubation of the surgical client.
Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? a) Allow the client to verbalize fears. b) Keep the family informed of the client's status. c) Verify the client's preoperative vital signs. d) Assess the client for allergies.
d) Assess the client for allergies. Explanation: The nurse must be aware of the client's allergies to prevent exposure to the client.
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) A distance of 3 feet must be maintained when moving around a sterile field. c) Circulating nurses may come in contact with the sterile field without contaminating it. d) The edges of a sterile package, once opened, are considered unsterile.
d) 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.
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) Maintaining hemostasis c) Suturing d) Specimen management e) Handling tissue
e) Handling tissue c) Suturing b) Maintaining hemostasis a) 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 aware that loss of consciousness occurs with which type of anesthesia? a) Local b) General c) Moderate sedation d) Regional
b) General Explanation: A therapeutic effect of general anesthesia is loss of consciousness.
A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed. 1 Turn the patient to the side. 2 Provide a basin for collection. 3 Lower the head of the surgical table. 4 Suction to remove saliva.
1) Turn the patient to the side. 3) Lower the head of the surgical table. 2) Provide a basin for collection. 4) 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.
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) Headache b) Seizures c) Itching d) Sore throat
a) Headache Explanation: Headache is a common effect following spinal anesthesia.
Which of the following is a nondepolarizing muscle relaxant? a) Fentanyl (Sublimaze) b) Pancuronium (Pavulon) c) Morphine Sulfate (MS) d) Succinylcholine (Anectine)
b) Pancuronium (Pavulon) Explanation: Pavulon is a nondepolarizing muscle relaxant.
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. 1 Shallow respirations 2 Unconsciousness 3 Pupil dilation 4 Ringing in the ears
4) Ringing in the ears 3) Pupil dilation 2) Unconsciousness 1) 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.
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? a) "Because of the type of anesthesia used, you may be aware of what is going on around you." b) "Anesthesia awareness is not a concern with type of surgery you are having." c) "The entire surgical team will monitor for anesthesia awareness and treat it appropriately." d) "Advances in medicines used decrease the chance of anesthesia awareness. What are your major concerns?"
a) "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.
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) 8:40 to 8:50 a.m. b) 9:00 to 9:10 a.m. c) 9:30 to 9:40 a.m. d) 10:00 to 10:10 a.m.
a) 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 dressed in street clothes enters the semirestricted zone. b) A staff member is wearing a surgical mask and shoe covers in the restricted zone. c) A staff member is wearing scrub clothes in the semirestricted zone. d) A staff member fails to wear a mask in the semirestricted zone.
a) 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) Ability to respond to verbal commands b) Unable to maintain airway c) Loss of consciousness d) Paralysis of the lower extremities
a) Ability to respond to verbal commands Explanation: The client receiving moderate sedation will be able to respond to verbal commands.
The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply. a) Avoid touching sterile items unless necessary. b) Wear a long-sleeved, sterile gown and gloves. c) Remove hair from the surgical site using a razor. d) Keep artificial nails clean and in good repair. e) Alert the surgical team of any breaches of sterile technique.
a) Avoid touching sterile items unless necessary. e) Alert the surgical team of any breaches of sterile technique. b) Wear a long-sleeved, sterile gown and gloves. Explanation: Nursing interventions to prevent infection during the intraoperative phase include wearing appropriate attire; avoiding touching sterile items; and alerting the surgical team of breaches of sterile technique. Artificial nails are banned for OR personnel, because they can harbor microorganisms. Excess hair is removed with clippers, not a razor.
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 tissue elasticity c) Impaired thermoregulation d) Increased anxiety level
a) 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) Discarding an object that comes in contact with the 1-inch border b) Reaching over the sterile field c) Touching sterile items with a clean-gloved hand d) Touching the edges of an open sterile package
a) Discarding an object that comes in contact with the 1-inch border Explanation: The 1-inch border of a sterile field is considered unsterile.
A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? a) Etomidate b) Isoflurane c) Tetracaine d) Nitrous oxide
a) 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.
Which stage of surgical anesthesia is also known as excitement? a) II b) III c) I d) IV
a) 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.
As a circulating nurse, what task are you solely responsible for? a) Keeping records. b) Estimating the client's blood loss. c) Handing instruments to the surgeon. d) Counting sponges and needles.
a) 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 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) Mask is placed over nose and extends to bottom lip. b) Scrub top and drawstring are tucked into pants. c) Shoe covers are used. d) Hair is pulled back and covered by a cap.
a) 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.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? a) Obtain the attention of all members of the surgical team. b) Discuss the surgical procedure and surgical site with the patient. c) Review the complications and allergies with the anesthesiologist. d) Ask the surgeon if the marked surgical site is correct.
a) 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 undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate? a) Place the patient in lithotomy position. b) Place the patient in the Trendelenburg position. c) Place the patient in a dorsal recumbent position. d) Place the patient in Sims' position.
a) 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) Preparing the sterile instruments for the surgical procedure b) Calling the "time-out" to verify the surgical site and procedure c) Monitoring the operating-room personnel for breaks in sterile technique d) Monitoring the administration of the anesthesia
a) 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 entire sterile field from use. b) Remove the item from the sterile field. c) Ask another nurse to review the technique used. d) Mark the patient's chart for future review of infections.
a) 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 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 perioperative positioning injury related to operative position b) Disturbed sensory perception related to sedation c) Anxiety related to the surgical experience d) Risk for injury related to effects of anesthetic agents
a) 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) Risk for perioperative positioning injury related to positioning in the OR b) Risk of latex allergy response related to possible exposure in the OR environment c) Anxiety related to ineffective coping with surgical concerns d) Disturbed sensory perception related to the effects of general anesthesia
a) 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 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) Scrub clothes b) Shoe covers c) Street clothes d) Masks e) Caps
a) Scrub clothes e) 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 of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? a) Supine position b) Lithotomy position c) Sims position d) Trendelenburg position
a) Sims position Explanation: The client undergoing renal surgery will be placed in the Sims position.
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) Sodium citrate (Bicitria) b) Famotadine (Pepcid) c) Midazolam (Versed) d) Vecuronium (Norcuron)
a) 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.
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.
a) Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.
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) Surgeon b) Scrub nurse c) Circulating nurse d) Anesthetist
a) 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 is often the earliest sign of malignant hyperthermia? a) Tachycardia b) Hypotension c) Oliguria d) Decreased cardiac output
a) 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.
Which of the following is an inappropriate nursing action by the surgical nurse? a) Wearing sterile gloves over artificial nails b) Covering the hair with a surgical cap c) Wearing a surgical jacket with knitted cuffs on the sleeves d) Changing shoe covers that become torn
a) Wearing sterile gloves over artificial nails Explanation: Artificial nails are prohibited in the clinical setting, because they can cause nosocomial infections.
The nurse recognizes older adults require lower doses of anesthetic agents due to: a) decreased lean tissue mass. b) decreased bone mass. c) increased tissue elasticity. d) increased liver mass.
a) 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.
The nurse recognizes that the older adult is at risk for surgical complications due to: a) decreased renal function b) decreased adipose tissue c) increased skeletal mass d) increased cardiac output
a) decreased renal function Explanation: Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.
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) hallucinations and respiratory depression. b) hiccups. c) respiratory depression. d) extrapyramidal reactions. e) hallucinations. f) extrapyramidal reactions and hiccups.
a) 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.
In developing the plan of care for the intraoperative client, the nurse recognizes that it is essential to consider: a) the client's cultural beliefs b) the schedule of the operating room c) the surgeon's skill in performing the procedure d) the wishes of the client's family
a) the client's cultural beliefs Explanation: A client's cultural beliefs may influence whether medical and nursing interventions are acceptable or unacceptable to the client.
Which statement by the client indicates further teaching about epidural anesthesia is necessary? a) "I will lose the ability to move my legs." b) "I will become unconscious." c) "A needle will deliver the anesthetic into the area around my spinal cord." d) "I will be able to hear the surgeon during the surgery."
b) "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 won't feel it, but I'll have a tube to help me breathe." b) "I'll be sleepy but able to respond to your questions." c) "I'm so glad that I will be unconscious during the surgery." d) "Only the surgical area will be numb."
b) "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.
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 placed flat on the table, face down." b) "You will be lying on your side with your knees to your chest." c) "You will be on your back with the head of the bed at 30 degrees." d) "You will be flat on your back with the table slanted so your head is below your feet."
b) "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 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) Temporarily set the OR temperature to 30°C. b) Apply a warm air blanket, gradually increasing body temperature. c) Administer IV fluids warmed to room temperature. d) Place warm damp drapes on the patient, replacing them every 5 minutes.
b) 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 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) Registered nurse first assistant b) Circulating nurse c) Scrub nurse d) Surgeon
b) 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? a) Place the client on a hypothermia blanket. b) Cover the client with a light blanket. c) Provide the client with warm fluids. d) Ensure that the room temperature is below 70°F.
b) 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.
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? a) Considering the gown sterile from mid-thigh to neck b) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff c) Positioning the sterile drape on a table from back to front d) Allowing circulating nurses to contact sterile equipment
b) 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.
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) Fentanyl (Sublimaze) c) Metocurine (Metubine) d) Etomidate (Amidate)
b) 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) Administering oxygen b) Frequent monitoring of vital signs c) Providing a quiet dark room d) Assessing for hallucinations
b) 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.
Which of the following would be included as a responsibility of the scrub nurse? a) Obtaining and opening wrapped sterile equipment b) Handing instruments to the surgeon and assistants c) Coordinating activities of other personnel d) Keeping all records and adjusting lights
b) 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.
The nurse recognizes the client has reached stage III of general anesthesia when the client: a) Complains of ringing or buzzing in the ears b) Has small pupils that react to light c) Exhibits shallow respirations and a weak, thready pulse d) Exhibits no change in behavior
b) 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.
A patient develops malignant hyperthermia. Which of the following most likely would be the first indicator of this complication? a) Tentanus-like jaw movements b) Heart rate over 150 beats per minute c) Body temperature rise of 2 degrees F d) Generalized muscle rigidity
b) 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 position is used for perineal surgical procedures? a) Dorsal recumbent b) Lithotomy c) Trendelenburg d) Sim's
b) 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) Latex b) Medications c) Plastic d) Fibrin sealants
b) 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) Notify the surgical team. c) Obtain cooling blankets. d) Document the assessment findings.
b) 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.
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) Pancuronium (Pavulon) c) Morphine sulfate d) Succinylcholine (Anectine)
b) Pancuronium (Pavulon) Explanation: Pavulon is a nondepolarizing muscle relaxant. Succinylcholine is a polarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents.
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) Absence of itching b) Peripheral pulses palpable c) Pulse oximetry 98% d) Vital signs within normal limits for client
b) 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 who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit? a) Weak, thready pulse and cyanosis b) Pupillary dilation and rapid pulse c) Unconsciousness and regular respirations d) Dizziness and a feeling of detachment
b) 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 scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a) Ensure the infection is covered with a dressing. b) Report the infection to an immediate supervisor. c) Return to work after being on antibiotics for 24 hours. d) Request role change to circulating nurse
b) 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) Respond verbally during the procedure c) Be anxious throughout the procedure d) Need an endotracheal tube
b) 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.
Which zone of the surgical area only allows for attire in the form of scrub clothes and caps? a) Unrestricted zone b) Semirestricted zone c) Operative zone d) Restricted zone
b) 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.
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 II b) Stage IV c) Stage III d) Stage I
b) 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 action during a surgical procedure requires immediate intervention by the circulating nurse? a) The registered nurse's first assistant suturing the surgical wound b) The scrub nurse calling the blood bank to obtain blood products c) The surgeon reaching within the sterile field to obtain equipment d) The anesthesiologist monitoring blood gas levels
b) 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.
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) Verify consent. c) Obtain a sponge and syringe count. d) Acquire ordered blood products.
b) 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.
Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply. a) Administer anti-anxiety medication. b) Verify scheduled procedure with client. c) Assess the client for allergies. d) Confirm the consent form is signed. e) Cover the client with warm blankets.
b) Verify scheduled procedure with client. c) Assess the client for allergies. d) Confirm the consent form is signed. Correct 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 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) administering I.V. antibiotics can prevent pneumonia. b) it may be necessary to raise the head of this client's bed. c) inserting a Foley catheter can decrease fluid retention. d) this client may need intubation.
b) 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 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) "You will inhale the medication through a mask the anesthesiologist will place over your face." c) "The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." d) "The anesthesiologist will inject the anesthetic through your IV."
c) "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.
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: a) Scrub nurse b) Anesthesiologist c) Circulating nurse d) Surgeon
c) Circulating nurse Explanation: The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.
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) Lithotomy b) Sims c) Dorsal recumbent d) Trendelenburg
c) 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 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? a) No action is needed. b) Immediately escort the medical student out of the area. c) Educate the medical student on required attire for each surgical zone. d) Provide the medical student a cap and mask.
c) 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.
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) Fentanyl b) Succinylcholine c) Halothane d) Propofol
c) Halothane Explanation: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.
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) I b) IV c) II d) III
c) 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 anesthesia is termed surgical anesthesia? a) I b) IV c) III d) II
c) 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.
In which position would a patient undergoing a lumbar puncture be placed? a) Supine b) Trendelenburg c) Semi-Fowler's d) Side-lying, knee to chest
d) Side-lying, knee to chest Explanation: For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Supine, semi-Fowler's, and Trendelenburg position would be inappropriate.
A nurse is reviewing the medical record of a patient who is to receive general anesthesia and notes a nursing diagnosis of anxiety related to surgical concerns. The nurse implements measures to reduce the patient's anxiety based on the understanding of which of the following? a) The patient is at risk for additional complications. b) The anesthetic will result in a more potent effect on the patient. c) Increased anxiety can increase the patient's postoperative pain level. d) Anxiety interferes with progression through the stages of general anesthesia.
c) Increased anxiety can increase the patient's postoperative pain level. Explanation: Anxiety increases the amount of anesthetic medication needed, the level of postoperative pain, and overall recovery time. Anxiety may place the patient at risk for complications, but other factors are usually also involved. When a patient is anxious, induction is slower and greater quantities of anesthetic agents are required because the brain receives a smaller quantity of anesthetic agent. Anxiety is unrelated to the patient's progression through the stages of general anesthesia. Additionally, when opioid agents and neuromuscular blockers are administered as part of general anesthesia, several of the stages are absent.
Fentanyl (Sublimaze) is categorized as which type of intravenous anesthetic agent? a) Dissociative agent b) Tranquilizer c) Opioid d) Neuroleptanalgesic
c) 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 patient is to receive general anesthesia with sevoflurane. The nurse anticipates the need for which of the following? a) Alfentanil b) Lidocaine c) Oxygen d) Rocuronium
c) 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 nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? a) Decreased cough and gag reflexes b) Heart rate of 84 beats/minute c) Oxygen saturation (SaO2) of 85% d) Blood-tinged stools
c) 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 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) Legs b) Abdomen c) Perineum d) Chest
c) 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.
A patient is to receive local anesthesia in combination with epinephrine. The nurse understands that epinephrine is used for which reason? a) Enhances the anesthetic's absorption b) Prevents anaphylaxis c) Prolongs the local action d) Reduces the amount of anesthetic needed
c) 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 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) Muscle rigidity b) Oliguria c) Rapid rise in body temperature d) Tachycardia
c) 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 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) Circulating nurse c) Scrub role d) Anesthetist
c) 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 position should the patient undergoing pelvis surgery be positioned? a) Reverse Trendelenburg b) Lithotomy c) Trendelenburg d) Sim's
c) Trendelenburg Explanation: 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. The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sim's or lateral position is used for renal surgery.
Hypothermia may occur as a result of a) being young. b) increased muscle activity. c) open body wounds. d) the infusion of warm fluids.
c) 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.
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) "Amnesia and analgesia are some of the negative effects of anesthesia." c) "Clients can experience pain and loss of consciousness." d) "Some possible negative effects include oversedation and bradycardia."
d) Some possible negative effects include oversedation and bradycardia." Explanation: Oversedation, allergic reaction, and bradycardia are potential adverse effects of surgery and anesthesia.
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include? a) "You won't be able to move, but you'll be able to feel sensations." b) "The anesthetic is introduced directly into the spinal cord." c) "Normally, the blood pressure drops fairly low initially." d) "You shouldn't experience a headache after this type of anesthesia."
d) "You shouldn't experience a headache after this type of anesthesia." Explanation: With epidural anesthesia, a headache usually does not occur. If the dura mater is punctured during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can occur, producing severe hypotension and respiratory depression and arrest. This is a complication and not a typical reaction. The anesthetic is introduced into the epidural space surrounding the dura mater of the spinal cord. It blocks sensory, motor, and autonomic functions.
The client who had spinal anesthesia complains of a headache. Which of the following is an inappropriate action by the nurse? a) Increase fluid intake. b) Maintain a quiet environment. c) Keep the head of the bed flat. d) Administer morphine sulfate.
d) Administer morphine sulfate. Explanation: The nurse implements interventions that increase cerebrospinal pressure, such as hydrating the client, keeping the head of the bed flat, and maintaining a quiet environment. A mild analgesic, such as acetaminophen, may be prescribed for the pain; morphine sulfate would be an inappropriate analgesic.
Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting? a) Disturbed sensory perception related to the effects of general anesthesia b) Risk of latex allergy response related to possible exposure in the OR environment c) Risk for perioperative positioning injury related to positioning in the OR d) Anxiety related to ineffective coping with surgical concerns
d) Anxiety related to ineffective coping with surgical concerns Explanation: Putting the client at ease helps the client prepare for the surgical experience by promoting psychological comfort of the client and giving the client a sense of control.
A nurse is reviewing the intraoperative record of a patient who has just returned from surgery. The patient received general anesthesia with intravenous agents. Which of the following would the nurse identify as a nondepolarizing muscle relaxant? a) Fentanyl b) Succinylcholine c) Sufentanil d) Atracurium
d) Atracurium Explanation: Atracurium is a nondepolarizing muscle relaxant. Succinylcholine is a depolarizing muscle relaxant. Fentanyl and sufentail are opioid analgesic agents.
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) No movement in right lower leg d) Denies sensation to perineum and lower abdomen
d) 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.
A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate? a) Position the patient on the side. b) Turn on the television for distraction. c) Notify the anesthesiologist immediately. d) Encourage increased fluid intake.
d) 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.
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) Cardiac arrest b) Cyanosis c) Mottled skin d) Increased urine output
d) 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) Ignore the comment. b) Report the resident to the attending surgeon. c) Discuss concerns regarding the comments with the charge nurse. d) Inform the resident that all communication needs to remain professional.
d) 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.
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following? a) Hypoxia b) Anaphylaxis c) Rebound hyperthermia d) Metabolic acidosis
d) Metabolic acidosis Explanation: When a patient's temperature falls, glucose metabolism is reduced. As a result, metabolic acidosis may develop. Rebound hyperthermia, anaphylaxis, and hypoxia are not associated with hypothermia during surgery.
After teaching a class about agents commonly associated with the development of malignant hyperthermia, the instructor determines that additional teaching is needed when the students identify which drug as a possible cause? a) Halothane b) Epinephrine c) Succinylcholine d) Morphine
d) Morphine Explanation: Morphine is not associated with malignant hyperthermia. Agents such as halothan, succinylcholine, and epinephrine can induce malignant hyperthermia.
During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? a) Warm IV and irrigating fluids. b) Increase the temperature of the OR environment. c) Remove wet gowns and drapes. d) Place a cooling blanket under the client.
d) 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.
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: a) verapamil (Isoptin) b) potassium chloride c) an acetaminophen suppository d) dantrolene sodium (Dantrium)
d) dantrolene sodium (Dantrium) Explanation: The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.
The nurse understands that the purpose of the "time out" is to: a) verify all necessary supplies are available. b) clarify the roles of the OR personnel. c) identify the client's allergies. d) maintain the safety of the client.
d) 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: a) is a type of regional anesthesia. b) is used as an adjunct to spinal anesthesia. c) requires the introduction of an anesthetic agent into the epidural space. d) may result in the administration of general anesthesia.
d) may result in the administration of general anesthesia. Explanation: Monitored anesthesia care may require the anesthsiologist to convert to general anesthesia.
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) When not using the mask, you can wear it around your neck. c) Masks should be tight fitting. d) You must change masks between treating patients. e) Masks should cover the nose and mouth completely. f) Masks must be worn at all times in the semirestricted zone.
e) Masks should cover the nose and mouth completely. d) You must change masks between treating patients. c) Masks should be tight fitting. Correct 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.