Adult Health Ch. 18
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?
Count the sponges.
Which of the following actions by the nurse is appropriate?
Discarding an object that comes in contact with the 1-inch border
A nurse is caring for a postoperative client who started shivering. What is the best action for the nurse?
Ensure that the room temperature is set at 25°C to 26.6°C (78°F to 80°F).
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate?
Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff
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
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?
Increased anxiety can increase the patient's postoperative pain level.
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.
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?
Risk for perioperative positioning injury related to positioning in the OR
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?
Scrub role
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5°F (39°C)
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
The Sims' or lateral position as shown in Option D would be used for renal surgery.
Which statement by the client indicates further teaching about epidural anesthesia is necessary?
"I will become unconscious."
Which of the following is an inappropriate nursing action by the surgical nurse?
Wearing sterile gloves over artificial nails
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'll be sleepy but able to respond to your questions."
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?
"Remain supine for the time specified by the physician."
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."
A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?
"The lungs primarily eliminate the anesthesia."
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.
A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?
Appropriately position the client using adequate padding and support.
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?
Cardiovascular system
Why should the nurse be vigilant with assessment of perioperative risks on the older adult client? Select all that apply.
Ciliary action decreases, reducing the cough reflex. Fatty tissue increases, prolonging the effects of anesthesia. Liver size decreases, reducing the metabolism of anesthetics.
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?
Circulating nurse
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:
Circulating nurse
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?
Coordinating the surgical team
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
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?
Decreased lean tissue mass
The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?
Denies sensation to perineum and lower abdomen
Which would be included as a responsibility of the scrub nurse?
Handing instruments to the surgeon and assistants
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?
Headache
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
Which stage of surgical anesthesia is also known as excitement?
II
Which stage of anesthesia is referred to as surgical anesthesia?
III
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).
Keep discussions about the client to a minimum. Avoid auditory and physical stimuli. Place client into operative position. Prepare for and assist in treatment of cardiac and/or respiratory arrest.
As a circulating nurse, what task are you solely responsible for?
Keeping records.
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 attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?
Mask is placed over nose and extends to bottom lip.
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
Oxygen saturation (SaO2) of 85%
Which conduction block anesthetizes the nerves supplying the chest, abdominal wall, and extremities?
Paravertebral anesthesia
The nurse positions the client in the lithotomy position in preparation for
Perineal surgery
The scrub nurse is responsible for:
Preparing the sterile instruments for the surgical procedure
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.
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
A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?
Risk for perioperative positioning injury related to operative position
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.
Scrub clothes Caps
The client vomits during the surgical procedure. The best action by the nurse is:
Suction the client to remove saliva and gastric secretions.
Which of the following techniques least exhibits surgical asepsis?
Suctioning the nasopharyngeal cavity of a client
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?
Surgeon
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
Tachycardia (heart rate >150 beats per minute)
A postoperative client returns to a surgical nursing unit. The nurse assesses the client and notes tachycardia and muscle rigidity. What is the most important nursing action?
administering supplemental oxygen
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:
dantrolene sodium (Dantrium)
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride 60 g IV. After administration, the nurse will monitor the client for what symptom?
hallucinations
A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?
heart rate over 150 beats per minute
The nurse recognizes the client has reached stage III of general anesthesia when the client:
lies quietly on the table
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?
malignant hyperthermia
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 client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?
Verify consent.
