Chapter 18: Intraoperative Nursing Management (Exam 2)
Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will be able to hear the surgeon during the surgery." "I will become unconscious." "A needle will deliver the anesthetic into the area around my spinal cord." "I will lose the ability to move my legs."
"I will become unconscious." The client receiving epidural anesthesia will remain conscious during the procedure.
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer? "These medications decrease gastric acidity and volume." "These medications decrease the amount of anesthesia you will need." "These medications decrease anxiety before surgery." "These medications slow motor activity."
"These medications decrease gastric acidity and volume." The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"? "Stop worrying. It only makes you more nervous." "Relax. Your recovery period will be shorter if you're less nervous." "You seem nervous about your surgery." "You needn't worry. Your doctor has done this surgery many times before."
"You seem nervous about your surgery." Use of the communication technique of "restating" is recommended as a way to encourage the patient to expand his or her thoughts and feelings.
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate? "You will be on your back with the head of the bed at 30 degrees." "You will be flat on your back with the table slanted so your head is below your feet." "You will be placed flat on the table, face down." "You will be lying on your side with your knees to your chest."
"You will be lying on your side with your knees to your chest." For the lumbar puncture procedure, the client usually lies on the side in a knees-to-chest position. A position flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the client lie on their back does not allow access to the surgical site.
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? Place warm damp drapes on the client, replacing them every 5 minutes. Temporarily set the OR temperature to 30°C. Apply a warm air blanket, gradually increasing body temperature. Administer IV fluids warmed to room 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.
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? Endocrine system Cardiovascular system Genitourinary system Gastrointestinal system
Cardiovascular system Depolarizing muscle relaxants can cause cardiac dysrhythmias.
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Surgeon Scrub nurse Circulating nurse Registered nurse first assistant
Circulating nurse The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.
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 is the priority action by the scrub nurse when the surgeon begins to close the surgical wound? Count the sponges. Hand equipment to the surgeon as needed. Prepare the necessary sutures. Label the tissue specimen.
Count the sponges. Standards call for the scrub nurse and the circulating nurse to count the sponges 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 before the surgeon needs them. Although the scrub nurse does hand equipment to the surgeon, the sponge count is a higher priority action.
When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply. Diaphoresis Increased urine output Muscle rigidity Cyanosis Irregular heart rate Hypertension
Cyanosis Muscle rigidity Diaphoresis Irregular heart rate Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Thiopental sodium Naloxone Dantrolene sodium Fentanyl citrate
Dantrolene sodium Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
Which of the following actions by the nurse is appropriate? Discarding an object that comes in contact with the 1-inch border Touching the edges of an open sterile package Reaching over the sterile field Touching sterile items with a clean-gloved hand
Discarding an object that comes in contact with the 1-inch border The 1-inch border of a sterile field is considered unsterile.
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff Allowing circulating nurses to contact sterile equipment Considering the gown sterile from mid-thigh to neck Positioning the sterile drape on a table from back to front
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 Providing a quiet dark room for recovery Frequently monitoring vital signs Administering oxygen
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 Propofol Fentanyl Succinylcholine
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? Handing instruments to the surgeon and assistants Keeping all records and adjusting lights Leading the surgical team in a debriefing session Coordinating activities of other personnel
Handing instruments to the surgeon and assistants 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 leading the surgical team in a debriefing session, keeping records, adjusting lights, and coordinating activities of other personnel.
Which stage of surgical anesthesia is also known as excitement? IV I III II
II Stage II is the excitement stage, which 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 client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.
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.
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? Trendelenburg position Supine position Lateral (Sims) position Lithotomy position
Lateral (Sims) position The client undergoing renal surgery will be placed in the Lateral, also known as the Sims position.
A client is undergoing a perineal surgical procedure. The nurse should place the client in which position? Lithotomy Trendelenburg Sims Dorsal recumbent
Lithotomy 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 Sims' or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.
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? Shoe covers are used. Scrub top and drawstring are tucked into pants. Mask is placed over nose and extends to bottom lip. Hair is pulled back and covered by a cap.
Mask is placed over nose and extends to bottom lip. 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.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? Ask the surgeon whether the marked surgical site is correct. Obtain the attention of all members of the surgical team. Discuss the surgical procedure and surgical site with the client. Review complications and allergies with the anesthesiologist.
Obtain the attention of all members of the surgical team. The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position? 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 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 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 held in position by padded shoulder braces.
The nurse positions the client in the lithotomy position in preparation for Abdominal surgery Perineal surgery Renal surgery Pelvic surgery
Perineal surgery The client undergoing perineal surgery will be placed in the lithotomy position.
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? Pulse oximetry 98% Absence of itching Peripheral pulses palpable Vital signs within normal limits for client
Peripheral pulses palpable Surgical clients are at risk for pressure ulcers and damage to nerves and blood vessels as a result of awkward positioning required for surgical procedures. Palpable peripheral pulses indicate integrity of the blood vessels.
A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? Propofol Nitrous oxide Isoflurane Tetracaine
Propofol Anesthesia induction begins with IV anesthesia, such as propofol, 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.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Request a role change to circulating nurse. Return to work after taking antibiotics for 24 hours. Ensure the infection is covered with a dressing. Report the infection to an immediate supervisor.
Report the infection to an immediate supervisor. The infection needs to be reported immediately because of the aseptic environment of the operating room. The usual barriers may not protect the client when an infection is present. The employee needs to follow the policy of the operating room regarding infections. Covering the infected area with a dressing may be necessary, but the infection must be reported first. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must be reported first.
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. Unconsciousness shallow respirations pupil dilation ringing in the ears
Ringing in the ears Pupil dilation Unconsciousness Shallow respirations In stage I of general anesthesia, the patient 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.
Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours? Anxiety related to ineffective coping with surgical concerns Disturbed sensory perception related to the effects of general anesthesia Risk of latex allergy response related to possible exposure in the OR environment Risk for perioperative positioning injury related to positioning in the OR
Risk for perioperative positioning injury related to positioning in the OR Pressure ulcers, nerve and blood vessel damage, and discomfort are risks associated with prolonged, awkward positioning required for surgical procedures.
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 II Stage I 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.
The client vomits during the surgical procedure. The best action by the nurse is: Administer an anti-emetic to alleviate nausea. Increase the IV infusion rate to compensate for lost fluids. Lower the head of the operating table to promote circulation to the brain. Suction the client to remove saliva and gastric secretions.
Suction the client to remove saliva and gastric secretions. The nurse immediately suctions the client to prevent aspiration of vomitus.
Which of the following techniques least exhibits surgical asepsis? Keeping sterile gloved hands above the waist Placing the sterile field at least one foot away from personnel Adding only sterile items to a sterile field Suctioning the nasopharyngeal cavity of a client
Suctioning the nasopharyngeal cavity of a client To maintain surgical asepsis, only sterile items should touch sterile items.
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? Supine Sims Trendelenburg Lithotomy
Supine The usual position for surgery is the supine position. The Trendelenburg position is used for surgery on the lower abdomen and pelvis. The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery.
An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? Medullary depression Surgical anesthesia Excitement Beginning anesthesia
Surgical anesthesia Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. In beginning anesthesia, as the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Medullary depression is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light.
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 40° c Pulse rate of 110 beats/min Respiratory rate of 18 breaths/min Blood pressure of 104/62 mm Hg
Temperature of 40° c Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
The Sims' or lateral position would be used for renal surgery
What action during a surgical procedure requires immediate intervention by the circulating nurse? The scrub nurse calling the blood bank to obtain blood products The surgeon reaching within the sterile field to obtain equipment The registered nurse's first assistant suturing the surgical wound The anesthesiologist monitoring blood gas levels
The scrub nurse calling the blood bank to obtain blood products 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" in and should only touch items within the sterile field. The anesthesiologist should monitor blood gas levels as needed, and it is appropriate for the registered nurse's first assistant to suture the surgical wound.
The _________ position is used for surgery on the lower abdomen and pelvis.
Trendelenburg position
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?Select all that apply. Encourage the client to increase activity if complaining of a headache. Assist the client to a sitting position at the side of the bed. Turn the client from side to side at least every 2 hours, if permitted. Monitor respiratory rate and sensation every 2 hours or as per ordered. Instruct the client to stay in bed until sensation and movement returns.
Turn the client from side to side at least every 2 hours, if permitted. Assist the client to a sitting position at the side of the bed. Instruct the client to stay in bed until sensation and movement returns. Monitor respiratory rate and sensation every 2 hours or as per ordered. The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit. If client complains of a headache, the client should not be encouraged to increase activity. The client may have to remain lying flat for a longer period of time.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? Document the start of surgery. Verify consent. Count sponges and syringes. Acquire ordered blood products.
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.
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) an acetaminophen suppository potassium chloride
dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 40 C. The nurse should prepare to administer: verapamil (Isoptin) dantrolene sodium (Dantrium) an acetaminophen suppository potassium chloride
dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.
The nurse recognizes older adults require lower doses of anesthetic agents due to: increased tissue elasticity. increased liver mass. decreased bone mass. decreased lean tissue mass.
decreased lean tissue mass. 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 _____ ______ position is used for most abdominal surgeries, except those for the gallbladder and pelvis.
dorsal recumbent position
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 generalized muscle rigidity tetanus-like jaw movements body temperature increase of 1 °C to 2 °C (2 °F to 4 °F)
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: shouts, talks, or sings lies quietly on the table displays agitation due to noise 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.
The __________ position is used for nearly all perineal, rectal, and vaginal procedures.
lithotomy position
The nurse understands that the purpose of the "time out" is to: clarify the roles of the OR personnel. verify all necessary supplies are available. identify the client's allergies. maintain the safety of the client.
maintain the safety of the client. Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? fluid volume excess hypothermia infection malignant hyperthermia
malignant hyperthermia Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.
Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care: is used as an adjunct to spinal anesthesia. requires the introduction of an anesthetic agent into the epidural space. may result in the administration of general anesthesia. is a type of regional anesthesia.
may result in the administration of general anesthesia. Monitored anesthesia care may require the anesthesiologist to convert to general anesthesia.
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? alfentanil rocuronium oxygen 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.
