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Intraoperative care (ch18 - lewis)
Terms in this set (28)
A patient is scheduled for a surgery that will be performed under epidural anesthesia. When reviewing the patient's medical record, the nurse notes a surgical history of postoperative immobility following epidural anesthesia. To prevent the postoperative complication, the nurse expects what revision to the anesthesia plan?
1 A decrease in the dose of the epidural anesthesia
2 An increase in the dose of the epidural anesthesia
3 The addition of an opioid drug to the epidural anesthesia
4 The addition of a benzodiazepine to the epidural anesthesia
In epidural anesthesia, a local anesthetic is injected into the epidural space. Lower concentrations of anesthetic lead to blockage of only sensory pathways, whereas, in higher doses both sensory and motor pathways are blocked. Therefore decreasing the dose will help this patient. Increasing the dose of epidural anesthesia would block both sensory and motor pathways. Adding adjunct drugs like opioid or benzodiazepine will not help.
The nurse is preparing the patient for a colonoscopy. Which type of anesthesia should the nurse expect to be used?
1 Local anesthesia
2 Moderate sedation
3 General anesthesia
4 Monitored anesthesia care
The nurse should expect monitored anesthesia care to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.
A patient is having general anesthesia, and the anesthesia care provider administers succinylcholine. The patient begins exhibiting signs of malignant hyperthermia. What indication does the surgical team have that this is occurring?
1 The patient is having hypocapnia.
2 The patient has a temperature of 97°F.
3 The patient is experiencing muscle rigidity.
4 The patient has a heart rate of 46 beats per minute.
Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias also may be seen with this disorder. Since the patient is in a hypermetabolic state, the heart rate will be elevated and not bradycardic.
The nurse is administering midazolam to a patient during a closed reduction of a shoulder. What outcome does the nurse anticipate achieving from the administration of the medication?
1 Analgesia and antiemetic
2 Analgesic and antianxiety
3 Provided conscious sedation
4 Relaxation of skeletal muscles and facilitation of endotracheal intubation
Midazolam is a benzodiazepine that is used widely for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.
Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be
A patient has been administered pancuronium during a surgical procedure. The nurse determines that what medication is administered at the end of surgery to reverse the action of pancuronium?
Pancuronium is a neuromuscular blocking agent that causes muscle paralysis. To reverse its action towards the end of surgery, an anticholinergic drug like neostigmine is administered. Methadone and remifentanil are opioid drugs. Dolasetron is an antiemetic.
In which phase of general anesthesia are H2 blockers used?
1 Induction phase
2 Emergence phase
3 Preinduction phase
4 Maintenance phase
To prevent aspiration of gastric contents during surgery, the surgeon administers H2 blockers in the preinduction phase of anesthesia. The induction phase is the period in which medications are given to render the patient unconscious. Benzodiazepines, opioids, and barbiturates are administered in the induction phase of anesthesia. The emergence phase is the period of completion of surgical procedure. The patient is prepared to be brought back to the preoperative state. Sympathomimetics, anticholinergics, and anticholinesterases are given during the emergence phase of anesthesia. The maintenance phase is the period of ongoing surgical procedure. Benzodiazepines, opioids, and barbiturates are administered in the maintenance phase.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
Which member of the intraoperative team remains in the unsterile field?
1 Scrub nurse
2 Circulating nurse
3 Surgeon's assistant
4 Registered nurse first assistant
The circulating nurse is not gowned and gloved and handles unsterile activities in the unsterile field during the intraoperative period. The scrub nurse is gowned and gloved and remains in the sterile field. The surgeon's assistant and registered nurse first assistant may handle and prepare surgical instruments and therefore remain in the sterile field during the intraoperative period.
The nurse is preparing to prep the patient's skin for surgery. In which surgical area will the patient's skin be prepped for surgery and what clothing will the person doing the prepping be wearing?
1 Surgical suite, wearing a lab coat
2 Preoperative holding area, wearing street clothes
3 Postanesthesia care unit (PACU), wearing scrubs
4 Operating room, wearing surgical attire and masks
Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. Lab coats are usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family might. The holding area and PACU will not include prepping the patient for surgery.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
The nurse is providing orientation to new surgical staff employees. What does the nurse inform the employee that proper attire for the restricted area of the surgery department would include?
1 Street clothing
2 Surgical attire and head cover
3 Surgical attire, head cover, and mask
4 Surgical attire, with the addition of shoe covers
In the surgical suite, in the restricted area, masks are required to supplement surgical attire. The restricted area can include the operating room (OR), scrub sink area, and clean core. The unrestricted area is where people in street clothes can interact with those in surgical attire. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station or control desk). The semirestricted area includes the surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair.
A patient is about to have a surgical procedure with general anesthesia. What does the nurse anticipate will be the initial stage?
1 The patient is intubated immediately.
2 Induction is performed with an intravenous (IV) agent.
3 The patient is given an oral tablet before the procedure.
4 Induction is performed by delivering an inhalation agent via a face mask.
Routine general anesthesia usually begins with an IV induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable. The patient is immediately intubated. An oral tablet would be contraindicated before surgery. Agents delivered via face mask are used, but not during initial stage.
Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.
The circulating nurse is preparing the patient for a surgical procedure. Prior to beginning, what National Patient Safety Goal (NPSG) requirement is enacted with a surgical time-out?
1 Prevention of infection
2 Improved staff communication
3 Identify patients at risk for suicide
4 Patient, surgical procedure, and site checked
During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide usually is not vital before surgery and does not occur during the time out.
Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. NCLEX item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints.
To ensure patient safety and reduce risks associated with surgical procedures, the circulating nurse calls a surgical timeout prior to surgery. Which activities should be included in the timeout? Select all that apply.
1 Verify patient identification.
2 Complete a fire risk assessment.
3 Verify surgical site and procedure.
4 Ensure that consent for the specific procedure was obtained.
5 Ensure that a significant other is available if needed for consultation
Correct 1, 2, 3, 4
Just before a surgical procedure, all surgical team members complete a surgical timeout to prevent risk of fire, wrong patient, wrong site, and wrong procedure. The team must also ensure that consent was obtained. Although a significant other may be present for a consultation if needed, this action is not an aspect of the surgical timeout process.
The nurse observes a new graduate nurse wearing protective attire when working in the operating room for surgery. The nurse should intervene when the new graduate performs what action?
1 Applies the cap and mask before applying the gloves
2 After surgery, removes the gown before removing the gloves
3 Gently pinches the upper metal band of the mask around the bridge of the nose
4 When removing the mask, unties the bottom strings before untying the top strings
The nurse should remove the gloves first to prevent contamination of hair, neck, and facial hair. Gently pinching the metal band prevents microorganisms from escaping around the nose and keeps the eyeglasses from steaming up. Applying gloves should be done after all other attire/equipment has been applied. Untying the bottom strings first prevents the top part of the mask from falling down over the uniform. If the mask falls and touches the uniform, the uniform will be contaminated.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
During surgery, a patient is administered ketamine hydrochloride, 60 mg, intravenously. Which is an important nursing intervention during recovery?
1 Monitor the patient for hyperthermia.
2 Maintain a calm and quiet environment.
3 Assess the patient's ability to move limbs.
4 Monitor blood sugar levels for hypoglycemia.
Ketamine can cause hallucinations, nightmares, and agitation; therefore it is important to maintain a calm and quiet environment. Ketamine does not cause hyperthermia or changes in blood sugar levels. It does not have a musculoskeletal effect that requires monitoring of musculoskeletal strength.
An older adult patient is scheduled to have a hip replacement. Of what risk areas will the nurse especially need to be aware for this patient during surgery?
3 Urine output
4 Skin integrity
Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery, but would not have an impact on any patient's skin integrity.
Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.
The anesthesia care provider is preparing to administer spinal anesthesia. When assisting with the procedure, where does the nurse determine the anesthetic injection will be administered?
1 Pleural space
2 Subdural space
3 Subpleural space
4 Subarachnoid space
In spinal anesthesia, local anesthetic injection is given into the cerebrospinal fluid in the subarachnoid space. It is mostly injected below the level of L2. As a result of mixing the anesthetic with cerebrospinal fluid, autonomic, sensory, and motor nerves are blocked. Spinal anesthesia is usually used for procedures on extremities, lower gastrointestinal, prostate, and gynecologic surgeries. Local anesthetics are not administered in the pleural space, subdural space, or subpleural space.
The circulating nurse is observing the area around the patient for continuity of sterility. What event observed by the nurse requires immediate intervention?
1 A glove contacts the leg of the table that supports the sterile field.
2 The cuff of the scrub nurse's sterile gown contacts the sterile field.
3 The sterile field was established at 0650 and the current time is 0900.
4 Bacteria are present in the nares and upper respiratory passages of the nurse.
A nurse educator discusses career options with a group of nursing students and describes the intraoperative activities of the perioperative nurses. What are the duties of a scrub nurse? Select all that apply.
1 Monitor the draping procedure.
2 Assist in the draping procedure.
3 Assist in induction of anesthesia.
4 Assist in preparing the operating room.
5 Provide a hand-off report to the postanesthesia care unit (PACU) nurse.
A scrub nurse always remains in a sterile environment. The scrub nurse has many duties, some of which include assisting in the draping procedure, assisting in preparing the operating room, and passing instruments to surgeons and assistants by anticipating their needs. Preparing the instrument table and maintaining a sterile environment are also the responsibilities of a scrub nurse. Assisting in induction of anesthesia, monitoring the draping procedure, and providing a hand-off report to the PACU nurse are the duties of a circulating nurse.
A patient undergoing a surgical procedure with general anesthesia exhibits muscle rigidity, temperature of 103° F (39.4° C), pulse 100 beats per minute (beats/minute), and a respiratory rate of 26 breaths per minute. The symptoms subside with the administration of dantrolene. What should the nurse include in the patient's postoperative instructions?
1 Taking antipyretics will bring your body temperature down.
2 Do not have any future surgeries under general anesthesia.
3 Consider getting genetic testing for malignant hyperthermia.
4 You should refrain from using any products that may contain latex.
Hyperthermia, tachycardia, and tachypnea, along with skeletal muscle rigidity induced by general anesthesia, are indications of malignant hyperthermia. The patient should undergo genetic testing to confirm the condition. These tests can help in taking preventive action in the future. Antipyretics may not help in bringing the body temperature down, because the temperature is increased because of an imbalance in intracellular calcium in the skeletal muscles. The patient can receive general anesthesia with appropriate precautions in future surgeries. The manifestations of latex allergy may range from urticaria to anaphylactic reaction, but that is not a factor for this patient.
Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the question stem that are the same or similar in nature to those in one or two of the options.
A patient being prepared for surgery asks if he or she will be given anything to help avoid nausea and vomiting postoperatively. Which medication does the nurse know can decrease the likelihood of nausea and vomiting?
Ondansetron (Zofran) is an antiemetic used to prevent nausea and vomiting in the intraoperative period. Sublimaze (Fentanyl) is an opioid used to induce and maintain anesthesia. Diazepam (Valium) is used to reduce anxiety in the intraoperative period. Pancuronium (Pavulon) is a neuromuscular blocking agent used to promote skeletal muscle relaxation.
The nurse is preparing to admit a patient to the operating room. According to the National Patient Safety Goals, what documents must be in the chart prior to the surgery beginning? Select all that apply.
2 Signed consent form
3 Functional status evaluation
4 Renal and liver function tests
5 A history and physical report
Correct 2, 5
The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the health care provider and other members of the surgical team. An electrocardiogram, functional status evaluation, and renal and liver function tests are not necessary.
A child is brought to the emergency room for the surgical reduction of a displaced shoulder. The parents ask the nurse if the child will undergo anesthesia. Which is the most appropriate response by the nurse?
1 "Your child will most likely be moderately sedated for the procedure."
2 "There is no need for anesthesia because the reduction does not involve an incision."
3 "Due to your child's age, your child will likely be given a general anesthetic before reduction."
4 "The primary care provider will most likely use an epidural or spinal block to numb the area for the procedure."
Moderate to deep sedation (previously referred to as conscious sedation) is generally used for minor therapeutic procedures such as fractures in the emergency room. General anesthetics are usually neither necessary nor appropriate in this situation. Despite the lack of an incision, the child will need some type of sedation for the procedure, which can be painful. An epidural or spinal block would not provide the necessary numbness needed in this situation.
The circulating nurse observes the scrub nurse washing hands prior to a surgical procedure and sees that the scrub nurse washes the fingers and hands before scrubbing the forearms and elbows, and then hands are placed lower than the level of the elbows. What should the circulator state to the scrub nurse?
1 "You have followed the correct procedure."
2 "You should have held your hands at the level of your elbows."
3 "You should have held your hands above the level of your elbows."
4 "You should have scrubbed your elbows before your fingers and hands."
After scrubbing hands, they should always be held away from the surgical attire and above the level of elbows to prevent draining of water from the unclean area above the elbows to the hands and fingers, which have been cleaned previously. It also prevents contamination from clothing. To hold hands at the level of elbows and to scrub elbows before fingers and hands are incorrect procedure because these increase the chances of the contamination.
A patient with diabetes is admitted for a prostatectomy. The patient will receive an antibiotic 60 minutes prior to the surgery, their usual dose of insulin, and etomidate IV for anesthesia. Considering the patient's diabetes, the nurse expects that which component of the preoperative plan will be revised?
1 The route of administration of etomidate
2 The administration of the preoperative antibiotic
3 The type of drug used to regulate the patient's glucose levels
4 The dosage of insulin used to regulate the patient's glucose levels
Etomidate is an intravenous anesthetic agent. It is a nonbarbiturate hypnotic and can cause hypoglycemia. Therefore the nurse should consider revising the dosage of insulin with the surgeon to prevent hypoglycemia. It is not appropriate to change the route of administration of etomidate, because it is an IV drug. Changing the drug or omitting administration of the antibiotic is not advised. Antibiotics are administered 30 to 60 minutes prior to surgery to reduce the incidence of postoperative infections.
A circulating nurse is preparing to scrub the skin of a patient who is scheduled for an appendectomy. What technique is appropriate for the nurse to use to ensure proper cleansing?
1 Use a zigzag motion from the area distal to the incision to the site of incision.
2 Use a zigzag motion from the site of the incision to the site distal to the incision.
3 Use a circular motion from the site of the incision to the area distal to the incision.
4 Use a circular motion from the area distal to the incision to the site of the incision.
It is important to scrub the skin appropriately in the process of skin preparation. It is done by a circulating nurse. The principle used here is to scrub a liberal area of skin using a circular motion from the clean area (i.e., the site of the incision) to the dirty area (i.e., the site distal to the incision) with an antimicrobial agent. This should be done in this way to reduce the microorganism migration to the surgical wound. Using a zigzag motion from the site of the incision to the area distal to the incision is not appropriate. Using a zigzag motion from the area distal to the incision to the site of the incision may contaminate the incision site. Using a circular motion from the area distal to the incision to the site of the incision may contaminate the incision site.
A nurse is providing immediate postoperative care for a patient who has undergone a thymectomy. What is the primary reason the anesthesia care provider prescribes naloxone for the nurse to administer postoperatively?
1 To decrease postoperative pain
2 To maintain normal blood pressures
3 To reverse opioid-induced respiratory depression
4 To reduce the incidence of postoperative infection
Narcan is the antidote of opioids. It contains naloxone. Opioid overdose induces respiratory depression. Narcan is prescribed to reverse this. Narcan is not useful in reducing postoperative pain or postoperative infection, or in maintaining blood pressure.
The nurse is caring for a patient receiving epidural anesthesia. The patient reports nausea. Upon assessment, the nurse notes a blood pressure of 80/60 mm Hg and a heart rate of 52. Which condition does the nurse expect the patient is experiencing?
1 Onset of hypoxemia
2 Increased intracranial pressure
3 Autonomic nervous system blockade
4 Development of emergence delirium
Autonomic nervous system blockade is characterized by hypotension, bradycardia, and nausea and vomiting. This condition can occur secondary to spinal and epidural anesthesia. Hypoxemia can occur secondary to many general anesthetics. Increased cranial pressure can occur with the use of ketamine for anesthesia, not epidural anesthesia. Emergence delirium is a disadvantage of inhalation agents used for general anesthesia, not epidural anesthesia.
The nurse is to administer ranitidine to a patient scheduled for a cholecystectomy. What would be the best time for the nurse to administer the drug?
1 After surgery
2 Before surgery
3 During surgery
4 Immediately after surgery
Ranitidine is an H2 receptor blocker used for aspiration prophylaxis. It should be given in the preinduction stage to avoid aspiration of secretions during anesthesia. Therefore the nurse should clarify the order from the primary health care provider and administer it before surgery. Administration of ranitidine after surgery, during surgery, and just after surgery does not serve the purpose of preventing aspiration of secretions during anesthesia
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