Nokea
A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?
- A. A 74-year-old woman with a low body mass index
- B. A 17-year-old boy with traumatic injuries
- C. A 45-year-old woman having an abdominal hysterectomy
- D. A 13-year-old girl undergoing craniofacial surgery
Correct Answer: A
Rationale: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other patients are likely at a lower risk.
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The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?
- A. Rub the patients back.
- B. Restrain the patient.
- C. Encourage the patient to express feelings.
- D. Stroke the patients hand.
Correct Answer: B
Rationale: In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled, so it is essential the nurse help to restrain the patient for safety. None of the other listed actions protects the patients safety.
When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply.
- A. Disturbed sensory perception related to anesthetic
- B. Risk for impaired nutrition: less than body requirements related to anesthesia
- C. Risk of latex allergy response related to surgical exposure
- D. Disturbed body image related to anesthesia
- E. Anxiety related to surgical concerns
Correct Answer: A,C,E
Rationale: Based on the assessment data, some major nursing diagnoses may include the following: anxiety related to surgical or environmental concerns, risk of latex allergy response due to possible exposure to latex in the OR environment, risk for perioperative positioning injury related to positioning in the OR, risk for injury related to anesthesia and surgical procedure, or disturbed sensory perception (global) related to general anesthesia or sedation. Malnutrition and disturbed body image are much less likely.
An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
- A. Sterile surfaces or articles may touch other sterile surfaces.
- B. Sterile supplies can be used on another patient if the packages are intact.
- C. The outer lip of a sterile solution is considered sterile.
- D. The scrub nurse may pour a sterile solution from a nonsterile bottle.
Correct Answer: A
Rationale: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.
A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?
- A. Have the patient sit in a chair and perform deep breathing exercises.
- B. Ambulate the patient as early as possible.
- C. Limit the patients fluid intake for the first 24 hours postoperatively.
- D. Keep the patient positioned supine.
Correct Answer: D
Rationale: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.
The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?
- A. Hypervolemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hyponatremia, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.