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A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?
- A. Administer an anxiolytic.
- B. Provide warm blankets.
- C. Introduce the surgical staff.
- D. Remain with the client.
Correct Answer: D
Rationale: The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An anxious client may need an anxiolytic, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.
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The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?
- A. Call the charge nurse.
- B. Consent for MIS procedure only
- C. Call prior anesthesia exposure
- D. Call prior anesthesia last to hours.
Correct Answer: B
Rationale: All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard. Calling the charge nurse is not the priority in this case.
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
- A. Allow the client to keep hearing aids in until anesthesia begins.
- B. Pad the table as appropriate for the surgical procedure.
- C. Position the client for maximum visualization of the site.
- D. Stay with the client, providing emotional comfort and support.
Correct Answer: A
Rationale: Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.
The nursing student observes the perioperative area and notes the unique functions of the circulating nurse, which include: (Select all that apply.)
- A. Accounting for all sharps
- B. Documenting all care given
- C. Maintaining the sterile field
- D. Monitoring traffic in the room
- E. Anticipating needs of the surgical team
Correct Answer: A,E
Rationale: The circulating nurse has several responsibilities, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document. Maintaining the sterile field is a joint responsibility of all members of the surgical team.
A client is having surgery. The circulating nurse notes the client's oxygen saturation is low and the heart rate is elevated. What is more important?
- A. Assess the client's end-tidal carbon dioxide level
- B. Document the findings in the client's chart.
- C. Inform the anesthesia provider of these findings.
- D. Prepare to administer dantrolene sodium (Dantrium).
Correct Answer: A
Rationale: Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs includes decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.
What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)
- A. Introducing oneself
- B. Providing warmth
- C. Positioning the client correctly
- D. Remaining present with the client
- E. Removing hearing aids
Correct Answer: A,B,C,D
Rationale: The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.