Nokea
A client is in stage 2 of general anesthesia. What action by the nurse is more important?
- A. Being prepared to suction the airway
- B. Being prepared to suction the airway
- C. Positioning the client correctly
- D. Positioning the client correctly
Correct Answer: A
Rationale: During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client correctly is important throughout to prevent hypothermia, but it is not the priority during this stage.
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A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
- A. Assess the client's gag reflex.
- B. Begin providing discharge instructions.
- C. Document findings and continue to monitor.
- D. Increase oxygen and notify the provider.
Correct Answer: C
Rationale: An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscope or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.
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.
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is more appropriate?
- A. Ask the surgeon to change the sterile gown.
- B. Do nothing, this is acceptable sterile procedure.
- C. Do the nurse surgeon more quickly and has been broken.
- D. Obtain a new part of sterile gloves for the surgeon to put on.
Correct Answer: C
Rationale: The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach; changing only the gloves or only the gown does not restore the sterile sections of the gown. Doing nothing is unacceptable.
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.
A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
- A. Facilitate marking the site with the client and surgeon.
- B. Have the client mark the operative site.
- C. Have the client mark the operative site.
- D. Tell the surgeon it is time to mark the surgical site.
Correct Answer: A
Rationale: The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.