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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.
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A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?
- A. Assist with administering muscle relaxants to the client.
- B. Monitor the client's respiratory and circulatory status.
- C. Prepare to administer intravenous antiemetics to the client.
- D. Provide warm blankets to prevent postoperative shivering.
Correct Answer: B
Rationale: Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should assist the client by monitoring respiratory and circulatory status using a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.
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.
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.
A client has developed malignant hyperthermia. The client weighs 113 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? (Enter your answer using whole numbers, separated by a hyphen.)
- A. 100-150 mg
- B. 124-155 mg
- C. 200-250 mg
- D. 50-75 mg
Correct Answer: B
Rationale: The safe dose range for dantrolene sodium (Dantrium) in treating malignant hyperthermia is 2.5 mg/kg. For a client weighing 113 pounds (51.36 kg), the dose is calculated as 51.36 kg ? 2.5 mg/kg = 128.4 mg. The safe range is typically rounded to whole numbers, making 124-155 mg appropriate for one dose.
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.