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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.
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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.
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 in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse is most appropriate?
- A. Administer insulin and glucose.
- B. Administer dantrolene sodium (Dantrium).
- C. Increase intravenous fluids.
- D. Monitor the client's electrocardiogram.
Correct Answer: B
Rationale: Malignant hyperthermia is a medical emergency, and dantrolene sodium (Dantrium) is the drug of choice to treat it. Hyperkalemia (potassium 6.5 mEq/L) may occur, but the priority is to administer dantrolene to reverse the malignant hyperthermia. Administering insulin and glucose or increasing fluids may be part of the treatment protocol, but dantrolene is the most critical. Monitoring the ECG is important but not the priority action.
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.