Nokea
An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.
- A. Absence of reflexes
- B. Diminished ability to communicate
- C. Loss of pain sensation
- D. Nausea resulting from anesthetic
- E. Reduced blood pressure
Correct Answer: A,B,C
Rationale: Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are adverse outcomes.
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A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner?
- A. Dorsal recumbent position
- B. Trendelenburg position
- C. Sims position
- D. Lithotomy position
Correct Answer: D
Rationale: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery and the Trendelenburg position usually is used for surgery on the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is flat on the back, but this would be impracticable for rectal surgery.
The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?
- A. Respiratory depression
- B. Hypothermia
- C. Anesthesia awareness
- D. Moderate sedation
Correct Answer: C
Rationale: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.
The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication?
- A. Hypothermia
- B. Anaphylaxis
- C. Infection
- D. Malignant hyperthermia
Correct Answer: B
Rationale: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because of the use of tissue adhesives.
Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following?
- A. Discharge planning
- B. Informed consent
- C. Analgesia prescription
- D. Educational resources
Correct Answer: B
Rationale: It is important to review the patients record for the following: correct informed surgical consent, with patients signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Discharge planning records and prescriptions are not normally necessary. Educational resources would not be included at this stage of the surgical process.
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.