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Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?
- A. 2 feet
- B. 18 inches
- C. 1 foot
- D. 6 inches
Correct Answer: C
Rationale: Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination.
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The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?
- A. Increased temperature
- B. Oliguria
- C. Tachycardia
- D. Hypotension
Correct Answer: C
Rationale: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.
The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?
- A. Wait for the patient to initiate dialogue.
- B. Use medically acceptable terms.
- C. Give preoperative medications prior to discussion.
- D. Use a tone that decreases the patients anxiety.
Correct Answer: D
Rationale: When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. The nurse should use language the patient can understand. The nurse should not withhold communication until the patient initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to patient leading. Giving medication is not a communication skill.
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.
The perioperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?
- A. Impaired skin integrity
- B. Hypoxia
- C. Malignant hyperthermia
- D. Hypothermia
Correct Answer: B
Rationale: If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity.
The OR nurse is participating in the appendectomy of a 20-year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?
- A. Ensure that IV fluids are warmed to the patients body temperature.
- B. Transfuse packed red blood cells to increase oxygen carrying capacity.
- C. Place warmed bags of normal saline at strategic points around the patients body.
- D. Monitor the patients blood pressure and heart rate vigilantly.
Correct Answer: A
Rationale: Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the patient is not common practice. The patient is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.