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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.
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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 circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?
- A. Call maintenance for repair.
- B. Check the machine before using.
- C. Control the piece of equipment.
- D. Notify the charge nurse.
Correct Answer: C
Rationale: The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.
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 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.
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.