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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.
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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.
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 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.
The nursing student observes the perioperative area and notes the unique functions of the circulating nurse, which include: (Select all that apply.)
- A. Accounting for all sharps
- B. Documenting all care given
- C. Maintaining the sterile field
- D. Monitoring traffic in the room
- E. Anticipating needs of the surgical team
Correct Answer: A,E
Rationale: The circulating nurse has several responsibilities, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document. Maintaining the sterile field is a joint responsibility of all members of the surgical team.
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.