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The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do?
- A. Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound.
- B. Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution.
- C. Continue packing the wound and inform the physician that an antibiotic is needed.
- D. Discard the gauze packing and repack the wound with new Iodoform gauze.
Correct Answer: D
Rationale: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the patients abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless ordered.
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An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
- A. Sterile surfaces or articles may touch other sterile surfaces.
- B. Sterile supplies can be used on another patient if the packages are intact.
- C. The outer lip of a sterile solution is considered sterile.
- D. The scrub nurse may pour a sterile solution from a nonsterile bottle.
Correct Answer: A
Rationale: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.
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.
The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR?
- A. The patient should be placed in Trendelenburg position.
- B. The patient must be firmly restrained at all times.
- C. Pressure points should be assessed and well padded.
- D. The preoperative shave should be done by the circulating nurse.
Correct Answer: C
Rationale: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.
A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe?
- A. The tube provides an airway for ventilation.
- B. The tube protects the patients esophagus from trauma.
- C. The patient may receive an antiemetic through the tube.
- D. The patients vital signs can be monitored with the tube.
Correct Answer: A
Rationale: The anesthetic is administered and the patients airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The patients vital signs are not monitored through the tube.
As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?
- A. By encouraging the patient to perform deep breathing preoperatively
- B. By limiting the patients contact with family members preoperatively
- C. By maintaining each of your patients privacy
- D. By eliciting informed consent from patients
Correct Answer: C
Rationale: Patient advocacy in the OR entails maintaining the patients physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.