Nokea
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104 F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?
- A. The patient may be experiencing presurgical anxiety.
- B. The patient may be at risk for malignant hyperthermia.
- C. The grandmothers surgery has minimal relevance to the patients surgery.
- D. The patient may be at risk for a sudden onset of postsurgical infection.
Correct Answer: B
Rationale: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. The patients anxiety is not relevant, the grandmothers surgery is very relevant, and all patients are at risk for hypothermia.
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The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?
- A. The patient must never be left unattended by the nurse.
- B. The patient should begin a course of antiemetics the day before surgery.
- C. The patient should be informed that he or she will remember most of the procedure.
- D. The patient must be able to maintain his or her own airway.
Correct Answer: A
Rationale: The patient receiving moderate sedation should never be left unattended. The patients ability to maintain his or her airway depends on the level of sedation. The administration of moderate sedation is not a counter indication for giving an antiemetic. The patient receiving moderate sedation does not remember most of the procedure.
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 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.
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.
The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?
- A. Hypervolemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hyponatremia, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.