Nokea
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.
You may also like to solve these questions
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.
The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?
- A. Rub the patients back.
- B. Restrain the patient.
- C. Encourage the patient to express feelings.
- D. Stroke the patients hand.
Correct Answer: B
Rationale: In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled, so it is essential the nurse help to restrain the patient for safety. None of the other listed actions protects the patients safety.
The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?
- A. Hypothermia
- B. Pulmonary edema
- C. Cerebral ischemia
- D. Arthritis
Correct Answer: A
Rationale: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia.
The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?
- A. Holding sterile objects above the level of the nurses waist
- B. Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated
- C. Pouring solution onto a sterile field cloth
- D. Opening the outermost flap of a sterile package away from the body
Correct Answer: C
Rationale: Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.
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.