Nokea
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.
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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.
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.
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.
Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner?
- A. Historical precedence
- B. Patient requests
- C. Physicians needs
- D. Evidence-based practice
Correct Answer: D
Rationale: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal patient care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.
A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply?
- A. Reassure the patient that modern surgery is free of significant risks.
- B. Describe the surgery to the patient in as much detail as possible.
- C. Clearly explain any information that the patient seeks.
- D. Remind the patient that the anesthetic will render her unconscious.
Correct Answer: C
Rationale: The nurse can alleviate anxiety by supplying information as the patient requests it. The nurse should not assume that every patient wants as much detail as possible and false reassurance must be avoided. Reminding the patient that she will be unconscious is unlikely to reduce anxiety.