Nokea
What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)
- A. Introducing oneself
- B. Providing warmth
- C. Positioning the client correctly
- D. Remaining present with the client
- E. Removing hearing aids
Correct Answer: A,B,C,D
Rationale: The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.
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A client has developed malignant hyperthermia. The client weighs 113 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? (Enter your answer using whole numbers, separated by a hyphen.)
- A. 100-150 mg
- B. 124-155 mg
- C. 200-250 mg
- D. 50-75 mg
Correct Answer: B
Rationale: The safe dose range for dantrolene sodium (Dantrium) in treating malignant hyperthermia is 2.5 mg/kg. For a client weighing 113 pounds (51.36 kg), the dose is calculated as 51.36 kg ? 2.5 mg/kg = 128.4 mg. The safe range is typically rounded to whole numbers, making 124-155 mg appropriate for one dose.
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 in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse is most appropriate?
- A. Administer insulin and glucose.
- B. Administer dantrolene sodium (Dantrium).
- C. Increase intravenous fluids.
- D. Monitor the client's electrocardiogram.
Correct Answer: B
Rationale: Malignant hyperthermia is a medical emergency, and dantrolene sodium (Dantrium) is the drug of choice to treat it. Hyperkalemia (potassium 6.5 mEq/L) may occur, but the priority is to administer dantrolene to reverse the malignant hyperthermia. Administering insulin and glucose or increasing fluids may be part of the treatment protocol, but dantrolene is the most critical. Monitoring the ECG is important but not the priority action.
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.
A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
- A. Assess the client's gag reflex.
- B. Begin providing discharge instructions.
- C. Document findings and continue to monitor.
- D. Increase oxygen and notify the provider.
Correct Answer: C
Rationale: An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscope or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.