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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.
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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 circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?
- A. Wait for the patient to initiate dialogue.
- B. Use medically acceptable terms.
- C. Give preoperative medications prior to discussion.
- D. Use a tone that decreases the patients anxiety.
Correct Answer: D
Rationale: When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. The nurse should use language the patient can understand. The nurse should not withhold communication until the patient initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to patient leading. Giving medication is not a communication skill.
A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required?
- A. Prime IV tubing with a unit of blood and keep it on hold.
- B. Check that the patients electrolyte levels have been assessed preoperatively.
- C. Ensure that the patient has had a current cross-match.
- D. Keep the blood on standby and warmed to body temperature.
Correct Answer: C
Rationale: Few patients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.
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.
Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following?
- A. Discharge planning
- B. Informed consent
- C. Analgesia prescription
- D. Educational resources
Correct Answer: B
Rationale: It is important to review the patients record for the following: correct informed surgical consent, with patients signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Discharge planning records and prescriptions are not normally necessary. Educational resources would not be included at this stage of the surgical process.