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You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient?
- A. Preventing the risk of hypotension
- B. Preventing respiratory depression
- C. Preventing the onset of a headache
- D. Preventing pain at the lumbar injection site
Correct Answer: C
Rationale: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.
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A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated?
- A. By planning care using a surgical approach
- B. By identifying the professional with the most knowledge of the patient
- C. By implementing an interdisciplinary approach to care
- D. By using the nursing process to guide all aspects of care and treatment
Correct Answer: C
Rationale: An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. This is superior to each of the other listed options.
An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
- A. Sterile surfaces or articles may touch other sterile surfaces.
- B. Sterile supplies can be used on another patient if the packages are intact.
- C. The outer lip of a sterile solution is considered sterile.
- D. The scrub nurse may pour a sterile solution from a nonsterile bottle.
Correct Answer: A
Rationale: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.
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.
The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?
- A. Respiratory depression
- B. Hypothermia
- C. Anesthesia awareness
- D. Moderate sedation
Correct Answer: C
Rationale: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.