Chapter 18 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 18

Question 1

Type: MCSA

An omission of information occurred when the nurse anesthetist informed the nurse in the postanesthesia care unit about a patients surgical procedure. The risk management nurse would review the standards of which process?

1. Handoff communication

2. Discharge summary

3. End-of-shift report

4. Surgical time-out

Correct Answer: 1

Rationale 1: Handoff communication describes any pertinent information about the patient and surgical procedure provided to the postanesthesia care unit nurse. This communication is to be free of interruptions and includes a systematic process of verification.

Rationale 2: This communication between nurses is not a discharge summary.

Rationale 3: End-of-shift report occurs when one group of nurses discusses the status of patients with the nurses assuming their care for the next shift.

Rationale 4: A surgical time-out takes place before the start of the surgical procedure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-3

Question 2

Type: MCSA

During a surgical procedure, the nurse assesses the patients response to anesthesia and determines the amount of pain medication to provide. Which role is this nurse fulfilling?

1. Scrub nurse

2. Certified registered nurse anesthetist

3. Registered nurse first assistant

4. Circulating nurse

Correct Answer: 2

Rationale 1: The scrub nurse works directly with the surgeon within the sterile field and passes instruments, sponges, and other items needed during the surgical procedure.

Rationale 2: The certified registered nurse anesthetist is an advanced-practice nurse educated to administer anesthesia and provide anesthesia-related care.

Rationale 3: The registered nurse first assistant collaborates with the surgeon and performs activities such as handling tissue, providing exposure, using instruments, and suturing wounds.

Rationale 4: The circulating nurse observes the surgical team from a broad perspective and assists the team to create and maintain a safe, comfortable environment for surgery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2

Question 3

Type: MCSA

A registered nurse is assisting the surgeon in conducting an exploratory laparoscopy. The nurse holds the tissue retractors, biopsies tissue, and sutures the patient at the conclusion of the case. Which role is this nurse fulfilling?

1. Circulating nurse

2. Scrub nurse

3. Certified registered nurse anesthetist

4. Registered nurse first assistant

Correct Answer: 4

Rationale 1: The circulating nurse observes the surgical team from a broad perspective and assists the team to create and maintain a safe, comfortable environment for surgery.

Rationale 2: The scrub nurse works directly with the surgeon within the sterile field and passes instruments, sponges, and other items needed during the surgical procedure.

Rationale 3: The certified registered nurse anesthetist is an advanced-practice nurse educated to administer anesthesia and provide anesthesia-related care.

Rationale 4: The registered nurse first assistant collaborates with the surgeon and performs activities such as handling tissue, providing exposure, using instruments, and suturing wounds.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2

Question 4

Type: MCSA

The surgical team is assembled and is preparing to conduct a procedure on a patient. Which health care professional is responsible for the overall functioning of the surgical team?

1. Surgeon

2. Circulating nurse

3. Scrub nurse

4. Registered nurse first assistant

Correct Answer: 1

Rationale 1: The surgeon heads the surgical team and is responsible for making decisions related to the surgical procedure.

Rationale 2: The circulating nurse observes the surgical team from a broad perspective and assists the team to create and maintain a safe, comfortable environment for surgery.

Rationale 3: The scrub nurse works directly with the surgeon within the sterile field and passes instrument, sponges, and other items needed during the surgical procedure.

Rationale 4: The registered nurse first assistant collaborates with the surgeon and performs activities such as handling tissue, providing exposure, using instruments, and suturing wounds.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-2

Question 5

Type: MCSA

A patient has just had surgery and is being transported to the postanesthesia care unit. Which team member will accompany the nurse

when transporting the patient?

1. The scrub nurse

2. The surgeon

3. The circulating nurse

4. The nurse anesthetist

Correct Answer: 4

Rationale 1: The scrub nurse will be performing other duties at this time.

Rationale 2: The surgeon will be performing other duties, such as talking with the family.

Rationale 3: The circulating nurse will be performing other duties at this time.

Rationale 4: Once the surgery is completed, the nurse anesthetist and the nurse will accompany the patient to the postanesthesia care unit.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-1

Question 6

Type: MCMA

The surgical team is participating in a surgical time-out. What activities are part of this procedure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Verification that the correct patient is prepared for surgery

2. Announcement of the name of the surgical procedure planned

3. A pause to allow last-minute preparation of the surgical suite

4. Determination of the body side on which the surgery will occur

5. Final surgical hand scrub

Correct Answer: 1,2,4

Rationale 1: Surgical time-out is a time to verify that the correct patient is present in the operating room.

Rationale 2: This announcement is made to prevent wrong surgery incidents.

Rationale 3: This time is specifically used for verification, not for additional preparation.

Rationale 4: Surgical time-out is used to reduce the number of right-site, wrong-side surgical errors.

Rationale 5: The final surgical hand scrub is completed before the surgical time-out.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-3

Question 7

Type: MCSA

Prior to bringing a patient into the operating room, the nurse examines an instrument that will be used for the surgical procedure. What is the rationale for this action?

1. To ensure the correct instrument is reflected in the charges to be made to the patients insurance for the surgical procedure

2. To allow the nurse to efficiently use the instrument as required

3. To ensure the patients safety when the instrument is used for the procedure

4. To determine if the instrument should be replaced with one that is disposable after use

Correct Answer: 3

Rationale 1: Charging for the correct instrument is not the reason for this inspection.

Rationale 2: The nurse will not be expected to use a surgical instrument during the procedure.

Rationale 3: Perioperative nursing responsibilities include ensuring proper instrument functioning through inspection. This is done to avoid inadvertent patient injury while the instrument is being used for the surgical procedure.

Rationale 4: This is not the time the nurse would evaluate whether a disposable version of the instrument should be stocked.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 8

Type: MCSA

After the anesthesiologist inserts the anesthetic agent into the patients spinal column, the nurse assists the patient into a supine position with the neck flexed. What is the rationale for the nurses action?

1. This position allows for better monitoring of the patients blood pressure and pulse.

2. Positioning can help the anesthetic agent reach the appropriate level in the spinal column.

3. This position helps to ensure the patients cardiac function will not be affected by the anesthesia.

4. The patient will be able to breathe more easily in this position.

Correct Answer: 2

Rationale 1: This position does not make it easier to monitor vital signs, nor are they more accurate in this position.

Rationale 2: Spinal anesthesia is the administration of a local anesthetic into the spinal column. Once the medication is introduced, having the patient assume a supine position with the neck flexed will ensure that the anesthesia will reach the appropriate level in the spinal column.

Rationale 3: This position does not have a positive effect on cardiac function.

Rationale 4: This position does not decrease the work of breathing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 9

Type: MCSA

The scrub nurse is preparing to access a sterilized item; however, the item is missing the appropriate sterilization tag. What action should the nurse take?

1. Substitute the item with another similar item that has been properly sterilized.

2. Use the item.

3. Request another item be brought that has the appropriate sterilization tag.

4. Inform the physician that the item does not have the sterilization tag and use the item.

Correct Answer: 3

Rationale 1: A similar item may not perform as well during the surgery.

Rationale 2: Using this item may expose the patient to pathogens.

Rationale 3: Intra-operative infections do occur, primarily because no sterilization procedure can completely eliminate all microorganisms. Sterilized items should have the appropriate tag or marking confirming sterilization. The nurse should reduce the patients risk for infection by requesting another item be brought that has the appropriate sterilization tag.

Rationale 4: The item should not be used, whether the physician is notified about the issue with sterility or not.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 10

Type: MCSA

A patient tells the nurse that her brother had surgery done on the wrong hand, and she wants to make sure the surgeon knows she is having surgery on her left shoulder. What should the nurse do to address the patients concerns?

1. Tell the patient that she should write the words Left Shoulder on a piece of paper and take it to the operating room with her.

2. Explain that the surgeon will mark the site of surgery directly on the patient during a preoperative visit.

3. Assure the patient that someone will tell the circulating nurse that the surgery is to be done on the left shoulder.

4. Show the patient where the site of the surgery has been documented on the medical record.

Correct Answer: 2

Rationale 1: Safety procedures are now in place to prevent wrong side surgery. Taking a note into the OR is not indicated.

Rationale 2: The Joint Commission recommends that the person doing the procedure should mark the correct site with an indelible marker at a preoperative visit.

Rationale 3: Another response would be more effective at reducing the patients anxiety.

Rationale 4: Another response would be more effective at reducing the patients anxiety.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 11

Type: MCSA

A patient fearful of anesthesia asks the nurse to make sure that she wakes up after surgery just so she can see her family one more time if she is going to die. What should the nurse do to support this patient?

1. Attempt to reduce the patients fears and discuss these fears with the surgical team.

2. Tell the patient that no one is going to let her die.

3. Explain that everyone who undergoes anesthesia thinks they wont wake up.

4. Tell the patient there is no guarantee that she wont die during the procedure.

Correct Answer: 1

Rationale 1: The nurse should try to reduce the patients fears but also communicate them to the surgical team. The anesthesiologist might be able to provide medication to help reduce the patients anxiety.

Rationale 2: The nurse should not promise the patient that she isnt going to die.

Rationale 3: The nurse should not minimize or invalidate the patients fears.

Rationale 4: The nurse should not compound the patients fears by saying there is no guarantee she wont die.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5

Question 12

Type: MCSA

A patient who is having surgery in a teaching hospital tells the nurse she wants only the surgeon and other necessary people in the operating room. She does not want the surgeon to be teaching medical students while conducting the surgery. How can the nurse support the patients request?

1. Ensure that the consent form contains this information and communicate the patients request to the surgical team.

2. Tell the patient that it really doesnt matter who is in the operating room during the surgery.

3. Explain to the patient that she has no control over who participates in the surgery.

4. Remind the patient that she can refuse the surgery at any time.

Correct Answer: 1

Rationale 1: Depending on the organization, surgical consent forms often identify who will be performing the surgery and if the surgeon will be using the procedure as an opportunity to teach. The nurse should ensure that the patients request is stated on the consent form and communicate the request to the surgical team.

Rationale 2: This response is dismissive of the patients concerns.

Rationale 3: This response would not be supportive of patient advocacy.

Rationale 4: The patient is not refusing to have surgery, and the nurse should not encourage her to do so.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-2

Question 13

Type: MCSA

A patient who received epidural anesthesia for surgery develops hypotension during the procedure. The nurse anticipates which intervention to support this patient?

1. Increasing pain medication

2. Intubating the patient

3. Increasing the amount of anesthesia being administered

4. Providing normal saline intravenously with medications to stimulate venous return

Correct Answer: 4

Rationale 1: There is no indication that the patient requires additional pain medication.

Rationale 2: Hypotension does not necessarily herald respiratory distress. The patient should be monitored, but there is no indication for intubation at this time.

Rationale 3: The hypotension is likely related to the anesthesia. There is no indication that additional anesthesia is required.

Rationale 4: Hypotension can occur during the surgical procedure in patients who receive epidural anesthesia. Hypotension is avoided with the administration of normal saline intravenously and with medications that have a strong alpha-adrenergic effect to stimulate venous return.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 14

Type: MCSA

While in the postanesthesia care unit, a patient recovering from spinal surgery tells the nurse that he cannot feel his right hand and that his right shoulder is painful. The nurses initial concern is in regard to which complication?

1. Thromboembolism in the brachial artery

2. Residual effects of spinal anesthesia

3. Infiltrated intravenous access site

4. Brachial plexus nerve injury

Correct Answer: 4

Rationale 1: Thromboembolism may have occurred but is not as likely as another complication.

Rationale 2: The patient is complaining of pain in a specific area, so this complication is not the most likely.

Rationale 3: Infiltration of the IV site is generally manifested by pain at the site. It also does not manifest with paresthesia.

Rationale 4: One complication due to patient positioning during a surgical procedure is injury to nerves. The patients complaint of reduced sensation of the right hand with right shoulder pain would indicate an injury to the brachial plexus nerve region.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-6

Question 15

Type: MCSA

At the conclusion of a surgical procedure, it has been determined that one sponge is missing. How should the nurse manage this situation?

1. Ask housekeeping personnel to look for the missing sponge while preparing the surgical suite for the next procedure.

2. Ask the surgeon to recount the sponges along with the nurse.

3. Refer to AORN standards for guidance.

4. Call the nursing supervisor to report the missing sponge.

Correct Answer: 3

Rationale 1: It is not the housekeeping staffs responsibility to look for the missing sponge.

Rationale 2: Sponge count is the responsibility of the perioperative nurses.

Rationale 3: Most facilities follow a legal counting procedure based on AORN recommended standards. The nurse should refer to these standards for guidance in this situation.

Rationale 4: It is not necessary to call the supervisor because the first sponge count is wrong.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 16

Type: MCSA

Before a patient goes into the surgical suite, the nurse anesthetist assesses the patients previous experience with anesthesia and answers any questions the patient might have about the anesthesia plan for the surgery. In which category of nurse anesthetist practice is this nurse functioning?

1. Maintenance

2. Induction

3. Perianesthetic clinical support

4. Preanesthetic preparation and evaluation

Correct Answer: 4

Rationale 1: Maintenance describes anesthesia being continually provided throughout the duration of the surgical procedure.

Rationale 2: During induction, the patient is initially provided anesthesia.

Rationale 3: In perianesthetic clinical support, the nurse anesthetist provides fluids or medications to support the patients physiologic

functioning while the surgical procedure is being conducted.

Rationale 4: The first category of nurse anesthetist practice is preanesthetic preparation and evaluation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7

Question 17

Type: MCSA

A patient has lost over 1,000 mL of blood during a surgical procedure that is estimated to continue for at least another 2 hours. The nurse anesthetist prepares to administer packed red blood cells during the procedure. Which patient care activity is the nurse anesthetist conducting?

1. Anesthesia maintenance

2. Preanesthetic preparation

3. Postanesthesia care

4. Perianesthetic clinical support

Correct Answer: 4

Rationale 1: In maintenance, the patient is continuously provided with anesthesia.

Rationale 2: Preanesthetic preparation includes assessing the patients previous experience with anesthesia and determining which type of anesthesia would be the most appropriate for the patient and the upcoming surgery.

Rationale 3: Postanesthesia care is that provided after the anesthesia has been stopped.

Rationale 4: Administering blood during a surgical procedure is an example of clinical support that is provided while the surgery and anesthesia are also occurring.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7

Question 18

Type: MCSA

The nurse anesthetist stops to see a patient recovering from surgery in the postanesthesia care unit to make sure the patient is not experiencing any untreated side effects from the anesthesia. The nurse anesthetist is conducting which aspect of patient care?

1. Preanesthesia evaluation

2. Emergence

3. Maintenance

4. Postanesthesia care

Correct Answer: 4

Rationale 1: Preanesthesia evaluation is done before the surgical procedure.

Rationale 2: Emergence occurs when the anesthesia amount is reduced to bring the patient out of anesthesia.

Rationale 3: In maintenance, the patient continues to receive a certain level of anesthesia to remain asleep during the surgical procedure.

Rationale 4: One category of care that certified registered nurse anesthetists provide is postanesthesia care. This includes assessing how well the patient is recovering from the effects of anesthesia and whether the patient is experiencing any untreated side effects from the anesthesia agents.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7

Question 19

Type: MCMA

The nurse is assigned as the surgical scrub nurse for todays outpatient cases. In addition to regular surgical attire, which equipment will the nurse wear?

Standard Text: Select all that apply.

1. Sterile gloves

2. Sterile gown

3. An eye shield

4. A sterile head cover

5. Sterile shoe covers

Correct Answer: 1,2

Rationale 1: To work within the sterile surgical field, the nurse will need to wear sterile gloves.

Rationale 2: To work within the sterile surgical field, the nurse will need to wear a sterile gown.

Rationale 3: Eye shields are not generally part of the standard scrub nurse attire. If splashing is anticipated, a shield should be worn.

Rationale 4: The nurse will wear a standard, clean head cover.

Rationale 5: The nurses feet are not within the sterile field, so standard, nonsterile shoe covers will be sufficient.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-2

Question 20

Type: MCMA

A patient is being prepared for surgery on the right arm. Which actions should the nurse take to prevent brachial plexus nerve injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Align the arm at a 135-degree angle from the body.

2. Pronate the wrist.

3. Pad the table extension on which the arm is positioned.

4. Protect the arm from pressure exerted by operative equipment.

5. Consider intraoperative position changes if possible.

Correct Answer: 3,4,5

Rationale 1: The arm should not be raised higher than a 90-degree angle from the body.

Rationale 2: The arm should be supinated.

Rationale 3: The surfaces with which the arm is in contact should be padded.

Rationale 4: Operative equipment should not be placed so that pressure is applied to the arm.

Rationale 5: If possible, position changes during surgery will help reduce pressure injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 21

Type: MCMA

Nurses who work in the operating room are asked to help design a new preoperative holding area. Which suggestions should the nurses offer?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Colors for the room should be bright and lively.

2. The room should be behind a securable door.

3. The room should be located on the quieter side of the surgical area.

4. The room should be centrally located with windows into the operating theaters.

5. There should be space for an emergency medical cart with a defibrillator.

Correct Answer: 2,3,5

Rationale 1: This room is designed to be an area for calm transition. Bright and lively colors are not calming.

Rationale 2: The holding area is semi-restricted, so the access door should be securable if necessary.

Rationale 3: This room is designed to be a quiet and calm transition area.

Rationale 4: The rooms should be shielded from the sights and sounds of the operating rooms themselves.

Rationale 5: Emergency resuscitation equipment and other basic medical assessment equipment should be available in this room.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-1

Question 22

Type: MCMA

A patient has been received in the preoperative holding area. Which interventions will the nurse perform in this environment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Review the patients medical record to ensure all relevant material is present.

2. Instruct the patient to remove all jewelry.

3. Review the medical record to ensure preoperative medications have been administered.

4. Have the patient empty the bladder.

5. Confirm that the patient has been NPO for the prescribed amount of time.

Correct Answer: 1,3,4,5

Rationale 1: The preoperative nurse reviews the medical record to ensure that all documents and reports of studies are present and consistent with expectations.

Rationale 2: Jewelry should be removed (with the exception of a wedding ring) prior to transport to the holding area.

Rationale 3: Preoperative medications are often scheduled for 30 minutes to 1 hour before surgery. The preoperative nurse must verify that the medications were administered.

Rationale 4: Just before the patient is taken to the operating room, the nurse should have him or her empty the bladder. This helps to prevent inadvertent bladder injury.

Rationale 5: The preoperative nurse asks the patient again about NPO status.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-1

Question 23

Type: MCSA

The patient is scheduled for an operative procedure that will require placement of an additional IV line, an indwelling urinary catheter, and a nasogastric tube. The nurse should advocate for these lines to be placed at what time?

1. Prior to transferring the patient to the preoperative holding area

2. In the preoperative holding area

3. After general anesthesia has been induced

4. In the postanesthesia recovery room

Correct Answer: 3

Rationale 1: The patient will feel pain or discomfort if these lines are inserted prior to transfer to the preoperative holding area.

Rationale 2: The patient will feel pain or discomfort if these lines are inserted in the preoperative holding area.

Rationale 3: The patient will not remember the placement of these lines if general anesthesia has been induced.

Rationale 4: The patient may be aware of pain or discomfort if these lines are inserted in the postanesthesia recovery room.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5

Question 24

Type: MCMA

The nurse in the preoperative holding area is checking to see if the correct patient has been transferred for the next surgical case. What questions would the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Are you Mary Smith?

2. What is your name?

3. What is your social security number?

4. What is your birth date?

5. What surgery are you having?

Correct Answer: 2,4

Rationale 1: The nurse should not ask a yes-no question in this situation.

Rationale 2: The nurse should have the patient state her name.

Rationale 3: The nurse is not likely to have documentation of the patients social security number.

Rationale 4: The nurse should ask for the entire date of birth.

Rationale 5: Many patients may be having the same surgery on the same day.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-4

Question 25

Type: MCMA

The certified nurse anesthetist has administered succinylcholine to a patient during surgery. The surgery has ended and the patient is awakening. The nurse would evaluate which findings as indicating recovery from this agent?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient can hold the head up.

2. The patient has a strong hand grasp.

3. The patient is still sleepy.

4. The patient is breathing with only minimal stimulation by the nurse.

5. The patients pupils react to light.

Correct Answer: 1,2

Rationale 1: The ability to hold ones head upright indicates recovery from this drug.

Rationale 2: A strong hand grasp is an indicator of recovery from this drug.

Rationale 3: Sleepiness may be the result of another agent. More information is needed to evaluate recovery from succinylcholine.

Rationale 4: If the patient must be stimulated to breathe, recovery is not adequate.

Rationale 5: Pupillary reaction is not a sign that the patient has recovered from succinylcholine.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-7

Question 26

Type: FIB

The certified nurse anesthetist suspects a patient is experiencing malignant hyperthermia and will administer dantrolene sodium 3 mg/kg IV. The patients documented weight is 143 pounds. The nurse will administer _____ mg in the first bolus.

Standard Text:

Correct Answer: 195

Rationale : 143 pounds/2.2 pounds per kg = 65 kg. 65 kg x 3mg = 195 mg in the first bolus. Additional boluses of up to 10 mg/kg may be indicated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 27

Type: MCMA

Which nursing actions indicate that a nurse has developed a surgical conscience?

Standard Text: Select all that apply.

1. The nurse stops a surgeon who has contaminated an instrument before it is used on the patient.

2. The nurse discards a urinary catheter kit because the catheter is the wrong size.

3. The nurse uses an instrument from a sterile package that became outdated yesterday.

4. The nurse changes gloves when a possible contamination occurs.

5. The nurse, working alone, touches the inside of a sterile package with ungloved hands but does not discard the contents.

Correct Answer: 1,4

Rationale 1: A surgical conscience mandates the reporting of breaks in sterile technique.

Rationale 2: Surgical conscience relates to the sterile field.

Rationale 3: The nurse should not use outdated sterile packages.

Rationale 4: The nurse who has a surgical conscience will act to protect the sterile field even if the breach is not certain.

Rationale 5: Surgical conscience means that the nurse maintains the sterile field even if no one else sees the breach of sterility.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5

Question 28

Type: MCMA

According to national guidelines for surgical wound classification, the nurse would classify which wounds as contaminated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A normal hysterectomy incision

2. A gunshot wound to the chest

3. A stab wound to the abdomen that does not enter the bowel

4. A pressure ulcer that has eschar present

5. The skin wound from a compound femur fracture

Correct Answer: 2,3,5

Rationale 1: This wound would be classified as clean-contaminated unless infection or a major break in technique occurred.

Rationale 2: Accidental wounds are considered contaminated.

Rationale 3: Accidental wounds are considered contaminated.

Rationale 4: Wounds that contain devitalized tissue are considered dirty or infected.

Rationale 5: Accidental wounds are considered contaminated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-6

Question 29

Type: MCSA

The nurse would be concerned that a patient may have a latex allergy if the patient reports allergy to which food?

1. Strawberries

2. Eggs

3. Avocados

4. Peanuts

Correct Answer: 3

Rationale 1: There is no cross-sensitivity between strawberries and latex.

Rationale 2: There is no cross-sensitivity between eggs and latex.

Rationale 3: The patient who is allergic to avocados is at higher risk for a latex allergy because of the cross-reactivity of the proteins in latex.

Rationale 4: There is no cross-sensitivity between peanuts and latex.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-6

Question 30

Type: MCSA

The patient has a documented allergy to latex. Which nursing actions are indicated?

1. Schedule surgery for the last case of the day.

2. Use powdered gloves.

3. Use a stopcock for the injection of intravenous drugs.

4. Disinfect the rubber tops on medication bottles with Betadine rather than alcohol.

Correct Answer: 3

Rationale 1: The surgery should be the first case of the day to minimize the patients exposure to aerosolized allergens from latex products.

Rationale 2: Gloves should be powderless.

Rationale 3: Use of a stopcock instead of a rubber stopper reduces the introduction of latex into the environment.

Rationale 4: The rubber cap on these bottles should be removed rather than drawing the medication up through the rubber. The choice of disinfectant will not remove the latex from the environment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

 

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