ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 18 : Intraoperative Nursing Management Questions
Question 1 of 5
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104 F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?
Correct Answer: B
Rationale: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. The patients anxiety is not relevant, the grandmothers surgery is very relevant, and all patients are at risk for hypothermia.
Question 2 of 5
While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond?
Correct Answer: B
Rationale: Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the patient and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?
Correct Answer: C
Rationale: Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.