ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 21 Questions
Question 1 of 5
Which of the following nursing actions should the preoperative nurse perform to prepare a patient for cranial surgery that requires hair removal?
Correct Answer: B
Rationale: For surgeries that require hair removal, the hair is either clipped or a depilatory agent is used for hair removal. There is no need to consider cancelling the surgery. Shaving the hair is contraindicated.
Question 2 of 5
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anaesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for which of the following adverse effects?
Correct Answer: D
Rationale: The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are not as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.
Question 3 of 5
Which of the following actions should the nurse include in the plan of care immediately after surgery for a patient who received ketamine as an anaesthetic agent?
Correct Answer: C
Rationale: Hallucinations are an adverse effect associated with the dissociative anaesthetics such as ketamine, so the postoperative environment should be kept quiet to decrease the risk of hallucinations. Since ketamine causes profound analgesia lasting into the postoperative period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations and nightmares.
Question 4 of 5
Which of the following actions should the scrub nurse use to maintain aseptic technique during surgery?
Correct Answer: D
Rationale: Once gloved, a nurse's hands are not to go below his or her waist, therefore, touching the surgeon's thigh would contaminate the nurse's gloves. Hands are always to be kept above waist level. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.
Question 5 of 5
The perioperative nurse is encouraging a family member to remain with a patient in the preoperative holding area until the patient is taken into the operating room. Which of the following reasons is the primary reason for this encouragement?
Correct Answer: D
Rationale: The presence of a family member or friend reduces the patient's anxiety and stress associated with the preoperative period. Although the family may give information about the patient's name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination.