Quiz 1 (Ch. 1, 16, 17, 18) Flashcards
The Institute of medicine report ‘To Err Is Human’ highlighted the need to improve patient safety. Which national organization requires it’s accredited agencies to meet specific national patient safety goals?
The joint commission
What is the purpose of the rapid response team?
Enable the nurse to recognize changes in patient status before an acute emergency
In addition to being able to provide care with skill in techniques and procedures, one must medical surgical nurse also be prepared to utilize and caring for the patient?
- Teaching
- Patient advocacy
- Spiritual counseling and support
- Coordination of care
- Rehabilitation
Which factors are likely to be causes of medical errors?
Lack of technical experience
Overload of info
Poor communication
Failure to follow accepted facility practices
Which is the best way for the nurse to asses the patients learning after teaching?
Ask the patient to repeat the info back
Which type of evidence is rated highest on a level of evidence scale?
Systematic review or meta analysis of all randomized controlled trials
Which is the best use of information from electronic sources, such as websites or email, in retrieving data for the evidence-based practice process?
Evaluating the information for credibility and reliability before putting it into use
Which action exemplifies the goal of case management in an acute care setting?
Making sure the patients dietary choices meet prescribed nutritional needs
Which actions best demonstrate a collaborative nursing function?
- Requesting the assistance of another staff member to turn a patient
- Administering meds as prescribed by he health care provider
- Making a referral to the case manager to assist with discharge planning
- Ensuring clear communication with other health care providers
Which occurrence does the joint commissions national patient safety goals designate as a high risk issue?
Administering medication that is not familiar to the nurse
What is the joint commission?
The joint commission is a national organization that offers peer evaluation for accreditation every 3 years for all types of U.S. Health care agencies that meet their standards
What do the national patient safety goals or NPSGs address?
They address high risk issues such as drug administration , fall reduction, pressure ulcer prevention, and communication among health care team members
What are the 6 core competences for health care professionals?
Patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety.
What are three essential ethical principles to consider when making clinical decisions?
- Self-determination
- Beneficence
- Justice
On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for the surgery have been made in the past three weeks. What is the nurses best action?
Call the laboratory to ensure that the blood is physically out the operating facility
Rationale: Many hospitals or surgical centers do not initially process autologous blood collections. Any donated blood must be in the facility where the surgery will take place before the client undergoes the planned surgical procedure.
The client scheduled for knee replacement surgery today performed all the following actions yesterday. Which action is most important for the nurse report to the surgeon?
Took 2 aspirin three times
Rationale: The aspirin taken yesterday will significantly reduce blood clotting for surgery. The surgeon may decide to delay the surgery for at least a week to ensure that adequate numbers of platelets capable of activation are present.
For which client preadmission testing laboratory result does the nurse take immediate action? A. International normalized ratio 0.9 B. White blood cell count 8500/mm3 C. Serum potassium level 2.8 mEq/L D. Serum sodium level 132 mEq/L
C.
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.
True or False
The terms outpatient and ambulatory refer to a patient who goes to the surgical center the day of the surgery and returns home the same day
True
What is Atelecttasis
Atelectasis is the collapse of alveoli. Atelectasis reduces gas exchange and causes intolerance of anesthesia. It is also a common problem after general Anesthia.
What are the limitations for autologous donations
Patients ca donate their own blood up to 5 weeks before their surgery if they are infection free ad have a hemoglobin level greater than 11 g.DL. The last donation cannot be made within 72 hours before surgery.
How does nutritional status affect surgey
Surgery increases metabolic rate and depletes potassium, vitamin c, B vitamins, all of which are needed for wound healing and blood clotting. In malnourished patients decreased serum protein levels slow healing. Negative nitrogen balance may result from depleted protein stores. This problem increases risk for skin breakdown, delayed wound healing, dehiscence, dehydration, and sepsis.
Hypokalemia and Surgery
Hypokalemia increases risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability.
Hyperkalemia and Surgery
Hyperkalemia increases the risk for dysrhythmias, especially with use of anesthesia.
What is the normal range for potassium
3.5-5.0 mEq L
What is the normal range for sodium
136-145 mEq L
What is the normal Range for chloride?
98-106 mEq/L
What is the normal white blood cell range?
5,000-10,000/ mm3
What is the normal range for hemoglobin?
Females: 12-16
Males: 14-18
Why is it important to be NPO before surgery ?
NPO status ensure that the stomach contains a limited volume of gastric secretions, which decreases the risk of aspiration.
NPO includes smoking
What are some procedures and exercises to prevent cardiovascular complications?
Anti embolism stocking
Pneumatic compression device
Leg exercises
Mobility
Which statement best describes the preoperative period?
- It ends at the time of transfer to the surgical suite
- It begins when the patient is scheduled for surgery
- It is a time during which the patient receives testing and education related to impending surgery
A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery?
Diagnostic
A patient who can barely ambulated with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery?
Restorative
A colostomy is scheduled to be done on a patient who has severe Crohn’s disease. What is the correct classification for this surgery?
Palliative
A male patient has a facial scar on his forehead from a third degree burn. What is the correct classification for this surgery?
Cosmetic
An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery?
Curative
A patient with an abdominal aortic aneurysm is having surgical repair. What is the correct classification for this surgery?
Emergent
A 76 yr old patient is having a bilateral cataract removal. What is the correct classification for this surgery?
Elective
A 47 yr old patient is having surgery to remove kidney stones. What is the correct classification for this surgery?
Urgent
The nurse screens a preoperative patient for conditions that may increase the risk for complications during the peri operative period. Which conditions are possible risk factors?
67 yrs old
Obesity
Pulmonary disease
Discharge planning is done for patients who had which types of surgery?
Minor Urgent Palliative Curative Emergent
The nurse has received a patient in the holding area who is scheduled for a left femoral popliteal bypass. What are the priority safety measures for this patient before surgery?
- The operative limb is marked by the surgeon
- The patient is positively identified by checking name and birth date
- The patient is asked to confirm the marked operative limb
Which common lab tests need to be ordered before surgery?
Electrolyte levels
Clotting studies
Serum creatine
Which statement best describes a collaborative role of nurses and surgeon when obtaining informed consent?
The nurse may serve as a witness to the patient signature after the physician has a consent form signed before the preoperative sedation is given and before surgery is performed
The patient with diabetes is scheduled for surgery at oh 700. What are the actions, in order of priority, that the nurse perform preoperatively? In order…
Have nonlicensed personnel obtain the patients Accutech and vital signs
Modify the dose of insulin given based on the patient’s blood glucose
Check if the patient has any jewelry on call security to secure valuable
Complete the preoperative checklist before 0700
To reduce the incidence of patients with a known history or risk of malignant hyperthermia, what best practices are put in place around the operating room?
- List of medications available for emergency treatment of MH
- Dedicated MH cart with treatment medications
- treatment before, during, and after surgery if the patient has a known history or risk
- additional nursing support on call if MH develops
- available MH hotline number
The patient has a malignant hyperthermia incident during surgery. To whom does the nurse report this incident?
North American malignant hypothermia registry
Who coordinates, overseas, and participates in the patient’s nursing care while the patient is in the operating room?
Circulating nurse
Who assumes responsibility for the surgical procedure and any surgical judgments about the patient?
The surgeon
Who manages the patient’s care will the patient is in this area and initiates documentation on the perioperative nursing record?
Holding area nurse
Who is educated in a particular type of surgery and responsible for intraoperative nursing care specific to patients needing that type of surgery?
Specialty nurse
Who sets up the sterile field, assist with the draping of the patient, and hands sterile supplies, sterile equipment, and instruments to the surgeon?
Scrub nurse
During surgery, what things do anesthesia personnel monitor, measure, and assess?
Intake and output, vital signs, cardiopulmonary function, level of anesthesia
Stage 1 of anesthesia
Close operating room doors and control traffic in and out of the room. Positioned patient securely with safety belts. Maintain minimum discussion in the operating room.
Stage 2 of anesthesia
Shield patient from excess noise and physical stimuli. Protect the patients extremities. Assist anesthesia personnel as needed. Stay with patient
Stage 3 of anesthesia
Assist anesthesia personnel with intubation of patient. Place the patient in position for surgery. Prep the patient skin and area of operative site
Stage 4 of anesthesia
Prepare for an assistant treatment of cardiovascular and or pulmonary arrest. Document in record
The acute, life-threatening complication of malignant hyperthermia results from the use of which agents?
Succinylcholine and inhalation agents
Which clinical features are found in an MH crisis?
Sinus tachycardia Tightness and rigidity of the patients Jaw area Lowering of the blood pressure Skin mottling and cyanosis Tachypnea
The surgical team understand that time is crucial in recognizing entreating and MH crisis once recognized. What is the treatment of choice?
Dantrolene sodium
The patient experiences MH immediately after induction of anesthesia. What interventions, and order of priority, does the nurse carry out?
- Stop all inhalation anesthetic agents and succinylcholine
- Administer IV dantrolene sodium 2-3 mg/KG
- Assess ABGs and serum chemistries
- Apply a cooling blanket over the torso
- Monitor cardiac rhythm by electrocardiograph to assess for dysrhythmias
In which situations is regional anesthesia used instead of general anesthesia?
- In patients who have had an adverse reaction to general anesthesia
- In some cases with pain management after surgery is enhanced by regional anesthesia
- In patients with serious medical problems
- When the patient has a preference and a choice is possible
Halothane
Less irritating to respiratory tract than other inhalation agents
Nitrous oxide
Needs addition of other agents for longer procedures
Desflurane
May increase heart rate and lower BP during induction
Thiopental sodium
Can depress respiratory and cardiac functions
Ketamine HCL
Dissociative emergence reactions, can induce nausea and vomiting
Propofol
Short acting, patient becomes responsive quickly postoperatively
Fentanyl
Excellent postoperative analgesia and epidural anesthesia
Midazolam
Induces amnesia around the event
To avoid electrical safety problems during surgery, what does the nurse do?
Ensure proper placement of the grounding pads
Which medical condition increases a patients risk for surgical wound infection?
Diabetes mellitus
Topical Anesthesia
Agents applied directly to the area of skin or mucous membrane to be anesthetized. Onset is within 1 minute, duration up to 30.
Local infiltration
Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion. Blocks peripheral nerve function at its origin.
Nerve block
Injection of anesthetic agent into or around a nerve or group of nerves, resulting in block sensation and motor impulse transmission. Used to prevent pain during procedure or to identify the causes pain. A type of regional anesthesia
Spinal anesthesia
Also called intrathecal block, injection of anesthetic agent into the cerebrospinal fluid in he subarachnoid space. Used for lower abdominal and pelvic surgery.
Which patient would be a candidate for moderate sedation?
- Endoscopy
- Closed fracture reduction
- Cardiac catheterization
- Cardioversion
The patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse responder to the patient’s request?
You can discuss your request for moderate sedation with your surgeon and anesthesiologist
Which medical condition influences whether a patient is to have moderate sedation for a laparoscopic cholecystectomy?
Chronic obstructive pulmonary disease
The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything “medical.” Which nursing action is most likely to reduce this client’s anxiety?
A. Administering the preoperative medication as soon as possible.
B. Assuring the client that his scheduled surgery is routine and that nothing will go wrong.
C. Determining whether the client wants family members to be with him in the holding area.
D. Explaining to the client that this hospital’s surgical area is the most technologically advanced in the city.
ANS: C
Rationale: Most anxious clients would feel some anxiety relief by having one or more familiar people waiting with them until the time of surgery. In addition, asking the client what he or she wants allows him to have more control over the situation. Telling the client about the advanced technology can imply to him that the procedure is dangerous. Stating that the procedure is routine and that nothing will go wrong does not address the client’s fears about his surgery and his lack of familiarity with “medical” routines.
The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse’s best action?
A. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table.
B. Place the sponge in the circulating area to include in the final count before incision closure.
C. Pick up the sponge and throw it out so no one slips on it.
D. Hand the sponge back to the scrub nurse.
ANS: B
Rationale: An accurate count of all sponges initially prepared on the instrument table is matched to the count of sponges present before the incision can be closed. This sponge was counted before surgery and needs to be included in the final count. It cannot be thrown away before the final count is performed. The sponge is now contaminated and cannot not given back to the scrub nurse or surgeon. A replacement sponge should not be needed. Additional sponges are added to the instrument table only if requested and must be added to the initial count.
The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse’s best response?
A. Call the anesthesia provider’s attention to this response.
B. Ensure the client is secured to the table.
C. Cover the client with a warm blanket.
D. Document this expected response.
ANS: D
Rationale: Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.
A very anxious patient, a 48-year-old attorney, has entered the preoperative holding area about 60 minutes before her scheduled procedure. Before the OR nurse can interview her, the patient is medicated with 2 mg midazolam (Versed). The OR schedule lists that she is scheduled to have a left breast lumpectomy as treatment for breast cancer. When you ask her what procedure she is having, her response is “I am going to have a lumpectomy of the RIGHT breast.” Upon further review, you determine that the surgeon wrote, “operative consent for lumpectomy of the right breast.” However, when you check the informed consent, the consent states lumpectomy, left breast, and the patient signature is present, as is the witness signature.
- How should you proceed with the discrepancies surrounding the operative procedure among the patient, operative consent, and OR schedule?
The anesthesia care provider, the surgeon, and nursing management should be notified immediately. Re-verify with the patient the correct site, side, and operative procedure according to facility policy. - Can the patient sign a new consent after she has been medicated with midazolam? Why or why not?
This will depend on the policy of the facility, the emergent or nonemergent nature of the surgical procedure, and the half-life of the preoperative medication. The team may wish to consult with the facility attorney to determine the best course of action. - How could this have happened?
Because of the nature of the surgical procedure, the patient may have been anxious when asked to sign the surgical consent and did not realize that it was incorrect. Changes in personnel and inadequate transfer of patient care information may have contributed to the error. - How can this occurrence be prevented in the future?
The anesthesia care provider should verify the correct patient, site, side, and operative procedure before any preoperative medication is administered.
The patient is a 50-year-old thin woman (115 lb) who will be placed in the prone position during surgery.
- What general safety considerations should be taken for a patient in the prone position?
Maintain the patient’s cervical neck alignment; protect the patient’s forehead, eyes, ears, and chin; use chest rolls to allow chest movement and decrease abdominal pressure; position the patient’s toes to hang over the end of the bed or to be raised off the bed with padding under the shins. - What areas on this patient are most likely to be injured as a result of poor positioning or inadequate padding?
Ocular injuries can occur due to direct pressure on the patient’s eyes. Brachial plexus damage can occur if the patient’s arms are positioned above the head. Ideally, the arms should be by the patient’s side or on padded arm boards at less than a 90-degree angle. Torsion or pressure can occur if the breasts and male genitalia are incorrectly positioned. Other pressure point areas of concern are the knees, elbows, shins, and iliac crests.
For which client preadmission testing laboratory result does the nurse take immediate action? A. International normalized ratio 0.9 B. White blood cell count 8500/mm3 C. Serum potassium level 2.8 mEq/L D. Serum sodium level 132 mEq/L
ANS: C
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.
The client scheduled to have surgery today cannot read or write. The surgeon obtaining the consent wants to have the client’s spouse sign the consent instead. What is the nurse’s best action?
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
B. Locate the spouse because the informed consent statement must be signed by the client’s closest relative.
C. Remind the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.
D. Notify the administration because the court must appoint a legal guardian to represent the client’s best interests and give consent for all surgical procedures.
ANS: C
Rationale: The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence for self-determination, he or she has the right to consent directly by using either his or her own signature or an X to demonstrate consent if the act is witnessed by two people.
The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM, and the client’s regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action?
A. Administer digoxin with minimal water and hold the other drugs.
B. Administer all medications parenterally.
C. Administer all medications orally.
D. Hold all medications.
ANS: A
Rationale: Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.
