Medical-Surgical Nursing Exam Key Part 1

1. The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Arthritis Ans: A Feedback: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia. 2. The OR nurse acts in the circulating role during a patient's scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patient's blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges Ans: A Feedback: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patient's safety and well-being. Estimating the patient's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse. Page 1 3. A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the team's next step in the care of this patient? A) Grounding B) Making the first incision C) Giving blood D) Intubating Ans: D Feedback: When the patient arrives in the OR, the anesthesiologist or anesthetist reassesses the patient's physical condition immediately prior to initiating anesthesia. The anesthetic is administered, and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. Grounding or blood administration does not normally follow anesthetic administration immediately. An incision would not be made prior to intubation. 4. A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery Ans: A Feedback: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other patients are likely at a lower risk. Page 2 5. The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? A) Last bowel movement B) Latex allergy C) Number of pregnancies D) Difficulty falling asleep Ans: B Feedback: Due to the increased number of patients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant. 6. An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves Ans: B Feedback: Masks are worn at all times in the restricted zone of the OR. Shoe covers are worn one time only; goggles and gloves are worn as required, but not necessarily at all times. 7. 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. Ans: A Feedback: 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. Page 3 8. 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 patient's back. B) Restrain the patient. C) Encourage the patient to express feelings. D) Stroke the patient's hand. Ans: B Feedback: 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 patient's safety. 9. A patient waiting in the presurgical holding area asks the nurse, “Why exactly do they have to put a breathing tube into me? My surgery is on my knee.” What is the best rationale for intubation during a surgical procedure that the nurse should describe? A) The tube provides an airway for ventilation. B) The tube protects the patient's esophagus from trauma. C) The patient may receive an antiemetic through the tube. D) The patient's vital signs can be monitored with the tube. Ans: A Feedback: The anesthetic is administered and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The patient's vital signs are not monitored through the tube. 10. The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia? A) The patient must never be left unattended by the nurse. B) The patient should begin a course of antiemetics the day before surgery. C) The patient should be informed that he or she will remember most of the procedure. D) The patient must be able to maintain his or her own airway. Ans: A Feedback: The patient receiving moderate sedation should never be left unattended. The patient's ability to maintain his or her airway depends on the level of sedation. The administration of moderate sedation is not a counter indication for giving an antiemetic. The patient receiving moderate sedation does not remember most of the procedure. Page 4 11. A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair and perform deep breathing exercises. B) Ambulate the patient as early as possible. C) Limit the patient's fluid intake for the first 24 hours postoperatively. D) Keep the patient positioned supine. Ans: D Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache. 12. The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control? A) A middle-aged man who is scheduled for a thoracotomy B) An older adult man who will undergo an inguinal hernia repair C) A 50-year-old woman who will be having a reduction mammoplasty D) A child who requires closed reduction of a right humerus fracture Ans: B Feedback: A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control. Page 5 13. The circulating nurse will be participating in a 78-year-old patient's total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse. Ans: C Feedback: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper. 14. 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? A) The patient may be experiencing presurgical anxiety. B) The patient may be at risk for malignant hyperthermia. C) The grandmother's surgery has minimal relevance to the patient's surgery. D) The patient may be at risk for a sudden onset of postsurgical infection. Ans: B Feedback: 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 patient's anxiety is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia. Page 6 15. While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patient's weight. How should the nurse best respond? A) Ignore the comment because the patient is unconscious. B) Discourage the colleague from making such comments. C) Report the comment immediately to a supervisor. D) Realize that humor is needed in the workplace. Ans: B Feedback: 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. 16. You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physician's 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 Ans: C Feedback: 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. Page 7 17. The nurse is packing a patient's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patient's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze. Ans: D Feedback: 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 patient's 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. 18. The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis? A) Holding sterile objects above the level of the nurse's waist B) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated C) Pouring solution onto a sterile field cloth D) Opening the outermost flap of a sterile package away from the body Ans: C Feedback: 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. 19. A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's 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 Ans: C Feedback: An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. This is superior to each of the other listed options. Page 8