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* Criteria for valid consent are: * Allergy to latex -- asks the medical supply personnel to
Voluntary, Informed, and Competent deliver:
Cotton pads and silk tape
* Patient seems confused about the procedure to be
performed -- appropriate response by the nurse is to: * Latex allergy -- intervention to be included in the plan:
Ask the patient what the physician told him and Apply a cloth barrier to the client’s arm under a
then call if necessary blood pressure cuff when taking the blood pressure.
* Thumb mark of a comatose patient in the informed * Erythema and itching around her mouth after blowing
consent is considered: up a balloon -- likely due to:
A not valid signature A latex allergy
* The nurse notices that the band was missing * Norcuron (vercuronium bromide) – important to
immediate action of the nurse is to: monitor:
Place a new identification band on the client’s Respiration
wrist before the client can be transported to the OR
* Third stage of anesthesia, the client is:
* Given sulfasuxidine and neomycin, primarily to: Already unconscious, has relaxed muscles and
reduce the bacterial content of the colon the surgery is started.
* Check for the medical clearance clearance primarily * General anethesia and is in stage II of anesthesia --
covers: intervention to implement during this stage:
Cardio-pulmonary system Restrain the patient
* Primary objective of preoperative skin prep is to: * Spinal anesthesia highest priority:
Prevent postoperative infection by reducing the Complaints of headache
number of microorganisms of the skin.
* Epidural anesthesia -- following administration of the
* If hair at the operative site is not shaved done to anesthesia, the nurse should:
make suturing easy and lessen chance of incision Priority: Monitor the client for respiratory
infection: depression
Clipped 2nd priority: hypotension (common side effect)
* Adrenalectomy -- priority nursing action preoperatively * Inherited muscle disorder chemically induced by
is to monitor: anethesia/anesthetic agents:
Vital signs Malignant hypethermia
* Single most important procedure for preventing * Malignant hyperthermia is a potential postoperative
hospital-acquired infections: complication gathering information on the patient’s
Handwashing medical history, the nurse should ask:
“Has anyone in your family ever had problems
* Complete scrub should last for how many minutes: with general anaesthesia?”
10-15 minutes
* Drug should be available to reverse malignant
* JCAHO’s universal protocol EXCEPT: hyperthermia crisis:
Take a video of the entire intra-operative dantrolene (Dantrium)
procedure
* Maintaining the client’s safety -- circulating nurse:
* Meet the safety need of the client after administering Strap made of strong non-abrasive materials are
preoperative narcotic: fastened securely around the joints of the knees and
Put side rails up and ask the client not to get out ankles and around the 2 hands around an arm
of bed board.
* Personal protective equipment -- worn at all times in * Ideal setting of the autoclave machine:
the restricted zone: 121 degrees Celsius for 15 minutes
Masks covering the nose and mouth
* Considerations for selecting chemical agents for
* Items that come in contact with the intact skin should disinfection:
be: Material compatibility and efficiency
Disinfected
* Not an advantage of steam sterilization:
* Spaulding’s classification system -- Gastroscopes, Items need not to be cleaned or freed from the
bronchoscopes, colonoscopes are: grease and oil.
Semi- critical items
* Liquid sterilizer versus autoclave machine – true:
* Instruments introduced directly into the blood stream or They are both capable of sterilizing the
into any normally sterile cavity or area of the body equipments; however, it is necessary to soak
classified as: supplies in the liquid sterilizer for a longer period of
Critical time
* Instruments that do not touch the patient or have * Types of sterilization -- not included:
contact only to intact skin is classified as: Sterilization by boiling
Non critical
* 2 organizations that endorsed that sterility are affected
* Classification of endoscopic instruments: by factors other than the time itself are:
Sterile instruments AORN and JCAHO
* Items that enter sterile tissue or vascular system are * Functionality and integrity of instruments
categorized as critical items and should be: responsibility of the:
Sterilized Bio-med technician
* Orthopedic cases -- department is usually informed to * Closure of the abdominal layers begins with the
be present in the OR: peritoneum followed by;
Radiology department Muscle, fascia, subcutaneous tissue, skin
* Does NOT belong to the sterile OR team:
X-ray technician * Prone to keloid formation and has low threshold of pain
– needle:
* Comprise the surgical team: Atraumatic needle
Surgeon, assistants, scrub nurse, circulating
nurse, anaesthesiologist * Another alternative “suture” for skin closure is the use
of:
* Nursing tandem for every surgery is: Staple
Scrub and circulating nurses
POST-OP
* Monitors the activities of each OR suite: IMMEDIATE
Circulating nurse * In the PACU, the nurse will monitor his vital signs:
Every 15 minutes
* Responsible for the operating room condition, verifying
the consent, coordinating the team, and availability of * Continue with postoperative assessment activities
the supplies from non-sterile field: Every 15 minutes for the first half hour, every 30
Circulating nurse minutes for 2 hours, every hour for 4 hours, and
then every 4 hours as needed.
* Hands out these items not in the sterile field by
opening its outer cover: AIRWAY
Circulating Nurse * Post-anesthesia -- transferred to the surgical unit -- first
on arrival of the client:
* Coordinates the activities outside, including the family: Assess the patency of the airway.
Circulating Nurse
* Positioning a client for surgical procedure -- priority
* Circulating nurse must do the following, except: care:
Passing an instrument to the surgeon. Access to the airway
* Count and identify the number of sponges, sharps and * MOST effective in promoting adequate respiratory
instruments use in a surgical procedure: function in an unconscious client recently admitted to the
Scrub nurse PACU with no contraindications to movement:
Extending client’s chin while on his side and
* Responsibility of the scrub nurse: pillow at the back
Account for the number of sponges, needles,
supplies, used during the surgical procedure. * Endoscopic examinations -- anesthetized with
xylocaine (Lidocaine) spray --interventions for post-
* Counting during the pre-incision phase, the endoscopic examination include:
operative phase and closing phase -- counts the Keeping patient NPO until gag reflex returns
sponges, needle and instruments:
Scrub nurse and the circulating nurse * General anesthesia in PACU -- signs that may indicate
his artificial airway should be removed is:
* Daily monitoring the standards of safe, nursing practice Gagging
in the operating suite: OR nurse supervisor
* Following a pneumonectomy, deep tracheal suction
* Monitor the status of the client like urine output, blood should be done with extreme caution because:
loss: The bronchial suture line maybe traumatized
Anaesthesiologist
* Inhalation anesthesia -- experienced severe shivering
* Administers anesthetics and monitors the patient’s postoperatively:
status throughout the procedure: Provide oxygen as prescribed
Anesthesiologist
* Unconscious on admission to the post-anesthesia care
* Report any discrepancy of counts to the: unit (PACU) -- position the client:
Surgeon In a lateral position
* Nurse in charge for scheduling surgical cases -- * Spleenectomy -- nursing priority assessment:
important information needed to be asked: The quality of the client’s respiration
Who are your assistant and anesthesiologist, and
what is your preferred time and type of surgery? * Assessment would prevent the patient’s transfer to
ward:
* First sponge/instrument count reported after an Pulse oximeter reading is 80% (Abnormal)
abdominal surgery:
Before peritoneum is closed * Pulse oximeter and gets a reading of 85% -- next
action should be to:
* Sutured with long tensile strength such as cotton or Awaken the patient and have him cough and
nylon or silk suture: deep breathe
Fascia
BREATHING
* Incentive spirometer:
The best results are achieved when the head of Splinting the patient’s chest with both hands
the bed is elevated 45-90 degrees. during the exercises
* Incentive spirometry has been effective if the patient * Smokes 3 packs of cigarettes a day for the past 10
has: years -- increased risk for:
Clear breath sounds Postoperative respiratory complications
* Purpose of NGT IMMEDIATELY after an operation is: * Indicative of a developing thrombophlebitis would be:
For gastric decompression Tender, painful area on the leg
* Whatever the person says it is and existing whenever * Visceral pain involves pain in:
the experiencing person says it does. The author of this Abdominal cavity
statement is:
McCaffery ASSESSMENT
* Pain -- she should initially:
* Pain receptors that stimulate transmission during Assess pain as automatic as she assesses the
actual tissue damage: pulse and blood pressure.
Nociceptors
* Has difficulty specifying the location of pain – how:
* Important responsibility related to pain that is Ask the client to point to the painful area by just
subjective in nature: one finger
Believe what the patient says about the pain
* In assessing pain, what should a nurse do if a patient
* Principles of pain treatment first consideration: says there is no pain?
The client must be believed about perceptions of Reassess the client appropriately to rule out
own pain. denial.
* Whatever the person says it is, existence whenever the * To get accurate information about the quality of pain --
experiencing person says it does, thus, nurse should: statements would be MOST APPROPRIATE?
Consider the patient as the best authority on the “Tell me what your pain feels like”
existence of the pain.
* Older adults -- risk of underrated pain. Nursing
* Pain in the elder persons requires careful assessment assessment and management of pain should address
because they: the following beliefs EXCEPT:
Experienced reduce sensory perception Older patients seldom tend to report pain than
the younger ones (this is not a belief/myth, this is
* TRUE Statement on pain is: true)
Patient’s reaction to pain varies
* Older persons require careful patient assessment
* Myth about pain: because older people:
It is better to wait until a client has pain before Are more sensitive to drugs
giving medication because client can validate its
existence. * Components of a thorough pain assessment is most
significant:
* Willing to endure severe pain rather than be treated for Intensity
it. This is known:
Pain tolerance *In pain assessment -- reliable indicator:
Patient’s description of the pain sensation
* Gate control theory of pain explains that a pain is
perceived as stimulation of receptors in the: * Triggering factor -- The nurse charts this as an
Small nerve fibers example of a/an:
Aggravating factor
TYPES AND CLASSIFICATION
* MOST appropriately describe pain sensation that has * Assesses the quality off pain:
periods of remission and exacerbation: In your own words, tell me what your pain feels
Chronic like
* The following describes chronic pain except: * Maximum amount of pain a person can tolerate:
Less than 6 months Pain tolerance
* Pain that originates from the skin and subcutaneous * Primary goal in caring for clients with chronic pain:
tissue is known as: Reduce the client’s perception of pain
Cutaneous
NON-PHARMACOLOGIC MGNT * Levels of pain:
* Appropriate non-pharmacologic intervention for pain 0 -no pain at all
includes all of the following EXCEPT: 1-3 -mild
Type of opioid being used 4-5 -moderate
* Indicate appropriate adaptation: 6-7 -severe
The client can distract himself during pain 8-9 -very severe
episodes 10 -worst possible pain
PHARMACOLOGIC MGNT
* The WHO analgesic ladder provides the health
professional with:
General pain management choices based on level
of pain
WHO
* Step 1 of the World Health Organization (WHO)
analgesic ladder:
NSAIDS, acetaminophen (Tylenol)
ADDITIONAL BULLETS:
* Breathing technique:
Inhale through the mouth and hold the breath for
5 seconds and exhale through the mouth