Pre-Op
The nurse’s responsibility for regarding consent form.
What is verify understanding and witness signature
Transfers with the patient from nurse to nurse to ensure relevant patient information is available at all times.
What is the SBAR.
SBAR ensures continuity of care when transferring to PACU.
This is typically undertreated after surgery.
What is pain.
Bright red drainage saturating a dressing.
What is hemorrhage.
Water moves from ECF to ICF by osmosis; Good maintenance fluids; Used to treat hypernatremia.
What is hypotonic fluids.
Prolonged diarrhea is a common cause of this acid-base imbalance.
What is metabolic acidosis.
Rationale: Loss of bicarbonate from diarrhea causes metabolic acidosis.
Responsible for marking the surgical site with an indelible marker?
Who is the surgeon.
Performed at the start of surgery, during surgery and at the conclusion of surgery to prevent retained surgical items.
What is a sponge count/instrument count.
A complication that is best prevented by early ambulation.
What is a deep vein thrombosis (DVT).
Restlessness, confusion and tachycardia in PACU likely indicate ...
What is hypoxemia.
Also known as the surgical IV fluid.
What is isotonic fluids. (LR, NS)
ABG results: pH 7.30, PaCO₂ 55, HCO₃⁻ 24
Respiratory acidosis
Rationale: Low pH and high CO₂ indicate respiratory acidosis.
The reason jewelry and piercings must be removed before surgery.
What is risk of burn from the electrocautery devices.
Jewelry must be removed as a safety measure when electrocautery devices will be used during surgery to prevent burns or electrical injury.
To prevent hypothermia in the OR, the circulating nurse uses what items for patient care?
What are warm blankets and warm IV fluids
Scoring system used to assess readiness to return to floor from PACU.
What is the Aldrete score.
Priority intervention for a patient that has not voided for 8 hrs post-op.
Insert a foley cath per orders.
Examples include albumin, fresh frozen plasma, and blood.
What are colloids.
The nurse notes muscle weakness, shallow respirations, and ECG changes. Which imbalance is suspected?
What is hypokalemia.
This practice allows accurate assessment of capillary refill and pulse oximetry readings, which are essential for monitoring circulation and oxygenation.
What is removal of nail polish and artificial nails before surgery.
Performed by the circulating nurse to verify patient, site, and procedure.
Sudden dyspnea, chest pain, tachycardia. High-risk: use SCDs, early ambulation, anticoagulation per protocol.
What is a pulmonary embolism.
Never given in a bolus or IVP.
What is a potassium drip.
Seizures and confusion are common with this electrolyte imbalance.
Rationale: Hyponatremia causes neurological symptoms such as confusion and seizures.
What is hyponatremia.
The reason patients void prior to going to the OR for surgery.
What is an empty bladder prevents involuntary elimination under anesthesia and reduces urinary retention risk. Additionally, preoperative drugs interfere with balance and increase fall risk during ambulation.
Dantrolene is the only effective treatment for this anesthesia complication.
What is malignant hyperthermia.
A postoperative patient has wound edges that are separated with serous drainage and inflammation. The temperature is 37.5°C (99.6°F), slightly elevated from baseline. What complication should the nurse suspect?
What is wound dehiscence with potential infection.
Wound separation, drainage, inflammation, tenderness, and slight temperature elevation are cues indicating impaired wound healing and infection risk
To cover with sterile saline-soaked dressings is the priority nursing intervention for what complication?
What is evisceration.
Fluid is trapped where it is difficult or impossible for it to move back into cells or blood vessels
What is third spacing.
Trousseau’s sign indicates neuromuscular irritability and is seen in this electrolyte imbalance.
What is hypocalcemia.