The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

Ill and the patient has depressed reflexes.

IV and the patient will not depend on the anesthesia machine of oxygenations.

Il and the surgical environment should be kept quiet.

and the patient's hearing is amplified.

Answer and Explanation

The Correct Answer is C

A. Stage III and the patient has depressed reflexes. Stage III of anesthesia is the surgical stage, where the patient is under deep anesthesia, and reflexes are typically depressed. However, tensed muscles and irregular respirations may indicate that the patient is still in an earlier stage of anesthesia (stage II).

B. Stage IV and the patient will not depend on the anesthesia machine for oxygenation. Stage IV is the deepest level of anesthesia, where respiratory and cardiovascular functions are severely depressed. It does not match the description of tensed muscles and irregular respirations, which are more characteristic of an earlier stage (stage II).

C. Stage II and the surgical environment should be kept quiet. Stage II of anesthesia is the excitement stage, where patients may exhibit tensed muscles, irregular respirations, and uncoordinated movements. The surgical environment should be kept quiet to minimize stimuli that could cause agitation or further excitement in this stage.

D. Stage I and the patient's hearing is amplified. Stage I is the stage of anesthesia where the patient is still conscious and responsive to stimuli. The description of tensed muscles and irregular respirations does not match this stage. Additionally, the patient’s hearing would not be amplified in stage I, but rather in stage II or as they begin to emerge from anesthesia.

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Correct Answer is B

Explanation

A. Irrigate the indwelling urinary catheter. There is no indication that the catheter is obstructed. Catheter irrigation should only be performed if there is a suspected blockage (e.g., absent urine output, blood clots).

B. Notify the surgeon of the findings. Urine output of less than 30 mL per hour is concerning for decreased renal perfusion, possibly due to hypovolemia or other postoperative complications. The provider should be notified for further evaluation and intervention.

C. Increase the flow rate of the IV for 10 to 15 minutes. Increasing IV fluids may help improve urine output, but it should only be done based on a provider’s order and after assessing the patient’s volume status.

D. Apply manual pressure to the patient's bladder. This action is inappropriate unless the patient has urinary retention, which should be confirmed through assessment before attempting bladder compression

A. Elective B. Emergency C. Palliative D. Reconstructive

Correct Answer is B

Explanation

A. Elective. Elective surgeries are planned in advance and are not urgent. Removing a bullet from the neck is not an elective procedure; it is necessary to treat an acute injury.

B. Emergency. The removal of a bullet from the neck is considered an emergency surgery. It is typically performed to address immediate life-threatening injury or to prevent further complications, such as damage to vital structures.

C. Palliative. Palliative surgeries are performed to relieve symptoms or improve quality of life in patients with terminal illnesses. Removing a bullet from the neck is not a palliative measure, as it is intended to treat an acute physical injury.

D. Reconstructive. Reconstructive surgeries aim to restore function or appearance after trauma, but removing a bullet is not primarily reconstructive. The goal here is to treat the immediate injury and prevent further harm.

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The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

Correct Answer is B

Explanation

The patient requires surgery to remove a bullet from his neck. This surgery is classified as:

Correct Answer is B

Explanation

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