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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Spray the surgical area with an antimicrobial solution. Spraying an antimicrobial solution on the surgical area is a common method of skin preparation to reduce the risk of infection during surgery. It is important to follow specific guidelines set by the facility or surgical team.

B. Shave the entire surgical site. Shaving the surgical site is not typically recommended anymore because it can cause micro-abrasions that increase the risk of infection. Hair clipping is preferred if hair removal is necessary.

C. Scrub the surgical area for 1 minute with antibacterial solution. Scrubbing the area with an antibacterial solution may be part of the preparation, but it is typically done by the surgical team or after following specific guidelines for cleaning, not as a general preoperative action.

D. Instruct the patient in the use of an antimicrobial soap in the shower. This is another common preoperative practice, but the nurse's role may be to instruct the patient rather than carry out the preparation directly.

A. dehiscence B. laceration C. evisceration D. autologous

Correct Answer is A

Explanation

A. Dehiscence: Dehiscence refers to the partial or total separation of the wound's layers, often occurring after surgery, such as when coughing increases intra-abdominal pressure.

B. Laceration: A laceration refers to a tear or break in the skin due to trauma, not a surgical complication.

C. Evisceration: Evisceration occurs when the internal organs protrude through the wound, which is a more severe complication than dehiscence.

D. Autologous: Autologous refers to using a person's own tissues or cells (e.g., blood transfusion), not a wound complication.

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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

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