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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Apple juice: Apple juice is a clear liquid, which is typically appropriate for a full liquid diet. This item does not need to be removed.
B. Cream of rice cereal: Cream of rice cereal is a proper component of a full liquid diet, as it is soft and liquid in nature.
C. Scrambled eggs: Scrambled eggs are considered a solid food and should not be included in a full liquid diet, which requires all foods to be liquid or semi-liquid.
D. Vanilla yogurt: Vanilla yogurt is a part of a full liquid diet as it is a smooth, creamy consistency that fits the requirements.
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