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","B","C","D"]
Explanation
A. The procedure to be performed. The surgical consent form must clearly state the procedure that will be performed so the patient understands what they are agreeing to.
B. The need for the procedure. The patient should be informed about the reason for the procedure to understand the necessity of the surgery.
C. Time and date signed. The time and date the consent is signed must be documented to confirm that the consent was given prior to surgery.
D. The related risks and benefits of the procedure. Informed consent requires that the risks and benefits of the procedure be explained to the patient to ensure they understand what they are consenting to.
E. Marital status. Marital status is not relevant to the informed consent process. The form should focus on the surgery details, not personal information unrelated to the procedure.
Correct Answer is C
Explanation
A. Time of last meal: Time of the last meal is essential for preventing aspiration during anesthesia but does not help determine the exact amount of anesthesia needed.
B. Pulse rate and blood pressure: Pulse rate and blood pressure are important for assessing the patient's cardiovascular status but are not directly used to calculate the amount of anesthesia needed.
C. Height and weight: Height and weight are critical for calculating the correct dose of anesthesia, as these factors affect the distribution and metabolism of the drug.
D. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are important for monitoring respiratory function, but they do not provide specific data needed to calculate the amount of anesthesia.
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