A nurse is monitoring a client after moderate sedation. The nurse ...

[swpotter12]

A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
 
  a. Assess the client's gag reflex.
  b. Begin providing discharge instructions.
  c. Document findings and continue to monitor.
  d. Increase oxygen and notify the provider.

Question 2

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
 
  a. Ask the surgeon to change the sterile gown.
  b. Do nothing; this is acceptable sterile procedure.
  c. Inform the surgeon that the sterile field has been broken.
  d. Obtain a new pair of sterile gloves for the surgeon to put on.

[kaylee05]

Answer to Question 1

ANS: C
An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.

Answer to Question 2

ANS: C
The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not restore the sterile sections of the gown. Doing nothing is unacceptable.

[swpotter12]

Thank you

[kaylee05]

No problemo