Test 1 Davis Preop
A patient's family is in the waiting room outside the postanesthesia care unit (PACU). What is the priority of the PACU nurse? Make contact with the family every hour. Encourage the family to leave the area and wait at home. Ask the surgeon to speak with the family. Take them coffee and make them comfortable. Test Taking Tips:Communication is the priority.
Make contact with the family every hour. Rationale: The nurse should inform the family when the patient arrives in the PACU and make contact every hour. Encourage the family to leave the area and wait at home. Rationale: Communicating and maintaining contact with a family member, as well as allowing visitation, is essential to help relieve anxiety and stress. Ask the surgeon to speak with the family. Rationale: This is not the role of the PACU nurse. Take them coffee and make them comfortable. Rationale: This is not the role of the PACU nurse. Test Taking Tips:Communication is the priority.
The nurse has concerns that there may be a risk for deep vein thrombosis in a patient who is scheduled for hip replacement. Which statement made by the patient most likely supports the nurse's suspicion?
N "I drink two glasses of wine per week." Rationale: Intake of alcohol may decrease the response to anesthesia. N "I have been diagnosed with asthma recently." Rationale: Asthma may not be a risk factor for deep vein thrombosis. N "I am allergic to few anesthetic agents." Rationale: Allergy to few anesthetic agents may cause allergic reactions such as rashes, which may cause further complications and lead to anaphylaxis. Y "I smoke five packs of cigarettes per day." Rationale: Smoking may increase the risk of deep vein thrombosis postoperatively and cause respiratory depression intraoperatively. Test Taking Tips:Consider risk factors.
The nurse reviews the patient's identification band as seen in this image. Which components are acceptable to be used as identifiers? Select all that apply.
Name and DOB
The nurse is performing a postsurgical dressing assessment in the postanesthesia care unit. The dressing is noted in this image(bandage soaked through with blood). Place the steps in order that the nurse needs to take. Reinforce the dressing. Correct Position: 1 Notify the provider. Correct Position: 3 Empty and measure the drains. Correct Position: 2 Document the event. Correct Position: 4 Rationale: Bleeding is a concern and may require the patient to return to surgery. When a lot of blood is evident through the dressing, the nurse reinforces the dressing, empties and measures the drains, and notifies the provider. After orders are received, the event is documented. Test Taking Tips:Assess before contacting the provider.
See face card
The registered nurse is teaching about levels of postanesthesia care unit (PACU) care to a nursing student while caring for a patient who is transferred from the operating room to the PACU. Which statement made by the nursing student indicates effective understanding? "I will transfer the patient to phase II when the patient is on a mechanical ventilator." "I will transfer the patient to phase II when the pulse rate is 55 beats/min." "I will transfer the patient to phase II when the pain score is 2." "I will transfer the patient with heavy bleeding to phase III." Test Taking Tips:Look for the answer that shows the patient is stable.
"I will transfer the patient to phase II when the pain score is 2." Rationale: The pain score of 2 indicates minimal pain, which can be easily controlled. Score 0 may not be possible, so the patient can be transferred to phase II in this condition.
The registered nurse is performing the steps of a time-out. Which components should be included? Select all that apply.
. Y Patient stating his/her full name Rationale: This is the most commonly used patient identifier. Y Patient stating his/her date of birth Rationale: This is often used as the second identifier. Y Patient stating the site of the procedure Rationale: This is asked during time-out to validate the correct surgery is being performed. Y Patient stating his/her social security number Rationale: Less commonly used, but this is an acceptable identifier N Patient stating his/her allergies Rationale: Allergies are not a part of the time-out process. Test Taking Tips:Focus on the points of time-out.
The nurse has received a patient from the operating room to the postanesthesia care unit. After assessing the vital signs, what are the priority assessments? Select all that apply. Monitor for nausea and vomiting. Monitor urine output. Check for bleeding of the surgical site and drains. Monitor for sign of malignant hyperthermia. Address physiological signs of pain. Test Taking Tips:All answers may be correct in a multiple response item.
ALL OF THEM Monitor for nausea and vomiting. Rationale: Nausea and vomiting places the patient at risk for aspiration and is a priority. Monitor urine output. Rationale: Urine output helps to tell the nurse about fluid status. Check for bleeding of the surgical site and drains. Rationale: Excess bleeding at the surgical site could require the patient to return to the operating room. Monitor for sign of malignant hyperthermia. Rationale: Malignant hyperthermia is a life-threatening condition and a priority. Address physiological signs of pain. Rationale: Since the patient cannot verbalize pain, physiological signs need to be evaluated. Test Taking Tips:All answers may be correct in a multiple response item.
A nurse is recovering a patient in the postanesthesia care unit (PACU). The nurse notes that the patient is restless, tachycardic, and has facial grimacing. What action should the nurse take? Assess the urine output. Medicate for pain. Notify the surgeon. Reposition the patient. Test Taking Tips:Consider non-verbal cues.
Assess the urine output. Rationale: Urine output is important, but the patient is not demonstrating signs of fluid imbalance. Y Medicate for pain. Rationale: The nurse should assess for physiological symptoms associated with pain, including restlessness, facial grimacing, or moaning. Notify the surgeon. Rationale: This does not indicate a need to communicate to the provider. Reposition the patient. Rationale: Although this may help, pain is what the symptoms are demonstrating. Test Taking Tips:Consider non-verbal cues.
What postoperative assessment is for possible complications? Assessment of type of IV fluids running Assessment of the smell of the urine Fingerstick glucose level Auscultation of bowel sounds Hint: Think of the check list
Assessment of type of IV fluids running Rationale: Although this is an assessment, it is not a complication assessment. Assessment of the smell of the urine Rationale: Although this is a possible sign of an infection, it is not a part of the postanesthesia care unit (PACU) assessment. Y Fingerstick glucose level Rationale: Hypo- and hyperglycemia are possible complications during the postoperative phase. Auscultation of bowel sounds Rationale: Bowel sounds are often hypoactive or absent from the medications given. This is not a priority at this time.
Which health-care professional accompanies the patient who is transferred from the operating room to the postanesthesia care unit (PACU) after surgery? Physician assistant Anesthesia provider Surgical technologist Operating room technician Test Taking Tips:The anesthesia provider manages the airway.
Physician assistant Rationale: Physician assistant performs the preoperative assessment in the patient who is scheduled for the surgery. Y Anesthesia provider Rationale: Anesthesia provider accompanies the patient while transferring the patient from the operating room to the PACU after surgery. Surgical technologist Rationale: Surgical technologist, known as a scrub, passes the instruments to the surgeon during surgery. Operating room technician Rationale: Operating room technician, also known as a scrub, ensures the functioning of the equipment in the operating room. Test Taking Tips:The anesthesia provider manages the airway.
The nurse in an outpatient surgical center is discharging a patient after surgery. What criteria must be met before discharge to home? The patient must verbalize that they are ready to go home. The patient has received and understands written discharge instructions and prescriptions. The patient has arranged for taxi cab for pick up. The patient is nauseated and cannot keep fluids down. Test Taking Tips:They must understand the discharge instructions.
The patient must verbalize that they are ready to go home. Rationale: The patient may not verbalize this, but if criteria are met, they are able to go. Y The patient has received and understands written discharge instructions and prescriptions. Rationale: A patient may be discharged go home when or he or she is voiding, walking, and drinking and eating normally; has no excess bleeding or drainage; and has received and understood written discharge instructions and prescriptions. The patient has arranged for taxi cab for pick up. Rationale: The patient must be accompanied by a responsible adult. The patient is nauseated and cannot keep fluids down. Rationale: The patient must be able to tolerate fluids without nausea or vomiting. Test Taking Tips:They must understand the discharge instructions.
The surgeon, after talking to the mother of a 1-year-old infant scheduled for heart surgery, decides to postpone surgery. Which statement made by the infant's mother most likely influenced the surgeon's decision?
Y "I fed the infant formula 2 hours ago." Rationale: Infant formula can be given up to 6 hours before surgery. Therefore, the surgery may be postponed to prevent the risk of aspiration if an infant has been fed only 2 hours prior. N "I fed the infant an apple 8 hours ago." Rationale: Solid foods such as apples may be given 8 hours before surgery. N "I fed the infant grape juice 6 hours ago." Rationale: Grape juice is a clear liquid without pulp that can be given 2 hours before surgery. N "I fed the infant breast milk 4 hours ago." Rationale: Breast milk may be given 4 hours before surgery. Test Taking Tips:Safety is the priority.
The registered nurse is teaching about how to prepare a patient before knee surgery. Which statement indicates a need for further teaching? "I will use a razor to shave the leg hair of the patient." "I will use a sterile electric clipper to cut the hair of the patient." "I will shave the hair of the patient after administering anesthesia." "I will instruct the patient to have a shower with hexachlorophene soap." Test Taking Tips:Find the incorrect answer.
Y "I will use a razor to shave the leg hair of the patient." Rationale: A razor increases the risk of infection by causing small nicks in the skin and impairing skin integrity. "I will use a sterile electric clipper to cut the hair of the patient." Rationale: The nurse uses a sterile electric clipper, if necessary, for better access to the site. "I will shave the hair of the patient after administering anesthesia." Rationale: Shaving may be done in the operating room after administering anesthesia. "I will instruct the patient to have a shower with hexachlorophene soap." Rationale: Hexachlorophene soap is an antiseptic soap that reduces the risk of infection. So, the patient should shower with this soap to reduce the risk of infection. Test Taking Tips:Find the incorrect answer.
The nurse is managing pain for a patient in the postanesthesia care unit (PACU). Which actions are the priority? Assessing for an increase in heart rate, respirations, and blood pressure Using strong opioids for pain control Monitoring the depth of sleep Holding pain medications until the patient requests them Test Taking Tips:Consider basic pain assessment.
Y Assessing for an increase in heart rate, respirations, and blood pressure Rationale: Signs of pain include restlessness; sweating; dilation of pupils; increase in respiration, blood pressure, and heart rate; and piloerection. Using strong opioids for pain control Rationale: The best results in postoperative pain management involve multimodal pharmacological therapy or synchronous administration of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, and local anesthetics. Monitoring the depth of sleep Rationale: The patient may be frowning, opening his or her eyes widely, making facial grimaces, clenching teeth, or moaning—all indications of pain. Holding pain medications until the patient requests them Rationale: Treatment for pain should occur when subtle changes occur. Test Taking Tips:Consider basic pain assessment.
What should be the immediate nursing intervention when a patient is transferred to the postanesthesia care unit (PACU) after surgery? Assessing the vital signs Providing IV fluids Administering acetaminophen Administering metoclopramide Test Taking Tips:Assessment is the priority.
Y Assessing the vital signs Rationale: Any change in vital signs may indicate complications. So, the patient should be connected to a monitor first, and vital signs should be assessed immediately upon admission to the PACU. Providing IV fluids Rationale: IV fluids are administered when the nurse suspects fluid loss and dehydration in the patient. This intervention may not be immediate and it can be performed later. Administering acetaminophen Rationale: The patient is administered acetaminophen after assessing the pain level of the patient. Administering metoclopramide Rationale: The patient is administered metoclopramide after receiving the postoperative order, which may not be an immediate intervention. Test Taking Tips:Assessment is the priority.
Which are roles of a preoperative nurse in the health-care facility? Select all that apply. Clarify information and ensure patient understanding. Obtain consent for the procedure. Witness the consent form even if the patient has not signed it in his or her presence. Correct common misconceptions and ease concerns of the patient and family members. Collect information and paperwork necessary for the procedure. Test Taking Tips:The nurse's role is patient focused.
Y Clarify information and ensure patient understanding. Rationale: It is the responsibility of the preoperative nurse to confirm the patient's understanding and to explain the information about the entire surgical process. N Obtain consent for the procedure. Rationale: The role of the surgeon is to obtain consent for the surgery procedure. It is the responsibility of the preoperative nurse to serve as the witness to the consent by seeing the physical signature of the patient. N Witness the consent form even if the patient has not signed it in his or her presence. Rationale: The preoperative nurse and the other witnesses should not sign the consent form if the patient has not provided his or her consent in their presence. Y Correct common misconceptions and ease concerns of the patient and family members. Rationale: The preoperative nurse should ease the discomfort of the patient and family members by being compassionate and open. Moreover, the nurse should also try to correct their common misconceptions about the disease and the surgical procedure. Y Collect information and paperwork necessary for the procedure. Rationale: It is the responsibility of the preoperative nurse to collect information and paperwork necessary for intra- and postoperative care. Test Taking Tips:The nurse's role is patient focused.
Which postoperative complications is the nurse most likely to anticipate in a patient with preoperative anxiety who is scheduled for surgery? Select all that apply.
Y Deep vein thrombosis Rationale: Anxiety may affect the recovery by decreasing the activity and mobility, which increases the risk of deep vein thrombosis. Delayed wound healing Rationale: Smoking may increase the healing time and thus causes delayed wound healing. Decreased risk of infection Rationale: Anxiety increases the risk for infection by decreasing the immune system response. Y Increased postoperative pain Rationale: Anxiety increases the postoperative pain and thus necessitates the requirement of more pain medications. Decreased response to anesthesia Rationale: Alcohol and drugs may compromise the patient's response to anesthesia. Test Taking Tips:Anxiety may increase the risk of most of the postoperative complications.
Which postoperative complications is the nurse most likely to anticipate in a patient with a history of chronic smoking who is scheduled for a surgery? Delayed wound healing Limited postoperative pain Decrease in the response to anesthesia Decreased immune system response Test Taking Tips:"Chronic smoking" are the key words.
Y Delayed wound healing Rationale: Smoking may increase the healing time and thus causes delayed wound healing. Limited postoperative pain Rationale: Anxiety increases the postoperative pain and thus necessitates the requirement of more pain medications. Decrease in the response to anesthesia Rationale: Alcohol and drugs may compromise the patient's response to anesthesia. Decreased immune system response Rationale: Anxiety increases the risk of infection by decreasing the immune system response. Test Taking Tips:"Chronic smoking" are the key words.
Which is true regarding informed consent?
Y It includes the reason for the surgery. It includes type of instruments used for surgery. Rationale: Type of instruments used may not be included in the informed consent. It includes the reason for the surgery. Rationale: Informed consent includes name, type, and reason for the surgery. It includes the name of the registered nurse. Rationale: Informed consent includes the name of the surgeon but not the registered nurse. It includes the allergic history of the patient. Rationale: Informed consent may not include the allergic history of the patient. Test Taking Tips:Informed consent is an educated patient.
Which information should the patient be given about the procedure before surgery is performed? Select all that apply. Name, type, and reason for surgery Name of the apparatus needed to be used for surgery Reason that intervention will benefit patient Name of all the members present in the operating room All alternative options to surgery Test Taking Tips:Consider requirements for informed consent.
Y Name, type, and reason for surgery Rationale: The patient should be informed about the name, type, and reason for surgery before performing the procedure. Name of the apparatus needed to be used for surgery Rationale: The patient need not be informed about the apparatus and their names used in the surgery. Y Reason that intervention will benefit patient Rationale: The patient should be informed about the reason why the intervention will benefit patient. Name of all the members present in the operating room Rationale: The name of the surgeon should be communicated to the patient before a surgery is performed. The patient need not know the names of the other surgical team members. Y All alternative options to surgery Rationale: All alternative options to surgery should be discussed with the patient before surgery. Test Taking Tips:Consider requirements for informed consen