Perioperative NCLEX Questions

Priority Decision: The nurse notes drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. In what order of priority should the nurse perform the following actions? Number the options with 1 for the first action and 5 for the last action. a. Reinforce the surgical dressing. b. Change the dressing and assess the wound as ordered. c. Notify the surgeon of excessive drainage type and amount. d. Recall the report from PACU for the number and type of drains in use. e. Note and record the type, amount, and color and odor of the drainage.

1. d. Recall the report from PACU for the number and type of drains in use. 2. a. Reinforce the surgical dressing. 3. e. Note and record the type, amount, and color and odor of the drainage. 4. c. Notify the surgeon of excessive drainage type and amount. 5. b. Change the dressing and assess the wound as ordered. Rationale: The nurse must be aware of drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds, and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient? A. Allow the patient to dangle the legs to help increase circulation and alleviate pain B. Instruct the patient to not sit in one position for a long period of time C. Elevate the extremity 30 degrees without allowing any pressure on affected area D. Administer anticoagulants as ordered by MD

A. Allow the patient to dangle the legs to help increase circulation and alleviate pain All options are correct except for "Allow the patient to dangle the legs to help increase circulation and alleviate pain". The patient should NOT dangle the legs because this causes blood to pool in the lower extremities which will put the patient at risk for another blood clot formation.

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST? A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room

A. Apply warm blankets & continue oxygen as prescribed Shivering is an early sign that the patient is starting to experience hypothermia. Immediately, the nurse would need to control the shivering by applying warm blankets and continue oxygen. When the patient starts to experience hypothermia, vital organs are not receiving as much oxygenated blood due to the vasoconstriction. Therefore, oxygen would need to be continued. Then the nurse would take the patient's temperature.

A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do? A. Put the patient in prone position with knees extended to put pressure on the site B. Cover the wound with sterile normal saline dressing C. Monitor for signs of shock D. Notify the MD and administer as prescribed antiemetic to prevent vomiting

A. Put the patient in prone position with knees extended to put pressure on the site The patient is experiencing wound evisceration. This is an emergent situation. The patient should be placed in low Fowler's position with the knees bent to prevent abdominal tension.

As a nurse, which statement is incorrect regarding an informed consent signed by a patient? A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form C. The nurse can witness the client signing the consent form D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained

A. The nurse is responsible for obtaining the consent for surgery All statements are correct except that it's the nurse's responsibility for obtaining the consent for surgery. It is the surgeon's responsibility.

You are observing your patient use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly? A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level B. The patient blows on the mouthpiece rapidly. C. The patient uses the incentive spirometry once a day D. The patient rapidly inhales on the devices and exhales

A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level All of the options are wrong expect for "The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level". The other options do not demonstrate how to properly use the incentive spirometry.

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? A. BP 100/80 B. 24-hour urine output of 300 ml C. Pain rating of 4 on 1-10 scale D. Temperature of 99.3' F

B. 24-hour urine output of 300 ml The nurse needs to watch the patient's urinary output closely. Urinary output within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5 ml/hr.

As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist? A. Assess for allergies B. Conducting the Time Out C. Informed consent is signed D. Ensuring that the history and physical examination has been completed

B. Conducting the Time Out The time out is conducted by the OR nurse prior to surgery. All of the other options are conducted by the nurse getting the patient ready for surgery.

What is a potential postoperative concern regarding a patient who has already resumed a solid diet? A. Failure to pass stool within 12 hours of eating solid foods B. Failure to pass stool within 48 hours of eating solid foods C. Passage of excessive flatus D. Patient reports a decreased appetite

B. Failure to pass stool within 48 hours of eating solid foods After a patient resumes solid food, they should have a bowel movement within 48 hours. The patient may be experiencing constipation and appropriate interventions must be followed.

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would? A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose

B. Notify the MD This is an emergency situation. The patient is more than likely experiencing a hemorrhage of some type. Notifying the MD would be the first line of action and then you could check the patient's blood glucose and obtain an EKG. This patient is probably going to need a surgical intervention.

You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient? A. Urinary Tract infections B. History of Premature Ventricle Beats C. Abuse of street drugs D. Hyperthyroidism

C. Abuse of street drugs If a patient has a history of street drug abuse this puts them at risk in surgery. This information is very important for the anesthesiologist due to the complications that can arise from the anesthesia. All of the other options are important to note but not a risk for surgery.

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day

C. Encourage ambulation, maintain NPO status, and monitor intake & output This patient is most likely experiencing a paralytic ileus which is failure for the bowels to move its contents. The only correct non-invasive option is to encourage ambulation, maintain NPO status, and monitor intake & output. Inserting a NG tube or administering IV fluids is invasive and requires a MD order. Patients with potential paralytic ileus are to be NPO (nothing by mouth) so encouraging fluid intake is incorrect.

A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery? A. Bowel Sounds B. Dysrhythmia C. Homan's Sign D. Hemoglobin Level

C. Homan's Sign Vaginal surgeries require the patient to be in the lithotomy position. This position can put the patient at risk for a deep vein thrombosis. Therefore, the nurse would want to check for this by using Homan's Sign. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis.

A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery? A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. The medication should be discontinued for 48 hours prior to the scheduled surgery date D. None of the above are correct

C. The medication should be discontinued for 48 hours prior to the scheduled surgery date Aspirin alters the normal clotting factors and increases the patient's chances of hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery as specified by the surgeon.

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours

D. Repositioning every 3-4 hours All options are correct expect for repositioning every 3-4 hours. If the patient is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours minimally.

After surgery your patient is semi-comatose with vital signs within normal limits. As the nurse, what position would be best for this patient? A. Semi-Fowlers B. Prone C. Low-Fowlers D. Side positioning preferably on the left side

D. Side positioning preferably on the left side A patient who is semi-comatose is at risk for aspiration (due to secretions pooling in the mouth or vomiting which is a common side effect of sedation). Placing the patient onto their side preferably the left will help decrease the risk of aspiration and help promote cardiovascular circulation.

When the nurse prepares to administer preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. What condition of informed consent has not been met in this situation?

Patient has a clear understanding of the information.

When the nurse prepares to administer preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. What action should be taken by the nurse?

The nurse should notify the surgeon because the patient requires further explanation of the planned surgery.

The primary advantage of the use of midazolam (Versed) as an adjunct to general anesthesia is its: a) Amnesic effects b) Analgesic effects c) Antiemetic effects d) Prolonged action

a) Amnesic effects Versed is a rapid, short-acting, sedative-hypnotic benzodiazepine that is used to prevent recall of events under anesthesia because of its amnesic properties.

When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. a) What action should be taken by the nurse? b) What criterion of informed consent has not been met in this situation?

a) Notify the health care provider b/c the patient needs further explanation of the planned surgery. b) the patient does not sufficiently comprehend

The patient being admitted for same-day surgery has inspiratory crackles and bilateral wheezes, and reports shortness of breath for several days. Which intervention should the nurse implement first? a) Notify the surgeon of the findings b) Document the assessment findings c) Apply 4 liters oxygen by nasal cannula d) Instruct on using Incentive Spirometry

a) Notify the surgeon of the findings The nurse should notify the surgeon of unanticipated changes in the health status of the preop client. Surgery may need to be postponed.

During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after the surgery in a patient with: a) Obesity b) Dehydration c) An enlarged liver d) Decreased peripheral pulse volume

a) Obesity Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during or after surgery. Dehydration may require preoperative fluid therapy, and an enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.

A nurse is caring for a patient who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? a) Prothrombin time b) Serum lipase c) Bilirubin d) Calcium

a) Prothrombin time A major complication following a liver biopsy is hemorrhage. Many patients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced.

Typical fears for the school-age child include... a. death and injury b. social incompetence c. strangers and sudden movements d. loss of income

a. death and injury

What is the primary advantage of the use of midazolam as an adjunct to general anesthesia? a. Amnestic effect b. Analgesic effect c. Prolonged action d. Antiemetic effect

a. Amnestic effect Rationale: Midazolam is a rapid, short-acting, sedative-hypnotic benzodiazepine that is used to prevent recall of events under anesthesia because of its amnestic properties.

A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, "I just want this to be over..." What should the nurse do to promote a positive surgical outcome for the patient? a. Ask the patient what his specific concerns are about the surgery. b. Redirect the patient's attention to the necessary preoperative preparations. c. Reassure the patient that the surgery will be over soon and he will be fine. d. Tell the patient he should not be so anxious because he is having a common, safe surgery.

a. Ask the patient what his specific concerns are about the surgery. Rationale: Excessive anxiety and stress can affect surgical recovery and the nurse's role in psychologically preparing the patient for surgery is to assess for potential stressors that could negatively affect surgery. Specific fears should be identified and addressed by the nurse by listening and explaining planned postoperative care. Ignoring his behavior, falsely reassuring, and telling him not to be anxious are not examples of therapeutic communication.

In caring for patients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant? a. Assist the patient with preparation of a sitz bath b. Monitor the patient for signs of discomfort while ambulating c. Coach the patient to deep breathe during painful procedures d. Evaluate relief after applying a cold application

a. Assist the patient with preparation of a sitz bath The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the patient, teaching techniques and evaluating outcomes are nursing responsibilities.

What is the primary goal of the circulating nurse during preparation of the OR, transferring and positioning the patient, and assisting the anesthesia team? a. Avoiding any type of injury to the patient b. Maintaining a clean environment for the patient c. Providing for patient comfort and sense of well-being d. Preventing breaks in aseptic technique by the sterile members of the team

a. Avoiding any type of injury to the patient Rationale: The protection of the patient from injury in the OR environment is maintained by the circulating nurse, who ensures functioning equipment; prevents falls and injury during transport, transfer, and positioning; monitors asepsis; and provides supportive care for the anesthetized patient.

What does progression of patients through various phases of care in a post-anesthesia care unit (PACU) primarily depend on? a. Condition of patient b. Type of anesthesia used c. Preference of surgeon d. Type of surgical procedure

a. Condition of patient Rationale: Although some surgical procedures and drug administration require more intensive post-anesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an inpatient unit.

The nurse is preparing a patient for transport to the operating room. The patient is scheduled for a right knee arthroscopy. What actions should the nurse take at this time? (select all that apply) a. Ensure patient has voided. b. Verify informed consent is signed. c. Complete preoperative nursing documentation. d. Verify right knee is marked with indelible marker. e. Ensure history and physical exam (H&P), Dx reports, and VS are on the chart.

a. Ensure patient has voided. b. Verify informed consent is signed. c. Complete preoperative nursing documentation. d. Verify right knee is marked with indelible marker. e. Ensure history and physical exam (H&P), Dx reports, and VS are on the chart. Rationale: All of these are actions that are needed to ensure that the patient is ready for surgery. In addition, the nurse should verify that the identification band and allergy band (if applicable) are on; the patient is not wearing any cosmetics; nail polish has been removed; valuables have been removed and secured; and prosthetics, such as eyeglasses, have been removed and secured.

Many common herbal products taken cause surgical problems. Which herbs listen below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding? (select all that apply) a. Garlic b. Fish oil c. Valerian d. Vitamin E e. Astragalus f. Ginkgo biloba

a. Garlic b. Fish oil d. Vitamin E f. Ginkgo biloba Rationale: Garlic, fish oil, vitamin E, and gingko biloba may increase bleeding for surgical patients. Valerian may increase sedation. Astragalus may increase blood pressure before and after surgery.

A patient scheduled for a procedure is expected to receive ketamine (Ketalar). What would be included in patient teaching regarding ketamine? a. Hallucinations may occur, so the patient will receive midazolam. b. An indwelling catheter may be needed if urinary retention occurs. c. Antiemetics will be given beforehand to reduce nausea and vomiting. d. Using ketamine will allow the patient to be fully awake during the procedure.

a. Hallucinations may occur, so the patient will receive midazolam. Rationale: Because ketamine is a phenyl cyclohexyl piperidine (PCP) derivative, the drug may cause hallucinations and nightmares, limiting its usefulness. Concurrent use of midazolam (Versed) can reduce or eliminate the hallucinations. Nausea and urinary retention are not common effects of ketamine. The patient who has received ketamine may appear catatonic, is amnesic, and has profound analgesia.

What type of procedural information should be given to a patient in preparation for ambulatory surgery? (select all that apply) a. How pain will be controlled b. Any fluid and food restrictions c. Characteristics of monitoring equipment d. What odors and sensations may be experienced e. Technique and practice of coughing and deep breathing, if appropriate

a. How pain will be controlled b. Any fluid and food restrictions e. Technique and practice of coughing and deep breathing, if appropriate Rationale: Procedural information includes what will be done for surgical preparation, including what to bring and what to wear to the surgery center, length and type of food and fluid restrictions, physical preparation required, pain control, need for coughing and deep breathing (if appropriate), and procedures done before and after surgery (such as vitals signs, IV lines, and how anesthesia is administered). Characteristics of monitoring equipment is process information. Odors and sensations experiences are sensory information.

With what are the postoperative respiratory complications of atelectasis and aspiration of gastric contents associated? a. Hypoxemia b. Hypercapnia c. Hypoventilation d. Airway obstruction

a. Hypoxemia Rationale: Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hypoventilation may occur with depression of central respiratory drive, poor respiratory muscle tone caused by disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess the patient for first? a. Hypoxemia b. Neurologic injury c. Distended bladder d. Cardiac dysrhythmias

a. Hypoxemia Rationale: The most common cause of emergence delirium is hypoxemia, and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as a distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury. Dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

Injection of anesthetic agent into a specific nerve a. Nerve block b. IV nerve block c. Spinal block d. Epidural block e. Local infiltration

a. Nerve block

During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem? a. Obesity b. Dehydration c. Enlarged liver d. Decreases peripheral pulses

a. Obesity Rationale: Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require preoperative fluid therap. An enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.

The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0° F (35.6° C). What treatment may also be used to treat the patient? a. Oxygen therapy b. Vasodilating drugs c. Antidysrhythmic drugs d. Analgesics or sedatives

a. Oxygen therapy Rationale: During hypothermia, oxygen demand is increased and metabolic processes slow down. Oxygen therapy is used to treat the increased demand for oxygen. Antidysrhythmics and vasodilating drugs would be used only if the hypothermia caused symptomatic dysrhythmias and vasoconstriction. Sedatives and analgesics are not indicated for hypothermia.

Which nursing actions are completed by the scrub nurse? (select all that apply) a. Prepares instrument table b. Documents intraoperative care c. Remains in the sterile area of the operating room (OR) d. Checks mechanical and electrical equipment e. Passes instruments to surgeon and assistants f. Monitors blood and other fluid loss and urine output

a. Prepares instrument table c. Remains in the sterile area of the operating room (OR) e. Passes instruments to surgeon and assistants Rationale: The scrub nurse is involved in sterile activities, including preparing instrument table and passing instruments to the surgeon, and remains in the sterile area of the operating room (OR). The circulating nurse documents intraoperative care, checks mechanical and electrical equipment, and monitors blood and other fluid loss and urine output.

A nurse is caring for a patient who is 4 hours postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? a. Right shoulder pain b. Urine output 20mL/hr c. Temperature 101.1 F d. Oxygen saturation 92%

a. Right shoulder pain The patient can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help patient comfort.

A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the ACP is notified? a. Surgery will be done as scheduled. b. Surgery will be rescheduled for the following day. c. Surgery will be postponed for 8 hours after the fluid intake. d. NG tube will be inserted to remove the fluids from the stomach.

a. Surgery will be done as scheduled. Rationale: Clear liquids can be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary.

On the patient's second postoperative day, the nurse assesses that the patient has diminished breath sounds in both lung bases, is taking shallow breaths, and achieves only 500ml on an IS. The patient smoked for the past 30 years. Which is the nurse's best interpretation of these findings? a. The patient has atelectasis b. The patient has pneumonia c. The findings are normal for this patient d. The patient's airways are obstructing.

a. The patient has atelectasis The patient is 2 days post-surgery. You need to think about the most common respiratory problems in the post-surgical patient.

The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing? a. Witnessing the patient's signature b. Obtaining informed consent from the patient for the surgery c. Verifying that the consent for surgery is truly voluntary and informed d. Ensuring that the patient is mentally competent to sign the consent form

a. Witnessing the patient's signature Rationale: The HCP is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient's signature on the consent form. The nurse must be a patient advocate during the signing of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient's signature.

A patient is scheduled for a hemorrhoidectomy at an ambulatory surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for... a. diagnostic studies and perioperative medications. b. preoperative and postoperative teaching by nurse. c. psychologic support to alleviate fears of pain and discomfort. d. preoperative nursing assessment related to possible risks and complications.

a. diagnostic studies and perioperative medications. Rationale: Ambulatory surgery is typically less expensive and more convenient, generally involving fewer diagnostic studies, medications, and less susceptibility to healthcare associated infections (HAIs). However, the nurse is still responsible for assessing, supporting, and teaching the patient, regardless of setting.

A break in sterile technique occurs during surgery when the scrub nurse touches... a. the mask with sterile gloved hands. b. sterile gloved hands to the gown at chest level. c. the drape at the incision site with sterile gloved hands. d. the lower arm to the instruments on the instrument tray.

a. the mask with sterile gloved hands. Rationale: The mask covering the face is not considered sterile and if in contact with sterile gloved hands, it contaminates the gloves. The gown at chest level and to 2 inches above the elbows is considered sterile, as is the drape placed at the surgical area.

Expected drainage of Hemovac a. wound drainage (exudate) b. urine c. bile d. gastric contents

a. wound drainage (exudate)

During the administration of an epidural or spinal anesthesia, the nurse should monitor the patient for: a) Spinal headache b) Hypotension and bradycardia c) Loss of consciousness and seizures d) Downward extension of nerve block

b) Hypotension and bradycardia During epidural and spinal anesthesia, a sympathetic nervous system blockade may occur that results in hypotension, bradycardia, and N/V. A spinal HA may occur after, not during, spinal anesthesia. Unconsciousness and seizures are indicative of IV absorption overdose. Upward extension of the effect of the anesthesia results in inadequate respiratory excursion and apnea.

A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. The perioperative nurse alerts the surgical team, knowing that if the patient is at risk for malignant hyperthermia: a) The surgery will have to be canceled b) Specific precautions can be taken to safely anesthetize the patient c) Dantrolene must be given to prevent hyperthermia during surgery d) The patient should be placed on a cooling blanket during the surgical procedure

b) Specific precautions can be taken to safely anesthetize the patient Although malignant hyperthermia can result in cardiac arrest and death. If the patient is known or suspected to be at risk for the disorder, appropriate precautions taken by the ACP can provide for safe anesthesia for the patient. Because preventive measures are possible if the risk is known, it is critical that preoperative assessment include a careful family history of surgical events.

Postoperatively, interventions that will assist a surgical patient to avoid nausea and abdominal discomfort include... a. assessing bowel sounds, encourage general diet right after surgery. b. assessing bowel sounds, advance from clear liquids as tolerated. c. assessing pain level, medicate with narcotics accordingly. d. assessing preoperative bowel pattern.

b. assessing bowel sounds, advance from clear liquids as tolerated.

A client has undergone a total hip replacement arthroplasty. Following surgery, the nurse notes an order for Coumadin and Lovenox to be given to the client. The best action for the nurse would be to... a. hold the medications because they are both anticoagulants and the patient could bleed. b. check the labs to see if a PT/INR has been drawn and then give the medications. c. call the provider and request that the order be changed to Heparin and Lovenox. d. question the client as to whether they were taking Coumadin prior to surgery to determine if they should restart the medication.

b. check the labs to see if a PT/INR has been drawn and then give the medications.

The most important nursing intervention to prevent the complication of DVT is... a. cough and deep breathing exercises q2hr. b. leg exercises and early ambulation. c. maintaining bedrest. d. maintaining strict intake and output.

b. leg exercises and early ambulation.

Nursing responsibilities for obtaining informed consent include... a. education regarding the procedure being done and answer any related questions the client may have. b. witnessing consent after acknowledging that the client understood the explanation of the procedure. c. notifying the patient of all associated surgical risks. d. discussing alternative treatments if surgery is declined.

b. witnessing consent after acknowledging that the client understood the explanation of the procedure.

Which patient(s) are appropriate to assign to the LPN, who will function under the supervision of the RN or team leader? (select all that apply) a. A patient who needs pre-op teaching for use of a PCA pump b. A patient with a leg cast who needs neurologic checks and PRN hydrocodone c. A patient post-op toe amputation with diabetic neuropathic pain d. A patient with terminal cancer and severe pain who is requiring IV push medication

b. A patient with a leg cast who needs neurologic checks and PRN hydrocodone c. A patient post-op toe amputation with diabetic neuropathic pain The patients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for the LPN under the supervision of the RN. The RN should take responsibility for preop teaching, and the terminal cancer patient client needs for refusal of medication.

What is the reason for using preoperative checklists on the day of surgery? a. The patient is correctly identified and preoperative medications administered. b. All preoperative orders and procedures have been carried out and documented. c. Voiding is the last procedure before the patient is transported to the operating room. d. Patients' families have been informed as to where they can accompany and wait for patients.

b. All preoperative orders and procedures have been carried out and documented. Rationale: The reason for using preoperative checklists on the day of surgery is to ensure that the many preparations and precautions performed before surgery have been completed and documented. Patient identification, administration of preoperative medications, voiding, and instructions to the family may be documented on the checklist, which ensures that no details are omitted.

Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate, the patient will need early in the anesthesia recovery period? a. Warm blankets b. Analgesic medication c. Observation for respiratory depression d. Airway protection in anticipation of vomiting

b. Analgesic medication Rationale: The volatile liquid inhalation agents have very little residual analgesia and patients experience early onset of pain when the agents are discontinued. These agents are associated with a low incidence of nausea and vomiting. Prolonged respiratory depression is not common because of their rapid elimination. Hypothermia is not related to use of these agents, but they may precipitate malignant hyperthermia in conjunction with neuromuscular blocking agents.

Which patient is ready for discharge from Phase I PACU care to the clinical unit? a. Arouses easily, pulse is 112 bpm, respiratory rate is 24 breaths/min, dressing is saturated, arterial oxygen saturation by pulse oximetry (SpO2) is 88% b. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92% c. Difficult to arouse, pulse is 52 bpm, respiratory rate is 22 breaths/min, dressing is dry and intact, SpO2 is 91% d. Arouses, BP higher than preoperative and respiratory rate is 10 breaths/min, no excess bleeding, SpO2 is 92%

b. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92% Rationale: On initial assessment in the PACU, the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SpO2 below 92% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a. Monitoring arterial blood gases b. Electrocardiographic (ECG) monitoring c. Determining fluid and electrolyte status d. Direct arterial blood pressure monitoring

b. Electrocardiographic (ECG) monitoring Rationale: Electrocardiogram (ECG) monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function. Determinations of arterial blood gases and direct arterial BP monitoring are used only in special cardiovascular or respiratory problems.

When transporting an inpatient to the surgical department, a nurse from another area of the hospital is able to access which area? a. Sterile core b. Holding area c. Corridors of surgical suite d. Unprepared operating room

b. Holding area Rationale: Persons in street clothes or attire other than surgical scrub clothing can interact with personnel of the surgical suite in unrestricted areas, such as the holding area, nursing station, control desk, or locker rooms. Only authorized personnel wearing surgical attire and hair covering are allowed in semi-restricted areas, such as corridors, and masks must be worn in restricted areas, such as operating rooms, sterile core, and scrub sink areas.

What condition should the nurse anticipate, that may occur during epidural and spinal anesthesia? a. Spinal headache b. Hypotension and bradycardia c. Loss of consciousness and seizures d. Downward extension of nerve block

b. Hypotension and bradycardia Rationale: During epidural and spinal anesthesia, a sympathetic nervous system blockade may occur that results in hypotension, bradycardia, and nausea and vomiting. A spinal headache may occur after (not during) spinal anesthesia and loss of consciousness and seizures are indicative of IV absorption overdose. Upward extension of the effect of the anesthesia results in inadequate respiratory excursion and apnea.

Injection of anesthetic agent into veins of extremity after limb is exsanguinated a. Nerve block b. IV nerve block c. Spinal block d. Epidural block e. Local infiltration

b. IV nerve block

What is the physical environment of a surgery suite primarily designed to promote? a. Electrical safety b. Medical and surgical asepsis c. Comfort and privacy of the patient d. Communication among the surgical team

b. Medical and surgical asepsis Rationale: Although all of the factors listed are important to the safety and well-being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient.

The patient newly admitted to the PACU is showing signs of airway obstruction, and the nurse intervenes. Which assessment finding should initially indicate to the nurse that insertion of an oral airway has been effective? a. Abdominal breathing pattern b. Oxygen saturation 92% c. Lung sounds clear to auscultation d. Blood pressure within desired range

b. Oxygen saturation 92% The purpose of the oral airway is to prevent the tongue from blocking the airway. Oxygen saturation of 92% is in the normal range.

A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. Knowing the patient is at risk for malignant hyperthermia, the perioperative nurse alerts the surgical team. What is likely to happen next? a. The surgery will have to be canceled. b. Specific precautions can be taken to safely anesthetize the patient. c. Dantrolene (Dantrium) must be given to prevent hyperthermia during surgery. d. The patient should be placed on a cooling blanket during the surgical procedure.

b. Specific precautions can be taken to safely anesthetize the patient. Rationale: Although malignant hyperthermia (MH) can result in cardiac arrest and death, if the patient is known or suspected to be at risk for the disorder, appropriate precautions taken by the ACP can provide for safe anesthesia for the patient. Because preventive measures are possible if the risk is known, it is critical that preoperative assessment include a careful family history of surgical events. The definitive treatment of MH is prompt administration of dantrolene (Dantrium). The cooling blanket would have no effect.

To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. When the patient is awake b. When the patient first arrives in the PACU c. When the patient becomes agitated or frightened d. When the patient can be aroused and recognizes where he or she is

b. When the patient first arrives in the PACU Rationale: Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

Expected drainage of indwelling catheter (Foley) a. wound drainage (exudate) b. urine c. bile d. gastric contents

b. urine

The nurse is performing a pre-surgical admission assessment of the patient. Which patient statement needs the most immediate follow-up? a) "I feel very hungry; I haven't eaten foods or had any fluids for the past 12 hours". b) "I donated my own blood in case I need a transfusion; the last donation was 4 days ago". c) "I took all my meds including warfarin and atenolol with a sip of water this morning". d) "I brought a copy of my healthcare directive in case my heart stops during surgery".

c) "I took all my meds including warfarin and atenolol with a sip of water this morning". Usually this is stopped a few days before surgery due to the risk of bleeding. The nurse should immediately contact the surgeon.

Goals for patient safety in the operating room include the Universal Protocol, in which: a) All surgical centers of any type must submit reports on patient safety infractions to the accreditation agencies b) The members of the surgical team stop whatever they are doing to check that all sterile items have been properly prepared c) A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site d) All members of the surgical team pause right before surgery to meditate for 1 minute to decrease stress and possible errors

c) A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site The Universal Protocol supported by The Joint Commission is used to prevent wrong site, wrong procedure, and wrong surgery in view of a high rate of these problems nationally. It involves pausing just before the procedure starts to verify identity, site and procedure.

During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. A common risk factor for this nursing diagnosis is: a) Skin lesions b) Break in sterile technique c) Musculoskeletal deformities d) Electrical or mechanical equipment failure

c) Musculoskeletal deformities Musculoskeletal deformities can be a risk factor for positioning injuries and require special padding and support on the operating table. Skin lesions and break in sterile technique are risk factors for infection, and electrical or mechanical equipment failure may lead to other types of injury.

Mr. Sandler, a Jewish client, says to you, "I think the cancer is a punishment from God because I have not followed the rules...I have not done right." What would your best response be? a. Let's not be superstitious Mr. Sandler, God would never punish you. b. Tell me about the rules you broke. I would like to hear about it. c. It sounds as though you're very upset Mr. Sandler. Would you like to talk about it or would you like me to contact the chaplain to request a rabbi to see you? d. Cancer is not a punishment, it can happen to anyone.

c. It sounds as though you're very upset Mr. Sandler. Would you like to talk about it or would you like me to contact the chaplain to request a rabbi to see you?

The RN notes evisceration of an abdominal wound. What is the best first action by the nurse? a. Place patient in upright position. b. Apply steri-strips and call surgeon. c. Take dry sterile dressing and moisten it with Normal Saline solution to cover. d. Provide fluids by mouth to prevent dehydration from wound loss.

c. Take dry sterile dressing and moisten it with Normal Saline solution to cover.

Immediate postoperative nursing care in the recovery area includes... a. encouraging family to visit. b. changing the surgical dressing. c. suctioning secretions from the airway as needed. d. discontinuing the IV.

c. suctioning secretions from the airway as needed.

In order to decrease the risk of HAIs, the most important intervention that the nurse does is... a. careful assessment of risk factors. b. planning room assignments to separate those at risk from the low risk patients. c. washing hands before and after each patient contact. d. taking a would culture of each new would patient.

c. washing hands before and after each patient contact.

While assessing a patient in the PACU, the nurse finds that the patient's blood pressure (BP) is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. A urinary output > 30 mL/hr b. An oxygen saturation of 88% c. A normal pulse with warm, dry, pink skin d. A narrowing pulse pressure with normal pulse

c. A normal pulse with warm, dry, pink skin Rationale: Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output > 30 mL/hr is desirable and indicates normal renal function.

How is the initial information given to the PACU nurses about the surgical patient? a. A copy of the written operative report b. A verbal report from the circulating nurse c. A verbal report from the anesthesia care provider (ACP) d. An explanation of the surgical procedure from the surgeon

c. A verbal report from the anesthesia care provider (ACP) Rationale: The admission of the patient to the PACU is a joint effort between the anesthesia care provider (ACP), who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patient safety and continuity of care.

When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next? a. Note this information in the patient's record as hay fever and food allergies. b. Place an allergy alert wristband that identifies the specific allergies on the patient. c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents. d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthesia.

c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents. Rationale: Risk factors for latex allergies include a history of hay fever and allergies to foods, such as avocados, kiwis, bananas, potatoes, peaches, and apricots. When a patient identifies such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens. A history of any allergic responsiveness increases risk for the hypersensitivity reactions to drugs used during anesthesia, but the hay fever and fruit allergies are specifically related to a latex allergy. After the nurse identifies the allergic reactions, the anesthesia care provider (ACP) should be notified, the allergy wristband should be applied, and the note in the record will include the allergies and reactions as well as the nursing actions related to the allergies.

A patient is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? a. Fever b. Nausea c. Diaphoresis d. Abdominal cramps

c. Diaphoresis Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48-72 hours.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. Diuresis b. Hyperkalemia c. Fluid retention d. Impaired blood coagulation

c. Fluid retention Rationale: The stress response causes fluid retention during the first 1 to 3 days postoperatively, and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates the adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention? (select all that apply) a. Surgical wound; Etiology: incision b. Risk for aspiration; Etiology: decreased level of consciousness c. Impaired physical mobility; Etiology: decreased muscle strength d. Impaired airway clearance; Etiology: decreased respiratory excursion e. Constipation; Etiology: decreased physical activity and impaired gastrointestinal (GI) motility f. Risk for ineffective tissue perfusion; Etiology: venous thromboembolism; Supporting data: dehydration, immobility, vascular manipulation, or injury

c. Impaired physical mobility; Etiology: decreased muscle strength d. Impaired airway clearance; Etiology: decreased respiratory excursion e. Constipation; Etiology: decreased physical activity and impaired gastrointestinal (GI) motility f. Risk for ineffective tissue perfusion; Etiology: venous thromboembolism; Supporting data: dehydration, immobility, vascular manipulation, or injury Rationale: These problems are improved with ambulation. Other collaborative problems could be potential complications: Risk for urinary retention, atelectasis, and pneumonia.

During surgery, a patient is at risk for perioperative positioning injury. What is a common risk factor for this problem? a. Skin lesions b. Break in sterile technique c. Musculoskeletal deformities d. Electrical or mechanical equipment failure

c. Musculoskeletal deformities Rationale: Musculoskeletal deformities can be a risk factor for positioning injuries and require special padding and support on the operating table. Skin lesions and break in sterile technique are risk factors for infection and electrical or mechanical equipment failure may lead to other types of injury.

Which tubes drain gastric contents? (select all that apply) a. T-tube b. Penrose c. Nasogastric tube d. Indwelling catheter e. GI tube

c. Nasogastric tube e. GI tube Rationale: The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Penrose drains wound drainage, and the indwelling catheter drains urine from the bladder.

The nurse notes drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. The nurse should: a. Change the dressing and assess the wound b. Notify the surgeon of the drainage type and amount c. Note and record the type, amount, and color of the drainage d. Observe the dressing every 15 minutes for an increase in drainage

c. Note and record the type, amount, and color of the drainage Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed. Some drainage is expected for most surgical wounds, and the drainage should be evaluated and recorded to establish a baseline for continuing assessment.

Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)? a. IV b. IM or SQ c. PO d. Transdermal e. PCA

c. PO If the GI system is functional, the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive then the IV, IM SQ, and PCA routes. Transdermal route: medication availability is limited compared to oral forms.

Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do? a. Teach the patient controlled breathing. b. Explain the rationale for these activities. c. Provide adequate and regular pain medication. d. Use an incentive spirometer to motivate the patient.

c. Provide adequate and regular pain medication. Rationale: Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation. Adequate and regular analgesic medications should be provided to encourage these activities. Controlled breathing may help the patient manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help gain patient participation but are more effective if pain is controlled.

Upon admission of a patient to the PACU, the nurse's priority assessment is the patient's: a. Vital signs b. Surgical site c. Respiratory adequacy d. Level of consciousness

c. Respiratory adequacy Physiologic status of the patient is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic, and renal function should be assessed as well as surgical site.

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope? a. Monitor vital signs after ambulation. b. Do not allow the patient to eat before ambulation. c. Slowly progress to ambulation with slow changes in position. d. Have the patient deep breathe and cough before getting out of bed.

c. Slowly progress to ambulation with slow changes in position. Rationale: Slow progression to ambulation by slowly changing the patient's position will help prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient's pulse and BP before, during, and after position changes. Elevate the patient's head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

Injection of anesthetic agent into subarachnoid space a. Nerve block b. IV nerve block c. Spinal block d. Epidural block e. Local infiltration

c. Spinal block

What should be included in the instructions given to the postoperative patient before discharge? a. Need for follow-up care with home care nurses b. Directions for maintaining routine postoperative diet c. Written information about self-care during recuperation d. Need to restrict all activity until surgical healing is complete

c. Written information about self-care during recuperation Rationale: All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Symptoms to report, instructions about medications, wound care, activities, diet, and follow-up care are individualized to the patient.

Expected drainage of T-Tube a. wound drainage (exudate) b. urine c. bile d. gastric contents

c. bile

A common reason that a nurse may need extra time when preparing older adults for surgery is their... a. difficulty coping. b. limited adaptation to stress. c. diminished vision and hearing. d. need to include caregivers in activities.

c. diminished vision and hearing.

Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is... a. vital signs. b. surgical site. c. respiratory adequacy. d. level of consciousness.

c. respiratory adequacy. Rationale: Physiologic status of the patient is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the postanesthesia care unit (PACU) from the operating room. Following assessment of respiratory function, cardiovascular, neurologic, and renal function should be assessed as well as the surgical site.

It is most important to monitor the patient for malignant hyperthermia if the patient received which anesthetic agent? a. ketamine b. pancuronium c. succinylcholine d. dexmedetomidine

c. succinylcholine Rationale: MH occurs in susceptible people when they are exposed to certain anesthetic agents. Succinylcholine (Anectine), especially when given with volatile inhalation agents, is the primary trigger. Other factors include stress, trauma, and heat.

The nurse is orienting the new nurse to a PACU. Which statement by the new nurse indicates further orientation? a) "LR and 5% dextrose with LR are typical IV solutions administered in the PACU" b) "If the patient has an opioid overdose, I should expect to administer naloxone hydrochloride" c) "I should monitor vital signs and perform a pain assessment every 15 minutes or more often if necessary" d) "Once the patient responds verbally after a spinal anesthetic, the patient can be transferred to the nursing unit"

d) "Once the patient responds verbally after a spinal anesthetic, the patient can be transferred to the nursing unit" Because the patient did not receive a general anesthetic that depressed the CNS the client may be verbally responsive immediately after surgery. The patient receiving a spinal should remain in the PACU until feeling and voluntary motor movement of the lower extremities have begun to return.

During a preoperative systems review, the patient reveals a history of renal disease. This finding suggests the need for preoperative diagnostic tests of: a) ECG and chest x-ray b) Serum glucose and CBC c) ABGs and coagulation tests d) BUN, serum creatinine, and electrolytes

d) BUN, serum creatinine, and electrolytes BUN, serum creatinine, and electrolytes are commonly abnormal in renal disease and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease.

The nurse determines that all of the following must be completed for the patient being prepared for surgery. Which intervention should the nurse complete first? a) Complete the preoperative checklist b) Assess the patient's preoperative vital signs c) Remove the patient's rings, gold chain, and wristwatch d) Give 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L

d) Give 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L Give KCL is priority. Abnormalities must be corrected before surgery. A low serum potassium level can induce cardiac dysrhythmias and delay surgery.

The nurse is caring for the patient who received conscious sedation during a surgical procedure. Which assessment is most important postoperatively? a) Bilateral lung sounds b) Amount of urine output c) Ability to swallow liquids d) Rate and depth of breathing

d) Rate and depth of breathing The rate and depth of breathing should be assessed to determine the adequacy of air exchange. A respiratory rate of less than 10 indicates drug induced respiratory depression. The primary concern with conscious sedation is the effect of the medications on the CNS.

The nurse is to witness the signature of a surgical consent for multiple patient scheduled for surgery the following day. After evaluating the health history of each patient, for which patient should the nurse plan to obtain a signature from the next of kin? a) The 75-year-old patient who is legally blind b) The 60-year-old patient who does not understand English c) The 50-year-old patient who is forgetful but fully oriented d) The 16-year-old patient who fully understands the surgery

d) The 16-year-old patient who fully understands the surgery The legal age for consent is 18 years unless the adolescent has emancipated status granted by a judge.

The nurse is reviewing the lab results for a preoperative patient. Which of these results should be brought to the attention of the surgeon? a) Hemoglobin of 15 g/dl b) Serum K+ of 3.8 mEq/L c) Blood glucose of 100 mg/dL d) White blood cell count (WBC) of 18,500/mL

d) White blood cell count (WBC) of 18,500/mL This finding may indicate an infection. The surgeon will probably postpone the surgery until the cause of the elevated WBC has been found.

What would be the most appropriate goal/outcome for the adult client who had surgery 2 hours ago? Client will... a. maintain urinary output of 15mL/hr. b. rate pain at 8/10 with acceptable level at 2/10. c. have bowel movement within 3 hours. d. maintain vital signs within normal limits.

d. maintain vital signs within normal limits.

Which patient is at greatest risk for respiratory depression while receiving opioids for analgesia? a. An elderly chronic pain patient with a hip fracture b. A patient with a heroin addiction and back pain c. A young female patient with advanced multiple myeloma d. A child with an arm fracture and cystic fibrosis

d. A child with an arm fracture and cystic fibrosis At greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary disease. The child has 2 of the 3 risk factors.

Goals for patient safety in the OR include the Universal Protocol. What is included in this protocol? a. All surgical centers of any type must submit reports on patient safety infractions to the accreditation agencies. b. Members of the surgical team stop whatever they are doing to check that all sterile items have been prepared properly. c. Members of the surgical team pause right before surgery to meditate for 1 minute to decrease stress and possible errors. d. A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site.

d. A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site. Rationale: The Universal Protocol supported by The Joint Commission (TJC) is used to prevent wrong site, wrong procedure, and wrong surgery in view of a high rate of these problems nationally. It involves pausing just before the procedure starts to verify patient identity, surgical site, and surgical procedure.

The health care provider has ordered IV morphine q2-4hr as needed for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. Before all planned painful activities b. Every 2 to 4 hours during the first 48 hours c. Every 4 hours as the patient requests the medication d. After assessing the nature and intensity of the patient's pain

d. After assessing the nature and intensity of the patient's pain Rationale: Before administering all analgesic medications, the nurse should first assess the nature and intensity of the patient's pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of as needed analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities, but activities may be scheduled around medication administration.

What is the best way to schedule medication for a patient with constant pain? a. PRN at the patient's request b. Prior to painful procedures c. IV bolus after pain assessment d. Around the clock

d. Around the clock If the pain is constant, the best schedule is around-the-clock, to provide steady analgesia and pain control.

During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic studies? a. ECG and CXR b. Serum glucose and CBC c. ABGs and coagulation tests d. BUN/Cr and electrolytes

d. BUN/Cr and electrolytes Rationale: Blood urea nitrogen (BUN), serum creatinine (Cr), and electrolytes are used to assess renal function and should be evaluated before surgery. Other studies are often evaluated in the presence of heart or respiratory disease, or bleeding tendencies.

Injection of anesthetic agent into space around the vertebrae a. Nerve block b. IV nerve block c. Spinal block d. Epidural block e. Local infiltration

d. Epidural block

Which procedures are done for curative purposes? (select all that apply) a. Gastroscopy b. Rhinoplasty c. Tracheotomy d. Hysterectomy e. Herniorrhaphy

d. Hysterectomy e. Herniorrhaphy Rationale: Hysterectomy and herniorrhaphy are done to eliminate and repair pathologic conditions. Gastroscopy is diagnostic. Rhinoplasty is cosmetic. Tracheotomy is palliative.

Which short-acting barbiturate is most often used for induction of general anesthesia? a. Nitrous oxide b. Propofol (Diprivan) c. Isoflurane (Forane) d. Methohexital (Brevital)

d. Methohexital (Brevital) Rationale: Methohexital (Brevital) is a rapid-acting, short-lasting barbiturate used to induce general anesthesia. Nitrous oxide is a weak gaseous anesthetic. Propofol (Diprivan) is a nonbarbiturate hypnotic that has a rapid onset and may be used for induction. Isoflurane (Forane) is a volatile liquid inhalation agent.

Thirty-six hours postoperatively, a patient has a temperature of 100° F (37.8° C). What is the most likely cause of this temperature elevation? a. Dehydration b. Wound infection c. Lung congestion and atelectasis d. Normal surgical stress response

d. Normal surgical stress response Rationale: During the first 24 to 48 postoperative hours, temperature elevations to 100.4° F (38° C) are a result of the inflammatory response to surgical stress. Dehydration and lung congestion or atelectasis in the first 2 days will cause a temperature elevation above 100.4° F (38° C). Wound infections usually do not become evident until 3 to 5 days postoperatively and manifest with temperatures above 100° F (37.8° C).

The patient will be placed under moderate sedation to allow realignment of a fracture in the emergency department. When the family asks about this anesthesia, what should the nurse tell them? a. Includes inhalation agents b. Induces high levels of sedation c. Frequently used for traumatic injuries d. Patients remain responsive and breathe without assistance

d. Patients remain responsive and breathe without assistance Rationale: Moderate sedation uses sedative, anxiolytic, and/or analgesic medications. Inhalation agents are not used. It is not expected to induce levels of sedation that would impair a patient's ability to protect the airway.

To prevent airway obstruction in the postoperative patient who is unconscious or semi-conscious, what will the nurse do? a. Encourage deep breathing. b. Elevate the head of the bed. c. Administer oxygen per mask. d. Position the patient in a side-lying position.

d. Position the patient in a side-lying position. Rationale: An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway.

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse: a. Encourages deep breathing b. Elevates the head of the bed c. Administers oxygen per mask d. Positions the patient in a side-lying position

d. Positions the patient in a side-lying position An unconscious or semiconscious pt should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway.

The nurse is reviewing the laboratory results for a preoperative patient. Which study result should be brought to the attention of the surgeon immediately? a. K+: 3.8 mEq/L b. Hgb: 15 g/dL c. Glucose: 100 mg/dL d. WBC: 18,500/uL

d. WBC: 18,500/uL Rationale: Elevated WBCs may indicate infection and the surgeon may need to postpone the surgery.

Which drainage is drained with a Hemovac? a. Bile b. Urine c. Gastric contents d. Wound drainage

d. Wound drainage Rationale: The Hemovac removes wound drainage, especially blood. Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

Expected drainage of NG Tube a. wound drainage (exudate) b. urine c. bile d. gastric contents

d. gastric contents

Expected drainage of gastronomy tube a. wound drainage (exudate) b. urine c. bile d. gastric contents

d. gastric contents

Monitored anesthesia care (MAC) is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care clinic. The patient asks the nurse, "What is this MAC?" The nurse's response is based on the knowledge that MAC... a. can be administered only by anesthesiologists or nurse anesthetists. b. should never be used outside of the OR because of the risk of serious complications. c. is so safe that it can be administered by nurses with direction from health care providers. d. provides maximum flexibility to match the sedation level with the patient and procedure needs.

d. provides maximum flexibility to match the sedation level with the patient and procedure needs. Rationale: Monitored anesthesia care (MAC) refers to sedation that is similar to general anesthesia using sedative, anxiolytic, and/or analgesic medications. It can be administered by an ACP. The patient must be assessed and the physiologic problems that may develop must be managed because of the high risk of complications resulting in clinical emergencies.

Injection of anesthetic agent directly into tissues a. Nerve block b. IV nerve block c. Spinal block d. Epidural block e. Local infiltration

e. Local infiltration