Chapter 17/18/19 315 Nursing NIU
Which criteria must a patient meet in order to be discharged from the postanesthesia care unit (PACU) (Phase I) to the clinical unit? Select all that apply.
No respiratory depression Oxygen saturation above 90% Patient reports pain level of 4 on a 1 to 10 scale
Prior to a first-ever surgery, a patient reports taking alprazolam the night before for anxiety. Preoperative vital signs include BP 158/88, heart rate (HR) 96, and respiratory rate (RR) 24. Which action would the nurse take?
Notify the anesthesia care provider (ACP)
When reviewing preoperative forms, the nurse notices that the patient's informed consent is not signed. Which action would the nurse take?
Notify the health care provider to obtain consent for surgery.
Which factor must the nurse be aware of regarding a patient's medication regimen and preparation for surgery?
Some medications are contraindicated for use with anesthetics.
Which intervention would the nurse take for a postoperative patient who was given a large dose of an opioid for pain and now has a decreased oxygenation saturation?
Stimulate patient to take deep breaths
Which information about the risk of postoperative bleeding would the nurse include in the teaching plan for a patient who is scheduled for surgery in two weeks?
Stop taking herbal medicines; they may increase the risk of postoperative bleeding.
While caring for a patient after surgery on the first postoperative day, the nurse notes new, bright red drainage about 4 cm in diameter on the surgical dressing. Which action would the nurse take first?
Take the patient's vital signs.
Which potential complication might a patient experience if he or she consumes a meal heavy with garlic the day before a surgery?
An increase in bleeding during the surgery
Which preoperative medication would the nurse administer to a patient with valvular heart disease to prevent complications related to this condition?
Antibiotics
While collecting a preoperative history, the patient reports to the nurse a history of diffuse skin rashes when hospitalized in the past as well as food allergies to bananas and avocados. Which action would the nurse take?
Ask additional questions to assess for a possible latex allergy.
After reviewing the documentation below, which medication would the circulating nurse prepare to administer? HR was 121
Dantrolene
An older adult patient has a complication after a cardiac catheterization and has to remain in the postanesthesia care unit (PACU) for several days. Which complication is the patient most at risk for?
Delirium
Which action will the nurse take when the patient going for surgery wants to give their hearing aid to their spouse so it will not be lost during surgery?
Encourage the patient to wear it for the surgery.
Which assessment finding in a patient who has just been admitted to the postanesthesia care unit (PACU) requires the nurse's immediate action?
The patient is restless, agitated, and hypotensive.
Which statements would the nurse include when teaching a patient with a body mass index (BMI) of 45 about the potential complications of abdominal surgery caused by obesity? Select all that apply.
The risk of wound infection is higher. Anesthesia administration is more difficult. The risk of a postoperative incisional hernia may be higher.
A nurse is caring for an older adult patient who had a knee replacement the previous day and denies any pain. Which response by the nurse would be most appropriate?
"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"
A patient is instructed not to have anything to eat or drink eight hours prior to surgery. When arriving to the preoperative holding area, the patient informs the nurse they ate eggs and toast about two hours ago. Which response by the nurse is most appropriate?
"I will inform the anesthesia care provider and surgeon to see what the options are."
Which duties are specific to a scrub nurse? Select all that apply.
Assist in the draping procedure. Assist in preparing the operating room.
Which patients would require administration of preoperative antibiotics? Select all that apply.
Patient undergoing cataract surgery Patients undergoing gastrointestinal surgery Patients undergoing joint replacement surgery
The nurse would monitor the patient for which indicators of autonomic nervous system blockade when spinal anesthesia is administered? Select all that apply.
Nausea Vomiting Bradycardia Hypotension
The nurse is preparing to administer a preoperative dose of cefazolin prior to an open cholecystectomy. Which explanation by the nurse about why the patient is receiving this medication is accurate?
"It will prevent postoperative surgical-site infection."
A preoperative patient asks why the dose of warfarin is being withheld. Which response by the nurse is most accurate?
"This medication could cause excessive bleeding during surgery if it is not stopped beforehand."
The circulating nurse observes the scrub nurse washing hands prior to a surgical procedure and sees that the scrub nurse washes the fingers and hands before scrubbing the forearms and elbows, and then hands are placed lower than the level of the elbows. Which response by the circulating nurse to the scrub nurse is accurate?
"You should have held your hands above the level of your elbows."
The nurse is doing a preoperative assessment on a patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia?
A body mass index of 48.8
Before a patient is admitted to the operating room, which preoperative documentation must be attached to the chart, according to The Joint Commission?
A complete physical exam
A patient is scheduled for a surgery that will be performed under epidural anesthesia. When reviewing the patient's medical record, the nurse notes a surgical history of postoperative immobility following epidural anesthesia. To prevent the postoperative complication, which revision to the anesthesia plan would be implemented?
A decrease in the dose of the epidural anesthesia
The nurse needs to instill different eyedrops into a preoperative patient's eyes. How many minutes would the nurse wait between each set of eyedrops?
5 mins
A patient scheduled for surgery reveals to the nurse fears about the projected length of time off work needed for recovery, as the patient is the primary source of income for the family. Which follow-up action would the nurse implement?
Consult a social worker to identify financial options for the patient
A patient with Alzheimer's dementia and confusion arrives via ambulance from a long-term care facility to the preoperative area for placement of a feeding tube, and there is no documentation of consent for the procedure. Which action would the nurse take?
Contact the family member identified as the patient's power of attorney on the patient's medical record so the surgeon can obtain consent.
The nurse is caring for a patient in the postanesthesia care unit (PACU), when the BP drops from 110/60 mm Hg to 92/58 mm Hg. Which actions would the nurse take? Select all that apply.
Assess electrocardiogram (ECG) tracing. Inspect the surgical site. Have the patient take deep breaths. Administer IV fluid bolus per protocol
Which actions would the nurse take when administering an analgesic to a postoperative patient? Select all that apply.
Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Time the analgesic administration for effectiveness during painful activities.
How would the nurse ensure a patient scheduled for surgery is not pregnant?
By checking human chorionic gonadotropin (hCG) level
Which action would the nurse implement to maintain patient safety during a surgery that is related directly to the use of regional anesthesia?
Ensure a smooth surface under the patient.
An older adult patient is being prepared for a cholecystectomy. Which patient information would the nurse include as part of the preoperative assessment? Select all that apply.
Fluid balance history Current mobility problems Current cognitive function
An older adult patient is being prepared for a cholecystectomy. Which patient information would the nurse include as part of the preoperative assessment? Select all that apply.
Fluid balance history Current mobility problems Current cognitive function
Which assessment finding is a side effect of ketamine?
Hallucinations
Which symptom would the nurse monitor in a patient who was given a benzodiazepine as an adjunct to general anesthesia? Select all that apply.
Hypotension Tachycardia
Which step occurs in the initial stage when a patient is receiving general anesthesia?
Induction is performed with an IV agent.
A patient going for surgery today informs the nurse she they took kava last night to help her sleep. Which action would the nurse take?
Inform the anesthesiologist of the patient's recent use of kava.
A patient who is being prepared for surgery tells the nurse: "I am afraid that I may die during surgery without being able to confess my sins. I don't want to die without receiving absolution." Which action by the nurse would best meet this patient's needs?
Inform the surgeon of the patient's fears and contact the appropriate religious leader to talk with the patient before surgery if possible.
When teaching a patient about the benefits of ambulatory surgery compared to inpatient surgery, which information is accurate? Select all that apply.
It involves minimal laboratory tests. It requires fewer preoperative medications. It reduces the risk of hospital-acquired infections.
A patient begins having hallucinations and agitation after receiving dissociative anesthesia. Which anesthetic agent is associated with this complication?
Ketamine
Which medication would the nurse prepare to administer to a patient to counteract the emetic effects of inhalation agents during surgery?
Ondansetron
An unconscious patient needs to undergo emergency surgery and has no family members or friends available. Which action would the nurse take regarding obtaining consent for the surgery?
Proceed with plans for surgery; consent is not required for a true medical emergency
A patient taking warfarin and digoxin for treatment of atrial fibrillation is instructed to discontinue the use prior to surgery. The nurse would closely monitor this patient for which complication?
Pulmonary embolism
During a preoperative assessment, the patient states that he developed allergic skin rashes when exposed to rubber gloves a few years ago. Which concern would the nurse review the patient's medical record for?
Reactions to latex
Which action will the nurse take for a postoperative patient who has low oxygen saturation and has crackles on auscultation?
Restrict fluid intake
A patient received a large amount of IV fluid during surgery. In the postanesthesia care unit (PACU), the nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. Which actions would the nurse take to relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply.
Restrict fluids. Administer prescribed diuretics. Administer oxygen therapy.
Which concern would be the first priority for the nurse when transporting a patient to the operating room?
Safety of the patient
Which action would the nurse take for a postoperative patient who has not voided for eight hours? Select all that apply.
Scan the bladder with a portable ultrasound. Help the patient to use a bedside commode. Reassure the patient regarding the ability to void Use techniques like pouring warm water over the perineum.
The nurse is to administer preoperative medications for a patient who is scheduled for surgery at 7:30: cefazolin IV to be infused 30 minutes before surgery, midazolam IV before surgery, and a scopolamine patch behind the ear. Which medication would the nurse administer first?
Scopolamine
A patient scheduled for surgery asks the nurse where his or her family can be in the surgical suite. Which response by the nurse is accurate?
The family can be with the patient in the preoperative holding area.
A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions would the nurse perform? Select all that apply.
Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets
When signing the consent, a patient states that the health care provider has not really explained what is involved in the surgical procedure. Which action will the nurse take?
tell the health care provider about the delay in signature
Which member of the surgical team would inform the blood bank regarding the need for a blood transfusion during a surgery?
circulating nurse
The nurse reviews data from a female patient scheduled for surgery. Based on the information in the electronic health record (EHR), which follow-up test would the nurse request to be ordered before this patient's surgery?
serum potassium