Exam 1

Created by JAndsager 

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Common Preoperative Medications:

1) Benzodiazepines and barbiturates: for sedation and amnesia
2) Anticholinergics: to reduce secretions
3) Opioids: to decrease intraoperative anesthetic requirements and pain
4) Additional drugs include antiemetics, antibiotics, eye drops, and regular prescription drugs

Drug Use in Pre-Op setting:
Benzodiazepines and barbiturates

Drug used in pre-op setting for sedation and amnesia

Drug Use in Pre-Op setting:
Anticholinergics

Drug used in pre-op setting to reduce secretions.

Drug Use in Pre-Op setting:
Opioids

Drug used in pre-op setting to decrease intraoperative anesthetic requirements and pain.

Pre-Op patients should be screened for possible critical allergies?

Pre-Op pts should be screened for critical allergies:
Latex, Iodine, and allergies to anesthesia that may result in Malignant Hyperthermia.

In the surgical setting, where is the center of the sterile field?

The center of the sterile field is the site of the surgical incision.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take?

A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done.
B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes.
C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room.

C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.

As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse?

A. Note the presence of the ring in the nurse's notes of the chart.
B. Insist the patient remove the ring.
C. Explain that the hospital will not be responsible for the ring.
D. Tape the ring securely to the finger.

C. Explain that the hospital will not be responsible for the ring.
It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that:

A. She must be NPO after breakfast.
B. She needs to be NPO after midnight.
C. She can drink clear liquids up to 2 hours before surgery.
D. She can drink clear liquids up until she is taken to the OR.

C. She can drink clear liquids up to 2 hours before surgery.
Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate?

A. Inform the anesthesiologist of the patient's ingestion of kava.
B. Tell the patient that using kava to help sleep was a good idea.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

A. Inform the anesthesiologist of the patient's ingestion of kava.
Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement.

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates:

A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia

B. Muscle rigidity
Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.

Before admitting a patient to the operating room, the nurse recognizes that which of the following must be attached to the chart of all patients?

A. A functional status evaluation
B. Renal and liver function tests
C. A physical examination report
D. An electrocardiogram

C. A physical examination report.
It is essential to have a physical examination report attached to the chart of a patient going for surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team.

Which of the following nursing interventions should receive highest priority when a patient is admitted to the postanesthesia care unit?

A. Positioning the patient
B. Observing the operative site
C. Checking the postoperative orders
D. Receiving report from operating room personnel.

A. Positioning the patient.
A patient is received in the postanesthesia care unit on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious patient. Observation of the operative site, receiving report from operating room personnel, and checking postoperative orders are interventions made after proper positioning of the patient.

Which of the following may be left in place when a patient is sent to the operating room?

A. Wig
B. Hearing aid
C. Engagement ring
D. Well-fitting dentures

B. Hearing aid
If a patient is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place. Wigs, engagement rings, and dentures are not necessary items to facilitate quality patient care in the operating room.

In caring for a person receiving an opioid analgesic through an epidural catheter, the nursing responsibility of prime importance is

A. assessing for respiratory depression.
B. establishing a baseline laboratory profile.
C. inspecting the catheter insertion site hourly.
D. ensuring that the patient remains on strict bed rest.

A. assessing for respiratory depression.
Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose. Establishing a baseline laboratory profile is outside the scope of practice for a nurse. Hourly inspection of the catheter insertion site is an unnecessary nursing intervention. In general, the site is assessed once a shift unless unexpected complications occur. Strict bed rest is not necessary for the patient with an epidural catheter; however, assistance with getting out of bed could be necessary related to effects of the opioid analgesic.

Which of the following is most appropriate after administration of preoperative medications?

A. Confirming that the patient has voided
B. Monitoring vital signs every 15 minutes
C. Placing the patient in bed with the rails up
D. Transporting the patient immediately to the operating room

C. Placing the patient in bed with the rails up.
After administration of preoperative medications, a nurse should instruct a patient not to get up without assistance because medications can cause drowsiness or dizziness. Confirming that the patient has recently voided should be done before preoperative medications are administered. Monitoring vital signs every 15 minutes is not a necessary intervention unless prescribed by the physician. Transporting the patient immediately to the operating room is not necessary unless the patient is called for.

Which of the following should be included in the plan of care for a patient who had spinal anesthesia?

A. Elevating the head of the bed to decrease nausea
B. Elevating the patient's feet to increase blood pressure
C. Instructing the patient to remain flat in bed for 6 hours
D. Administering oxygen to reduce hypoxia produced by spinal anesthesia

C. Instructing the patient to remain flat in bed for 6 hours.
In addition to interventions designed to replace fluids and indirectly replace lost spinal fluid after administration of spinal anesthesia, the patient is instructed to lie flat for 6 to 8 hours. Elevating the head of the bed after spinal anesthesia can precipitate "spinal headache" or nausea related to losses of cerebrospinal fluid or changes in ICP. Elevating the patient's feet or administering oxygen are not necessary interventions unless the patient becomes hypotensive or hypoxic.

A nurse has requested and gotten permission to observe a surgical procedure of interest in the hospital in which the nurse is employed. While the patient is being draped, the nurse notices that a break in sterile technique occurs. Which of the following actions on the nurse's part is most appropriate?

A. Tell the surgeon before an incision is made.
B. Tell the circulating nurse at the end of the surgery.
C. Say nothing because someone else is likely to notice also.
D. Point out the observation immediately to the personnel involved.

D. Point out the observation immediately to the personnel involved.
Any break in sterile technique in the operating room should be immediately pointed out and remedied.

In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action?

A. Ask the patient his name.
B. Notify the surgeon and anesthesiologist.
C. Check to see whether the patient has received any preoperative medications.
D. Assume that the patient is a little confused because he is older and has received midazolam intramuscularly.

A. Ask the patient his name.
Ensuring proper identification of a patient is a responsibility of all members of the surgical team. In a specialty surgical setting where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses do not assume in the care of their patients. The priority is with the nurse identifying the patient and the patient's consent form before the physicians are notified.

When administering low-molecular-weight heparin (LMWH) after an operation, a nurse should

A. explain that the drug will help prevent clot formation in the legs.
B. check the results of the partial thromboplastin time before administration.
C. administer the dose with meals to prevent GI irritation and bleeding.
D. inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.

A. explain that the drug will help prevent clot formation in the legs.
Unfractionated heparin or LMWH is given as a prophylactic measure for venous thrombosis and pulmonary embolism. These anticoagulants work by inhibiting thrombin-mediated conversion of fibrinogen to fibrin. LMWH is injected subcutaneously with no relationship to meals. It has a more predictable dose response and less risk of bleeding complications. It does not require anticoagulant monitoring and dosage adjustments.

A physician is performing a sterile procedure at a patient's bedside. Near the end of the procedure, the nurse thinks that the physician has contaminated a sterile glove and the sterile field. The nurse should

A. report the physician for violating surgical asepsis and endangering the patient.
B. not say anything, because the nurse is not sure that the gloves and field were contaminated.
C. ask the physician whether the contaminated glove and the sterile field have been contaminated.
D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.

D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.
It is the responsibility of the nurse to point out any possible break in surgical asepsis when others are unaware that they have contaminated the field. Reporting the physician is not indicated, nor does it protect the patient. Asking the physician may lead to infection if the physician is unaware of the break in technique that the nurse believes may have happened. Saying nothing does not protect the patient and is negligence on the part of the nurse.

Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

A. Serum sodium level of 140 mEq/L
B. Serum potassium level of 3 mEq/L
C. Hb concentration of 13.5 mg/dl
D. Partial thromboplastin time of 25 seconds

B. Serum potassium level of 3 mEq/L.
Electrolyte imbalances increase operative risk. Preoperative laboratory results should be checked to see whether they are within the normal range. The normal potassium level is 3.5 to 5.0 mEq/L. A low serum potassium level puts the patient at risk for cardiac dysrhythmias. A serum sodium level of 140 mEq/L is considered a normal value. An Hb concentration of 13.5 mg/dl is considered a normal value by most laboratory standards and does not interfere with operative decisions. A partial thromboplastin time of 25 seconds is a normal value and conducive to proceeding with a surgical procedure.

Which of the following is most likely to be effective in meeting a patient's teaching/learning needs preoperatively?

A. Teaching only the patient
B. Teaching the patient and family
C. Using brief verbal instructions
D. Using only written instructions

B. Teaching the patient and family.
A nurse should determine learning needs preoperatively and teach both the patient and the family before surgery. Using only written instructions does not provide the opportunity for evaluation for learning. Brief verbal instructions are often forgotten. Teaching only the patient limits learning preoperatively because the patient can be anxious and not receptive to new information.

Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

A. Excessive thirst
B. Gradual weight gain
C. Overwhelming fatigue
D. Recurrent blurred vision

A. Excessive thirst.
The classic clinical manifestations of diabetes mellitus are increased frequency of urination (polyuria); increased thirst and fluid intake (polydipsia); and as the disease progresses, weight loss despite increased hunger and food intake (polyphagia). Weakness, fatigue, and recurrent blurred vision are associated with diabetes mellitus but are not considered priority manifestations because of the generalization of these complaints being applied to other disease processes. Weight loss is the cardinal sign related to the depletion of water, glycogen, and triglyceride stores.

What would be the most effective way for a nurse to validate "informed consent"?

A. Ask the family whether the patient understands the procedure.
B. Check the chart for a completed and signed consent form.
C. Ask the patient what he or she understands regarding the procedure.
D. Determine from the physician what was discussed with the patient.

C. Ask the patient what he or she understands regarding the procedure.
Informed consent in the health care setting is a process whereby a patient is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done.

If a 77-year-old patient who is NPO after surgery has dry oral mucous membranes, which of the following is the most appropriate nursing intervention?

A. Increase oral fluid intake.
B. Perform oral hygiene frequently.
C. Swab the inside of the mouth with petroleum.
D. Increase the rate of IV fluid administration.

B. Perform oral hygiene frequently.
Frequent oral hygiene will help alleviate discomfort for a patient who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a patient who is NPO.

While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states, "My doctor was here and told me a lot of stuff I didn't understand and then I signed a paper for her." To fulfill the role of advocate, what is the best nursing action?

A. Reassure the patient that the surgery will go as planned.
B. Explain the surgery and possible outcomes to the patient.
C. Complete her first priority, the preoperative teaching plan.
D. Call the physician to return and clarify information for the patient.

D. Call the physician to return and clarify information for the patient.
Examples of nursing advocacy include questioning doctors' orders, promoting patient comfort, and supporting patient decisions regarding health care choices.

A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for

A. laboratory tests and perioperative medications.
B. preoperative and postoperative teaching by the nurse.
C. psychologic support to alleviate fears of pain and discomfort.
D. preoperative nursing assessment related to possible risks and complications.

A. laboratory tests and perioperative medications.
Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychological stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient undergoing surgery, regardless of where the surgery is performed.

A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will

A. decrease nausea and vomiting during and after surgery.
B. decrease oral and respiratory secretions, thereby drying the mouth.
C. decrease anxiety and produce amnesia of the preoperative period.
D. induce sleep, so the patient will not be aware during transport to the operating room.

B. decrease oral and respiratory secretions, thereby drying the mouth.
Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.

The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is

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.
The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction.

Conscious sedation is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care provider's office. The patient asks the nurse, "What is this conscious sedation?" The nurse's response is based on the knowledge that conscious sedation

A. can be administered only by anesthesiologists or nurse anesthetists.
B. enables the patient to respond to commands and accept painful procedures.
C. is so safe that it can be administered by nurses with direction from health care providers.
D. should never be used outside of the OR because of the risk of serious complications.

B. enables the patient to respond to commands and accept painful procedures.
Conscious sedation is a moderate sedation that allows the patient to manage his or her own airway and respond to commands, and yet the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety and/or provide amnesia. It can be administered by personnel other than anesthesiologists, but nurses should be specially trained in the techniques of conscious sedation to carry out this procedure because of the high risk of complications resulting in clinical emergencies.

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 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.

In the absence of postoperative vomiting, GI suctioning, and wound drainage, the physiologic responses to the stress of surgery are most likely to cause

A. diuresis.
B. hyperkalemia.
C. fluid overload.
D. impaired blood coagulation.

C. fluid overload.
Secretion and release of aldosterone and cortisol from the adrenal gland and ADH from the posterior pituitary as a result of the stress response cause fluid retention during the first 2 to 5 days postoperatively, and fluid overload is possible during this time. Aldosterone causes renal potassium loss with possible hypokalemia, and blood coagulation is enhanced by cortisol.

Select all that apply.
Which of the following best describes a consent form?

A. May be signed by an emancipated minor.
B. Protects the health care facility but not the physician
C. Signifies that the patient understands all aspects of the procedure.
D. Signifies that the patient and family have been told about the procedure
E. Must be signed by the patient or responsible party at the health care facility, and that consent may not be obtained by phone or fax

A. May be signed by an emancipated minor. (&)
C. Signifies that the patient understands all aspects of the procedure.
A consent form may be signed by an emancipated minor, and consent may be obtained by fax or phone with appropriate witnesses. Only in the cases of underage children or unconscious or mentally incompetent people must a family member be aware of the procedure. The document protects the surgeon and the health care facility in that it indicates that the patient knows and understands all aspects of the procedure.

Select all that apply.
Advantages of laser surgery include diminished

A. bleeding.
B. swelling.
C. tissue damage.
D. postoperative pain.
E. postoperative infection.

A, B, C, D, & E
(All of the above)
Laser surgery offers the benefits of diminished bleeding, swelling, tissue damage, and postoperative pain and infection.

Select all that apply.
A nurse is caring for a surgical patient in the preoperative area. The nurse obtains the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent?

A. Informed consent must be signed while the patient is free from mind-altering medications.
B. Informed consent must be witnessed.
C. Informed consent may be withdrawn at any time.
D. Informed consent must be signed by patients age 16 and older.
E. Informed consent must be obtained by the physician.
F. Informed consent must be obtained from the family even in a life-threatening emergency.

A. Informed consent must be signed while the patient is free from mind-altering medications.
B. Informed consent must be witnessed.

An informed consent must be signed while the patient is free from mind-altering medications and must be witnessed after it has been determined that the patient has received all of the necessary information needed to make an informed decision. An informed consent may be withdrawn at any time before the procedure and must be signed by patients age 18 and older. A parent or guardian's signature is required for minors. The informed consent may be obtained by the physician or the nurse and is not required in the event of a life-threatening emergency.

Select all that apply.
A nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly?

A. A 20-year-old unconscious patient
B. A 90-year-old frail patient
C. A 65-year-old patient who is visually impaired
D. A 40-year-old patient who has paraplegia

A. A 20-year-old unconscious patient
B. A 90-year-old frail patient (&)
D. A 40-year-old patient who has paraplegia

Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed.

What are some common Nursing Interventions to reduce risk/avoid post-op complications?

1. Turn & reposition the pt to promote circulation and reduce the risk of skin breakdown, especially over boney prominences.
Initially position pt in a Lateral recumbant position until arousal from anesthesia, then position pt in Semi or Fowler position to reduce breathing effort.
2. Encourage coughing & deep breathing.
This helps clear anestetics from the body, lowers risk of pulmonary/fat emboli, and hypostatic pneumonia associated with secretion buildup in the airways.
3. Encourage use of Incentive Spirometer.
4. Monitor In's and Out's.
Hydration and protein rich nutrition promotes healing and provides energy to meet the needs of the pts increased metabolism associated with surgery.
5. Promote early ambulation.
Early post-op exercise and ambulation significantly reduce the risk of thromboembolism.

Definition:
Atelectasis

Respiratory complication when the alveoli within the lung becomes deflated, resulting in a complete or partial collapse of a lung.

Common causes/ risk factors:
Atelectasis

Respiratory complication that may be the result of a blocked airway, diminished surfactant, or mucus plug.
Recent general anesthesia, shallow breathing, respiratory muscle weakness and immobility are common risk factors.

The reason pts are sent to a PACU after surgery is:

A. to be monitored while recovering from anesthesia.
B. to remain near the surgeon immediately after surgery.
C. to allow the medical-surgical unit time to prepare for transfer.
D. to provide time for the pt to cope with the effects of surgery.

A.
Pts are sent to a PACU to be monitored while they're recovering from anesthesia.

Which statement should be stressed while giving instructions after adrenalectomy?

A. Stop taking medication when pts physical appearance improves.
B. Pt should take steroids on an empty stomach.
C. Pt should take the prescribed medication as directed.

C.
The pt should take prescribed medication as directed. Sudden withdrawl of steroids can precipitate adrenal crisis.

An adrenal crisis is characterized by all of the signs and symptoms except:

A. weakness and fatigue
B. nausea & vomiting
C. hypotension
D. sodium & fluid retention

D.
Sodium and fluid retention are characteristics of Cushing's Syndrome.
Adrenal crisis causes decreased sodium levels and hypotension.

Which statement about diabetes mellitus is false?

A. Type 2 diabetes commonly occurs in adults <40 yr. old.
B. Type 1 diabetes usually occurs before age 30.
C. Type 1 diabetes is treatable with exercise, meal planning, and antidiabetic drugs.
D. An increasing number of adolescents are being diagnosed with type 2 diabetes.

C.
Type 1 diabetes is treated with insulin and dietary management.

Patients may experience which problem 24-48 hrs post-op as a result of anesthetics?

A. colitis
B. Stomatitis
C. Paralytic ileus
D. Gastrocolic reflux

C.
After surgery, pts are clients are at risk for paralytic ileus as a result of anesthesia.

What are some common RN interventions to prevent/ minimize paralytic ileus?

The nurse can prevent/minimize paralytic ileus after surgery with pt positioning and early ambulation.
Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool.

A pt has returned from surgery with a tracheostomy tube in place. After about 10 minutes in postoperative recovery, the pt begins to have noisy, increased respirations and an elevated heart rate. What action should the RN take immediately?

A. Suction the tracheostomy.
B. Readjust the tracheostomy tube and tighten the ties.
C. Preform a complete respiratory assessment.

A.
Noisy, increased respiration & increased pulse are signs that the pt needs immediate suctioning to clear the airway of secretions. A complete respiratory assessment may then be completed.

A nurse is assessing a pt with a closed chest tube drainage system connected to suction. Which finding would require additional evaluation in the post-operative period?

A. 75ml of bright red drainage in the system.
B. A column of water 20cm high in the suction control chamber.
C. Constant bubbling in the water seal chamber.

D.
Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire system to the pt to find the sourse of he leak. The leak may be with in the pts chest or at the insertion site. If it is, notify physician. This could cause the lung to collapse due to a buildup of air pressure within the plural cavity.

A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as:

A. Transplantation surgery
B. Constructive surgery
C. Palliative surgery
D. Reconstructive surgery

B) Cleft palate repair considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting. Transplant surgery replaces organs or structures that are diseased or malfunctioning, such as a liver or kidney transplant. Palliative surgery is not a curative and seeks to relieve or reduce the intensity of an illness, such as debridement or necrotic tissue.

Upon assessment, a patient reports that he drinks 5-6 bottles of beer every evening after work. Based upon this information, the nurse is aware that the patient may require:

A. Larger doses of anesthetic agents and larger doses of postoperative analgesics.
B. Larger doses of anesthetic agents and lower doses of postoperative analgesics.
C. Lower doses of anesthetic agents and larger doses of postoperative analgesics.
D. Lower doses of anesthetics agents and lower doses of postoperative analgesics.

A) Patients with a larger habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.

The nurse is providing teaching to a patient regarding pain control after surgery. The nurse informs the patient that the best time to request pain medication is:

A. Before the pain becomes severe.
B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale.
C. After the pain becomes severe and relaxation techniques have failed.
D. When there is no pain, but it is time for the medication to be administered.

A) The question states that the patient is being instructed on when to "request" pain medication. If a pain medication is ordered PRN, the patient should be instructed to ask for the medication before the pain becomes severe.

The nurse is preparing to send a patient to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the patient's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the patient. The nurse's best action to the physician's request is to:

A. Inform the physician that is his responsibility to obtain the signature.
B. Obtain the signature and ask another nurse to co-sign the signature.
C. Inform the physician that the nurse manager will need to obtain the signature.

A) The responsibility for securing informed consent from the patient lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his responsibility to obtain the signature.

The PACU has received a semiconscious patient from the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. In this situation, in what position will the nurse place the patient?

A. Trendelenburg position
B. Prone position
C. Side-lying position
D. Supine position

C) If the patient is not fully conscious, place the patient in the side-lying position, unless there is an ordered position on the patient's chart.

The nurse is preparing a patient for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia os commonly used for his procedure?

A. Spinal anesthesia
B. Nerve block
C. Conscious sedation
D. Epidural anesthesia

C) Moderate sedation/analgesia is also known as conscious sedation or procedural sedation and is used for short-term and minimally invasive procedures such as a colonoscopy.

The telemetry unit nurse is reviewing laboratory results for a patient who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the patient has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the patient's operative risk for:

A. Cardiac problems
B. Bleeding with anemia
C. Fluid imbalances
D. Infection

A) Hyper/hypokalemia increases the patient's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated WBC occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.

Upon admission for an appendectomy, the patient provides the nurse with a document that specifies instructions his healthcare team should follow in the event he is unable to communicate these wishes postoperatively. This document is best known as:

A. An informed consent
B. An insurance card
C. A Patient's Bill of Rights
D. An advance directive

D) An advance directive, a legal document, allows the patient to specify instructions for his or her healthcare treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the patient to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for healthcare.

A patient returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to:

A. Hold all medications.
B. Avoid strong smelling foods.
C. Avoid oral hygiene until the nausea subsides.
D. Provide clear liquids with a straw.

B)Nursing care for a patient with nausea includes avoiding strong smelling foods. Providing oral hygiene, administering prescribed medications (especially if medications ordered are anti-nausea/antiemetics), and avoid the use of a straw.

The operating room is aware that which of the following patients are at a greater risk related to a surgical procedure?

A. 34 yr old female
B. 83 yr old female
C. 48 yr old male
D. 8 yr old male

B)Infants and older adults are at greatest risk from surgery than are children and young or middle-aged adults. Physiologic changes associated with aging increase the surgical risk for older patients.

A client who is started on metformin and glyburide would have initially present with with symptoms?

A. Polydipsia, polyuria, and weight loss
B. Weight gain, tiredness, and bradycardia
C. irritability, diaphoresis and tachycardia
D. Diarrhea, abdominal pain and weight loss

A) symptoms of hyperglycemia included polydispia, polyuria, and weightloss. Metformin and sulfonylureas are commonly ordered medications. Weight gain, tiredness, and bradycardia are symptoms of hypothyroidism. Irritability, diaphoresis, and tachycardia are symptoms of hypoglycemia. Symptoms of Crohn's disease include diarrhea, abdominal pain, and weight loss.

What drug classes are used as adjuncts to general anesthesia?

Opioids, Benzodiazepines, Neuromuscular Blocking Agents, & Antiemetics

Which benzo is most frequently used as an anesthesia adjunct?

midazolam (Versed): Because of its excellent amnesic property, shorter duration of action, and absence of pain on injection. The other agents in this drug class are limited in their usefulness because of their long duration of action.

What is the antagonist that may be used to reverse marked benzodiazepine-induced respiratory depression?

Flumazenil (Romazicon)

Decreased SaO2 recorded by pulse oximetry is a late sign of respiratory depression. Assessment of respiratory rate and depth is critical in the management of the patient who has received ___________.

Opioids

Opioid-induced respiratory depression can be reversed with ___________.

naloxone (Narcan)

What are the four levels of sedations?

(1) At minimal sedation the patient responds normally; (2) at moderate sedation/analgesia (conscious sedation) airway and cardiovascular function are maintained; (3) at deep sedation/analgesia the patient is not easily aroused; and (4) at anesthesia level the patient requires assisted ventilation.

For conscious sedation often a combination of _______ and ______ drugs are used to provide analgesia, relieve anxiety, and/or provide amnesia.

anxiolytic (e.g., midazolam [Versed]) and opioid (e.g., fentanyl)

T/F Conscious sedation is within the RN's scope of practice.

True: Although managing the care of patients receiving conscious sedation falls within the professional nurse's scope of practice, the risks of conscious sedation for the patient are considerable.

Anesthesia can be classified into which three categories?

General, Local, & Regional

Antiemetics are used prophylactically in patients who are most at risk for nausea and vomiting associated with anesthesia. Who is considered to be at the highest risk?

At highest risk is the female nonsmoker with a history of motion sickness.
(Risk factors include gender, age, smoking history, history of motion sickness, and history of prior postoperative nausea.)

______ is a commonly administered dissociative anesthetic.

Ketamine (Ketalar): particularly advantageous because it can be administered intravenously or intramuscularly; it is a potent analgesic and amnesic. It is used in asthmatic patients undergoing surgery because it promotes bronchodilation and in trauma patients requiring surgery because it increases heart rate and helps maintain cardiac output.

What is EMLA cream?

Eutectic mixture of local anesthetics (EMLA cream), a combination of lidocaine and prilocaine, can be applied to the skin to produce localized dermal anesthesia. EMLA should be applied to the site 30 to 60 minutes before painful procedures.

Spinal anesthesia involves the injection of a local anesthetic into __________.

the cerebrospinal fluid found in the subarachnoid space, usually below the level of L2.

A spinal anesthetic produces an autonomic, sensory, and motor blockade. What does the pt experience with each blockade?

Patients experience vasodilation and may become hypotensive as a result of the autonomic block, feel no pain as a result of the sensory block, and are unable to move as a result of the motor block.

An epideral catheter allows for continued use into the postoperative period, this method of analgesia uses lower doses of epidurally administered local anesthetic, usually in combination with an _______.

opioid

During epideral or spinal anesthesia the patient must be closely observed for signs of autonomic nervous system blockade, including......

hypotension, bradycardia, nausea, and vomiting.
Should "too high" a block be achieved, the patient may experience inadequate breathing and apnea.

A technique used to decrease the amount of expected blood loss by lowering the blood pressure during the administration of anesthesia is called _________.

controlled hypotension

The deliberate lowering of body temperature to decrease metabolism, thus reducing both the demand for oxygen and anesthetic requirements is called ________.

hypothermia

Cryoanesthesia involves ____ or ______ a localized area to block pain impulses.

cooling or freezing

Two catastrophic events that could occur in the OR are.....

analphylactic reactions or malignant hyperthermia

An anaphylactic reaction causes ______, _______, _________, and possibly _______.

hypotension, tachycardia, bronchospasm, and possibly pulmonary edema.

_________ is a rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death.

malignant hyperthermia

What appears to be the primary trigger of malignant hyperthermia, although other factors, such as stress, trauma, and heat, have been implicated?

Succinylcholine (Anectine), especially in conjunction with the volatile inhalation agents

To prevent malignant hyperthermia, it is important for the nurse to obtain a careful family history and be alert to its development perioperatively, why?

MH is genetic (although inconsistant) & the patient known or suspected to be at risk for this disorder can be anesthetized with minimal risks if appropriate precautions are taken.

Unless promptly detected with rapid initiation of appropriate intervention, malignant hyperthermia can result in ______ and ________.

cardiac arrest and death

The definitive treatment of malignant hyperthermia is prompt administration of _______.

dantrolene (Dantrium), which slows metabolism, along with symptomatic support to correct hemodynamic instability, acidosis, hypoxemia, and elevated temperature.

Surgeons often require that patients not take any aspirin or NSAIDs for how long before surgery?

1 to 2 weeks

It is important to consider the effects of opioids and prescribed medications for heart disease, hypertension, immunosuppression, seizure control, anticoagulation, and endocrine replacement because of the interactions they may have with anesthetics.

For example, tranquilizers potentiate the effect of opioids and barbiturates, which are agents that can be used for anesthesia. Antihypertensive drugs may predispose the patient to shock from the combined effect of the drug and the vasodilator effect of some anesthetic agents. Insulin or oral hypoglycemic agents may require dose or agent adjustments during the perioperative period because of increased body metabolism, decreased caloric intake, stress, and anesthesia. Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) may inhibit platelet aggregation and may contribute to postoperative bleeding complications.

Nutritional deficiencies of ______ and vitamins ___, ___, & ______ are particularly significant because these substances are essential for wound healing.

protein and vitamins A, C, and B complex

What are the three phases of the PACU?

Phase I postanesthesia care involves providing intensive monitoring and care of the patient in the immediate postoperative period. Patients move from Phase I care either to Phase II care in the PACU or to an inpatient unit. Phase II postanesthesia care provides less intensive care to surgery patients who will then be transferred to Phase III care, to home, or to an extended care facility. Phase III postanesthesia care is provided when patients are being prepared for self-care and discharge from the surgical facility.

EKG monitoring would be which phase of the PACU?

Phase 1

On addmission to phase 1 of the PACU the priority nursing assesment is.....

Assessment should begin with an evaluation of the airway, breathing, and circulation (ABC) status of the patient.

What is the first sense to return in the unconscious patient?

Hearing: because hearing is the first sense to return in the unconscious patient, the nurse should explain all activities to the patient from the moment of his or her admission to the PACU.

Common causes of airway compromise include obstruction, hypoxemia, and hypoventilation. Which patients are at the most risk for respiratory problems?

Patients at risk include those who have had general anesthesia, are older, smoke heavily, have lung disease, are obese, or have undergone airway, thoracic, or abdominal surgery.

An unconscious pt should be put in which position?

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if vomiting occurs. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated. This position maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

To help the patient prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. The patient should be encouraged to do what?

Breathe deeply 10 times every hour while awake. The use of an incentive spirometer is helpful.

The patient's position should be changed how often?

Every 1 to 2 hours to allow full chest expansion and to increase perfusion of both lungs. Ambulation, not just sitting in a chair, should be aggressively carried out as soon as physician approval is given.

A urine output of at least __________ is generally considered indicative of adequate renal function.

0.5 ml/kg/hr

What may form in leg veins as a result of inactivity, body position, and pressure, all of which lead to venous stasis and decreased perfusion?

Deep Vein Thrombosis (DVT)

The most common cause of postoperative agitation in the PACU is _____.

hypoxemia

Temperature variation in the postoperative period provides valuable information about the patient's status. Fever may occur at any time during the postoperative period. A mild elevation (up to 100.4° F [38° C]) during the first 48 hours usually reflects the ____(a)______. A moderate elevation (higher than 100.4° F [38° C]) is caused more frequently by _____(b)______ . After the first 48 hours, a moderate to marked elevation (higher than 99.9° F [37.7° C]) is usually caused by ___(c)______.

(a)surgical stress response
(b)respiratory congestion or atelectasis and less frequently by dehydration
(c)infection

The patient's temperature is usually measured every ______ hours for the first 48 hours postoperatively.

4

When using any external warming device, body temperature should be monitored at _______ minute intervals, and care should be taken to prevent skin injuries. In addition, oxygen therapy via nasal prongs or mask is used to treat the increased demand for oxygen accompanying the increase in body temperature.

15 min intervals

Following abdominal surgery, motility in the large intestine may be reduced for __(a)___, although motility in the small intestine resumes within ____(b)___.

(a) 3 to 5 days
(b) 24 hours

Depending on the nature of the surgery, the patient may resume oral intake as soon as the ____(a)___ returns. The patient who had abdominal surgery is usually allowed nothing by mouth (NPO) until the presence of ____(b)_____ .

(a) gag reflex
(b) bowel sounds indicates the return of peristalsis

T/F: Low urine output (800 to 1500 ml) in the first 24 hours after surgery may be expected, regardless of fluid intake.

True: This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery, fluid restriction before surgery, and fluid loss through surgery, drainage, and diaphoresis. By the second or third day, the patient will begin to have increasing urinary output after fluid has been mobilized and the immediate stress reaction subsides.

Most patients urinate within ________ after surgery. If no voiding occurs, the abdominal contour should be inspected and the bladder assessed for distention.

6 to 8 hours

T/F: A small amount of serous drainage is common from any type of wound.

True: In general, drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear yellow). The drainage output should decrease over hours or days, depending on the type of surgery.
-Wound infection may be accompanied by purulent drainage.
-Wound dehiscence (separation and disruption of previously joined wound edges) may be preceded by a sudden discharge of brown, pink, or clear drainage.

If there is no wound drainage after 24 to 48 hours, the dressing may be......

removed and the incision left open to the air.

There are two types of glands, what are they?

exocrine glands and endocrine glands. Exocrine glands secrete their substances into ducts that then empty into a body cavity or onto a surface (e.g., skin). For example, salivary glands produce saliva, which is secreted through salivary ducts into the mouth. By contrast, endocrine glands do not have ducts. They secrete their substances directly into the blood.

The action of oxytocin in childbirth is an example of which feedback for hormone regulation? (The hormone oxytocin from the posterior pituitary stimulates and increases uterine contractions. Oxytocin's release is stimulated by pressure receptors in the vagina. As the fetus enters the vagina during childbirth, the pressure receptors sense increased pressure and signal the brain to release more oxytocin. Oxytocin release leads to stronger uterine contractions. With birth, the stimulus to the pressure receptors in the vagina ends, thus leading to decreased oxytocin secretion.)

positive feedback

The pattern of insulin secretion is a physiologic example of which type of feedback between glucose and insulin? (Elevated blood glucose levels stimulate the secretion of insulin from the pancreas. As blood glucose levels decrease, the stimulus for insulin secretion also decreases.)

negative feedback

The major physiologic role of ADH is what?

regulation of fluid volume by stimulating reabsorption of water in the renal tubules. ADH, also called vasopressin, is also a potent vasoconstrictor.

ADH and oxytocin come from the ___(a)___ which is essentially an extension of the ___(b)______.

(a) posterior pituitary
(b) hypothalamus

Iodine is necessary for the synthesis of which hormones?

the thyroid hormones, thyroxine (T4) and triiodothyronine (T3)

The major role of parathyroid hormone is regulate the blood level of what?

calcium: When the serum calcium level is low, PTH secretion increases; when the serum calcium level rises, PTH secretion falls.

The most common nonspecific symptoms of an endocrine disorder are what?

fatigue and depression
They often are accompanied by other manifestations such as changes in energy level, alertness, sleep patterns, mood, affect, weight, skin, hair, personal appearance, and sexual function.

A fasting blood glucose level between 100 & 126 would be considered___________.

prediabetic

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