Hodgepodge
11.56 The Phase 1 PACU perianesthesia nurse receives a patient from the OR. This nurse knows that a report must be received from the anesthesia provider, vital signs must be obtained, an initial assessment must be completed and:
a. Electronic documentation must be initiated
b. Clinical monitors must be connected
c. Thorough skin and wound assessment must be conducted
d. Transfer of care must be accepted or acknowledged
D. Transfer of care must be accepted or acknowledged
ASPAN Practice Recommendations defines the critical elements of accepting a patient into Phase 1 to include handoff report.
2.13 Signs and symptoms associated with OSA include all of the following EXCEPT:
a. impotence
b. nocturia
c. hypotension
d. loud snoring
C. hypotension
4.1 Patients who are hypothermic after surgery require gradual rewarming in the Phase 1 PACU to prevent:
a. Fluid loss
b. Hypotension
c. Nausea
d. Bradycardia
B. Hypotension
If a patient is warmed rapidly, it can lead to vasodilation and therefore hypotension.
2.28 A 73-year-old patient arrives in the procedural Phase 2 PACU after his fistulogram. He has been assessed by the nurse, and his vital signs are stable. He has a good thrill and bruit on his left AV fistula. Preoperatively, he was not assessed to be a fall risk. The patient tells the nurse that he needs to urinate and cannot urinate in a supine position. What should the nurse do?
a. Because the patient needs to remain supine for 1 hour, provide a urinal
b. Offer to raise the head of the bed so that the patient can try to urinate in a sitting position
c. Assist the patient to ambulate to the bathroom to urinate
d. Allow the patient to stand at the bedside with the curtain pulled for privacy
C. Assist the patient to ambulate to the bathroom
This patient may ambulate after the procedure as long as they are hemodynamically stable.
10.35 Which of the following descriptions does NOT generally apply to the learning style of an adult?
a. Self-directed
b. Relies on experience
c. Problem centered
d. Tactile oriented
The adult learner is motivated internally, self-directed, and self-governed. They use past experiences as a resource and may have difficulty accepting new concepts and have a problem-centered orientation to learning.
3.55 The basics of care for vomiting in the Phase 1 PACU include giving oxygen immediately and placing the patient in:
a. Semi-Fowler's position with head turned to one side.
b. Head-down position
c. High-Fowler's position, head forward
d. Left lateral position
B. Head down
The head- down position is to allow fluid to flow away from the lungs rather than into the lungs.
4.3 Neonates are intolerant of both dehydration and fluid overload. This is because:
a. Their larger body surface area allows for more insensible fluid loss
b. Neonates' increased metabolic rate causes more fluid shifts
c. Neonates retain sodium, rapidly clear fluid overload, and conserve fluid
d. Neonates low sodium, slowly clear fluid overload, and have an inability to conserve fluid
D. Neonate renal function is characterized by obligate sodium loss, slow clearance of fluid overload, adn an inability to conserve fluid.
3.53 Assessment of motor and sensory functioning in the immediate postoperative period is:
a. Necessary to know when motor function returns to normal
b. An essential part of an ongoing neurological assessment compared with baseline function
c. Focused on laterality changes
d. Done to determine movement that increases pain intensity
B. An essential part of an ongoing neurological assessment compared with baseline function
It is essential that there is a preprocedure neurological assessment on which to measure postoperative function.
7.24 When providing discharge instructions, the perianesthesia nurse in the Phase 2 PACU reiterates the need to call a physician when there is pain not relieved by the prescribed pain management protocol, bleeding beyond the expected volume, symptoms of urinary retention, and a fever with a temperature above:
a. 37.8C
b. 38C
c. 38.3C
d. 39C
C. 38.3C or 101F
10.13 Patient education is more effective when the content and methods are:
a. Individualized for the patient and family
b. Generic and scripted
c. Standardized
d. Incorporating medical and technical terminology
A. Individualized for the patient and family
Care should be tailored to the individual and family and their learning characteristics.
The patient awakens in the operating room under the observation of the anesthesia care provider. To ensure patient safety and proceed directly to Phase II care, the perianesthesia nurse understands the MOST important element for safe fast tracking is that the patient must:
a. Meet Phase 1 discharge criteria in the OR
b. Be pain free at the end of surgery
c. Meet Phase 1 discharge criteria within minutes of arrival to Phase 2
d. Be free of PONV at the end of surgery
A. Meet Ph 1 discharge criteria in the OR
According to ASPAN Fast Tracking Practice Recommendations, appropriate patient assessment must be conducted in the OR at the end of the procedure by the anesthesia provider and include the same criteria which determines readiness for discharge from Phase 1 level of care.
4.21 The most common skin injuries related to surgical positioning are:
a. Pressure injuries
b. Superficial areas of ecchymosis
c. Breaks in skin integrity from shearing
d. Multiple variegated petechiae
2.46 After general anesthesia, while the patient is in the Phase 1 PACU, cardiac rate and rhythm are monitored:
a. Continuously
b. For 30 minutes
c. For 1 hour
d. For 4 hours
In the immediate postop period, dysrhythmias are likely due to light anesthesia during emergence or due to drugs given that alter sympathetic activity.
10.30 The BEST time to provide discharge instructions is:
a. Just before the discharge to enhance retention of information
b. Just before going to the operating room to distract from preoperative anxiety
c. During the preoperative nursing assessment for early review
d. During the postoperative follow-up visit with the surgeon
C. During the preoperative nursing assessment
Ideally, discharge instructions are provided before the day of surgery to help prepare the patient and family.
9.23 While caring for a 5-year-old patient in the Phase 2 PACU, what approach or techniques will the nurse incorporate to enhance discharge teaching?
a. Speaking clearly to the parents
b. Hands on experience for the child
c. Plan teaching to last 5 to 10 minutes
d. Parallel play to clarify the topic
B. Hands-on experience for the child
Children between the ages of 4 and 7 have demonstrated hands-on experiences work well. The information provided should be short and concise, and the amount of time spent on the topic should be less than 5 minutes.
7.33 The most common clinical symptom of malignant hyperthermia is:
a. masseter jaw spasm
b. unstable blood pressure
c. hypercarbia
d. hypoxia
C. hypercarbia
4.63 In patients with multiple skin folds and redundant skin, the nurse is aware that a thorough inspection of the skin is necessary to determine if there are any excoriations or rashes. Problem areas tend to be found in the groin, perineum, axilla, and large skin folds, and:
a. Between the toes
b. Behind the knees
c. Under the chin folds
d. Beneath the breasts
D. Beneath the breasts
Issues with break down are related to impaired hygiene due to the difficulty the patient has with reaching and properly cleaning and drying skin.
10.17 When teaching a patient to deep breathe and cough after surgery, the nurse has the patient:
a. Take a rapid deep breath and cough once as she or he lets the breath out quickly
b. Take a rapid deep breath and cough multiple times as he or she lets the breath out at decreasing lung volumes
c. Take slow deep breaths and cough once as he or she lets the breath out slowly
d. Take slow deep breaths and cough multiple times as he or she lets the breath out quickly
B. Take a rapid deep breath and cough multiple times as he/she lets the breath out at decreasing lung volumes
Cough effectiveness depends on the inspired tidal volume and the velocity of expired air flow. The cascade cough is the most effective method.
11.9 When discharging a 6-month-old after a bilateral myringotomy and tube placement, the Phase 2 PACU nurse evaluates all of the following EXCEPT:
a. Interactions between the child and parent or significant other
b. Patient and home care provider knowledge of discharge instructions
c. Ability of the home care provider to demonstrate how to measure temperature
d. Transportation plans to include a second responsible person to sit with the child
C. Ability of the home care provider to demonstrate how to measure temperature
10.24 The best way to evaluate patient and family understanding of instructions given is:
a. Ask if they understand the information
b. Ask them to teach the information back to you
c. Provide the patient and family with a written quiz based on the information given
d. Have them sign an attestation form
B. Ask them to teach the information back to you
Asking the patient to teach the information back to the nurse in their own words allows the nurse to check for understanding.
2.18 Signs and symptoms of bronchospasm include:
a. cough, expiratory wheezing, and dyspnea
b. bradycardia, inspiratory wheezing, and tachypnea
c. crowing respirations, fever, and use of accessory muscles
d. cough, sneezing, and bradycardia
A. cough, expiratory wheezing, and dyspnea
2.50 Risks and complications specific to pulmonary artery catheter monitoring include:
a. perforation of the left ventricle
b. rupture of the aorta
c. perforation of the aorta
d. perforation of the right ventricle
D. perforation of the right ventricle
11.1 While caring for the Phase 1 PACU patient, the perianesthesia nurse ensures patient safety by providing 1:1 care until critical elements are met. Critical elements include an initial nursing assessment, ensuring that the patient has a stable airway and hemodynamic stability, the patient is free from restlessness or combative behavior, and:
a. The patient is able to deep breathe and cough
b. The patient can comply with a stir-up regimen
c. Transfer of care has taken place
d. Clinical monitors have been applied
C. Transfer of care has taken place
Critical elements defined by ASPAN include report has been received from the anesthesia care provider, questions answered, and transfer of care has taken place, along with the other elements listed.
11.31 The frequency with which the Phase 2 perianesthesia nurse documents on a patient is:
a. Every 5 minutes
b. Every 10 minutes
c. Every 15 minutes
d. As per institutional policy
D. Per institutional policy
Documentation should be accurate, comprehensive, objective, and legible. It should be done as promptly as possible, but no recommendation exists reguarding specific time frames.
10.28 Based on theories of growth and development, school-aged children:
a. Experience separation anxiety
b. Fear body mutilation
c. Learn through play
d. Have short attention spans
B. Fear body mutilation
School-aged children fear other body parts may be hurt during the operation.