Deck 10: Postoperative Patient Care and Pain Management

Question 1

There are many therapeutic management strategies that have been successful in treating PONV.What evidence-based practice best improves patient comfort,readiness for discharge,and satisfaction with care?

A) Administration of promethazine as soon as the patient complains of nausea
B) Pharmacologic prophylaxis
C) Prophylaxis paralleled with anesthesia induction
D) Administration of postoperative opioids

Answer 1

B
Management of nausea and vomiting begins preoperatively and continues into the intraoperative period.Preventive therapy for patients at high risk of PONV is effective in reducing its incidence.There is no single method to prevent or treat PONV.Many causative factors relate to anesthesia and surgery.Pharmacologic prophylaxis improves patient comfort,readiness for discharge,and satisfaction with care.

Question 2

Delirium is described as an extreme disturbance of arousal,attention,orientation,perception,affect,and intellectual function accompanied by fear and agitation.What is the most common cause of postoperative agitation?

A) Organic brain disease
B) Hypoxemia
C) Preoperative anxiety
D) Excessive blood loss

Answer 2

B
Causes of agitation range from residual effects of anesthetics to pain and anxiety.Hypoxemia is ruled out first; it remains the most common cause of postoperative agitation.

Question 3

The initial primary assessment by the perianesthesia nurse,on the patient's admission to the postanesthesia care unit (PACU),begins with which criterion?

A) Patient's level of consciousness and hanging intravenous (IV) fluid level
B) Patient identification using attached identification (ID) band with two identifiers
C) Vital signs and ABCs, beginning with the respiratory system
D) The surgical/interventional procedure performed and surgeon

Answer 3

C
After the immediate primary assessment of the ABCs and completion of the hand-off report,the PACU nurse begins a more thorough postanesthesia assessment.The assessment is performed quickly and is specific,in part,to the type of operative procedure.Recommended elements of an initial assessment in the PACU are presented in Box 10-2.

Question 4

An opioid-naïve patient,one who has not used short-acting opioids in the last 60 days,resedated on admission to the PACU and received which opioid antagonist to reverse the respiratory depression?

A) Romazicon
B) Ropivicaine
C) Naloxone
D) Pavulon

Question 5

Select the most reliable indicator of pain.

A) A proxy pain rating by someone who knows the patient well
B) Facial grimacing and crying
C) The patient's self-report of pain
D) Physiologic indicators, such as elevated vital signs

Question 6

Evidence indicates that early analgesia reduces postoperative problems.Recent studies endorse the multimodal approach to both preemptive (preventative)and postoperative analgesia customized to patient needs based on meticulous preoperative assessment.A 72-year-old physically active woman was seen in the preoperative admission center in preparation for her total knee replacement surgery on Thursday.She has not had any opioid medications in her lifetime that she can remember.She has inflammatory bowel and gastric disease and was told she cannot take ibuprofen in any form.Select a multimodal analgesic treatment plan that would best serve the patient's perianesthesia experience.

A) Intraoperative: Preincision-IV opioids, local lidocaine injection into the incision site before skin closure. Postoperative: Patient-controlled analgesia (PCA) with opioids and nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Intraoperative: Preincision-regional block, IV opioids during the procedure. Postoperative: PCA with opioids and nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative: Systemic analgesia with COX-2-selective inhibitors, IV PCA with strong opioids
D) Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative: Systemic analgesia with COX-2-selective inhibitors, IV PCA with strong opioids (titrated to effect), and IM meperidine

Question 7

Postoperative nausea and vomiting (PONV)is a problem that affects approximately 30% of PACU patients.Patients with four or more risk factors have a higher incidence of PONV.Select the option that best reflects relevant risk factors for PONV.

A) Reaction to nitrous oxide, atopy, postmenopausal, use of volatile anesthetics
B) Latex sensitivity, male gender, use of halogenated gas induction
C) Predisposition to malignant hyperthermia, night sweats, motion sickness, male gender
D) Nonsmoker, female gender, postoperative opioids, use of nitrous oxide

Question 8

Select the patient who is the most vulnerable and at high risk for hypothermia in the perianesthesia phase based on diagnosis or surgical procedure.

A) A 62-year-old patient who recently lost 80 lb after a gastric sleeve and is scheduled for a cataract extraction.
B) A 3-year-old child with otitis media having bilateral myringotomy with tube placement.
C) A 3-week-old neonate undergoing surgery for a cardiac anomaly.
D) A 26-year-old patient undergoing escharotomy (fasciectomy) of an ankle with second- and third-degree burns.

Question 9

A 33-year-old female,who had a dilation and curettage (D&C)with laparoscopic tubal ligation and has been in phase II recovery for 3 hours,collapsed while sitting on the toilet.The perianesthesia nurse had recently finished giving the patient her discharge instructions and helped her dress.The patient was assessed for loss of consciousness and airway patency.What action should the phase II nurse take next?

A) Transfer the patient back to phase I PACU and begin airway interventions.
B) Determine if the patient has resedated and is a candidate for a dose of naloxone.
C) Begin airway interventions; revert to phase I criteria.
D) Initiate a cardiac arrest call and get the code cart; prepare to intubate.

Question 10

Hypotension is a blood pressure reading that is 20% less than the patient's normal baseline pressure.Hypovolemia is the most common cause of hypotension; however,hypotension may also be caused by cardiac dysfunctions.Which triad of cardiac conditions will present with hypotension?

A) Myocardial infarction, myocardial tamponade, and pulmonary embolism
B) Cardiac ischemia, subaortic stenosis, and pericarditis
C) Congestive heart failure, valvular dysfunction, and tachypnea
D) Certain anesthetic agents and cardiac stimulants, conduction defects, and endocarditis

Question 11

Select the statement below that best reflects the effects of hypothermia in the perianesthesia period.

A) Hypothermia shortens the period of elimination of muscle relaxants.
B) Hypothermia has often been shown to cause life-threatening morbidities.
C) Shivering can increase the need for oxygen by 300% to 400%.
D) Hypothermia increases platelet activity and decreases fibrinolysis.

Question 12

A healthy 18-year-old was admitted to the PACU spontaneously breathing through his endotracheal tube.Shortly after the perianesthesia nurse extubated the patient,he stopped breathing and his color changed to pale,dusky-beige.What is the most ideal action that should occur immediately?

A) Administer oxygen 5 L/min by nasal cannula.
B) Administer oxygen 5 L/min by bag-valve-mask.
C) Perform head tilt-chin lift with gentle stimulation.
D) Reintubate and manually ventilate with bag-valve-mask at 4 L/min oxygen.

Question 13

A patient,who collapsed while sitting on the toilet,admitted that she had been straining while seated on the toilet.The anesthesia provider and perianesthesia nurse surmised that the patient experienced a vagal response,which led to bradycardia and syncope (fainting).The patient's heart rate and blood pressure are less than 20% of her admission parameters; she is awake and lucid and is able to appropriately follow commands.What phase of the nursing process will impact the patient's next step and what can she expect?

A) The assessment phase: The nurse will pursue laboratory diagnostic chemistry panels and arterial blood gases to determine oxygenation and potential for internal bleeding.
B) The planning phase: The nurse will compare current vital signs and symptoms to admission values, and the patient will continue to be monitored with IV fluids.
C) The implementation phase: The nurse will administer a titrated IV atropine until the patient's blood pressure and heart rate are at or above preadmission values.
D) The evaluation phase: The nurse will initiate a period of watchful waiting while she receives IV fluids and sips juice.

Question 14

Laryngospasm is a common but serious complication in the immediate postoperative pediatric tonsillectomy and adenoidectomy patient.What is the ideal immediate and last resort response by the anesthesia provider or perianesthesia nurse in an emerging patient who has been in spasm for over 1 minute,is not responding to positive-pressure ventilation,and is in significant distress?

A) Gentle stimulation and bag-valve-mask ventilation with oxygen
B) Suctioning, IV succinylcholine administration, and reintubation
C) Emergency tracheostomy with a cricothyrotomy approach
D) IV bronchodilator administration and nebulized oxygen treatment in the PACU

Question 15

A key component of postoperative discharge instructions requires verification of patient/family understanding of the instructions.A recent study found that only 67% of the discharge instruction comprehension was retained by day 3 postdischarge.What strategy best ensures patient/family understanding and comprehension of the discharge instructions?

A) Written and signed instruction sheet with emergency and information contact numbers
B) Follow-up e-mail video clip of the patient/family teaching encounter
C) Follow-up e-mail or telephone review of the discharge instructions on day 1 post discharge
D) Patient/family teach-back of the discharge instructions to the nurse

Question 16

Unfortunately,patients who are managed with opioids as part of their analgesic program can have adverse events related to the medication.What are two of the most serious opioid-related adverse events?

A) Pruritis followed by anaphylaxis
B) Unintended advancing sedation and respiratory depression
C) Respiratory depression and alveolar collapse
D) Urticaria followed by anaphylaxis

Question 17

A 46-year-old healthy male,admitted for a diagnostic arthroscopy,was prewarmed in the preoperative holding lounge using a warming device.After transfer to the OR bed,he was continuously warmed using the same device.IV fluids cycled through a fluid warmer and the irrigation bags of sterile saline cycled through a warming device during the procedure.The perioperative nurse had preset the OR ambient temperature to 75° F.Select the statement that best reflects the justification for these practices.

A) The patient will not produce heat when administered a general anesthetic.
B) The patient will require more pain medication in the PACU if he is cold while recovering.
C) The patient is at high risk for fever and shivering because of the possibility of an abscessed knee.
D) The patient is at high risk for malignant hyperthermia and shivering is one of the triggers.

Question 18

A 49-year-old healthy male is beginning to emerge from general endotracheal anesthesia after a transurethral laser lithotripsy of the left ureter.He is restlessly turning side-to-side and moaning.During the hand-off report from the anesthesia provider and circulating nurse,the perianesthesia nurse learned that the patient will probably continue to pass "sludge" (small granular ureteral stone material)for the next hour.As the surgical team rushes back to the OR to start the next case,the perianesthesia nurse thanks them and tells them they can go,because she knows what is wrong with the patient and will take care of him.The perianesthesia nurse's comment reflects which phase of the nursing process and what will be her next actions?

A) Her nursing diagnosis will prompt her to ask the patient to describe his pain.
B) She is in the implementation phase as she checks the patient record for analgesia orders.
C) She is in the assessment phase because she is not confident that the patient is awake enough to experience pain and continues to review vital signs and arouse him enough to speak.
D) She has established a nursing diagnosis and is going to deliver the first dose on his patient-controlled analgesia pump to get medication circulating before he is fully awake.

Question 19

It is estimated that 9% of women and 24% of men in the United States show disordered breathing while asleep,and 2% of women and 4% of men show overt symptoms of obstructive sleep apnea (OSA).Postanesthesia management concerns with OSA patients include use of analgesia,appropriate oxygenation,patient positioning,and monitoring.What additional therapy is recommended for OSA patients during postoperative recovery?

A) Incentive spirometry every 30 minutes while awake
B) Coughing and forced deep breathing
C) Continuous positive airway pressure (CPAP)
D) Use of telemetry for monitoring pulse oximetry

Question 20

A 12-year-old developmentally delayed male scheduled for dental rehabilitation became agitated on admission to the preoperative holding unit.In spite of sedation and the calming attention of the nurses and his parents,he was screaming and rapidly turning his head from side-to-side.He vomited and choked twice before he fell into a light but restless sleep.During the short procedure,the anesthesia provider was aware of rigidity and difficulty with ventilation in the patient's chest,yet his oxygen saturation was between 96% and 100% throughout the procedure.On extubation,he presented with coughing,wheezing,dyspnea,use of accessory muscles,and tachypnea.The patient is presenting with ____________ probably caused by ____________.

A) aspiration; vomiting
B) bronchospasm; aspiration
C) hypoxia; laryngospasm
D) laryngospasm; traumatic intubation

Question 21

The perianesthesia nurse completes a systematic and comprehensive secondary assessment of the patient (e.g.,head-to-toe assessment or major body systems' approach).Select the responses that best reflect the parameters of a comprehensive respiratory assessment.

A) Rate, rhythm, and breath sounds
B) Evidence of unabsorbed residual anesthetic vapors
C) Oxygen saturation level
D) Artificial airway and oxygen delivery system
E) Patient's ability to take deep breaths on command

Question 22

Select three appropriate components of the hand-off report from the perioperative nurse to the perianesthesia nurse as the patient is received in the PACU.

A) Allergies, incisions, dressings, and drains
B) Use of radiologic shielding of the patient in the OR
C) For pediatric patients, mother's perinatal history
D) Prognosis and presumed discharge date or time
E) Patient's identity and procedure performed
F) Opportunity for clarification and questions

Question 23

Hypothermia is a common side effect of surgery and the perianesthesia setting.Which of the following interventions is most effective in normalizing and maintaining body temperature?

A) Prewarming patients in normothermia
B) Warming patients in hypothermia
C) Setting ambient OR and PACU temperatures to 65° to 75° F and using warming devices
D) Using warmed skin prep solution during surgery
E) Using continuous fluid-circulating blankets or warm-water mattresses
F) Reapplying warmed cotton blankets every 10 minutes

Question 24

What parameters and questions will the perianesthesia nurse investigate while assessing neurologic status?

A) Position of the patient's arms at rest
B) Ability to follow commands
C) Pupillary reaction to light
D) Orientation to person and place
E) Level of consciousness