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?

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

Naloxone is the opioid antagonist used most frequently to reduce opioid-induced respiratory depression.It is administered slowly,never as a bolus,while the nurse observes the patient's response.The patient should be able to open his or her eyes and talk to the nurse within 1 to 2 minutes of administration; naloxone is discontinued when the patient can take deep breaths on instruction and respond to physical stimulation.

Question 5

Select the most reliable indicator of pain.

Accepted Answer

Pain is a subjective experience and may or may not be verbalized.Often healthcare providers require objective signs of discomfort in addition to subjective reports of pain from the patient,which can lead to undertreatment of pain.The guiding principle in pain care is that pain is whatever the patient says it is; the most reliable indicator of the existence and intensity of pain is the patient's self-report.

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.

Accepted Answer

During preadmission testing/preparation,staff should identify candidates for PCA and teach its use,including the benefits of effective pain control,use of the pain scale,and the importance of reporting pain early.Evidence indicates that early analgesia reduces postoperative problems.Nonsteroidal anti-inflammatory drugs (NSAIDs)and opiates are the analgesics of choice.Generally,they are used in combination (multimodal therapy)in the PACU.Using NSAIDs in combination with opiates can reduce opioid requirements by 20% to 40%.Traditionally,pain was treated with intramuscular (IM)injections of opioids at intervals from 3 to 6 hours as needed.Avoid meperidine except for treatment of shivering or allergy to other opioids.Contraindications to NSAIDs are aspirin-sensitive asthma,bleeding,coagulopathy disorders,history of gastrointestinal bleeding,renal compromise,and hypovolemia.

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.

Accepted Answer

Primary risk factors associated with PONV are female gender,nonsmoker,history of PONV or motion sickness,use of volatile anesthetics,use of nitrous oxide,postoperative use of opioids,duration of surgery,and type of surgery.Patients with four or more risk factors have a higher incidence of PONV.

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.

Accepted Answer

In many surgical services departments,postoperative cardiac surgery patients are transferred directly to the cardiac intensive care unit (ICU)rather than the PACU; however,their thermic needs must be met during this perianesthesia phase.Cardiac patients have considerable skin exposed during surgery and are often cooled to therapeutic hypothermic levels in order to decrease metabolic rate and oxygen demands during cardiopulmonary bypass.Especially vulnerable to the effects of hypothermia are the elderly and children 2 years old or younger.There are four major risk factors for hypothermia; this includes three patient populations-neonates less than 1 month of age,burn patients,and patients whose surgery included general anesthesia with neuraxial anesthesia-along with low ambient temperature of the OR.Other risk factors include female gender,extreme age,length and type of surgical procedure,cachexia,significant fluid shift,and use of cold irrigants.

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?

Accepted Answer

While phase II PACU prepares the patient for discharge,phase I activities focus on primary assessment,breathing,and circulation and facilitating the patient to a level of physiologic stability.The patient's current status requires advanced care at the phase I level.

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?

Accepted Answer

Hypotension has been defined as a blood pressure reading that is 20% less than baseline or preoperative blood pressure measurement.It indicates either relative or absolute hypovolemia.Cardiac output and vascular resistance determine blood pressure.Hypotension may be caused by cardiac dysfunction (such as myocardial infarction,tamponade,embolism,ischemia,dysrhythmias,congestive heart failure,valvular dysfunction)or by medications (including anesthetic agents).

Question 11

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

Accepted Answer

Often hypothermia is not life-threatening; it does,however,cause physiologic stress.Hypothermia can prolong recovery time and contribute to postoperative morbidity.In the PACU,tremendous demands are made on the body when the patient shivers.Shivering can increase the need for oxygen by 300% to 400%.Other problems associated with hypothermia include intravascular volume loss attributable to a fluid shift from the extracellular space,probably related to vasoconstriction and the prolonged elimination of muscle relaxants in hypothermic patients.Clotting abnormalities can occur.Platelet activity declines,and fibrinolysis increases; both conditions enhance the tendency to bleed.

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?

Accepted Answer

The patient had an airway obstruction.The first priority in the care of the postanesthesia patient is to establish a patent airway.A common cause of airway obstruction is the tongue,which is relaxed because of anesthetic agents and muscle relaxants used during surgery.The nursing action taken may be simple,such as stimulating the patient to take deep breaths,positioning the patient on the side,or providing supplemental oxygen.If the patient is still unresponsive,the nurse may need to open the airway with a chin tilt or jaw thrust.

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?

Accepted Answer

Based on the assessment and nursing diagnosis,the nurse sets measurable and achievable short- and long-range goals.The outcome set for this patient is that she will maintain adequate cardiac output on discharge from the PACU as evidenced by blood pressure within preoperative range,her skin will be warm and dry,she will be oriented to person and place,and her pulse will be strong and regular.The nurse will monitor vital signs and physiologic parameters,level of consciousness,surgical site,intake and output; administer fluid and medication if indicated to improve depressed myocardial contractility,increase cardiac output,and promote diuresis.The patient will be monitored through phase I and phase II criteria until discharge.

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?

Accepted Answer

Laryngospasm is a serious complication,usually the result of an irritable airway.The muscles of the larynx contract and partially or completely obstruct the airway; the patient can become hypoxemic quickly.If symptoms last longer than 1 minute and are unrelieved by positive pressure,administration of a muscle relaxant,such as succinylcholine,is required to relax the muscles of the larynx.Reintubation is undesirable and used only as a last resort.

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?

Accepted Answer

Review with the patient before discharge the interventions used and their efficacy,and provide specific discharge instructions regarding pain and its management.Have patient "teach-back" or repeat instructions in his or her own words.

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?

Accepted Answer

Two of the most serious opioid-related adverse events are unintended advancing sedation (which generally precedes respiratory depression)and respiratory depression.Education of the perioperative healthcare team and use of multimodal pain management are of utmost importance in decreasing these events.

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.

Accepted Answer

Prevention of heat loss continues in the OR.Under general anesthesia patients do not produce heat and depend on ambient temperature.Prevention of heat loss includes increasing the ambient temperature in the OR,providing the patient with warm blankets on arrival in the OR,and using draping techniques that minimize exposure during the procedure.Heated humidifiers and fluid warmers add heat.

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?

Accepted Answer

The nurse's statement reflects that she has formulated a nursing diagnosis based on a few objective signs and the report about further ureteral sludge passage: acute pain related to operative procedure.His outcome goal is to exhibit a decreased level of pain or pain at a tolerable level on discharge from the PACU.The nurse's next response is to assess for subjective signs of pain: patient reports pain; patient is given a visual analogue or numeric scale to rate pain level and assess for objective signs of pain-protective guarding behavior,moaning,crying,whimpering,restlessness,irritability,diaphoresis,dilated pupils,facial expression of pain,and changes in vital signs (blood pressure,respiratory rate,or pulse).

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?

Accepted Answer

Supplemental oxygen should be used immediately postoperatively.Patients who use CPAP or noninvasive positive-pressure ventilation at home should continue to use these therapies during the postsurgery stay.The patient's position can be changed based on the type of surgery to decrease the chance of airway obstruction.Lateral,prone,and sitting positions result in better airway management for the OSA patient compared to supine.Patients with OSA may require extended monitoring in the postoperative period.

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 ____________.

Accepted Answer

The patient has bronchospasm caused by aspiration of vomitus.Aspiration is the passage of regurgitated material into the lungs and can occur during the perioperative period,with most aspirations occurring during tracheal intubation or extubation.Prevention of aspiration postoperatively includes responding quickly to reports of nausea and vomiting,avoiding conversations that could elicit nausea and vomiting,and preventing rapid movement of the head.Bronchospasm is a lower airway obstruction caused by spasms of the bronchial tubes.The patient presents with wheezing,dyspnea,use of accessory muscles,and tachypnea.Bronchospasm can result from aspiration,pharyngeal suctioning,or histamine release secondary to allergic response or related to medication use.

Quiz 10: Postoperative Patient Care and Pain Management