Deck 9: Postoperative Patient Care and Pain Management

Question 1

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) Anesthesia technique and agents administered
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,using attached ID band with two identifiers f.Patient's emotional status on arriving in the OR

Answer 1

A,E,F
After the PACU nurse assesses the ABCs (airway,breathing,circulation),the perioperative nurse and anesthesia provider give a comprehensive hand-off report,which includes the following:relevant preoperative information-vital signs,temperature,radiologic findings,lab values;oxygen saturation;allergies (including latex);medication use/last dose;NPO status;disabilities;substance abuse;mobility limitations;prostheses;and sensory limitations.For pediatric patients:birth history,developmental stages,gestational age,and parent/child interactions;anesthesia technique;agents administered;procedures performed;estimated fluid or blood loss,replacement therapy;complications;treatment initiated;patient responses;emotional status on arrival in the OR/procedure room;pain and comfort management;and patient's ASA physical classification status.

Question 2

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) Artificial airway and oxygen delivery system
D) Patient's ability to take deep breaths on command

Answer 2

A,C
Some PACUs use a head-to-toe assessment to organize the data obtained .Other PACUs take a major body systems' approach.In any case,the PACU nurse assesses admitting vital signs and the ABCs,beginning with the respiratory system.Respiratory assessment comprises rate,rhythm,auscultation of breath sounds for ventilatory adequacy,and oxygen saturation level.Any artificial airway and the type of oxygen delivery system are noted.

Question 3

Jason Snyder,a 46-year-old healthy male admitted for a diagnostic arthroscopy,was prewarmed in the preoperative holding lounge wearing a specialized patient gown with inlets for a forced air-warming device hose.After transfer to the OR bed,he was covered with an over-body adapted blanket of 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) Jason will not produce heat when administered a general anesthetic.
B) Jason will require more pain medication in the PACU if he is cold while recovering.
C) Jason is at high risk for fever and shivering because of the possibility of an abscessed knee.
D) Jason is at high risk for malignant hyperthermia and shivering is one of the triggers.

Answer 3

A
Assessment of the need for prewarming begins preoperatively.Preventive warming measures are begun for normothermic patients and active warming measures instituted for hypothermic patients (ASPAN,2009b).Prevention of heat loss continues in the OR.Under general anesthesia,the patient does not produce heat and depends on ambient temperature.Prevention 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.A common device to prevent hypothermia in the OR is a forced air-warming device.

Question 4

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.Marin Summers,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 Mrs.Summers' 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 antiinflammatory drugs (NSAIDs)
B) Intraoperative:Preincision-regional block,IV opioids during the procedure.Postoperative:PCA with opioids and nonsteroidal antiinflammatory drugs (NSAIDs)
C) Intraoperative:Spinal anesthesia with femoral nerve block.Postoperative:Systemic analgesia with COX-2-selective inhibitors,IV PCA with strong opioids (titrated to effect),and paracetamol
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 5

Randall Preston,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 Randall 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 as she knows what is wrong with Randall 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) The perianesthesia nurse's nursing diagnosis will prompt her to ask Randall 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 as she is not confident that Randall 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 press the button on his patient-controlled analgesia pump to get medication circulating before he is fully awake.

Question 6

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? Select all that apply.

A) Prewarming patients in normothermia
B) Warming patients in hypothermia
C) Setting ambient OR and PACU temperatures at 65° to 75° F and placing patient within forced air-warming blankets
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 7

Select the treatment strategy for PONV that is considered a best practice in the perioperative and perianesthesia setting.

A) Scopolamine patch left on up to 24 hr,comfort measures and aromatherapy of patient's selection,droperidol for refractory nausea
B) Prophylactic antiemetic agent(s) of two different receptor sites,bimodal pain management,H2 blockers,antacids,and oxygen therapy
C) Normalized hydration and blood pressure,appropriate rescue antiemetic (rescue antiemetic should affect a different receptor site than prophylactic agents already given),multimodal pain management
D) Intraoperative IV dexamethasone 8 mg and ondansetron (ODT) 4 mg,followed by a 1-mg oral disintegrating ondansetron tablet taken on discharge and each of the next two mornings

Question 8

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

A) A thin,malnourished 92-year-old patient having 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

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

A) Hypothermia causes physiologic stress and prolongs recovery time,primarily as a result of shivering.
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 causes fluid shift from the intracellular space,resulting from vasodilation.

Question 10

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 11

Virginia admitted that she had been straining while seated on the toilet and the anesthesia provider and perianesthesia nurse surmised that Virginia experienced a vagal response,which led to bradycardia and syncope (fainting).While Virginia feels weak and tired from her experience,she is eager to go home and pleads to be discharged.Her 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.Her incision and dressings are intact and her abdomen is soft.She claims that her pain is slight and tolerable.The nurse must now determine the next step in Virginia's recovery based on this recent evaluation.What phase of the nursing process will impact Virginia's next step and what can she expect?

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

Question 12

Virginia Grier,a 33-year-old female who had a 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 Virginia her discharge instructions and helped her dress.Virginia was assessed for loss of consciousness and ineffective breathing patterns and lifted to a transport vehicle.What action should the phase II nurse take next?

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

Question 13

What parameters and questions will the perianesthesia nurse investigate while assessing neurologic status? Select all that apply.

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

Question 14

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 15

Luci Edwards,a patient of Dr.Jordan,has been admitted to the PACU after a bilateral bunionectomy.During the hand-off report from the anesthesia provider and circulating nurse,Luci began to awaken,crying in drowsy garbled speech that she was thirsty and wanted water.What would be the perianesthesia nurse's appropriate response?

A) Explain to Luci,in a comforting manner,that she cannot have anything to drink until phase II.
B) Check Luci's intake and output,check return of gag reflex,and offer her sips of water.
C) Ask the anesthesia provider if Luci may begin oral intake.
D) Review Luci's intake and output and cardiac status,and increase her intravenous flow rate.

Question 16

Select the appropriate example of physiologic symptoms 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 17

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-mailed 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 18

Daniel Powers,a 32-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 Daniel's chest,yet his oxygen saturation was between 96% and 100% throughout the procedure.On extubation,Daniel presented with coughing,wheezing,dyspnea,use of accessory muscles,and tachypnea.Daniel is presenting with probably caused by .

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

Question 19

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

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

Question 20

Wayne Freeman was admitted to the PACU spontaneously breathing through his endotracheal tube.Shortly after the perianesthesia nurse extubated Wayne,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.