,ATI PN FUNDAMENTALS PROCTORED EXAM
1. The nurse is concerned about the skin integrity of the patient in the
intraoperative phase of surgery. Which action will the nurse take to minimize skin
breakdown?
a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery
ANS: B
Although it may be necessary to place a patient in an unusual position, try to
maintain correct alignment and protect the patient from pressure, abrasion, and
other injuries. Special mattresses, use of foam padding, and attachments to the
operating suite table provide protection for the extremities and bony
prominences. Bathing before surgery helps to decrease the number of microbes
on the skin. Periodically adjusting the patient during the surgical procedure is
impractical and can present a safety issue with regard to maintaining sterility of
the field and maintaining an airway. Measuring the time the patient is in one
position may help with monitoring the situation but does not prevent skin
breakdown. 2. The nurse is assessing a postoperative patient with a history of
obstructive sleep apnea for airway obstruction. Which assessment finding will
best alert the nurse to this complication?
a. Drop in pulse oximetry readings
b. Moaning with reports of pain
c. Shallow respirations
d. Disorientation
, A&E I Comprehensive Testbank
ANS: A
One of the greatest concerns after general anesthesia is airway obstruction,
especially in patients with obstructive sleep apnea. A drop in oxygen
saturation by pulse oximetry is a sign of airway obstruction in patients with
obstructive sleep apnea. Weak pharyngeal/laryngeal muscle tone from
anesthetics; secretions in the pharynx, bronchial tree, or trachea; and
laryngeal or subglottic edema also contribute to airway obstruction. In the
postanesthetic patient, the tongue is a major cause of airway obstruction.
Shallow respirations are indicative of respiratory depression. Moaning and
reports of pain are common in all surgical patients and are an expected
event. Disorientation is common when first awakening from anesthesia but
can be a sign of hypoxia.
3. The nurse is caring for a patient in the operating suite who is experiencing
hypercarbia, tachypnea, tachycardia, premature ventricular
contractions, and muscle rigidity. Which condition does the nurse suspect
the patient is experiencing?
a. Malignant hyperthermia
b. Fluid imbalance
c. Hemorrhage
d. Hypoxia
ANS: A
A life-threatening, rare complication of anesthesia is malignant
hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia,
tachypnea, premature ventricular contractions, unstable blood pressure,
cyanosis, skin mottling, and muscular rigidity. It often occurs during
anesthesia induction. Hypoxia would manifest with decreased oxygen
saturation as one of its signs and symptoms. Fluid imbalance would be
assessed with intake and output and can manifest with tachycardia and
blood pressure fluctuations but does not have muscle rigidity. Hemorrhage
can manifest with tachycardia and decreased blood pressure, along with a
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1. The nurse is concerned about the skin integrity of the patient in the
intraoperative phase of surgery. Which action will the nurse take to minimize skin
breakdown?
a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery
ANS: B
Although it may be necessary to place a patient in an unusual position, try to
maintain correct alignment and protect the patient from pressure, abrasion, and
other injuries. Special mattresses, use of foam padding, and attachments to the
operating suite table provide protection for the extremities and bony
prominences. Bathing before surgery helps to decrease the number of microbes
on the skin. Periodically adjusting the patient during the surgical procedure is
impractical and can present a safety issue with regard to maintaining sterility of
the field and maintaining an airway. Measuring the time the patient is in one
position may help with monitoring the situation but does not prevent skin
breakdown. 2. The nurse is assessing a postoperative patient with a history of
obstructive sleep apnea for airway obstruction. Which assessment finding will
best alert the nurse to this complication?
a. Drop in pulse oximetry readings
b. Moaning with reports of pain
c. Shallow respirations
d. Disorientation
, A&E I Comprehensive Testbank
ANS: A
One of the greatest concerns after general anesthesia is airway obstruction,
especially in patients with obstructive sleep apnea. A drop in oxygen
saturation by pulse oximetry is a sign of airway obstruction in patients with
obstructive sleep apnea. Weak pharyngeal/laryngeal muscle tone from
anesthetics; secretions in the pharynx, bronchial tree, or trachea; and
laryngeal or subglottic edema also contribute to airway obstruction. In the
postanesthetic patient, the tongue is a major cause of airway obstruction.
Shallow respirations are indicative of respiratory depression. Moaning and
reports of pain are common in all surgical patients and are an expected
event. Disorientation is common when first awakening from anesthesia but
can be a sign of hypoxia.
3. The nurse is caring for a patient in the operating suite who is experiencing
hypercarbia, tachypnea, tachycardia, premature ventricular
contractions, and muscle rigidity. Which condition does the nurse suspect
the patient is experiencing?
a. Malignant hyperthermia
b. Fluid imbalance
c. Hemorrhage
d. Hypoxia
ANS: A
A life-threatening, rare complication of anesthesia is malignant
hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia,
tachypnea, premature ventricular contractions, unstable blood pressure,
cyanosis, skin mottling, and muscular rigidity. It often occurs during
anesthesia induction. Hypoxia would manifest with decreased oxygen
saturation as one of its signs and symptoms. Fluid imbalance would be
assessed with intake and output and can manifest with tachycardia and
blood pressure fluctuations but does not have muscle rigidity. Hemorrhage
can manifest with tachycardia and decreased blood pressure, along with a
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