Perioperative Nursing (Test Bank)
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 thready pulse. Usually some sign or symptom of blood loss is noted
(e.g., drains, incision, orifice, and abdomen). - ANS-32. 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 primary focus of intraoperative care is to prevent injury and complications related to
anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery
grounding pad for the prevention of burns. The perioperative nurse is an advocate for the
patient during surgery and protects the patient's dignity and rights at all times. Signs and
symptoms of infection do not have the time to present during the intraoperative phase.
During the intraoperative phase, the patient is anesthetized and unconscious and typically
has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically
begin in the postoperative phase of the experience. - ANS-29. The nurse is caring for a
patient in the operating suite. Which outcome will be most appropriate for this patient at the
end of the intraoperative phase?
a. The patient will be free of burns at the grounding pad.
b. The patient will be free of nausea and vomiting.
c. The patient will be free of infection.
d. The patient will be free of pain.
\ANS: A
Depending on the surgery, some patients do not regain voluntary control over urinary
function for 6 to 8 hours after anesthesia. Palpate the lower abdomen just above the
symphysis pubis for bladder distention. Another option is to use a bladder scan or ultrasound
to assess bladder volume. The nurse must assess before deciding if the patient can try
again. Not everyone feels as if they need to go but can't after surgery. Calling the health care
provider is not the initial best action. The nurse needs to have data before calling the
provider. - ANS-35. The nurse is caring for a patient in the postanesthesia care unit. The
, patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom,
but I can't." Which nursing intervention will be most appropriate initially?
a. Assess the patient for bladder distention.
b. Encourage the patient to wait a minute and try again.
c. Inform the patient that everyone feels this way after surgery.
d. Call the health care provider to obtain an order for catheterization.
\ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be
contraindicated because of the potential increase in intraocular or intracranial pressure. The
nurse will need to see this patient first to control the cough and intraocular pressure. All the
rest are normal postoperative patients. Leg exercise should not be performed on the
operative leg with vascular surgery. A patient after knee surgery should receive heparin and
be wearing intermittent pneumatic compression devices; while the nurse will check on the
patient, it does not have to be first. Monitoring vital signs after surgery is required and this is
the standard schedule. - ANS-38. The nurse is caring for a group of patients. Which patient
will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression devices and
receiving heparin.
d. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes
twice, hourly for 2 hours then every 4 hours.
\ANS: A
Induction of regional anesthesia results in loss of sensation in an area of the body—in this
case, the left leg. The peripheral nerve block influences the portions of sensory pathways
that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch,
and cyanosis are indications of decreased blood flow and are not expected findings. Reports
of pain in the left foot may indicate that the block is not working or is subsiding and is not an
expected finding in the immediate postoperative period. - ANS-6. The nurse is caring for a
patient in the post-anesthesia care unit who has undergone a left total knee arthroplasty. The
anesthesia provider has indicated that the patient received a left femoral peripheral nerve
block. Which assessment will be an expected finding for this patient?
a. Sensation decreased in the left leg
b. Patient report of pain in the left foot
c. Pulse decreased at the left posterior tibia
d. Left toes cool to touch and slightly cyanotic
\ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus increase the
risk of hemorrhaging. Discontinue at least 48 hours before surgery. Acetaminophen is a pain
reliever that has no special implications for surgery. Vitamin C actually assists in wound
healing and has no special implications for surgery. Prednisone is a corticosteroid, and
dosages are often temporarily increased rather than held. - ANS-8. The nurse is completing
a medication history for the surgical patient in preadmission testing. Which medication
should the nurse instruct the patient to hold (discontinue) in preparation for surgery
according to protocol?
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 thready pulse. Usually some sign or symptom of blood loss is noted
(e.g., drains, incision, orifice, and abdomen). - ANS-32. 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 primary focus of intraoperative care is to prevent injury and complications related to
anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery
grounding pad for the prevention of burns. The perioperative nurse is an advocate for the
patient during surgery and protects the patient's dignity and rights at all times. Signs and
symptoms of infection do not have the time to present during the intraoperative phase.
During the intraoperative phase, the patient is anesthetized and unconscious and typically
has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically
begin in the postoperative phase of the experience. - ANS-29. The nurse is caring for a
patient in the operating suite. Which outcome will be most appropriate for this patient at the
end of the intraoperative phase?
a. The patient will be free of burns at the grounding pad.
b. The patient will be free of nausea and vomiting.
c. The patient will be free of infection.
d. The patient will be free of pain.
\ANS: A
Depending on the surgery, some patients do not regain voluntary control over urinary
function for 6 to 8 hours after anesthesia. Palpate the lower abdomen just above the
symphysis pubis for bladder distention. Another option is to use a bladder scan or ultrasound
to assess bladder volume. The nurse must assess before deciding if the patient can try
again. Not everyone feels as if they need to go but can't after surgery. Calling the health care
provider is not the initial best action. The nurse needs to have data before calling the
provider. - ANS-35. The nurse is caring for a patient in the postanesthesia care unit. The
, patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom,
but I can't." Which nursing intervention will be most appropriate initially?
a. Assess the patient for bladder distention.
b. Encourage the patient to wait a minute and try again.
c. Inform the patient that everyone feels this way after surgery.
d. Call the health care provider to obtain an order for catheterization.
\ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be
contraindicated because of the potential increase in intraocular or intracranial pressure. The
nurse will need to see this patient first to control the cough and intraocular pressure. All the
rest are normal postoperative patients. Leg exercise should not be performed on the
operative leg with vascular surgery. A patient after knee surgery should receive heparin and
be wearing intermittent pneumatic compression devices; while the nurse will check on the
patient, it does not have to be first. Monitoring vital signs after surgery is required and this is
the standard schedule. - ANS-38. The nurse is caring for a group of patients. Which patient
will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression devices and
receiving heparin.
d. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes
twice, hourly for 2 hours then every 4 hours.
\ANS: A
Induction of regional anesthesia results in loss of sensation in an area of the body—in this
case, the left leg. The peripheral nerve block influences the portions of sensory pathways
that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch,
and cyanosis are indications of decreased blood flow and are not expected findings. Reports
of pain in the left foot may indicate that the block is not working or is subsiding and is not an
expected finding in the immediate postoperative period. - ANS-6. The nurse is caring for a
patient in the post-anesthesia care unit who has undergone a left total knee arthroplasty. The
anesthesia provider has indicated that the patient received a left femoral peripheral nerve
block. Which assessment will be an expected finding for this patient?
a. Sensation decreased in the left leg
b. Patient report of pain in the left foot
c. Pulse decreased at the left posterior tibia
d. Left toes cool to touch and slightly cyanotic
\ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus increase the
risk of hemorrhaging. Discontinue at least 48 hours before surgery. Acetaminophen is a pain
reliever that has no special implications for surgery. Vitamin C actually assists in wound
healing and has no special implications for surgery. Prednisone is a corticosteroid, and
dosages are often temporarily increased rather than held. - ANS-8. The nurse is completing
a medication history for the surgical patient in preadmission testing. Which medication
should the nurse instruct the patient to hold (discontinue) in preparation for surgery
according to protocol?
