ATI PN FUNDAMENTALS PROCTORED EXAM
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 thready pulse. Usually some sign or symptom of
blood loss is noted (e.g., drains, incision, orifice, and abdomen).
4. The nurse is caring for a postoperative patient who has had a minimally
invasive carpel tunnel repair. The patient has a temperature of 97° F and is
shivering. Which reason will the nurse most likely consider as the primary
cause when planning care?
a. Anesthesia lowers metabolism.
b. Surgical suites have air currents.
,c. The patient is dressed only in a gown.
d. The large open body cavity contributed to heat loss.
ANS: A
The operating suite and recovery room environments are extremely cool. The
patient’s anesthetically depressed level of body function results in lowering of
metabolism and a fall in body temperature. Although the patient is dressed in a
gown and there are air currents in the operating room, these are not the
primary reasons for the low temperature. Also, the patient in this type of case
does not have a large open body cavity to contribute to heat loss.
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
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 thready pulse. Usually some sign or symptom of
blood loss is noted (e.g., drains, incision, orifice, and abdomen).
4. The nurse is caring for a postoperative patient who has had a minimally
invasive carpel tunnel repair. The patient has a temperature of 97° F and is
shivering. Which reason will the nurse most likely consider as the primary
cause when planning care?
a. Anesthesia lowers metabolism.
b. Surgical suites have air currents.
,c. The patient is dressed only in a gown.
d. The large open body cavity contributed to heat loss.
ANS: A
The operating suite and recovery room environments are extremely cool. The
patient’s anesthetically depressed level of body function results in lowering of
metabolism and a fall in body temperature. Although the patient is dressed in a
gown and there are air currents in the operating room, these are not the
primary reasons for the low temperature. Also, the patient in this type of case
does not have a large open body cavity to contribute to heat loss.
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
