Perioperative Nursing (Test Bank)Questions and Answers
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). - ans32. 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. - ans29. 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. - ans35.
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. - ans38. 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. - ans6. 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. - ans8.
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?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
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
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). - ans32. 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. - ans29. 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. - ans35.
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. - ans38. 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. - ans6. 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. - ans8.
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?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
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
