Lewis’s Medical-Surgical Nursing in Canada
Advanced Prep: Master Perioperative
Nursing Practice Questions & Detailed
Explanations
Subject: Medical-Surgical Nursing / Perioperative Care
Question 1: A 68-year-old patient with a history of heart failure and chronic obstructive
pulmonary disease (COPD) is scheduled for a total hip arthroplasty under general anesthesia.
Which physiological change poses the highest risk for intraoperative cardiovascular instability in
this patient?
A) Increased systemic vascular resistance due to anesthetic-induced sympathetic blockade.
B) Decreased venous return and preload resulting from positive pressure ventilation.
C) Elevation of pulmonary artery wedge pressure secondary to fluid sequestration.
D) Compensatory tachycardia masking myocardial ischemia.
Correct Answer: B) Decreased venous return and preload resulting from positive pressure
ventilation.
Explanation: Positive pressure ventilation increases intrathoracic pressure, which decreases
venous return to the heart, thereby reducing preload. In a patient with heart failure, the
myocardium is highly dependent on Starling's Law; reduced preload can lead to a significant
drop in cardiac output and systemic hypotension. While the other options present clinical
concerns, the immediate mechanical impact of positive pressure ventilation on preload is the
primary risk factor for hemodynamic compromise in patients with limited cardiac reserve.
Question 2: During the intraoperative phase, the nurse notes the patient’s end-tidal $CO_2$ is
rising rapidly while the temperature remains stable, but the patient exhibits masseter muscle
rigidity following succinylcholine administration. What is the priority nursing intervention?
A) Administer a rapid-acting beta-blocker to control tachycardia.
B) Notify the anesthesia care provider immediately to initiate the malignant hyperthermia (MH)
protocol.
C) Increase the concentration of inhaled anesthetic to deepen the level of sedation.
D) Perform an arterial blood gas analysis to confirm respiratory acidosis.
,Correct Answer: B) Notify the anesthesia care provider immediately to initiate the
malignant hyperthermia (MH) protocol.
Explanation: Masseter muscle rigidity following succinylcholine is a classic early sign of
Malignant Hyperthermia. Although hyperthermia is a hallmark, it is often a late finding. The
rapid rise in $CO_2$ indicates hypermetabolism. Immediate intervention, including the
discontinuation of triggering agents (succinylcholine and volatile gases) and the administration
of dantrolene, is required to prevent fatal consequences. Waiting for further diagnostic
confirmation (like ABGs) would delay life-saving treatment.
Question 3: A patient in the postanesthesia care unit (PACU) is experiencing emergence
delirium. Which intervention should the nurse prioritize to ensure patient safety while addressing
the underlying etiology?
A) Immediately administer a bolus of intravenous benzodiazepines.
B) Apply physical restraints to prevent the patient from dislodging surgical drains.
C) Assess the bladder for distention and ensure adequate oxygenation.
D) Increase the infusion rate of intravenous maintenance fluids.
Correct Answer: C) Assess the bladder for distention and ensure adequate oxygenation.
Explanation: Emergence delirium is frequently caused by physiological factors such as hypoxia,
hypercapnia, bladder distention, or severe pain. Assessment and correction of these underlying
reversible causes are the priority over chemical sedation (benzodiazepines) or physical
restraints, which may worsen the patient's agitation and increase the risk of injury.
Question 4: Which of the following preoperative laboratory findings in a patient scheduled for
abdominal surgery necessitates a delay in the procedure?
A) Serum potassium of 3.4 mEq/L.
B) International Normalized Ratio (INR) of 1.7 in a patient taking warfarin.
C) Hemoglobin of 10.5 g/dL.
D) Fasting blood glucose of 145 mg/dL.
Correct Answer: B) International Normalized Ratio (INR) of 1.7 in a patient taking
warfarin.
Explanation: An INR of 1.7 indicates a significant alteration in the coagulation cascade.
Proceeding with elective surgery carries an unacceptably high risk of hemorrhage. While
hypokalemia (3.4 mEq/L) requires correction, it is generally managed concurrently or shortly
,before surgery, unlike coagulopathy which requires reversal. Mild anemia and elevated glucose
are commonly managed perioperatively.
Question 5: A surgical patient is receiving a peripheral nerve block for anesthesia. What is the
most critical assessment for the nurse to perform during the recovery phase regarding this block?
A) Monitoring for signs of systemic local anesthetic toxicity (LAST).
B) Evaluating the patient’s ability to verbalize pain scores.
C) Assessing for delayed surgical site infection.
D) Tracking the return of bowel sounds.
Correct Answer: A) Monitoring for signs of systemic local anesthetic toxicity (LAST).
Explanation: LAST is a life-threatening complication characterized by central nervous system
excitation (seizures) followed by cardiovascular collapse. Because peripheral nerve blocks
involve the injection of large volumes of anesthetic near highly vascularized areas, the risk of
systemic absorption is high. Early detection of symptoms like tinnitus, metallic taste, or dizziness
is essential for emergency intervention with lipid emulsion therapy.
Question 6: When preparing a patient for a surgical procedure requiring general anesthesia, the
nurse emphasizes the importance of the NPO status. What is the primary physiological
mechanism this instruction aims to prevent?
A) Increased gastric acidity leading to mucosal erosion.
B) Aspiration pneumonitis caused by gastric acid reflux.
C) Postoperative ileus due to over-distention of the stomach.
D) Electrolyte imbalance from prolonged fasting.
Correct Answer: B) Aspiration pneumonitis caused by gastric acid reflux.
Explanation: General anesthesia suppresses protective airway reflexes (cough, swallow, gag). If
the stomach contains contents, there is a significant risk of aspiration, which can lead to
Mendelson's syndrome (aspiration pneumonitis), a severe and potentially fatal inflammatory
response in the lungs.
Question 7: A patient undergoing spinal anesthesia develops a sudden drop in blood pressure and
bradycardia. This is known as a "high spinal" or "total spinal." Which physiological mechanism
is responsible?
A) Sympathetic blockade causing vasodilation and cardiac accelerator fiber inhibition.
, B) Vagal nerve stimulation from the surgeon manipulating the viscera.
C) Decreased venous return leading to myocardial ischemia.
D) Excessive dose of intravenous sedation administered concurrently.
Correct Answer: A) Sympathetic blockade causing vasodilation and cardiac accelerator
fiber inhibition.
Explanation: Spinal anesthesia acts by blocking sympathetic outflow. When the block rises too
high (cephalad spread), it inhibits the sympathetic cardiac accelerator fibers (T1-T4), leading to
profound bradycardia and massive vasodilation (due to loss of sympathetic tone to the
peripheral vasculature), resulting in severe hypotension.
Question 8: The nurse is caring for a patient who has received a neuromuscular blocking agent
(NMBA) during surgery. Before the patient is extubated, what criteria must be met to ensure the
reversal of the agent is complete?
A) The patient is able to open their eyes for 5 seconds.
B) Sustained tetany or a train-of-four (TOF) ratio greater than 0.9.
C) The patient has a normal oxygen saturation on room air.
D) The patient has clear lung sounds bilaterally.
Correct Answer: B) Sustained tetany or a train-of-four (TOF) ratio greater than 0.9.
Explanation: Clinical signs like "opening eyes" are unreliable indicators of adequate
neuromuscular recovery. A train-of-four (TOF) ratio of 0.9 or greater is the gold standard
clinical benchmark to ensure that the patient has sufficient respiratory muscle strength to
maintain spontaneous ventilation and airway protection post-extubation.
Question 9: During the assessment of a surgical patient, the nurse identifies a "surgical site
infection" (SSI) risk factor that is categorized as "host-related." Which of the following is it?
A) Duration of the surgical procedure.
B) Surgical site preparation technique.
C) Presence of uncontrolled diabetes mellitus.
D) Use of prophylactic antibiotics.
Correct Answer: C) Presence of uncontrolled diabetes mellitus.
Advanced Prep: Master Perioperative
Nursing Practice Questions & Detailed
Explanations
Subject: Medical-Surgical Nursing / Perioperative Care
Question 1: A 68-year-old patient with a history of heart failure and chronic obstructive
pulmonary disease (COPD) is scheduled for a total hip arthroplasty under general anesthesia.
Which physiological change poses the highest risk for intraoperative cardiovascular instability in
this patient?
A) Increased systemic vascular resistance due to anesthetic-induced sympathetic blockade.
B) Decreased venous return and preload resulting from positive pressure ventilation.
C) Elevation of pulmonary artery wedge pressure secondary to fluid sequestration.
D) Compensatory tachycardia masking myocardial ischemia.
Correct Answer: B) Decreased venous return and preload resulting from positive pressure
ventilation.
Explanation: Positive pressure ventilation increases intrathoracic pressure, which decreases
venous return to the heart, thereby reducing preload. In a patient with heart failure, the
myocardium is highly dependent on Starling's Law; reduced preload can lead to a significant
drop in cardiac output and systemic hypotension. While the other options present clinical
concerns, the immediate mechanical impact of positive pressure ventilation on preload is the
primary risk factor for hemodynamic compromise in patients with limited cardiac reserve.
Question 2: During the intraoperative phase, the nurse notes the patient’s end-tidal $CO_2$ is
rising rapidly while the temperature remains stable, but the patient exhibits masseter muscle
rigidity following succinylcholine administration. What is the priority nursing intervention?
A) Administer a rapid-acting beta-blocker to control tachycardia.
B) Notify the anesthesia care provider immediately to initiate the malignant hyperthermia (MH)
protocol.
C) Increase the concentration of inhaled anesthetic to deepen the level of sedation.
D) Perform an arterial blood gas analysis to confirm respiratory acidosis.
,Correct Answer: B) Notify the anesthesia care provider immediately to initiate the
malignant hyperthermia (MH) protocol.
Explanation: Masseter muscle rigidity following succinylcholine is a classic early sign of
Malignant Hyperthermia. Although hyperthermia is a hallmark, it is often a late finding. The
rapid rise in $CO_2$ indicates hypermetabolism. Immediate intervention, including the
discontinuation of triggering agents (succinylcholine and volatile gases) and the administration
of dantrolene, is required to prevent fatal consequences. Waiting for further diagnostic
confirmation (like ABGs) would delay life-saving treatment.
Question 3: A patient in the postanesthesia care unit (PACU) is experiencing emergence
delirium. Which intervention should the nurse prioritize to ensure patient safety while addressing
the underlying etiology?
A) Immediately administer a bolus of intravenous benzodiazepines.
B) Apply physical restraints to prevent the patient from dislodging surgical drains.
C) Assess the bladder for distention and ensure adequate oxygenation.
D) Increase the infusion rate of intravenous maintenance fluids.
Correct Answer: C) Assess the bladder for distention and ensure adequate oxygenation.
Explanation: Emergence delirium is frequently caused by physiological factors such as hypoxia,
hypercapnia, bladder distention, or severe pain. Assessment and correction of these underlying
reversible causes are the priority over chemical sedation (benzodiazepines) or physical
restraints, which may worsen the patient's agitation and increase the risk of injury.
Question 4: Which of the following preoperative laboratory findings in a patient scheduled for
abdominal surgery necessitates a delay in the procedure?
A) Serum potassium of 3.4 mEq/L.
B) International Normalized Ratio (INR) of 1.7 in a patient taking warfarin.
C) Hemoglobin of 10.5 g/dL.
D) Fasting blood glucose of 145 mg/dL.
Correct Answer: B) International Normalized Ratio (INR) of 1.7 in a patient taking
warfarin.
Explanation: An INR of 1.7 indicates a significant alteration in the coagulation cascade.
Proceeding with elective surgery carries an unacceptably high risk of hemorrhage. While
hypokalemia (3.4 mEq/L) requires correction, it is generally managed concurrently or shortly
,before surgery, unlike coagulopathy which requires reversal. Mild anemia and elevated glucose
are commonly managed perioperatively.
Question 5: A surgical patient is receiving a peripheral nerve block for anesthesia. What is the
most critical assessment for the nurse to perform during the recovery phase regarding this block?
A) Monitoring for signs of systemic local anesthetic toxicity (LAST).
B) Evaluating the patient’s ability to verbalize pain scores.
C) Assessing for delayed surgical site infection.
D) Tracking the return of bowel sounds.
Correct Answer: A) Monitoring for signs of systemic local anesthetic toxicity (LAST).
Explanation: LAST is a life-threatening complication characterized by central nervous system
excitation (seizures) followed by cardiovascular collapse. Because peripheral nerve blocks
involve the injection of large volumes of anesthetic near highly vascularized areas, the risk of
systemic absorption is high. Early detection of symptoms like tinnitus, metallic taste, or dizziness
is essential for emergency intervention with lipid emulsion therapy.
Question 6: When preparing a patient for a surgical procedure requiring general anesthesia, the
nurse emphasizes the importance of the NPO status. What is the primary physiological
mechanism this instruction aims to prevent?
A) Increased gastric acidity leading to mucosal erosion.
B) Aspiration pneumonitis caused by gastric acid reflux.
C) Postoperative ileus due to over-distention of the stomach.
D) Electrolyte imbalance from prolonged fasting.
Correct Answer: B) Aspiration pneumonitis caused by gastric acid reflux.
Explanation: General anesthesia suppresses protective airway reflexes (cough, swallow, gag). If
the stomach contains contents, there is a significant risk of aspiration, which can lead to
Mendelson's syndrome (aspiration pneumonitis), a severe and potentially fatal inflammatory
response in the lungs.
Question 7: A patient undergoing spinal anesthesia develops a sudden drop in blood pressure and
bradycardia. This is known as a "high spinal" or "total spinal." Which physiological mechanism
is responsible?
A) Sympathetic blockade causing vasodilation and cardiac accelerator fiber inhibition.
, B) Vagal nerve stimulation from the surgeon manipulating the viscera.
C) Decreased venous return leading to myocardial ischemia.
D) Excessive dose of intravenous sedation administered concurrently.
Correct Answer: A) Sympathetic blockade causing vasodilation and cardiac accelerator
fiber inhibition.
Explanation: Spinal anesthesia acts by blocking sympathetic outflow. When the block rises too
high (cephalad spread), it inhibits the sympathetic cardiac accelerator fibers (T1-T4), leading to
profound bradycardia and massive vasodilation (due to loss of sympathetic tone to the
peripheral vasculature), resulting in severe hypotension.
Question 8: The nurse is caring for a patient who has received a neuromuscular blocking agent
(NMBA) during surgery. Before the patient is extubated, what criteria must be met to ensure the
reversal of the agent is complete?
A) The patient is able to open their eyes for 5 seconds.
B) Sustained tetany or a train-of-four (TOF) ratio greater than 0.9.
C) The patient has a normal oxygen saturation on room air.
D) The patient has clear lung sounds bilaterally.
Correct Answer: B) Sustained tetany or a train-of-four (TOF) ratio greater than 0.9.
Explanation: Clinical signs like "opening eyes" are unreliable indicators of adequate
neuromuscular recovery. A train-of-four (TOF) ratio of 0.9 or greater is the gold standard
clinical benchmark to ensure that the patient has sufficient respiratory muscle strength to
maintain spontaneous ventilation and airway protection post-extubation.
Question 9: During the assessment of a surgical patient, the nurse identifies a "surgical site
infection" (SSI) risk factor that is categorized as "host-related." Which of the following is it?
A) Duration of the surgical procedure.
B) Surgical site preparation technique.
C) Presence of uncontrolled diabetes mellitus.
D) Use of prophylactic antibiotics.
Correct Answer: C) Presence of uncontrolled diabetes mellitus.
