are important to patient safety after discharge by ensuring patient discharge instructions are
written in the vocabulary grade level:
a. 3
b. 5
c. 9
d. 12
Correct Answer: B
Rationale:
A 5th-grade reading level is the recommended standard for patient discharge instructions to
ensure clarity and safety.
2. While assessing an elderly patient who is anxious and fearful, a perianesthesia nurse observes
old and new bruises with torn skin on the patient’s arms, face, and hairline. The perianesthesia
nurse’s best action is to:
a. Approach the family about possible abuse
b. Evaluate, observe, and further assess the patient
c. Use appropriate paper tape on the patient’s skin
d. Report this information to social services
Correct Answer: D
Rationale:
Unexplained injuries in a vulnerable adult must be reported. Nurses are mandated reporters of
suspected abuse.
3. The perianesthesia nurse instructs a patient scheduled for a laparoscopic cholecystectomy to
remove body piercings prior to arrival as they may cause:
a. Injury and infection
b. Increased pain at the incision site
,c. Adverse medication interaction
d. EKG monitoring interference
Correct Answer: A
Rationale:
Metal piercings can cause burns, injury, and infection during electrocautery procedures.
4. The perianesthesia nurse suspects a Type IV latex allergy in a patient exhibiting:
a. Tachyphylaxis
b. Erythema
c. Hypotension
d. Bronchospasm
Correct Answer: B
Rationale:
Type IV latex allergy is a delayed skin reaction, commonly presenting as redness, rash, or
irritation.
1. A patient with vancomycin-resistant enterococcus is being admitted to the PACU following
surgery. A perianesthesia nurse should know which precaution provides the safest environment
for both the patient and others in the PACU?
a. Having the anesthesiologist recover the patient in the OR
b. Placing a special respirator mask over the nasal cannula on the patient
c. Providing a 1:1 nurse-to-patient ratio for the patient
d. Having the anesthesiologist bypass the PACU and transporting the patient directly to the
surgical floor
Correct Answer: C
Rationale:
VRE requires contact precautions and increased monitoring. A 1:1 ratio ensures safety while
preventing spread in a crowded PACU.
2. A combative, restless, and thrashing patient arrives in the Phase I PACU. After an initial
assessment of the patient’s airway, the NEXT intervention for the perianesthesia nurse is to:
a. Bring family members to the bedside
b. Arouse the patient
c. Provide a safe environment
d. Medicate the patient for pain
Correct Answer: C
, Rationale:
After confirming the airway is secure, the priority is preventing injury to the patient and staff by
ensuring a safe environment.
3. The perianesthesia nurse is aware that the most important intervention for the pediatric patient
in emergence delirium is:
a. Monitoring and controlling body temperature
b. Having a parent present
c. The presence of padded side rails
d. Providing tender loving care
Correct Answer: C
Rationale:
Emergence delirium causes agitation and risk of falling or injury. Padded side rails provide
immediate safety.
4. A patient is admitted to the Phase I PACU following cleft palate repair. Which of the following
is the proper positioning of this patient in the immediate postoperative phase?
a. Semi-prone
b. High Fowler’s
c. Reverse Trendelenburg
d. Lateral recumbent
Correct Answer: A
Rationale:
Semi-prone prevents aspiration, keeps the airway clear, and protects the surgical site in cleft
palate patients.
5. A patient with active tuberculosis is expected in the PACU. The perianesthesia nurse prepares
for:
a. Airborne precautions
b. Droplet precautions
c. Contact precautions
d. Standard precautions
Correct Answer: A
Rationale:
Active TB spreads through airborne particles; N95 masks and isolation measures are required.