NUR 371 - Week 2 Review Questions and
Correct Answers
What does pre-operative nursing care focus on? ✅obtaining baseline pt information
(health hx and assessment, vital signs)
ensuring safety and minimizing risk
identifying operative risk (ABCDE, intervening to prevent complications/error)
patient teaching/education (what to expect pre, intra, and post-op)
obtain informed consent
complete pre-op intervention/orders
What does intra-operative nursing care focus on? ✅assisting with the flow and function
of surgery (circulating and scrub nurses, maintenance of sterile field, devices,
knowledge of surgical procedures)
maintaining pt safety (positioning, ID, surgical plan, instrument count)
preparing for smooth discharge from OR to PACU (debriefing, Transfer of Accountability
TOA)
Post Anesthesia Care Unit (PACU) ✅the recovery room where patients are taken
following surgery so that they can be closely monitored by the health care team to make
sure that they are recovering without complications from the surgery or the anesthesia;
adjacent to OR
What is the priority care concern in the PACU? ✅priority care is to identify actual and
potential complications related to anesthetic administration and surgical interventions
What is monitored and managed in the PACU by nurses? ✅ABCs
Vital signs
Temperature
Neuro status (awakening from anesthetic, neuromuscular blocker)
Surgical site and bleeding
Fluid status
Pain
Nausea
Transfer of accountability/transfer of primary responsibility ✅transferring pt-specific
information from one caregiver to another, for the purpose of ensuring continuity of care
and safety of the pt
What information does a TOA include? ✅General pt info
Pt Hx
Intra-operative management
PACU care
, Potential problems post-op: Neuro-psychological
What concerns are we monitoring for? ✅delirium
fever
hypothermia
pain
post-op cognitive dysfunction
Potential problems post-op: Respiratory
What concerns are we monitoring for? ✅airway obstruction
aspiration (choking)
atelectasis (complete or partial collapse of the entire lung or a lobe; alveoli become
deflated - common after surgery and anesthesia)
bronchospasm
hypoventilation
hypoxemia
pneumonia
pulmonary edema
pulmonary embolus
Potential problems post-op: GI
What concerns are we monitoring for? ✅delayed gastric emptying
distension and flatulence
hiccups
nausea and vomiting
postoperative ileus (prolonged absence of bowel function after surgery)
Potential problems post-op: Urinary
What concerns are we monitoring for? ✅infection
retention
Potential problems post-op: Cardiovascular
What concerns are we monitoring for? ✅Dysrhythmias
Hemorrhage
Hypertension
Hypotension
Superficial thrombo-phlebitis
Venous thrombo-embolism
Potential problems post-op: Integumentary (incision site)
What concerns are we monitoring for? ✅Dehiscence
Hematoma
Infection
Potential problems post-op: Fluid and Electrolytes
Correct Answers
What does pre-operative nursing care focus on? ✅obtaining baseline pt information
(health hx and assessment, vital signs)
ensuring safety and minimizing risk
identifying operative risk (ABCDE, intervening to prevent complications/error)
patient teaching/education (what to expect pre, intra, and post-op)
obtain informed consent
complete pre-op intervention/orders
What does intra-operative nursing care focus on? ✅assisting with the flow and function
of surgery (circulating and scrub nurses, maintenance of sterile field, devices,
knowledge of surgical procedures)
maintaining pt safety (positioning, ID, surgical plan, instrument count)
preparing for smooth discharge from OR to PACU (debriefing, Transfer of Accountability
TOA)
Post Anesthesia Care Unit (PACU) ✅the recovery room where patients are taken
following surgery so that they can be closely monitored by the health care team to make
sure that they are recovering without complications from the surgery or the anesthesia;
adjacent to OR
What is the priority care concern in the PACU? ✅priority care is to identify actual and
potential complications related to anesthetic administration and surgical interventions
What is monitored and managed in the PACU by nurses? ✅ABCs
Vital signs
Temperature
Neuro status (awakening from anesthetic, neuromuscular blocker)
Surgical site and bleeding
Fluid status
Pain
Nausea
Transfer of accountability/transfer of primary responsibility ✅transferring pt-specific
information from one caregiver to another, for the purpose of ensuring continuity of care
and safety of the pt
What information does a TOA include? ✅General pt info
Pt Hx
Intra-operative management
PACU care
, Potential problems post-op: Neuro-psychological
What concerns are we monitoring for? ✅delirium
fever
hypothermia
pain
post-op cognitive dysfunction
Potential problems post-op: Respiratory
What concerns are we monitoring for? ✅airway obstruction
aspiration (choking)
atelectasis (complete or partial collapse of the entire lung or a lobe; alveoli become
deflated - common after surgery and anesthesia)
bronchospasm
hypoventilation
hypoxemia
pneumonia
pulmonary edema
pulmonary embolus
Potential problems post-op: GI
What concerns are we monitoring for? ✅delayed gastric emptying
distension and flatulence
hiccups
nausea and vomiting
postoperative ileus (prolonged absence of bowel function after surgery)
Potential problems post-op: Urinary
What concerns are we monitoring for? ✅infection
retention
Potential problems post-op: Cardiovascular
What concerns are we monitoring for? ✅Dysrhythmias
Hemorrhage
Hypertension
Hypotension
Superficial thrombo-phlebitis
Venous thrombo-embolism
Potential problems post-op: Integumentary (incision site)
What concerns are we monitoring for? ✅Dehiscence
Hematoma
Infection
Potential problems post-op: Fluid and Electrolytes
