ATIPNFUNDAMENTALS PROCTORED EXAM
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1. The nurse is concerned about the skin integrity of the patient in the
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intraoperative phase of surgery. Which action will the nurse take to minimize skin brea f f f f f f f f f f f f f
kdown?
a. Encouraging the patient to bathe before surgery f f f f f f
b. Securing attachments to the operating table with foam padding f f f f f f f f
c. Periodically adjusting the patient during the surgical procedure f f f f f f f
d. Measuring the time a patient is in one position during surgery f f f f f f f f f f
ANS: B f
Although it may be necessary to place a patient in an unusual position, try to maintain c
f f f f f f f f f f f f f f f f
orrect alignment and protect the patient from pressure, abrasion, and other injuries. Spe
f f f f f f f f f f f f
cial mattresses, use of foam padding, and attachments to the operating suite table provi
f f f f f f f f f f f f f
de protection for the extremities and bony prominences. Bathing before surgery helps t
f f f f f f f f f f f f
o decrease the number of microbes on the skin.
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Periodically adjusting the patient during the surgical procedure is impractical and can p
f f f f f f f f f f f f
resent a safety issue with regard to maintaining sterility of the field and maintaining an a
f f f f f f f f f f f f f f f
irway. Measuring the time the patient is in one position may help with monitoring the sit
f f f f f f f f f f f f f f f
uation but does not prevent skin breakdown.
f f f f f f
2. The nurse is assessing a postoperative patient with a history of
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obstructive sleep apnea for airway obstruction. Which assessment finding will b
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est alert the nurse to this complication?
f f f f f f
a. Drop in pulse oximetry readings f f f f
b. Moaning with reports of pain f f f f
c. Shallow respirations f
d. Disorientation
, A&EfIfComprehensivefTestbank
ANS: A f
One of the greatest concerns after general anesthesia is airway obstruction, especi
f f f f f f f f f f f
ally in patients with obstructive sleep apnea. A drop in oxygen saturation by pulse
f f f f f f f f f f f f f f
oximetry is a sign of airway obstruction in patients with obstructive sleep apnea.
f f f f f f f f f f f f f
Weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the phary
f f f f f f f f f
nx, bronchial tree, or trachea; and laryngeal or subglottic edema also contribute to
f f f f f f f f f f f f f
airway obstruction. In the postanesthetic patient, the tongue is a major cause of air
f f f f f f f f f f f f f
way obstruction. f
Shallow respirations are indicative of respiratory depression. Moaning and repo
f f f f f f f f f
rts of pain are common in all surgical patients and are an expected event. Disorien
f f f f f f f f f f f f f f
tation is common when first awakening from anesthesia but can be a sign of hypo
f f f f f f f f f f f f f f
xia.
3. The nurse is caring for a patient in the operating suite who is experiencin
f f f f f f f f f f f f f
g hypercarbia, tachypnea, tachycardia, premature ventricular
f f f f f
contractions, and muscle rigidity. Which condition does the nurse suspect the p f f f f f f f f f f f
atient is experiencing? f f
a. Malignant hyperthermia f
b. Fluid imbalance f
c. Hemorrhage
d. Hypoxia
ANS: A f
A life- f
threatening, rare complication of anesthesia is malignant hyperthermia. Malignan f f f f f f f f
t hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricula
f f f f f f f
r contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigi
f f f f f f f f f f
dity. It often occurs during anesthesia induction.
f f f f f f
Hypoxia would manifest with decreased oxygen saturation as one of its signs and
f f f f f f f f f f f f f
symptoms. Fluid imbalance would be assessed with intake and output and can ma f f f f f f f f f f f f
nifest with tachycardia and blood pressure fluctuations but does not have muscle r
f f f f f f f f f f f f
igidity. Hemorrhage can manifest with tachycardia and decreased blood pressure
f f f f f f f f f
, along with a thready pulse. Usually some sign or symptom of blood loss is noted (
f f f f f f f f f f f f f f f f
e.g., drains, incision, orifice, and abdomen).
f f f f f
4. The nurse is caring for a postoperative patient who has had a minimally inv
f f f f f f f f f f f f f
asive carpel tunnel repair. The patient has a temperature of 97° F and is
f f f f f f f f f f f f f
shivering. Which reason will the nurse most likely consider as the primary cause w
f f f f f f f f f f f f f
hen planning care? f 2 f
a. Anesthesia lowers metabolism. f f
, A&EfIfComprehensivefTestbank
b. Surgical suites have air currents. f f f f
c. The patient is dressed only in a gown. f f f f f f f
d. The large open body cavity contributed to heat loss.
f f f f f f f f
ANS: A f
The operating suite and recovery room environments are extremely cool. The pat
f f f f f f f f f f f
ient’s anesthetically depressed level of body function results in lowering of metab
f f f f f f f f f f f
olism and a fall in body temperature. Although the patient is dressed in a gown an
f f f f f f f f f f f f f f f
d there are air currents in the operating room, these are not the primary reasons for
f f f f f f f f f f f f f f f f
the low temperature. Also, the patient in this type of case does not have a large ope
f f f f f f f f f f f f f f f f
n body cavity to contribute to heat loss.
f f f f f f f
5. The nurse is monitoring a patient in the postanesthesia care unit
f f f f f f f f f f
(PACU) for postoperative fluid and electrolyte imbalance. Which action wi
f f f f f f f f f
ll be most appropriate for the nurse to take?
f f f f f f f f
a. Encourage copious amounts of water. f f f f
b. Start an additional intravenous (IV) line. f f f f f
c. Measure and record all intake and output. f f f f f f
d. Weigh the patient and compare with preoperative weight. f f f f f f f
ANS: C f
Accurate recording of intake and output assesses renal and circulatory function.
f f f f f f f f f f f
Measure and record all sources of intake and output. Encouraging copious amount
f f f f f f f f f f f
s of water in a postoperative patient might encourage nausea and vomiting. In the P
f f f f f f f f f f f f f f
ACU, it is impractical to weigh the patient while waking from surgery, but in the da
f f f f f f f f f f f f f f f
ys afterward, it is a good assessment parameter for fluid imbalance. Starting an ad
f f f f f f f f f f f f f
ditional IV is not necessary and is not important at this juncture.
f f f f f f f f f f f
6. The nurse is caring for a patient in the postanesthesia care unit. The patient
f f f f f f f f f f f f f
asks for a bedpan and states to the nurse, “I feel like I need to go to the bathroo
f f f f f f f f f f f f f f f f f f f
m, but I can’t.” Which nursing intervention will
f f f f f f f
be most appropriate initially?
f f f
a. Assess the patient for bladder distention. f f f f f
3
b. Encourage the patient to wait a minute and try again. f f f f f f f f f
f f f f
1. The nurse is concerned about the skin integrity of the patient in the
f f f f f f f f f f f f
intraoperative phase of surgery. Which action will the nurse take to minimize skin brea f f f f f f f f f f f f f
kdown?
a. Encouraging the patient to bathe before surgery f f f f f f
b. Securing attachments to the operating table with foam padding f f f f f f f f
c. Periodically adjusting the patient during the surgical procedure f f f f f f f
d. Measuring the time a patient is in one position during surgery f f f f f f f f f f
ANS: B f
Although it may be necessary to place a patient in an unusual position, try to maintain c
f f f f f f f f f f f f f f f f
orrect alignment and protect the patient from pressure, abrasion, and other injuries. Spe
f f f f f f f f f f f f
cial mattresses, use of foam padding, and attachments to the operating suite table provi
f f f f f f f f f f f f f
de protection for the extremities and bony prominences. Bathing before surgery helps t
f f f f f f f f f f f f
o decrease the number of microbes on the skin.
f f f f f f f f
Periodically adjusting the patient during the surgical procedure is impractical and can p
f f f f f f f f f f f f
resent a safety issue with regard to maintaining sterility of the field and maintaining an a
f f f f f f f f f f f f f f f
irway. Measuring the time the patient is in one position may help with monitoring the sit
f f f f f f f f f f f f f f f
uation but does not prevent skin breakdown.
f f f f f f
2. The nurse is assessing a postoperative patient with a history of
f f f f f f f f f f
obstructive sleep apnea for airway obstruction. Which assessment finding will b
f f f f f f f f f f
est alert the nurse to this complication?
f f f f f f
a. Drop in pulse oximetry readings f f f f
b. Moaning with reports of pain f f f f
c. Shallow respirations f
d. Disorientation
, A&EfIfComprehensivefTestbank
ANS: A f
One of the greatest concerns after general anesthesia is airway obstruction, especi
f f f f f f f f f f f
ally in patients with obstructive sleep apnea. A drop in oxygen saturation by pulse
f f f f f f f f f f f f f f
oximetry is a sign of airway obstruction in patients with obstructive sleep apnea.
f f f f f f f f f f f f f
Weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the phary
f f f f f f f f f
nx, bronchial tree, or trachea; and laryngeal or subglottic edema also contribute to
f f f f f f f f f f f f f
airway obstruction. In the postanesthetic patient, the tongue is a major cause of air
f f f f f f f f f f f f f
way obstruction. f
Shallow respirations are indicative of respiratory depression. Moaning and repo
f f f f f f f f f
rts of pain are common in all surgical patients and are an expected event. Disorien
f f f f f f f f f f f f f f
tation is common when first awakening from anesthesia but can be a sign of hypo
f f f f f f f f f f f f f f
xia.
3. The nurse is caring for a patient in the operating suite who is experiencin
f f f f f f f f f f f f f
g hypercarbia, tachypnea, tachycardia, premature ventricular
f f f f f
contractions, and muscle rigidity. Which condition does the nurse suspect the p f f f f f f f f f f f
atient is experiencing? f f
a. Malignant hyperthermia f
b. Fluid imbalance f
c. Hemorrhage
d. Hypoxia
ANS: A f
A life- f
threatening, rare complication of anesthesia is malignant hyperthermia. Malignan f f f f f f f f
t hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricula
f f f f f f f
r contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigi
f f f f f f f f f f
dity. It often occurs during anesthesia induction.
f f f f f f
Hypoxia would manifest with decreased oxygen saturation as one of its signs and
f f f f f f f f f f f f f
symptoms. Fluid imbalance would be assessed with intake and output and can ma f f f f f f f f f f f f
nifest with tachycardia and blood pressure fluctuations but does not have muscle r
f f f f f f f f f f f f
igidity. Hemorrhage can manifest with tachycardia and decreased blood pressure
f f f f f f f f f
, along with a thready pulse. Usually some sign or symptom of blood loss is noted (
f f f f f f f f f f f f f f f f
e.g., drains, incision, orifice, and abdomen).
f f f f f
4. The nurse is caring for a postoperative patient who has had a minimally inv
f f f f f f f f f f f f f
asive carpel tunnel repair. The patient has a temperature of 97° F and is
f f f f f f f f f f f f f
shivering. Which reason will the nurse most likely consider as the primary cause w
f f f f f f f f f f f f f
hen planning care? f 2 f
a. Anesthesia lowers metabolism. f f
, A&EfIfComprehensivefTestbank
b. Surgical suites have air currents. f f f f
c. The patient is dressed only in a gown. f f f f f f f
d. The large open body cavity contributed to heat loss.
f f f f f f f f
ANS: A f
The operating suite and recovery room environments are extremely cool. The pat
f f f f f f f f f f f
ient’s anesthetically depressed level of body function results in lowering of metab
f f f f f f f f f f f
olism and a fall in body temperature. Although the patient is dressed in a gown an
f f f f f f f f f f f f f f f
d there are air currents in the operating room, these are not the primary reasons for
f f f f f f f f f f f f f f f f
the low temperature. Also, the patient in this type of case does not have a large ope
f f f f f f f f f f f f f f f f
n body cavity to contribute to heat loss.
f f f f f f f
5. The nurse is monitoring a patient in the postanesthesia care unit
f f f f f f f f f f
(PACU) for postoperative fluid and electrolyte imbalance. Which action wi
f f f f f f f f f
ll be most appropriate for the nurse to take?
f f f f f f f f
a. Encourage copious amounts of water. f f f f
b. Start an additional intravenous (IV) line. f f f f f
c. Measure and record all intake and output. f f f f f f
d. Weigh the patient and compare with preoperative weight. f f f f f f f
ANS: C f
Accurate recording of intake and output assesses renal and circulatory function.
f f f f f f f f f f f
Measure and record all sources of intake and output. Encouraging copious amount
f f f f f f f f f f f
s of water in a postoperative patient might encourage nausea and vomiting. In the P
f f f f f f f f f f f f f f
ACU, it is impractical to weigh the patient while waking from surgery, but in the da
f f f f f f f f f f f f f f f
ys afterward, it is a good assessment parameter for fluid imbalance. Starting an ad
f f f f f f f f f f f f f
ditional IV is not necessary and is not important at this juncture.
f f f f f f f f f f f
6. The nurse is caring for a patient in the postanesthesia care unit. The patient
f f f f f f f f f f f f f
asks for a bedpan and states to the nurse, “I feel like I need to go to the bathroo
f f f f f f f f f f f f f f f f f f f
m, but I can’t.” Which nursing intervention will
f f f f f f f
be most appropriate initially?
f f f
a. Assess the patient for bladder distention. f f f f f
3
b. Encourage the patient to wait a minute and try again. f f f f f f f f f
