(solved)Surgery: Prophecy PACU RN A v1- complete solution guide;

Meperidine (Demerol) 12.5mg every 15 minutes, IV prn is ordered for shivering in the PACU. Meperidine is available in 50mg/1ml. How many mililiters should be given? - 0.25 mililiters Upon inspecting a patient's epidur ...

Meperidine (Demerol) 12.5mg every 15 minutes, IV prn is ordered for shivering in the PACU. Meperidine is available in 50mg/1ml. How many mililiters should be given? - 0.25 mililiters Upon inspecting a patient's epidural insertion site, you notice swelling around the catheter. What should you do? - A) Position the patient on their side B) Place the patient in a prone position C) Check the epidural line for kinks D) Contact the anesthesia provider What set of findings indicates a patient is likely to be ready for phase 1 discharge? - A) Has received discharge instructions, pain level 9 out 10, shortness of breath B) Drowsy, blood pressure returned to preoperative levels, on 6 liters oxygen via face mask C) Drowsy, oxygen saturation of 96%, able to cough, and move all extremities D) Fully alert, shallow breathing, on 3 liters via T-piece, can move 2 extremities What do you consider to be a safe dose of intravenous fentanyl for an adult who does not have tolerance to opioids? - A) 1.5 miligrams B) 25 micrograms C) 100 micrograms D 25 miligrams Your patient in the PACU has a blood pressure of 171/92 mmHg, a heart rate of 120, respiratory rate of 24, is grimacing, restless, and moaning in bed. What medication should you prepare to give FIRST? - A) 10 mg hydralazine IV push B) 50 mcg fentanyl IV push C) 2 mg lorazepam IV push D) 5 mg metoprolol IV push You are about to discharge a day surgery patient with aphasia and you discover the family members are not available for the discharge instructions and are not responding to your phone calls. Business hours are over and the PACU is about to close. How will you handle the situation? - A) Wait until the family returns B) Leave the discharge education on voicemail and discharge patient C) Discharge patient with non-emergency transport D) Take patient home yourself You received a patient from OR post hip replacement surgery. The anesthesiologist is planning a nerve block in PACU, but the patient did not sign the consent for the nerve block. How will you proceed? - A) Wake up the patient to sign the consent B) Ask a friend to sign the consent C) Obtain the consent from medical POA D) Proceed with the procedure What position would help alleviate headaches after spinal anesthesia? - A) Prone B) Trendelenburg C) Semi-fowlers D) Flat to supine What is a physical manifestation of neuromuscular blockade (Roc, succinylcholine)? - A) Decreased consciousness B) Decreased pupillary light reflex C) Decreased respiratory effort D) Decreased sensation of pain The surgeon has ordered ampicillin (Ancef) for a patient. When you check their chart, you see an allergy to penicillin. What is the BEST action? - A) Administer the medication with diphenhydramine B) Ask the patient to describe their reaction to penicillin C) Contact the pharmacist to clarify the order D) Contact the provider to question the order You are receiving report for a patient who had a percutaneous transluminal angioplasty for right lower extremity peripheral vascular disease and is now recovering in the PACU. What type of surgical dressing do you expect to find for this patient? - A) JP drain sutured in place near the lateral calf B) Several small incisions in calf groin covered with gauze C) Clear dressing applied to the right groin D) 3 in incision on the right upper thigh with bulky dressing You are receiving a report on a post op patients from the OR nurse and during the report when you asked for clarifications, the OR nurse became angry, belligerent, and rude. She ended up not answering your question. How will you proceed? - A) Report the incident to your charge nurse B) Refuse to take the patient C) Take the report as she gave it to you D) Figure out the clarifications from computer You are reviewing your orders for you 8 year-old patient that recently arrive in PACU. Which PRN pain order would you question? - A) IV acetaminophen (maybe??? bc super expensive???) B) PO acetaminophen C) PO ketorolac (maybe???? bc shows increased risk of bleeding than tylenol, and is oral, which maybe they're trying to avoid PO after surgery) D) IV ketorolac What is a physiologic effect related to unrelieved pain? - A) Hypoglycemia B) Bradycardia C) Decreased metabolism D) Decreased healing You are caring for a patient after placement of a percutaneous J tube. A student nurse asks you, " Where does this tube go in the patient?" How should you answer? - A) The tube is placed into the Jejunum B) The tube passes from the esophagus into the jejunum This tube is inserted into the stomach D) The tube is inserted directly into the colon When caring for a patient who is recovering from placement of a new arteriovenous fistula in their right arm, you observe the presence of mild edema at the site. What should you do? - A) Hold pressure on the anastomosis graft B) Elevate the right arm above the heart C) Apply an ice pack to the arm D) Contact the surgical team You are caring for patient who is intubated, receiving ventilatory support, and is sedated with a propofol infusion. Over the last 5 minutes you have decreased the propofol infusion in preparation for extubation. The patient is now opening their eyes to voice and following commands. What should you do NEXT to prepare the patient for immediate extubation? - A) Place a manual, resuscitator device at the bedside B) Insert an oral airway C) Stop the propofol infusion D) As the patient to cough When caring for a patient who is receiving outpatient surgery, what is the BEST way to know that a patient's post-operative blood pressure is sufficient for discharge to home? - A) The pressure is greater than 100 mmHg SBP B) It is +/- 20% of baseline pre-operative levels C) Adhere to professional standards D) Follow the anesthesia order set After surgery, a sleepy yet responsive patient with an intact gag reflex has a large amount of salivary secretions. What should you do? - A) Turn the patient on their side B) Provide oral suctioning C) Contact the anesthesia provider D) Insert an oral airway Where is the phlebostatic axis for leveling the transducer of an arterial line? - A) Fourth intercostal level at the midaxillary line B) Fourth intercostal level at the midclavicular line C) Fifth intercostal level at the midaxillary line D) Fifth intercostal level at the midclavicular line A carotid endarterectomy patient arrives to you in the PACU. What initial assessment is MOST important? - A) pupil checks B) pain scale C) capillary refill D) blood glucose There are 4 patients in PACU: A patient who is alert but disoriented to time, a patient who reports dizziness upon sitting upright, a patient who has partial return of sensation after spinal, and a patient who is drowsy but awakens to touch. Which patient is MOST ready to transfer to phase 2 post-anesthesia care? - A) The patient who has partial return of sensation after spinal block B) The patient who is alert but disoriented to time C) The patient who is drowsy but awakens to touch D) The patient who reports dizziness upon sitting upright Your patient arrives to PACU with lactated ringer's ordered at 100ml/hr. Which pre-existing condition would make you question this order? - A) Sickle cell anemia B) End Stage Renal Disease C) Gastroesophageal reflux D) Diabetes Mellitus While assessing your post-op patient with a new dialysis graft, what should the PACU nurse monitor to evaluate the functionality of the graft? - A) Brisk capillary refill at the access site B) No numbness or tingling of the hand C) Clean, dry, and intact dressing D) A palpable thrill and audible bruit You are taking care of a 300lb male status post abdominal surgery, and he requests to be repositioned. He is currently on a hover mat. What is the BEST way to achieve this? - A) Inflate the hover mat yourself and move the patient to his desired position B) Ask patient to move himself up in the bed C) Wait for additional assistance before moving the patient D) Tell your patient it is unsafe to move at this time What is an example of Phase 1 discharge criteria? - A) The patient's family member has arrived to take them home B) The patient is ready and able to ambulate to the bathroom C) The patient can maintain their airway D) The patient's vital signs have been monitored for 60 minutes You were called in at 2am and did not leave the hospital until 4am. However, your regular shift starts at 7am, and you are extremely tired. What is the appropriate action? - D) Call your manager and ask for the unit protocol **** You are caring for a patient in Phase 1 recovery and they appear ready to transfer except that their blood pressure continues to stay 50mmHg above their pre-anesthetic SBP. At home the patient takes a diuretic and beta-blocker for hypertension. What should you do? - A) Evaluate the patient's pain level (probs correct) ****B) Administer 20mg furosemide orally C) Transfer the patient to the unit D) Contact the anesthesia provider You receive a patient to Phase I recovery from IR status post cerebral aneurysm clipping. Which assessment is most important for you to perform? - A) Cardiac rhythm, heart rate, blood pressure B) Pupil response, facial and extremity movement C) Bowel sounds, urinary output, and oral cavity D) RR, BP, Temp Which patient is MOST at risk for developing postoperative cardiogenic shock? - A) A 78 year old male adult with CKD B) Pt with recent MI C) Female pt with ES liver disease D) Pediatric patient with metastatic lymphadenopathy When setting up a morphine PCA pump for a 5'10'' female patient recovering from hip surgery who is 49 years old, 180 lb, and has no history of sleep apnea, what is an expected 4-hr dose limit? - **A) 5 mg B) 20 mg (probs correct) C) 3 mg D) 40 mg You are caring for a postoperative thyroidectomy patient in the PACU. What is the least likely finding for this patient? - A) Paresthesia of the fingers and toes B) Low Hgb C) Muscle Cramps D) Tingling in hands and feet ** After a 6-hour abdominal surgery during which a patient was on their back, a patient reports persistent lower back pain. What should you do next? - A) Help them to a new position B) Administer pain medication C) Inspect their lower back (probs correct, pt might be bleeding into back) D) Check their hematocrit What is a result of shivering? - A) Decreased oxygen consumption B) Increased oxygen demand C) Peripheral vasoconstriction D) Elevated end tidal CO2 What combination of medications is an example of multi-modal pain management? - A) IV PCA morphine with IV fentanyl B) Oral morphine ER and IV morphine C) IV hydromorphone and IV acetaminophen (probs correct, one is opioid, other is not) D) IV hydromorphone and IV morphine You are caring for a patient with a brachial plexus block after surgery. The patient begins to report chest discomfort on the side where the block was placed. A 12 lead EKG was normal. What order do you expect to be completed NEXT for this patient? - A) Echo B) Cardiac biomarkers C) CMP D) Chest X-ray You need to obtain consent from a sedated patient post hip replacement surgery for a regional block. Two women showed up at bedside as next of kin. One has a child with patient and the other is the patient's girlfriend. How will you obtain the consent? - A) Proceed with patient signature B) Look for patient's parents or immediate family members C) Allow one of the women to sign D) Allow both women to sign What instructions for care should you include when educating a patient about their Penrose drain? - WORNGA) You will have bright red drainage from the tube for several days B) Change your dressing 2 times a day or when it becomes wet (very probs correct) C) This drainage tube helps prevent accumulation of bile D) Remove the safety pin at the end of the tube when you get home You are caring for a patient with a continuous basal rate PCA infusion when the patient becomes difficult to awaken. What should you do FIRST? - A) Hold the PCA infusion B) Elevate the head of bed 45 degrees C) Stay with patient D) Contact anesthesia provider Which factor puts a patient MOST at risk for confusion upon awakening from general anesthesia? - B) Advanced Age You are providing care for a diabetic patient in the PACU. What care should you provide to decrease their risk of surgical site infections? - B) Maintain blood glucose levels per protocol and hand hygiene What department approves and reviews medical aspects of care in the PACU including policies and procedures? - Department of Anesthesia When providing care to a patient in the PACU who is receiving placement of a new permanent vascular access graft, what finding should you report immediately to the surgeon? - Inability to palpate a thrill While helping to prepare a patient for surgery, you notice that their medical record indicates DNR. What should you do? - Ask the patient to explain their wishes about resuscitation A patient's DNR order was revoked during surgery. When can it be reinstated? - Per institutional policy A patient who received general anesthesia tells you that their throat is sore and you notice their voice is hoarse. What should you do? - provide ice chips and sips of water There are 4 patients in PACU: a patient who received surgery to repair their maxilla bone fracture, a patient recovering from esophageal resection for squamous cell cancer, a patient who is recovering from surgical placement of a tracheostomy, and a patient who is recovering from Roux-en Y gastric bypass surgery. For which of the patient is the insertion of a nasopharyngeal airway contraindicated? - C) Maxilla bone fracture (probs correct) D) Patient recovering from tracheostomy You are caring for a patient when suddenly their ECG monitor shows coarse ventricular fibrillation. They become unable to rouse and pulseless. What is the PRIORITY intervention for this patient? - A) IV Epi B) IV Amio C) Chest compressions (probs correct) *D) Defib You're about to discharge a patient who speaks a Vietnamese dialect. The patient has a friend who speaks that same dialect but this friend is at home. What will you do in order to give patient appropriate discharge instructions? - Use your organization's designated translating system What do you consider to be the SAFEST initial dose of IV hydromorphone for a 70 year-old without renal impairment? - A) 0.5 mg B) 1 mg C) 0.2 mg D) 0.5 mcg In PACU, upon reviewing the order for a PCA, you have a question about it. Who should you contact? - A) Hospitalist B) Anesthesiologist C) Critical Care Intensivist D) Surgeon What information is important to include when providing patient education about the use of a PCA? - Only you should press the button to receive pain medicine You observe a small amount of blood in the tubing of a continuous regional nerve block. What should you do FIRST? - A) Look for signs of anesthesia toxicity B) Call anesthesia provider C) Asses patient's vital signs D) Apply ice pack to insertion site What safety measure should you take when applying a fentanyl transdermal patch? - Wear gloves (very confused) You are caring for a patient in the PACU who is receiving an interscalene block for an upper extremity operation. When assessing the patient, you discover bilateral numbness of the chest and neck. What should you do NEXT? - A) Clamp the infusion tubing B) Stop the infusion pump C) Double check the pump settings D) Provide supplemental oxygen To whom might you ask to apply a BiPAP? - Respiratory Therapy A patient in phase 2 recovery has yet to urinate after surgery. You take the patient to the bathroom, and they are still unable to void. What should you do FIRST? - A) Offer the patient a cup of water B) Perform a bladder scan (probs correct) C) Document unable to void D) Obtain an order for a catheter What sign or symptom should you closely monitor for in a patient after they have neck surgery? - A) Severe Headache B) Tracheal Deviation C) Sudden disorientation D) Pain at incision site A patient had malignant hyperthermia during surgery. What kind of monitoring should they receive? - Intensive care unit monitoring for 24 hours Threshold for hypothermia in PACU? - Less than 36 degrees Celsius You receive a patient who has just arrived from surgery and is in Phase 1 PACU. The patient is unresponsive to name, has a respiratory rate of 12, is receiving 6 L with a face mask, and is making a gurgling sound with each exhalation. What action is MOST appropriate? - A) Ask the patient to state their name B) Turn patient on their side C) Insert oral airway (maybe???) D) Increase oxygen level After day surgery, a patient is drowsy, nauseated, reporting 7 out of 10 pain, and requiring 4 liters oxygen to maintain sat greater than 92%. What level of care should this patient receive? - Phase 1 What condition increases a patient's risk of respiratory depression when using a PCA pump? - Sleep apnea What assessment finding indicates that a patient is ready to tolerate ice chips? - Patient is able to cough After day surgery, the patient is awake, reports 2 out of 10 pain, denies nausea, has voided, has stable vital signs, but has yet to receive discharge instructions. What level of care should this patient receive? - Phase 2 Reversal of Midazolam - Flumazenil A sedated patient has just arrived to the PACU from the operating room with the anesthesia provider and a member of the surgical team. What should you do next? - Assess their airway and oxygenation (no idea what correct answer is) What drug is MOST effective in upper airway emergencies? - A) Terbutaline B) Nebulized albuterol C) Humidified oxygen D) Racemic epinephrine You are caring for a patient in the PACU who was intubated and received general anesthesia during surgery. Now extubated, the patient reports feeling pain in their front tooth. Upon inspection, the tooth appears loose. What should you do? - A) Contact the anesthesia provider and ask them to inspect the oral cavity (probs correct) B) Review the preoperative documentation about the patient's dentition C) Secure the tooth by packing folded or rolled gauze around it D) Contact the surgical team and ask them to inspect the patient's throat What would delay discharge home when caring for a patient who received spinal anesthesia? - Inability to void