!DOCTYPE html> 11-1. While caring for the Phase I PACU patient, the perianesthesia nurse ensures patient safety by providing 1:1 care until critical elements are met. Critical elements include an initial nursing assessment, ensuring that the patient has a stable airway and hemodynamic stability, the patient is free from restlessness or combative behaviors, and: a. The patient is able to deep-breathe and cough b. The patient can comply with a stir-up regimen c. Transfer of care has taken place d. Clinical monitors have been applied 11-2. In preparation for extubation, the perianesthesia nurse assesses and documents adequate muscle strength. All of these criteria are indications of adequate muscle strength EXCEPT the ability to: a. Lift the head from the bed for at least 5 seconds b. Lift the head from the bed for at least 15 seconds c. Open eyes widely d. Swallow 11-3. A right-handed, 36-year-old male patient with a history of chronic pain treated with long-acting opioids has gone to the operating room for a closed reduction of a right wrist fracture. The perianesthesia nurse considers all of the following when determining this patient’s length of stay after the administration of intravenous opioid medications EXCEPT: a. Medication half-life b. Drug hypersensitivity c. Cumulative effects d. Surgical procedure 11-4. Patient and family education includes preparing the patient for surgery. To avoid postoperative infection, the patient should be taught to: a. Request that staff wash their hands b. Shave surgical site at home c. Avoid harsh antimicrobial soaps d. Prepare for a high carbohydrate diet postoperatively 11-5. Standard III of ASPAN’s 2015-2017 Perianesthesia Nursing Standards, Staffing and Personnel Management, identifies that the professional perianesthesia nurse providing Phase I level of care maintains certain competencies concerning advanced cardiac life support (ACLS) and pediatric advanced life support (PALS). This standard identifies that: a. An ACLS equivalency course can be provided by each facility b. Current ACLS or PALS provider status is maintained appropriate to patient population served c. PALS is only required when the pediatric population exceeds 15 cases/day d. Current ACLS and PALS provider status is strongly encouraged 11-6. To aid in ensuring patient safety, the Centers for Medicare & Medicaid Services (CMS) requires that a postanesthesia evaluation be completed in accordance with state law and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care. This evaluation must be performed by: a. Any advanced practitioner b. A perianesthesia nurse c. A practitioner who is qualified to administer anesthesia d. An anesthesiologist on staff 11-7. As a perianesthesia nurse, the MOST important element of the American Society of PeriAnesthesia Nurses (ASPAN) Staffing and Personnel Management Standard is: a. The standard is endorsed by ASPAN b. Staffing patterns reflect patient acuity, census, and workflow c. The staffing matrix should be based on a formula incorporating adjusted patient days d. Staffing schedules should be addressed within an organization’s service standards 11-8. The perianesthesia nurse is preparing to administer packed red cells to a patient. To identify the patient, the nurse will: a. Check the room number and procedure of the patient b. Review the operating room number, procedure, and surgeon’s name c. Ask the patient to state his mother’s name and maiden name d. Use identifiers such as the patient’s name, identification number, or birth date 11-9. When discharging a 6-month-old after a bilateral myringotomy and tube placement, the Phase II PACU nurse evaluates all of the following EXCEPT: a. Interactions between the child and parent or significant other b. Patient and home care provider knowledge of discharge instructions c. Ability of home care provider to demonstrate how to measure temperature d. Transportation plans to include a second responsible person to sit with the child 11-10. The practice of applying sequential compression devices during the perioperative phase of patient care is an example of: a. Clinical inquiry b. Process improvement c. Research utilization d. Research design 11-11. According to the Occupational Safety and Health Administration Bloodborne Pathogens (OSHA BPP) standard, institutional plans to reduce employee needlestick injuries must include input from: a. Employees responsible for direct patient care b. Registered clinical pharmacists and pharmacy technicians c. Nurse managers d. Employee health directors 11-12. When caring for a medical-surgical overflow patient in the Phase I PACU or the Phase II ambulatory surgery unit (ASU), the perianesthesia nurse: a. Demonstrates appropriate competencies required for the patient populations b. Groups the Phase I and medical-surgical patients in order to provide appropriate nursing ratios c. Advocates for a modified surgical schedule to accommodate the overflow d. Contacts the director of anesthesia services for medical management of the patient 11-13. Critical elements of the Phase I PACU admission include all of the following EXCEPT: a. Report has been received, questions have been answered, and transfer of care has taken place b. The patient has a stable/secure airway c. The patient is able to answer questions d. The patient is hemodynamically stable and free from agitation, restlessness, and combative behaviors 11-14. When participating in a study to delineate the use of a perianesthesia scoring tool, the perianesthesia nurse knows that the outcome of this study will have the most impact on the nurse’s: a. Clinical role b. Educational role c. Management role d. Collaborative role 11-15. The Phase II perianesthesia nurse is caring for the following patients: one 9-year-old patient with parents at bedside, one 54-year-old patient just returning from the operating room as an initial admission, and one 45-year-old patient who is preparing for discharge (IV is discontinued and the patient is dressed in street clothes). This situation: a. Is below the American Society of PeriAnesthesia Nurses (ASPAN) Standard for staffing b. Meets the ASPAN Standard for staffing c. Exceeds the ASPAN Standard for staffing d. Has never been tried as a staffing pattern 11-16. The perianesthesia nurse reviews The Joint Commission (TJC) National Patient Safety Goals, acknowledging that: a. The goals are only applicable in the hospital setting b. TJC revises the goals only when new safety issues arise c. The goals are updated annually d. TJC does not require adherence to the goals 11-17. Factors that influence the level of opioid-induced sedation include the dose of medication, the route of administration, the patient’s opioid tolerance, current medical conditions and comorbidities, and: a. Age 15 and younger b. Age between 15 and 40 c. Age between 40 and 55 d. Age 55 and older 11-18. An 85-year-old male patient is being prepared for surgery to repair a fractured hip. The perianesthesia nurse assigned to care for him is aware that older patients are at an increased risk of unwanted sedation secondary to a reduction in tissue perfusion, drug metabolism, drug clearance, and: a. Total body water b. Bone density c. Circulating hormones d. Cerebral blood flow 11-19. Patient safety is primarily defined as: a. The highest priority of perianesthesia practice b. An updated resource for evidence-based policies and procedure c. Having a surgical team that is collaborative d. Sustaining no injury from a near-miss event 11-20. The most important criteria to be assessed and documented regarding the patient with a right-sided chest tube include all of the following EXCEPT: a. Vital signs to include blood pressure, heart rate, and rhythm b. Fluctuations in the water seal chamber c. Frequency of Trendelenburg positioning for fluid drainage d. Condition of dressing and surrounding tissue 11-21. The Phase II PACU nurse assesses his patient’s readiness for discharge. When the patient reports that she has no transportation and no one to stay with her at home, the Phase II nurse: a. Keeps the patient in the department an extra 4 to 6 hours b. Notifies the surgeon/primary care provider and follows the department procedures and policies c. Calls the patient’s nearest neighbor to request assistance and to check on the patient d. Obtains a taxi/bus voucher and accompanies the patient to the appropriate exit 11-22. The perianesthesia Phase I nurse has worked a hectic 10-hour shift, and the current schedule implies there will be at least 8 more hours of surgery and recovery time ahead. The schedule indicates this nurse will begin an “on-call” status in 2 hours. The perianesthesia nurse taking a call knows the following criteria should be met: a. A minimum of 2 hours provided between shifts to allow for adequate nurse recuperation b. Staff refusing to complete “on-call” requirements are subject to discipline c. Minimum staffing ratios are rarely necessary when working “on-call” d. Leadership should provide a plan to augment “on-call” staff based on patient census and acuity 11-23. A new orientee is reviewing guidelines for clinical documentation in the Phase I PACU. When discussing the documentation of any phone calls made to report changes in a patient’s condition, a number of important elements are identified. These include the time the call was made, the person who made the call, the individual who was called, and: a. What the person who was called was doing at the time of the call b. What the person who made the call was doing at the time of the call c. All information given and received during the call d. The number of patients and staff in the unit at the time of the call 11-24. An 18-year-old female patient is scheduled for a diagnostic laparoscopy for suspected endometriosis. She is a healthy nonsmoker, with a passion for sports and athletic training. She was recently accepted into a health coach program. She reports a history of seasickness when on watercraft. Current vital signs include a BP of 92/54 and a resting HR of 56. When documenting her risks for postoperative complications, the perianesthesia nurse notes risk factors for postoperative nausea and vomiting (PONV) to include all of the following EXCEPT: a. Female gender b. Smoking status c. Motion sickness d. Cardiac output 11-25. Providing translation services for non-English–speaking patients is required under: a. The Civil Rights Act b. The Centers for Medicare & Medicaid Services c. The Joint Commission Standards d. The Health Insurance Portability and Accountability Act 11-26. The perianesthesia nurse arrives at the bedside of the patient undergoing an operative procedure. Before entering the patient’s care area, the nurse will: a. Use an alcohol-based hand sanitizer provided by her facility b. Obtain latex-free gloves and ensure the gloves are sized correctly c. Answer the call light of the patient in the next bay d. Wipe off the keyboard of the bedside computer with bleach cloths 11-27. When documenting electronically, the nurse must be diligent to perform what function to protect her documentation? a. Use the “save” button on the keyboard b. Print the record for transfer of care to the next provider c. Sign in and out with user name and password d. Electronically sign name after completing documentation 11-28. The American Society of PeriAnesthesia Nurses (ASPAN) Standards state “two registered nurses, one of whom is a RN competent in Phase I Postanesthesia Nursing are in the same room/unit where the patient is receiving Phase I level of care.” The PRIMARY intent is that the second nurse is: a. Anywhere in the hospital itself b. A phone call away c. Within the surgery department d. In the same room where the patient is 11-29. A patient arrives at the same-day unit before surgery complaining that the elevator doors shut too quickly, knocking the patient to the floor. After appropriate assessment, investigation of the complaint, and communication of the event to nursing leadership, the perianesthesia nurse prepares to chart the event. Documentation of the patient incident should be factual and objective but should NOT include which of the following? a. Patient subjective description of an event b. Description of any injuries sustained c. Outcomes of the event investigation d. The completed incident report 11-30. The perianesthesia nurse caring for the perinatal patient develops care plans, protocols, and clinical practices that support the unique needs of the childbearing family during surgical birth that include topics such as bringing the newborn into the Phase I PACU, providing early skin-to-skin contact with the newborn, and: a. Allowing for music therapy as part of the birthing plan b. Encouragement to breastfeed c. Keeping opioid therapy to a minimum d. Bringing the doula for active uterine management 11-31. The frequency with which the Phase II perianesthesia nurse documents on a patient is: a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. As per institutional policy 11-32. The perianesthesia nurse understands that the sources of standards include all of the following EXCEPT: a. Accrediting organizations b. State boards of nursing c. Specialty nursing organizations d. Health care nurse executives 11-33. When caring for the patient with increased intracranial pressure, the perianesthesia nurse assesses and documents all of the important nursing interventions, including: a. Maintaining the head of the bed at 15 degrees b. Inducing hourly Valsalva maneuvers to keep pressure low c. Spacing all nursing care to allow frequent rest periods d. Obtaining adequate support to turn the patient from supine to prone every 2 hours 11-34. The perianesthesia nurse accompanies the patient being transported if the patient requires all of the following EXCEPT: a. Evaluation during transport b. Continuous intravenous infusions c. A higher level of care d. Treatment during transport 11-35. Ms. Z, 54 years old, arrives in the Phase I PACU after an inguinal hernia repair. Ms. Z’s history includes obesity, diabetes mellitus, a previous cerebrovascular accident (CVA) with residual right-sided weakness, and a myocardial infarction (MI) within the past 9 months. Ms. Z arrives slightly diaphoretic, with respirations regular and facial color ruddy. Initial vital signs are BP 108/54 (preoperative BP was 147/91), HR 67, RR 16, T 96.2° F, and SpO2 of 97% with O2 at 5 L/nasal cannula. The inguinal dressing is clean and dry, and the abdomen is distended and firm. Your initial action for this patient is to conduct and then document: a. Application of pulse oximetry b. Application of cardiac monitor c. Assessment of respiratory status d. Assessment of neurologic status 11-36. When describing an observation regarding a patient, it is MOST important to document: a. Immediately b. Objectively c. Chronologically d. Subjectively 11-37. When caring for a patient with local anesthetic systemic toxicity (LAST), the perianesthesia nurse is prepared to document which of the following EARLY signs of cardiovascular toxicity? a. Hypertension and atrial irritability b. Hypotension and atrial irritability c. Hypertension preceding hypotension d. Atrial irritability and tachycardia 11-38. Mr. J arrived in the Phase I PACU after a renal transplant. He has a history of type 1 diabetes and end-stage renal failure, treated with hemodialysis. Laboratory tests for potassium and calcium were drawn approximately 15 minutes after his arrival. Forty-five minutes later, the laboratory technician is calling with critical results, and the clerk asks the nurse to take the phone call. The perianesthesia registered nurse expects: a. The results are out of the normal range b. The patient will need insulin for hyperglycemia c. The tests need to be redrawn due to hemolysis d. Treatment for an abnormal value will not be necessary 11-39. An 85-year-old male patient is recovering from spinal anesthesia after a repair of a fractured hip. The patient is relatively healthy for his age, having fractured his hip while climbing a ladder. The perianesthesia nurse knows that in order to document the first indication that the block is resolving, the patient will need to be assessed for: a. Return of sensation to sharp stimulus b. Return of temperature sensation c. Resolution of hypotension d. Ability to move lower extremities 11-40. The patient awakens in the operating room under the observation of the anesthesia care provider. To ensure patient safety and proceed directly to Phase II care, the perianesthesia nurse understands the MOST important element for safe fast tracking is that the patient must: a. Meet Phase I discharge criteria in the OR b. Be pain free at the end of surgery c. Meet Phase I discharge criteria within minutes of arrival to Phase II d. Be free of postoperative nausea and vomiting (PONV) at the end of surgery 11-41. The perianesthesia nurse working the early shift has left for the day. About 45 minutes after she clocked out, she calls on her cell phone to report that she forgot to chart a medication that was given to a patient who was transferred to Phase II just before she left. What should be done? a. Take down the exact information (drug, dose, and time given) and chart it on the patient’s chart b. File an incident report and ask her to come back to work immediately and chart this information c. Report the information to the nurse caring for the patient and save the chart for a late entry to be made d. Refer the call to the manager and let her decide what to do 11-42. An 8-month-old patient has been brought to the same-day surgery unit for a hernia repair under general anesthesia. When collecting preanesthesia data on the pediatric patient of this age, the perianesthesia nurse considers additional components of assessment and management beyond the adult components, which include: a. Birth history and gestational age b. Current favorite play objects c. Birth order of the child compared with siblings d. Condition of the posterior fontanel 11-43. The perianesthesia nurse follows documentation guidelines that include charting accurately, comprehensively, and promptly and: a. Providing honest critique of events b. Offering carefully described subjective findings c. Charting with common nursing abbreviations d. Charting objectively to describe only what is observed 11-44. Mr. G is preparing for discharge after an uneventful laparoscopic cholecystectomy. With knowledge that right shoulder pain after laparoscopic surgery is common, the Phase II perianesthesia nurse teaches and documents patient education to include: a. Sleeping at a 45-degree angle to eliminate the pain b. Calling 911 if the shoulder pain is not resolved within 12 hours c. Reassurance that the temporary pain is from surgical positioning d. Instructions to use oral analgesics for the shoulder pain 11-45. Site marking is done when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient. The following statements are correct regarding site marking, according to The Joint Commission, EXCEPT: a. The mark is unambiguous and is used consistently throughout the organization b. The mark is sufficiently permanent to be visible after skin preparation and draping c. Alternative processes may be needed for mucosal surfaces and minimal access procedures d. The mark is the signature of the licensed independent practitioner (LIP) 11-46. The perianesthesia nurse supervises and delegates to unlicensed assistive perianesthesia (UAP) support staff. Competencies recommended for the UAP include: a. Unsterile dressing changes as needed b. PEARS (pediatric emergency assessment recognition and stabilization) training c. Basic airway support d. Interpretation of monitor alarms 11-47. Standards of care for which perianesthesia nurses are held accountable are those standards that a reasonably prudent nurse would follow. These standards are set forth in all of the following ways EXCEPT: a. Standards established by institutional policies and procedures b. Standards that may vary from community to community c. Standards established by the national nursing organizations d. Standards that are integrated into annual performance evaluations 11-48. The competent perianesthesia nurse demonstrates teamwork, collaboration, and effective communication and will participate in: a. Professional development b. Multidisciplinary rounds c. Policy implementation d. Nursing grand rounds 11-49. To promote positive outcomes, perianesthesia nurses seek knowledge of and develop skills in the care of the pediatric patient. To provide optimal care of the pediatric patient, the perianesthesia nurse demonstrates a commitment to: a. Nurse-managed care (NMC) b. Value-based pediatric care (VBPC) c. Accountable care (AC) d. Family-centered care (FCC) 11-50. Mr. S is undergoing an open reduction and internal fixation of a tibial and fibular fracture of his left leg after a motor vehicle accident. He is awake and alert and complaining of severe leg pain. The procedure site will be marked: a. After the patient is in the operating room and asleep b. By the preoperative nurse using a skin marker while the patient confirms the site c. By the licensed independent practitioner (LIP) who is performing the procedure d. With an adhesive marker at or near the procedure site 11-51. The perianesthesia nurse understands that a policy exists to ensure safe transportation of patients. This nurse determines the: a. Mode of transportation, number of accompanying personnel, and disposition of patient b. Number and competency of accompanying personnel and disposition of patient c. Mode of transportation, number, and competency of accompanying personnel d. Mode of transportation, disposition of patient, and competency level of accompanying personnel 11-52. When caring for a Muslim perianesthesia patient, the practice of care is based on philosophical and ethical concepts that recognize and maintain privacy, dignity, and: a. Seclusion b. Confidentiality c. Enmity d. Dependence 11-53. Perianesthesia nurses implement safe medication practices by reviewing allergies and being alert to look-alike/sound-alike medications. Another example includes: a. Proper labeling of multivial drugs b. Using prefilled saline flushes to carefully titrate doses c. Following institutional policy that overrides physician orders d. Maintaining free-flow capacity of infusion devices 11-54. To ensure safe medication administration to patients, the perianesthesia nurse is responsible for all of the following EXCEPT: a. Proper labeling with the name of the medication, dose, and/or concentration b. Storage of controlled medications per institutional policy c. Witnessed discard of any unused opioids and/or sedatives d. Transfer of unused opioids to a relief nurse only if properly labeled 11-55. The perianesthesia nurse knows the best way to prevent the spread of drug-resistant organisms (DROs) is to follow standard precautions. To prevent the spread of DROs, the perianesthesia nurse does the following: a. Uses only industrial-strength hand soap when hand hygiene is necessary b. Maintains one-to-one nurse:patient ratio throughout the PACU Phase I period c. Accepts a second patient when there is sufficient time for donning and removing personal protective equipment (PPE) d. Groups two patients to allow one nurse to use the same PPE barriers between patients with similar DROs 11-56. The Phase I PACU perianesthesia nurse receives a patient from the operating room. This nurse knows that a report must be received from the anesthesia provider, vital signs must be obtained, an initial assessment must be completed, and: a. Electronic documentation must be initiated b. Clinical monitors must be connected c. Thorough skin and wound assessment must be conducted d. Transfer of care must be accepted or acknowledged 11-57. As the perianesthesia nurse accepts a patient from interventional radiology, handoff of care includes the accurate transmittal of patient information, including treatment, current condition, and anticipated changes. According to the postprocedure plan of care, a patient having a gastrostomy tube (GT) placed should be observed for which of the following? a. Sepsis or peritonitis b. Embolization syndrome c. Hypotension d. Pseudothrombosis 11-58. The perianesthesia nurse serves as an advocate, not only for her patient, but also for peers and other members of the health care team. Characteristics of a healthy work environment when working with an impaired professional include all of the following EXCEPT: a. Provision of treatment options
ASPAN Standards, Documentation, Regulatory Guidelines, and Patient Safety Needs
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