Podcast
Questions and Answers
Which information does the post-anesthesia care unit (PACU) nurse include in the hand-off to the nurse who will assume care on the medical-surgical unit? (Select all that apply)
Which information does the post-anesthesia care unit (PACU) nurse include in the hand-off to the nurse who will assume care on the medical-surgical unit? (Select all that apply)
- Fluid intake and blood loss (correct)
- Over-the-counter (OTC) medications taken at home (correct)
- Patient identification using one identifier
- Information regarding the surgical procedure (correct)
- Placement of intravenous (IV) lines (correct)
The nurse monitors for which clinical manifestations in the patient diagnosed with malignant hyperthermia? (Select all that apply)
The nurse monitors for which clinical manifestations in the patient diagnosed with malignant hyperthermia? (Select all that apply)
- Flaccid muscles (correct)
- PaCO2 48 mm Hg (correct)
- Pulse 54
- pH 7.32 (correct)
- Dark brown urine (correct)
Which is included in the scope of practice for the circulating registered nurse (RN)? (Select all that apply)
Which is included in the scope of practice for the circulating registered nurse (RN)? (Select all that apply)
- Labeling patient samples and sending for analysis (correct)
- Documenting information pertinent to the surgical procedure (correct)
- Assisting the certified RN anesthetist with patient monitoring (correct)
- Conducting the initial assessment in the operating room (correct)
- Obtaining informed consent
The nurse correlates increased risk of deep vein thrombosis formation in patients placed in which position during a surgical procedure? (Select all that apply)
The nurse correlates increased risk of deep vein thrombosis formation in patients placed in which position during a surgical procedure? (Select all that apply)
The perioperative nurse educator is preparing an inservice for new staff. In describing settings where post-anesthesia care is provided, the nurse includes which of the following? (Select all that apply)
The perioperative nurse educator is preparing an inservice for new staff. In describing settings where post-anesthesia care is provided, the nurse includes which of the following? (Select all that apply)
During preoperative teaching, the nurse explains to the patient and family that which of the following staff will take part in providing care during the intraoperative period of the surgical process? (Select all that apply)
During preoperative teaching, the nurse explains to the patient and family that which of the following staff will take part in providing care during the intraoperative period of the surgical process? (Select all that apply)
The nurse monitors for which potential complications in the patient who is receiving spinal anesthesia? (Select all that apply)
The nurse monitors for which potential complications in the patient who is receiving spinal anesthesia? (Select all that apply)
Before advancing to phase II of postanesthesia care, the patient must achieve which outcomes? (Select all that apply)
Before advancing to phase II of postanesthesia care, the patient must achieve which outcomes? (Select all that apply)
Which statements are most true about the concept of acculturation? (Select all that apply)
Which statements are most true about the concept of acculturation? (Select all that apply)
The nurse is caring for a school-age child with tinea capitis. Which nursing diagnoses would be a part of this client's care plan? (Select all that apply)
The nurse is caring for a school-age child with tinea capitis. Which nursing diagnoses would be a part of this client's care plan? (Select all that apply)
Which clinical manifestations are indicative of pain in the postoperative patient? (Select all that apply)
Which clinical manifestations are indicative of pain in the postoperative patient? (Select all that apply)
A nurse demonstrates an understanding of multiculturalism when they can demonstrate which of the following? (Select all that apply)
A nurse demonstrates an understanding of multiculturalism when they can demonstrate which of the following? (Select all that apply)
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Study Notes
Post-Anesthesia Care Unit (PACU) Hand-off
- Key information includes fluid intake, blood loss, IV line placement, and surgical procedure details.
- Patient identification should use at least one identifier.
- Consider patient's OTC medications taken at home in hand-offs.
Malignant Hyperthermia Monitoring
- Clinical manifestations to monitor include metabolic acidosis (pH 7.32) and increased carbon dioxide (PaCO2 48 mm Hg).
- Symptoms include dark brown urine and flaccid muscles.
- Bradycardia possible with pulse at 54.
Circulating RN Scope of Practice
- Responsibilities include obtaining informed consent and documenting information relevant to the surgical procedure.
- Conducting the initial assessment in the OR and assisting the anesthetist is included in their duties.
- Labeling patient samples for analysis falls under their practice.
Deep Vein Thrombosis Risk
- Surgical positions raising the risk of DVT include lateral and prone positions.
- Fowler's, jackknife, and reverse Trendelenburg positions have lesser associated risks.
Settings for Post-Anesthesia Care
- Post-anesthesia care settings include inpatient PACUs, intensive care units, and outpatient PACUs.
- Medical-surgical inpatient units and procedure areas also provide post-anesthesia care.
Intraoperative Care Team Members
- Key staff involved during the intraoperative period include the surgeon, anesthesiologist, circulating nurse, and PACU nurse.
- Role of the respiratory therapist is less direct during surgery.
Complications of Spinal Anesthesia
- Potential complications from spinal anesthesia include headache, hematuria, and hypotension.
- Hyperthermia and hyperventilation are not typically associated.
Phase II Post-Anesthesia Care Criteria
- Patient must achieve stable vital signs, clear urine voiding, and satisfactory oxygen saturation (98%).
- Alertness and proper airway stability are prerequisites for advancing to phase II care.
Acculturation Principles
- Acculturation involves embracing both one's own and a new culture, integrating core values and behaviors.
- It can take years for immigrant groups to fully acculturate.
- Acculturation reflects a need for survival and adaptation rather than mere culture maintenance.
Nursing Diagnoses for Tinea Capitis
- Nursing diagnoses may include disturbed body image and impaired skin integrity due to lesions.
- Assess for bathing self-care deficits and risk for infection.
- Nutritional needs should also be evaluated.
Indicators of Postoperative Pain
- Signs of pain in postoperative patients include restlessness, diaphoresis, hypotension, constricted pupils, and piloerection.
Multiculturalism Understanding
- Multiculturalism is demonstrated by accommodating diversity and incorporating inclusion.
- Identifying cultural archetypes while avoiding stereotypes is essential.
- Embracing ethnocentrism is not aligned with multicultural principles.
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