Alexanders Care of the Patient in

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Chapter 10: Postoperative Patient Care and Pain Management
Rothrock: Alexander’s Care of the Patient in Surgery, 16th Edition

MULTIPLE CHOICE

1. The initial primary assessment by the perianesthesia nurse, on the patient’s admission to
the postanesthesia care unit (PACU), begins with which criterion?
a. Patient’s level of consciousness and hanging intravenous (IV) fluid level
b. Patient identification using attached identification (ID) band with two identifiers
c. Vital signs and ABCs, beginning with the respiratory system
d. The surgical/interventional procedure performed and surgeon
ANS: C
After the immediate primary assessment of the ABCs and completion of the hand-off
report, the PACU nurse begins a more thorough postanesthesia assessment. The
assessment is performed quickly and is specific, in part, to the type of operative procedure.
Recommended elements of an initial assessment in the PACU are presented in Box 10-2.

2. Delirium is described as an extreme disturbance of arousal, attention, orientation,

perception, affect, and intellectual function accompanied by fear and agitation. What is the
most common cause of postoperative agitation?
a. Organic brain disease
b. Hypoxemia
c. Preoperative anxiety
d. Excessive blood loss
ANS: B
Causes of agitation range from residual effects of anesthetics to pain and anxiety.
Hypoxemia is ruled out first; it remains the most common cause of postoperative agitation.

3. A 33-year-old female, who had a dilation and curettage (D&C) with laparoscopic tubal
ligation and has been in phase II recovery for 3 hours, collapsed while sitting on the toilet.
The perianesthesia nurse had recently finished giving the patient her discharge instructions
and helped her dress. The patient was assessed for loss of consciousness and airway
patency. What action should the phase II nurse take next?
a. Transfer the patient back to phase I PACU and begin airway interventions.
b. Determine if the patient has resedated and is a candidate for a dose of naloxone.
c. Begin airway interventions; revert to phase I criteria.
d. Initiate a cardiac arrest call and get the code cart; prepare to intubate.
ANS: C
While phase II PACU prepares the patient for discharge, phase I activities focus on
primary assessment, breathing, and circulation and facilitating the patient to a level of
physiologic stability. The patient’s current status requires advanced care at the phase I
level.
4. A patient, who collapsed while sitting on the toilet, admitted that she had been straining
while seated on the toilet. The anesthesia provider and perianesthesia nurse surmised that
the patient experienced a vagal response, which led to bradycardia and syncope (fainting).
The patient’s heart rate and blood pressure are less than 20% of her admission parameters;
she is awake and lucid and is able to appropriately follow commands. What phase of the
nursing process will impact the patient’s next step and what can she expect?
a. The assessment phase: The nurse will pursue laboratory diagnostic chemistry
panels and arterial blood gases to determine oxygenation and potential for internal
bleeding.
b. The planning phase: The nurse will compare current vital signs and symptoms to
admission values, and the patient will continue to be monitored with IV fluids.
c. The implementation phase: The nurse will administer a titrated IV atropine until
the patient’s blood pressure and heart rate are at or above preadmission values.
d. The evaluation phase: The nurse will initiate a period of watchful waiting while
she receives IV fluids and sips juice.
ANS: B
Based on the assessment and nursing diagnosis, the nurse sets measurable and achievable
short- and long-range goals. The outcome set for this patient is that she will maintain
adequate cardiac output on discharge from the PACU as evidenced by blood pressure
within preoperative range, her skin will be warm and dry, she will be oriented to person
and place, and her pulse will be strong and regular. The nurse will monitor vital signs and
physiologic parameters, level of consciousness, surgical site, intake and output; administer
fluid and medication if indicated to improve depressed myocardial contractility, increase
cardiac output, and promote diuresis. The patient will be monitored through phase I and
phase II criteria until discharge.

5. A 49-year-old healthy male is beginning to emerge from general endotracheal anesthesia

after a transurethral laser lithotripsy of the left ureter. He is restlessly turning side-to-side
and moaning. During the hand-off report from the anesthesia provider and circulating
nurse, the perianesthesia nurse learned that the patient will probably continue to pass
“sludge” (small granular ureteral stone material) for the next hour. As the surgical team
rushes back to the OR to start the next case, the perianesthesia nurse thanks them and tells
them they can go, because she knows what is wrong with the patient and will take care of
him. The perianesthesia nurse’s comment reflects which phase of the nursing process and
what will be her next actions?
a. Her nursing diagnosis will prompt her to ask the patient to describe his pain.
b. She is in the implementation phase as she checks the patient record for analgesia
orders.
c. She is in the assessment phase because she is not confident that the patient is
awake enough to experience pain and continues to review vital signs and arouse
him enough to speak.
d. She has established a nursing diagnosis and is going to deliver the first dose on his
patient-controlled analgesia pump to get medication circulating before he is fully
awake.
ANS: A
 The nurse’s statement reflects that she has formulated a nursing diagnosis based on a few
objective signs and the report about further ureteral sludge passage: acute pain related to
operative procedure. His outcome goal is to exhibit a decreased level of pain or pain at a
tolerable level on discharge from the PACU. The nurse’s next response is to assess for
subjective signs of pain: patient reports pain; patient is given a visual analogue or numeric
scale to rate pain level and assess for objective signs of pain—protective guarding
behavior, moaning, crying, whimpering, restlessness, irritability, diaphoresis, dilated
pupils, facial expression of pain, and changes in vital signs (blood pressure, respiratory
rate, or pulse).

6. A healthy 18-year-old was admitted to the PACU spontaneously breathing through his
endotracheal tube. Shortly after the perianesthesia nurse extubated the patient, he stopped
breathing and his color changed to pale, dusky-beige. What is the most ideal action that
should occur immediately?
a. Administer oxygen 5 L/min by nasal cannula.
b. Administer oxygen 5 L/min by bag-valve-mask.
c. Perform head tilt–chin lift with gentle stimulation.
d. Reintubate and manually ventilate with bag-valve-mask at 4 L/min oxygen.
ANS: C
The patient had an airway obstruction. The first priority in the care of the postanesthesia
patient is to establish a patent airway. A common cause of airway obstruction is the
tongue, which is relaxed because of anesthetic agents and muscle relaxants used during
surgery. The nursing action taken may be simple, such as stimulating the patient to take
deep breaths, positioning the patient on the side, or providing supplemental oxygen. If the
patient is still unresponsive, the nurse may need to open the airway with a chin tilt or jaw
thrust.

7. Laryngospasm is a common but serious complication in the immediate postoperative

pediatric tonsillectomy and adenoidectomy patient. What is the ideal immediate and last
resort response by the anesthesia provider or perianesthesia nurse in an emerging patient
who has been in spasm for over 1 minute, is not responding to positive-pressure
ventilation, and is in significant distress?
a. Gentle stimulation and bag-valve-mask ventilation with oxygen
b. Suctioning, IV succinylcholine administration, and reintubation
c. Emergency tracheostomy with a cricothyrotomy approach
d. IV bronchodilator administration and nebulized oxygen treatment in the PACU
ANS: B
Laryngospasm is a serious complication, usually the result of an irritable airway. The
muscles of the larynx contract and partially or completely obstruct the airway; the patient
can become hypoxemic quickly. If symptoms last longer than 1 minute and are unrelieved
by positive pressure, administration of a muscle relaxant, such as succinylcholine, is
required to relax the muscles of the larynx. Reintubation is undesirable and used only as a
last resort.
 8. A 12-year-old developmentally delayed male scheduled for dental rehabilitation became
agitated on admission to the preoperative holding unit. In spite of sedation and the calming
attention of the nurses and his parents, he was screaming and rapidly turning his head from
side-to-side. He vomited and choked twice before he fell into a light but restless sleep.
During the short procedure, the anesthesia provider was aware of rigidity and difficulty
with ventilation in the patient’s chest, yet his oxygen saturation was between 96% and
100% throughout the procedure. On extubation, he presented with coughing, wheezing,
dyspnea, use of accessory muscles, and tachypnea. The patient is presenting with
____________ probably caused by ____________.
a. aspiration; vomiting
b. bronchospasm; aspiration
c. hypoxia; laryngospasm
d. laryngospasm; traumatic intubation
ANS: B
The patient has bronchospasm caused by aspiration of vomitus. Aspiration is the passage
of regurgitated material into the lungs and can occur during the perioperative period, with
most aspirations occurring during tracheal intubation or extubation. Prevention of
aspiration postoperatively includes responding quickly to reports of nausea and vomiting,
avoiding conversations that could elicit nausea and vomiting, and preventing rapid
movement of the head. Bronchospasm is a lower airway obstruction caused by spasms of
the bronchial tubes. The patient presents with wheezing, dyspnea, use of accessory
muscles, and tachypnea. Bronchospasm can result from aspiration, pharyngeal suctioning,
or histamine release secondary to allergic response or related to medication use.

9. Hypotension is a blood pressure reading that is 20% less than the patient’s normal baseline
pressure. Hypovolemia is the most common cause of hypotension; however, hypotension
may also be caused by cardiac dysfunctions. Which triad of cardiac conditions will present
with hypotension?
a. Myocardial infarction, myocardial tamponade, and pulmonary embolism
b. Cardiac ischemia, subaortic stenosis, and pericarditis
c. Congestive heart failure, valvular dysfunction, and tachypnea
d. Certain anesthetic agents and cardiac stimulants, conduction defects, and
endocarditis
ANS: A
Hypotension has been defined as a blood pressure reading that is 20% less than baseline or
preoperative blood pressure measurement. It indicates either relative or absolute
hypovolemia. Cardiac output and vascular resistance determine blood pressure.
Hypotension may be caused by cardiac dysfunction (such as myocardial infarction,
tamponade, embolism, ischemia, dysrhythmias, congestive heart failure, valvular
dysfunction) or by medications (including anesthetic agents).

10. Select the patient who is the most vulnerable and at high risk for hypothermia in the
perianesthesia phase based on diagnosis or surgical procedure.
a. A 62-year-old patient who recently lost 80 lb after a gastric sleeve and is scheduled
for a cataract extraction.
b. A 3-year-old child with otitis media having bilateral myringotomy with tube
placement.
c. A 3-week-old neonate undergoing surgery for a cardiac anomaly.
 d. A 26-year-old patient undergoing escharotomy (fasciectomy) of an ankle with
second- and third-degree burns.
ANS: C
In many surgical services departments, postoperative cardiac surgery patients are
transferred directly to the cardiac intensive care unit (ICU) rather than the PACU;
however, their thermic needs must be met during this perianesthesia phase. Cardiac
patients have considerable skin exposed during surgery and are often cooled to therapeutic
hypothermic levels in order to decrease metabolic rate and oxygen demands during
cardiopulmonary bypass. Especially vulnerable to the effects of hypothermia are the
elderly and children 2 years old or younger. There are four major risk factors for
hypothermia; this includes three patient populations—neonates less than 1 month of age,
burn patients, and patients whose surgery included general anesthesia with neuraxial
anesthesia—along with low ambient temperature of the OR. Other risk factors include
female gender, extreme age, length and type of surgical procedure, cachexia, significant
fluid shift, and use of cold irrigants.

11. Select the statement below that best reflects the effects of hypothermia in the
perianesthesia period.
a. Hypothermia shortens the period of elimination of muscle relaxants.
b. Hypothermia has often been shown to cause life-threatening morbidities.
c. Shivering can increase the need for oxygen by 300% to 400%.
d. Hypothermia increases platelet activity and decreases fibrinolysis.
ANS: C
Often hypothermia is not life-threatening; it does, however, cause physiologic stress.
Hypothermia can prolong recovery time and contribute to postoperative morbidity. In the
PACU, tremendous demands are made on the body when the patient shivers. Shivering
can increase the need for oxygen by 300% to 400%. Other problems associated with
hypothermia include intravascular volume loss attributable to a fluid shift from the
extracellular space, probably related to vasoconstriction and the prolonged elimination of
muscle relaxants in hypothermic patients. Clotting abnormalities can occur. Platelet
activity declines, and fibrinolysis increases; both conditions enhance the tendency to
bleed.

12. A 46-year-old healthy male, admitted for a diagnostic arthroscopy, was prewarmed in the
preoperative holding lounge using a warming device. After transfer to the OR bed, he was
continuously warmed using the same device. IV fluids cycled through a fluid warmer and
the irrigation bags of sterile saline cycled through a warming device during the procedure.
The perioperative nurse had preset the OR ambient temperature to 75° F. Select the
statement that best reflects the justification for these practices.
a. The patient will not produce heat when administered a general anesthetic.
b. The patient will require more pain medication in the PACU if he is cold while
recovering.
c. The patient is at high risk for fever and shivering because of the possibility of an
abscessed knee.
d. The patient is at high risk for malignant hyperthermia and shivering is one of the
triggers.
ANS: A
 Prevention of heat loss continues in the OR. Under general anesthesia patients do not
produce heat and depend on ambient temperature. Prevention of heat loss includes
increasing the ambient temperature in the OR, providing the patient with warm blankets on
arrival in the OR, and using draping techniques that minimize exposure during the
procedure. Heated humidifiers and fluid warmers add heat.

13. Select the most reliable indicator of pain.

a. A proxy pain rating by someone who knows the patient well
b. Facial grimacing and crying
c. The patient’s self-report of pain
d. Physiologic indicators, such as elevated vital signs
ANS: C
Pain is a subjective experience and may or may not be verbalized. Often healthcare
providers require objective signs of discomfort in addition to subjective reports of pain
from the patient, which can lead to undertreatment of pain. The guiding principle in pain
care is that pain is whatever the patient says it is; the most reliable indicator of the
existence and intensity of pain is the patient’s self-report.

14. Evidence indicates that early analgesia reduces postoperative problems. Recent studies
endorse the multimodal approach to both preemptive (preventative) and postoperative
analgesia customized to patient needs based on meticulous preoperative assessment. A
72-year-old physically active woman was seen in the preoperative admission center in
preparation for her total knee replacement surgery on Thursday. She has not had any
opioid medications in her lifetime that she can remember. She has inflammatory bowel
and gastric disease and was told she cannot take ibuprofen in any form. Select a
multimodal analgesic treatment plan that would best serve the patient’s perianesthesia
experience.
a. Intraoperative: Preincision—IV opioids, local lidocaine injection into the incision
site before skin closure. Postoperative: Patient-controlled analgesia (PCA) with
opioids and nonsteroidal anti-inflammatory drugs (NSAIDs)
b. Intraoperative: Preincision—regional block, IV opioids during the procedure.
Postoperative: PCA with opioids and nonsteroidal anti-inflammatory drugs
(NSAIDs)
c. Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative:
Systemic analgesia with COX-2–selective inhibitors, IV PCA with strong opioids
d. Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative:
Systemic analgesia with COX-2–selective inhibitors, IV PCA with strong opioids
(titrated to effect), and IM meperidine
ANS: C
 During preadmission testing/preparation, staff should identify candidates for PCA and
teach its use, including the benefits of effective pain control, use of the pain scale, and the
importance of reporting pain early. Evidence indicates that early analgesia reduces
postoperative problems. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates are
the analgesics of choice. Generally, they are used in combination (multimodal therapy) in
the PACU. Using NSAIDs in combination with opiates can reduce opioid requirements by
20% to 40%. Traditionally, pain was treated with intramuscular (IM) injections of opioids
at intervals from 3 to 6 hours as needed. Avoid meperidine except for treatment of
shivering or allergy to other opioids. Contraindications to NSAIDs are aspirin-sensitive
asthma, bleeding, coagulopathy disorders, history of gastrointestinal bleeding, renal
compromise, and hypovolemia.

15. Postoperative nausea and vomiting (PONV) is a problem that affects approximately 30%
of PACU patients. Patients with four or more risk factors have a higher incidence of
PONV. Select the option that best reflects relevant risk factors for PONV.
a. Reaction to nitrous oxide, atopy, postmenopausal, use of volatile anesthetics
b. Latex sensitivity, male gender, use of halogenated gas induction
c. Predisposition to malignant hyperthermia, night sweats, motion sickness, male
gender
d. Nonsmoker, female gender, postoperative opioids, use of nitrous oxide
ANS: D
Primary risk factors associated with PONV are female gender, nonsmoker, history of
PONV or motion sickness, use of volatile anesthetics, use of nitrous oxide, postoperative
use of opioids, duration of surgery, and type of surgery. Patients with four or more risk
factors have a higher incidence of PONV.

16. A key component of postoperative discharge instructions requires verification of

patient/family understanding of the instructions. A recent study found that only 67% of the
discharge instruction comprehension was retained by day 3 postdischarge. What strategy
best ensures patient/family understanding and comprehension of the discharge
instructions?
a. Written and signed instruction sheet with emergency and information contact
numbers
b. Follow-up e-mail video clip of the patient/family teaching encounter
c. Follow-up e-mail or telephone review of the discharge instructions on day 1 post
discharge
d. Patient/family teach-back of the discharge instructions to the nurse
ANS: D
Review with the patient before discharge the interventions used and their efficacy, and
provide specific discharge instructions regarding pain and its management. Have patient
“teach-back” or repeat instructions in his or her own words.

17. There are many therapeutic management strategies that have been successful in treating
PONV. What evidence-based practice best improves patient comfort, readiness for
discharge, and satisfaction with care?
a. Administration of promethazine as soon as the patient complains of nausea
b. Pharmacologic prophylaxis
c. Prophylaxis paralleled with anesthesia induction
 d. Administration of postoperative opioids
ANS: B
Management of nausea and vomiting begins preoperatively and continues into the
intraoperative period. Preventive therapy for patients at high risk of PONV is effective in
reducing its incidence. There is no single method to prevent or treat PONV. Many
causative factors relate to anesthesia and surgery. Pharmacologic prophylaxis improves
patient comfort, readiness for discharge, and satisfaction with care.

18. It is estimated that 9% of women and 24% of men in the United States show disordered
breathing while asleep, and 2% of women and 4% of men show overt symptoms of
obstructive sleep apnea (OSA). Postanesthesia management concerns with OSA patients
include use of analgesia, appropriate oxygenation, patient positioning, and monitoring.
What additional therapy is recommended for OSA patients during postoperative recovery?
a. Incentive spirometry every 30 minutes while awake
b. Coughing and forced deep breathing
c. Continuous positive airway pressure (CPAP)
d. Use of telemetry for monitoring pulse oximetry
ANS: C
Supplemental oxygen should be used immediately postoperatively. Patients who use
CPAP or noninvasive positive-pressure ventilation at home should continue to use these
therapies during the postsurgery stay. The patient’s position can be changed based on the
type of surgery to decrease the chance of airway obstruction. Lateral, prone, and sitting
positions result in better airway management for the OSA patient compared to supine.
Patients with OSA may require extended monitoring in the postoperative period.

19. Unfortunately, patients who are managed with opioids as part of their analgesic program
can have adverse events related to the medication. What are two of the most serious
opioid-related adverse events?
a. Pruritis followed by anaphylaxis
b. Unintended advancing sedation and respiratory depression
c. Respiratory depression and alveolar collapse
d. Urticaria followed by anaphylaxis
ANS: B
Two of the most serious opioid-related adverse events are unintended advancing sedation
(which generally precedes respiratory depression) and respiratory depression. Education of
the perioperative healthcare team and use of multimodal pain management are of utmost
importance in decreasing these events.

20. An opioid-naïve patient, one who has not used short-acting opioids in the last 60 days,
resedated on admission to the PACU and received which opioid antagonist to reverse the
respiratory depression?
a. Romazicon
b. Ropivicaine
c. Naloxone
d. Pavulon
ANS: C
 Naloxone is the opioid antagonist used most frequently to reduce opioid-induced
respiratory depression. It is administered slowly, never as a bolus, while the nurse
observes the patient’s response. The patient should be able to open his or her eyes and talk
to the nurse within 1 to 2 minutes of administration; naloxone is discontinued when the
patient can take deep breaths on instruction and respond to physical stimulation.

MULTIPLE RESPONSE

1. Select three appropriate components of the hand-off report from the perioperative nurse to
the perianesthesia nurse as the patient is received in the PACU. (Select all that apply.)
a. Allergies, incisions, dressings, and drains
b. Use of radiologic shielding of the patient in the OR
c. For pediatric patients, mother’s perinatal history
d. Prognosis and presumed discharge date or time
e. Patient’s identity and procedure performed
f. Opportunity for clarification and questions
ANS: A, E, F
The perioperative nurse may report in her hand off: identity of patient; preoperative
diagnosis; procedure performed; location of incision(s), dressings, drains, catheters, tubes,
packing, stomas; surgical complications; allergies and reactions; medications, fluids,
irrigations delivered by surgeon or registered nurse (RN); positioning during surgery;
communication of other pertinent issues; questions and answers.

2. The perianesthesia nurse completes a systematic and comprehensive secondary assessment

of the patient (e.g., head-to-toe assessment or major body systems’ approach). Select the
responses that best reflect the parameters of a comprehensive respiratory assessment.
(Select all that apply.)
a. Rate, rhythm, and breath sounds
b. Evidence of unabsorbed residual anesthetic vapors
c. Oxygen saturation level
d. Artificial airway and oxygen delivery system
e. Patient’s ability to take deep breaths on command
ANS: A, C, D
Some PACUs use a head-to-toe assessment to organize the data obtained. Other PACUs
take a major body systems’ approach. In any case, the PACU nurse assesses admitting
vital signs and the ABCs, beginning with the respiratory system. Respiratory assessment
comprises rate, rhythm, auscultation of breath sounds for ventilatory adequacy, and
oxygen saturation level. Any artificial airway and the type of oxygen delivery system are
noted.

3. What parameters and questions will the perianesthesia nurse investigate while assessing
neurologic status? (Select all that apply.)
a. Position of the patient’s arms at rest
b. Ability to follow commands
c. Pupillary reaction to light
d. Orientation to person and place
e. Level of consciousness
 ANS: B, D, E
The PACU nurse assesses neurologic function by asking questions such as the following:
Has the patient reacted (awakened from anesthesia)? Can the patient follow commands? Is
the patient oriented, at least to name and hospital? Can the patient move all extremities?

4. Hypothermia is a common side effect of surgery and the perianesthesia setting. Which of
the following interventions is most effective in normalizing and maintaining body
temperature? (Select all that apply.)
a. Prewarming patients in normothermia
b. Warming patients in hypothermia
c. Setting ambient OR and PACU temperatures to 65° to 75° F and using warming
devices
d. Using warmed skin prep solution during surgery
e. Using continuous fluid-circulating blankets or warm-water mattresses
f. Reapplying warmed cotton blankets every 10 minutes
ANS: A, B, C
Postoperative hypothermia, defined as a temperature less than 36° C (96.8° F), continues
to be a widespread PACU problem. Hypothermia can prolong recovery time and
contribute to postoperative morbidity. Preventive warming measures are begun for
normothermic patients and active warming measures instituted for hypothermic patients.
Prevention includes increasing the ambient temperature in the OR and providing the
patient with warm blankets on arrival in the OR.