NCLEX Practice Exam for Pharmacology: Anesthetic and Narcotic Medications

EXPLANATION

✔Correct answer:

Slow heart rate. Atropine is given preoperatively to prevent bradycardia, or slow heart rate, which can occur due to the effects of anesthesia and vagal stimulation during surgery. Atropine is an anticholinergic medication that works by blocking the action of the vagus nerve on the heart, thereby preventing a decrease in heart rate.

The vagus nerve, part of the parasympathetic nervous system, can be stimulated during surgical procedures, leading to a significant drop in heart rate. Atropine inhibits the action of acetylcholine at muscarinic receptors, thus reducing vagal tone on the heart and helping to maintain a normal heart rate.

Think of the heart rate as a car engine that can slow down if the brakes (vagus nerve) are applied too strongly. Atropine acts like releasing the brake pedal slightly, preventing the engine from slowing down too much.

Nurse Taylor should monitor Mr. Smith's heart rate and vital signs closely after administering atropine. She should be aware of potential side effects of atropine, such as dry mouth, blurred vision, and urinary retention, and provide appropriate care and education to the patient.

• Monitor the patient's heart rate and blood pressure before and after administration of atropine.
• Educate the patient about the purpose of atropine and potential side effects, such as dry mouth and blurred vision.
• Provide comfort measures for any side effects experienced, such as offering sips of water for dry mouth if allowed.
• Ensure the patient is aware of the need to report any unusual symptoms, such as difficulty urinating or significant changes in vision.
• Document the administration of atropine and the patient's response to the medication.

✘Incorrect answer options:

Elevated blood pressure. Atropine is not typically used to prevent elevated blood pressure. Its primary function in the preoperative setting is to counteract bradycardia.

Preoperative anxiety. Atropine does not have anxiolytic properties. Medications such as benzodiazepines are more commonly used to manage preoperative anxiety.

Dry mouth symptoms. Atropine can actually cause dry mouth as a side effect due to its anticholinergic properties. It is not given to prevent dry mouth; rather, it may exacerbate this symptom.

EXPLANATION

✔Correct answer:

Preventing depolarization. The primary mechanism by which local and regional anesthesia function is by preventing depolarization of nerve cells. Local and regional anesthetics work by blocking sodium channels on the nerve cell membranes. This blockage inhibits the influx of sodium ions, which is essential for the initiation and propagation of nerve impulses. Without the ability to depolarize, the nerves cannot transmit pain signals to the brain, resulting in localized anesthesia.

Nerve impulses are generated by the movement of ions across nerve cell membranes, specifically the influx of sodium ions during depolarization. Local anesthetics, such as lidocaine and bupivacaine, bind to sodium channels and prevent this influx, effectively stopping the nerve from sending signals. This action is localized to the area where the anesthetic is applied, allowing for specific regions of the body to be anesthetized without affecting the patient's overall consciousness or motor functions beyond the targeted area.

Imagine a hallway with light switches (sodium channels) that control lights (nerve impulses). Local anesthesia works like a tape over the switches, preventing them from being turned on (depolarized), so the lights (pain signals) stay off.

Nurse Anna should understand the importance of this mechanism to appreciate how local and regional anesthetics achieve their effects. This knowledge will also help her anticipate the actions and potential side effects of these medications.

• Explain to patients that local and regional anesthetics work by blocking nerve signals in the targeted area, leading to temporary numbness and pain relief.
• Monitor patients for signs of effective anesthesia, such as loss of sensation in the targeted area, while ensuring there are no adverse reactions.
• Educate patients about the expected duration of anesthesia and any precautions they should take while the anesthetic is active, such as avoiding injury to the numb area.
• Be prepared to manage any side effects or complications, such as allergic reactions or toxicity, which can occur if the anesthetic spreads beyond the intended area or if excessive amounts are used.

✘Incorrect answer options:

Inducing a semiconscious state. This is incorrect as local and regional anesthesia do not induce a semiconscious state; they target specific areas to block sensation without affecting the patient's overall level of consciousness.

Enhancing depolarization. Enhancing depolarization would increase nerve activity and pain sensation, which is contrary to the purpose of local and regional anesthetics.

Restricting motor movement. While some regional anesthetics can affect motor functions if they block nerves responsible for movement, this is not the primary mechanism. The main goal is to prevent depolarization to block pain signals.

EXPLANATION

✔Correct answer:

Episodes of nausea and vomiting. Thiopental (Pentothal) is a barbiturate used for the induction of anesthesia. One of the common adverse effects of thiopental is episodes of nausea and vomiting. These symptoms can occur as the anesthetic wears off and the patient begins to regain consciousness.

Thiopental works by depressing the central nervous system, and as its effects diminish, the transition from unconsciousness to wakefulness can be associated with nausea and vomiting. This is a typical response to many anesthetic agents and can be managed with antiemetics if necessary.

Think of waking up from anesthesia like coming off a rollercoaster. Just as you might feel dizzy and nauseous after a fast ride, the body can react similarly as it adjusts from the effects of anesthesia.

Nurse Williams should inform the patient about the possibility of experiencing nausea and vomiting postoperatively. She should be prepared to administer antiemetic medications as prescribed and provide supportive care to alleviate these symptoms.

• Educate the patient about the potential for nausea and vomiting after receiving thiopental.
• Monitor the patient for signs of nausea and vomiting during the postoperative period.
• Administer antiemetic medications as prescribed to manage these symptoms.
• Encourage the patient to report any feelings of nausea or discomfort so that appropriate interventions can be initiated promptly.
• Provide reassurance and support to the patient, explaining that these symptoms are common and usually temporary.

✘Incorrect answer options:

Occurrence of emergence delirium. Emergence delirium is more commonly associated with anesthetics like ketamine or inhalational agents in pediatric patients rather than thiopental.

Onset of a headache. Headaches are not typically a common adverse effect of thiopental. They can occur postoperatively due to other factors, but they are not specifically linked to thiopental use.

Development of paralysis. Paralysis is not a common adverse effect of thiopental. Thiopental is a barbiturate that induces anesthesia, but it does not cause paralysis. Neuromuscular blocking agents would be responsible for inducing paralysis during surgery.

EXPLANATION

✔Correct answer:

Medications that relax skeletal muscles. Nurse Lee should highlight that general anesthetics enhance the effects of medications that relax skeletal muscles, also known as muscle relaxants. These medications are often used during surgery to facilitate intubation and provide optimal surgical conditions by relaxing the skeletal muscles. General anesthetics potentiate the effects of both depolarizing and non-depolarizing muscle relaxants, making them more effective.

Muscle relaxants work by interfering with the transmission of nerve impulses at the neuromuscular junction. General anesthetics enhance this effect by either prolonging the action of muscle relaxants or increasing their potency. This combined action ensures adequate muscle relaxation during surgery, which is crucial for surgical access and patient safety.

Think of general anesthesia and muscle relaxants as a team working together. The anesthetic is the coach, enhancing the performance of the muscle relaxant players, making sure they work more effectively to achieve the best surgical conditions.

Nurse Lee should ensure that Mr. Thompson understands the importance of disclosing all medications he is currently taking, especially those that might interact with muscle relaxants. She should also monitor Mr. Thompson closely during the perioperative period for any adverse effects related to enhanced muscle relaxation.

• Explain to Mr. Thompson that general anesthetics enhance the effects of muscle relaxants, which are used to relax skeletal muscles during surgery.
• Emphasize the importance of disclosing all current medications, including over-the-counter drugs and supplements.
• Monitor for signs of prolonged muscle relaxation postoperatively, which may require intervention.
• Educate Mr. Thompson on the potential interactions between muscle relaxants and other medications he may be taking.
• Coordinate with the anesthesiologist and surgical team to manage any potential drug interactions effectively.

✘Incorrect answer options:

Volatile liquid anesthetics. Volatile liquid anesthetics are a type of general anesthetic administered via inhalation. Their effects are not specifically enhanced by other general anesthetics; rather, they are primary agents used during surgery.

Agents that cause depolarization. Depolarizing agents, such as succinylcholine, are muscle relaxants whose effects are enhanced by general anesthetics. However, the category "medications that relax skeletal muscles" more accurately describes the range of drugs affected.

Anesthetics administered via inhalation. Inhalation anesthetics themselves are used to maintain general anesthesia, but the focus should be on the interaction between general anesthetics and muscle relaxants rather than on the administration route of anesthetics.

EXPLANATION

✔Correct answer:

Monitoring respiratory status. In the immediate postoperative period, the most crucial assessment is monitoring the patient's respiratory status. General anesthesia can depress the respiratory system, leading to hypoventilation, airway obstruction, and inadequate oxygenation. Ensuring that the patient maintains a patent airway and adequate ventilation is paramount to prevent complications such as hypoxia and respiratory arrest.

General anesthesia affects the central nervous system, which can depress the respiratory drive and muscle tone, potentially leading to compromised airway patency and gas exchange. The effects of anesthesia agents can persist into the postoperative period, necessitating vigilant monitoring of respiratory rate, oxygen saturation, and airway patency.

Think of the respiratory system like the foundation of a house. If the foundation is unstable, the entire house is at risk of collapsing. Similarly, if the respiratory system is compromised, the patient's overall stability is at risk.

In the PACU, Nurse Anna should continuously monitor the patient’s respiratory rate, rhythm, depth, and effort. She should also check the oxygen saturation levels using pulse oximetry and ensure that the airway remains clear, possibly using airway adjuncts if necessary. If signs of respiratory distress or hypoxia are observed, immediate intervention is required.

• Position the patient to maintain an open airway (e.g., head tilt-chin lift or lateral position).
• Administer supplemental oxygen as needed to maintain adequate oxygenation.
• Use capnography to monitor end-tidal CO2 levels, which can provide early warning of hypoventilation.
• Be prepared to assist with advanced airway management techniques if necessary.
• Regularly reassess the patient’s respiratory status to detect any changes early.

✘Incorrect answer options:

Evaluating pain levels. While pain assessment is important, it is not the most critical initial assessment in the immediate postoperative period. Ensuring that the patient is breathing adequately takes precedence over pain management, which can be addressed once the patient’s respiratory status is stabilized.

Checking level of consciousness. Assessing the patient’s level of consciousness is also important, but it is secondary to ensuring that the patient has a patent airway and adequate respiration. Changes in consciousness can be related to hypoxia, making respiratory assessment the priority.

Measuring vital signs. Measuring vital signs is essential in the postoperative period, but the respiratory status is the most critical component of the initial assessment. Vital signs include blood pressure, heart rate, and temperature, which are important but follow the establishment of effective respiration.

EXPLANATION

✔Correct answer:

Blocks a specific group of nerves in tissues near the surgical site. Infiltration anesthesia involves injecting a local anesthetic directly into the tissues around the surgical site to block nerve endings and small nerve branches. This numbs a specific, localized area, providing pain relief for minor surgical procedures, wound suturing, or dental work.

Local anesthetics, such as lidocaine or bupivacaine, work by inhibiting the sodium channels on nerve cells. This inhibition prevents the initiation and transmission of nerve impulses, thereby blocking the sensation of pain in the targeted area. The anesthetic is usually administered in small amounts and targets the specific tissues where the procedure will occur.

Think of infiltration anesthesia like applying a numbing cream to a small cut on your skin. You apply the cream only around the cut (injection around the surgical site), and it numbs just that specific area without affecting the rest of your body.

Nurses should ensure proper administration techniques to maximize the effectiveness of infiltration anesthesia and minimize complications. They should also monitor the patient for any adverse reactions to the anesthetic and provide appropriate patient education on what to expect.

• Administer the local anesthetic accurately in the designated tissue area.
• Monitor for signs of allergic reactions or systemic toxicity.
• Educate the patient about the temporary numbness and what sensations to expect during and after the procedure.
• Reassure the patient and provide comfort during the administration of the anesthetic.

✘Incorrect answer options:

Numbs sensation in an entire limb or a large part of the face. This describes regional anesthesia techniques such as nerve blocks or epidural anesthesia, which affect larger areas by targeting major nerves or nerve plexuses.

Provides numbness to large regional areas like the lower abdomen and legs. This is typical of spinal or epidural anesthesia, which are used for more extensive surgical procedures and affect broader areas of the body.

Is used only on mucous membranes to achieve local anesthesia. This describes topical anesthesia, which is applied to mucous membranes for procedures like bronchoscopy or dental work, not infiltration anesthesia.

EXPLANATION

✔Correct answer:

2 to 4 hours. The half-life of morphine is typically 2 to 4 hours. This means that it takes about 2 to 4 hours for the concentration of morphine in the blood plasma to reduce by half. Understanding the half-life of a medication is important for determining dosing schedules and ensuring that therapeutic levels are maintained while avoiding toxicity.

Morphine is metabolized primarily in the liver and then excreted by the kidneys. Its half-life can be affected by various factors including liver and kidney function, age, and the presence of other medications. Regular monitoring and adjustments may be necessary to achieve optimal pain control and minimize side effects.

Think of morphine in the body like a cup of water that starts to evaporate. If it takes 2 to 4 hours for half of the water to evaporate, you would need to refill the cup periodically to keep the water level (pain relief) constant.

Nurses need to be aware of the half-life of morphine to appropriately schedule doses and monitor for signs of accumulation or withdrawal. They should also educate patients on the importance of adhering to the prescribed dosing schedule to maintain effective pain control.

• Administer morphine at regular intervals based on its half-life to maintain consistent pain relief.
• Monitor the patient for signs of morphine toxicity, such as respiratory depression, especially if they have impaired liver or kidney function.
• Educate the patient on the importance of taking morphine exactly as prescribed to avoid breakthrough pain or overdose.
• Adjust the dosing schedule as necessary based on patient response and side effects.

✘Incorrect answer options:

6 to 8 hours. The half-life of morphine is generally shorter than 6 to 8 hours. This range is more typical of extended-release formulations or different opioid medications.

30 minutes to 1 hour. This half-life is too short for morphine. Some drugs have a very short half-life, but morphine's duration is longer, reflecting the time it stays active in the system.

4 to 6 hours. While this range is somewhat close, the correct and more commonly accepted range for morphine’s half-life is 2 to 4 hours. The 4 to 6-hour range could be more appropriate for the duration of action rather than the half-life itself.

EXPLANATION

✔Correct answer:

Euphoria, miosis, and nausea with vomiting. Besides pain relief, narcotics (opioids) can cause several other effects due to their action on the central nervous system and gastrointestinal system. These effects include euphoria, miosis (pupil constriction), and nausea with vomiting. These occur because opioids affect various receptors and areas of the brain that control mood, pupil size, and the vomiting reflex.

• Euphoria: Opioids stimulate the release of dopamine in the brain's reward pathways, leading to a sense of well-being or euphoria.
• Miosis: Opioids activate the parasympathetic nervous system, causing constriction of the pupils.
• Nausea and vomiting: Opioids can stimulate the chemoreceptor trigger zone (CTZ) in the brain, leading to nausea and vomiting.

Think of narcotics as a strong wave hitting the shore. The initial impact brings relief (pain reduction), but it also washes in other elements (euphoria, pupil constriction, and nausea), which are additional effects that come along with the primary effect.

Nurses should be vigilant in monitoring these additional effects and managing them appropriately to ensure patient safety and comfort.

• Assess the patient for signs of euphoria and educate them about the risk of dependence and addiction.
• Monitor the patient's pupils for miosis, which can indicate effective opioid dosing but also central nervous system effects.
• Administer antiemetic medications as prescribed to manage nausea and vomiting.
• Provide education on the safe use of opioids and the potential side effects.

✘Incorrect answer options:

Respiratory depression and increased blood pressure. Narcotics are known to cause respiratory depression, but they typically lower blood pressure rather than increase it due to their vasodilatory effects.

Dependence, seizures, and muscle spasms. While dependence is a well-known risk of narcotics, seizures and muscle spasms are not common effects associated with narcotic use. These symptoms might occur in cases of overdose or with certain specific opioids, but they are not typical effects.

Euphoria, diarrhea, and increased respiration rate. While euphoria is a common effect, narcotics usually cause constipation (not diarrhea) and respiratory depression (not increased respiration rate). Narcotics slow down gastrointestinal motility, leading to constipation, and they depress the respiratory centers in the brain, leading to decreased respiration rate.

EXPLANATION

✔Correct answer:

Hyperthermia. The most dangerous metabolic side effect that could arise during surgery under general anesthesia is hyperthermia, specifically malignant hyperthermia. Malignant hyperthermia is a rare but life-threatening condition triggered by certain anesthetic agents, such as volatile anesthetics and succinylcholine, in susceptible individuals. It results in a rapid increase in body temperature and severe muscle contractions.

Malignant hyperthermia is a genetic disorder of the skeletal muscle, where an abnormal release of calcium leads to sustained muscle contractions and a hypermetabolic state. This causes a dramatic increase in oxygen consumption and carbon dioxide production, leading to severe acidosis, hyperthermia, and rhabdomyolysis. If not promptly treated, it can result in multi-organ failure and death.

Imagine a car engine suddenly running at extremely high speeds without the ability to slow down, causing it to overheat rapidly. This overheating can damage the engine severely if not stopped immediately. Similarly, malignant hyperthermia causes the body's metabolic processes to accelerate uncontrollably, leading to a dangerous rise in body temperature.

Nurse Alex should closely monitor the patient's vital signs, including body temperature, and be vigilant for signs of malignant hyperthermia. Immediate treatment involves discontinuing triggering agents, administering dantrolene (a muscle relaxant that inhibits calcium release), and supportive measures to stabilize the patient.

• Monitor the patient's body temperature continuously during surgery.
• Watch for early signs of malignant hyperthermia, such as rapid increase in end-tidal CO₂, muscle rigidity, and unexplained tachycardia.
• Have dantrolene readily available in the operating room for immediate administration if malignant hyperthermia is suspected.
• Initiate cooling measures, such as ice packs and cooled intravenous fluids, if hyperthermia occurs.
• Provide supportive care, including correcting acidosis and monitoring for complications such as rhabdomyolysis and electrolyte imbalances.

✘Incorrect answer options:

Hypoglycemia Hypoglycemia, or low blood sugar, can occur but is not typically considered the most dangerous metabolic side effect during general anesthesia. It is manageable with glucose administration.

Hyperglycemia Hyperglycemia, or high blood sugar, is also a concern but is usually not immediately life-threatening and can be managed with insulin therapy.

Hypothermia Hypothermia, or low body temperature, is a common side effect of anesthesia but is generally not as acutely dangerous as malignant hyperthermia. It can be managed with warming measures.

EXPLANATION

✔Correct answer:

Hypertension. Hypertension is not typically an early sign of local anesthetic toxicity. Early signs of local anesthetic toxicity are primarily neurological and include symptoms such as numbness around the mouth, tinnitus (ringing in the ears), and lightheadedness. These symptoms occur due to the effects of the anesthetic on the central nervous system before cardiovascular symptoms develop.

Local anesthetic toxicity usually manifests first as central nervous system (CNS) symptoms because the CNS is more sensitive to the effects of local anesthetics. Initial signs include circumoral numbness, tinnitus, and lightheadedness, which can progress to more severe symptoms such as seizures and eventually cardiovascular collapse if the toxicity is severe.

Imagine you are feeling dizzy and hearing ringing in your ears after spinning around quickly. These early signs of dizziness and sensory changes are similar to what happens with early local anesthetic toxicity affecting the nervous system first.

Nurse Kelly should closely monitor the patient for these early signs of toxicity and be prepared to take immediate action if symptoms develop. This includes stopping the administration of the local anesthetic, providing supportive care, and alerting the healthcare team.

• Monitor for early neurological signs of toxicity, such as numbness around the mouth, tinnitus, and lightheadedness.
• Be prepared to stop the administration of the local anesthetic if toxicity is suspected.
• Provide supportive care, such as oxygen and IV fluids, and monitor vital signs closely.
• Have emergency equipment and medications, such as lipid emulsion therapy, readily available in case of severe toxicity.
• Educate the patient about the signs of local anesthetic toxicity and encourage them to report any unusual symptoms immediately.

✘Incorrect answer options:

Numbness around the mouth. This is an early sign of local anesthetic toxicity and occurs due to the anesthetic's effect on sensory nerves.

Tinnitus. Tinnitus, or ringing in the ears, is another early sign of local anesthetic toxicity and indicates the anesthetic's effect on the auditory nerves.

Lightheadedness. Lightheadedness is also an early sign of local anesthetic toxicity and reflects the CNS effects of the anesthetic.

EXPLANATION

✔Correct answer:

Activating opiate receptors. Narcotics, also known as opioids, alleviate pain primarily by activating opiate receptors in the central nervous system. These receptors include mu, delta, and kappa receptors. When opioids bind to these receptors, they mimic the action of endogenous pain-relieving chemicals like endorphins and enkephalins, leading to a reduction in the perception of pain.

Opiate receptors are G-protein-coupled receptors found throughout the nervous system. Activation of these receptors inhibits the release of neurotransmitters involved in pain transmission, such as substance P and glutamate. This results in reduced neuronal excitability and diminished pain perception.

Imagine opiate receptors as locks and opioids as keys. When the key (opioid) fits into the lock (receptor), it turns and activates a mechanism that stops the pain signals from reaching the brain, similar to how locking a door prevents someone from entering.

Nurses should monitor patients for effectiveness of pain relief and potential side effects, such as respiratory depression, constipation, and sedation. They should also educate patients on the safe use of opioids and the risks of dependency and addiction.

• Assess the patient's pain level before and after opioid administration.
• Monitor for signs of opioid toxicity, including respiratory depression and altered mental status.
• Educate the patient on the potential for addiction and safe usage practices.
• Implement measures to prevent and manage common side effects, such as prescribing laxatives for constipation.

✘Incorrect answer options:

Blocking the mu receptors. Blocking the mu receptors would prevent the action of opioids, leading to increased pain perception rather than pain relief.

Encouraging the release of excitatory transmitters. Encouraging the release of excitatory neurotransmitters would increase pain perception rather than reduce it. Opioids work by inhibiting these neurotransmitters.

Triggering the release of large amounts of endorphins. While endorphins do have pain-relieving properties, narcotics do not work by triggering their release. Instead, they directly activate opiate receptors to produce analgesia.

EXPLANATION

✔Correct answer:

"Cocaine causes vasoconstriction, which can reduce bleeding in the area where it is applied." Cocaine is a local anesthetic that also has significant vasoconstrictive properties. When applied topically, particularly on mucous membranes, it can cause blood vessels to constrict, reducing bleeding in the area. This dual action makes cocaine useful in certain medical procedures where both anesthesia and reduced bleeding are desired, such as in nasal or throat surgeries.

Cocaine works by blocking sodium channels, which inhibits the conduction of nerve impulses, providing local anesthesia. Additionally, it stimulates the sympathetic nervous system, leading to vasoconstriction. This reduces blood flow to the area, which helps control bleeding during procedures.

Imagine a garden hose (blood vessel) that you need to temporarily stop water flow (bleeding) from. Cocaine acts like a clamp on the hose, reducing the flow of water while also numbing the area around the clamp, making it easier to perform tasks without interference from water flow or sensation.

Nurses should understand the properties of cocaine and monitor for potential side effects, especially cardiovascular ones, due to its vasoconstrictive effects. They should also be aware of the potential for abuse and the necessary precautions for handling and administering this drug.

• Ensure proper application of cocaine to the targeted mucous membranes to achieve both anesthetic and vasoconstrictive effects.
• Monitor the patient for any signs of cardiovascular side effects, such as increased heart rate or blood pressure.
• Educate the patient about the effects and potential risks of cocaine as a local anesthetic.
• Take appropriate measures to store and handle cocaine securely to prevent misuse or diversion.

✘Incorrect answer options:

"Cocaine should be used for its systemic effects to treat chronic pain." Cocaine is not used for systemic effects or for treating chronic pain. Its use is limited to local anesthesia due to its potential for abuse and significant systemic side effects.

"Cocaine can be administered intravenously to achieve local anesthesia." Cocaine is not administered intravenously for local anesthesia. It is typically applied topically to mucous membranes where its local anesthetic and vasoconstrictive properties are needed.

"Cocaine is often used because it has a long duration of action compared to other anesthetics." Cocaine does not have a particularly long duration of action compared to other local anesthetics. Its use is more limited and specific due to its unique properties and potential for abuse.

EXPLANATION

✔Correct answer:

Stop the administration and suggest using plain lidocaine. Nurse James should stop the administration and suggest using plain lidocaine instead. Lidocaine with epinephrine is contraindicated for treating cardiac arrhythmias such as premature ventricular contractions (PVCs). Epinephrine can increase heart rate and contractility, which may exacerbate arrhythmias. For cardiac purposes, plain lidocaine (without epinephrine) is used to stabilize the cardiac membrane and reduce ectopic pacemaker activity.

Lidocaine is an antiarrhythmic medication that works by blocking sodium channels, which helps to stabilize the cardiac cell membrane and prevent abnormal electrical activity in the heart. Epinephrine, on the other hand, is a sympathomimetic that increases heart rate and myocardial oxygen demand, potentially worsening arrhythmias and causing adverse cardiovascular effects.

Think of lidocaine as a fire extinguisher that calms the electrical "fire" in the heart. Adding epinephrine would be like adding fuel to the fire, making it worse instead of putting it out.

Nurse James should immediately stop the preparation of lidocaine with epinephrine and explain to the colleague why plain lidocaine should be used. He should ensure that the correct medication is prepared and administered to the patient.

• Stop the administration of lidocaine with epinephrine and explain the reasoning to the colleague.
• Prepare plain lidocaine for administration as an antiarrhythmic treatment.
• Educate the colleague on the appropriate use of lidocaine with and without epinephrine.
• Monitor the patient’s heart rhythm and vital signs after administering the correct medication.
• Report the near-miss to the supervisor to ensure proper education and protocols are reinforced to prevent future errors.

✘Incorrect answer options:

Take no action; the medication choice is appropriate. This is incorrect because lidocaine with epinephrine is not appropriate for treating cardiac arrhythmias like PVCs. The epinephrine could worsen the patient's condition.

Report the error to the supervisor. While reporting medication errors is important, the immediate priority is to prevent the administration of an inappropriate medication. Nurse James should first stop the incorrect medication and suggest the correct one before reporting the incident.

Volunteer to monitor the patient's heart rhythm. Monitoring the patient’s heart rhythm is important, but it does not address the immediate issue of administering the incorrect medication. Nurse James must first ensure that the correct medication is used.

EXPLANATION

✔Correct answer:

Be aware that you may experience nausea, vomiting, shivering, and pain after the surgery. It is essential for Nurse Avery to inform John about common postoperative symptoms he may experience after surgery involving general anesthesia. These symptoms include nausea, vomiting, shivering, and pain. Providing this information helps the patient prepare mentally and physically for the recovery process and reduces anxiety by setting realistic expectations.

General anesthesia affects the entire body and can lead to several common side effects. Nausea and vomiting can occur due to the anesthetic agents used. Shivering (post-anesthetic shivering) can result from the body's response to the anesthesia and the cool operating room environment. Pain is expected as the surgical site begins to heal.

Think of general anesthesia as a deep sleep induced by strong medication. Waking up from this 'sleep' can sometimes feel unpleasant, similar to waking up groggy and disoriented after a long nap, but with added discomfort due to the surgery.

Nurse Avery should provide comprehensive preoperative teaching to John, covering what to expect postoperatively and how to manage these symptoms. She should also ensure John understands the importance of following preoperative fasting guidelines and taking medications as instructed by his healthcare provider.

• Inform John about the possibility of nausea, vomiting, shivering, and pain after the surgery and how these symptoms will be managed.
• Reiterate the importance of following preoperative fasting guidelines to reduce the risk of aspiration during anesthesia.
• Advise John to take his usual dose of prescribed medications unless otherwise directed by his healthcare provider.
• Provide instructions on how to manage postoperative pain and when to seek medical attention for severe or unusual symptoms.
• Offer reassurance and support to help alleviate any preoperative anxiety.

✘Incorrect answer options:

Have a substantial breakfast before coming in. This is incorrect as patients are typically required to fast before surgery to prevent aspiration during anesthesia. Eating a substantial breakfast could increase the risk of complications.

Take double the usual dose of your medications. This is incorrect and potentially dangerous advice. Medications should be taken as prescribed. Doubling the dose can lead to toxicity and adverse effects.

Expect to be incontinent of urine after the procedure. While some patients might experience temporary urinary retention or incontinence due to anesthesia or surgery, this is not a common or expected outcome for all patients. Providing this information could unnecessarily alarm the patient.

EXPLANATION

✔Correct answer:

Shivering can happen even if the patient is not experiencing hypothermia. Nurse Parker should inform her patient that shivering can occur after anesthesia even if the patient is not hypothermic. Post-anesthetic shivering is a common phenomenon and can result from multiple factors, including the effects of anesthetic agents on the body's thermoregulatory center, which is primarily located in the hypothalamus.

General anesthesia can alter the body's normal thermoregulation, leading to shivering as a compensatory mechanism. Even if the core body temperature is within the normal range, the body may still respond with shivering due to the disruption of normal thermoregulatory processes.

Think of the body’s temperature regulation system like a thermostat in a house. Anesthesia can disrupt the thermostat, causing the heating system (shivering) to turn on even if the house (body) isn’t cold.

Nurse Parker should reassure the patient that shivering is a common and manageable side effect of anesthesia. She should monitor the patient’s temperature and provide appropriate interventions, such as warming blankets or medications if necessary, to alleviate discomfort.

• Explain to the patient that shivering is a common response after anesthesia and can occur without hypothermia.
• Monitor the patient’s temperature to ensure they are not actually hypothermic.
• Provide warm blankets or other warming measures to help reduce shivering and provide comfort.
• Administer medications such as meperidine (Demerol), which is commonly used to treat post-anesthetic shivering, if prescribed by the healthcare provider.
• Educate the patient on other potential side effects of anesthesia and how they will be managed.

✘Incorrect answer options:

Shivering can be effectively managed with small doses of naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose and is not used to treat shivering. Meperidine is more commonly used for this purpose.

Shivering is regulated by the brainstem. Shivering is primarily regulated by the hypothalamus, not the brainstem. The hypothalamus is responsible for the body’s thermoregulation.

Shivering, though uncomfortable, is a harmless side effect of anesthesia. While shivering can be uncomfortable and is usually not harmful, it can increase metabolic demand and oxygen consumption, which can be problematic in certain patients, particularly those with cardiac or respiratory conditions. Therefore, it should be appropriately managed.

EXPLANATION

✔Correct answer:

Codeine is known to be very constipating. Codeine, like other opioids, is known to cause constipation. This is due to its action on the gastrointestinal tract, where it slows down peristalsis and increases the tone of the smooth muscles in the intestines. As a result, the bowel movements become less frequent and harder to pass, leading to constipation.

Opioids, including codeine, bind to opioid receptors in the gastrointestinal tract. This binding decreases the motility of the intestines and reduces the secretion of fluids into the bowel, resulting in dry and hard stools. The prolonged transit time of the bowel contents contributes to the increased absorption of water, further exacerbating constipation.

Think of the intestines as a conveyor belt. Codeine slows down the conveyor belt, causing items (stool) to pile up and dry out, making them harder to move along and eventually pass.

Nurses should anticipate and manage constipation in patients receiving codeine. This includes monitoring bowel habits, encouraging hydration and dietary fiber intake, and potentially using stool softeners or laxatives to prevent or treat constipation.

• Monitor the patient’s bowel movements regularly.
• Encourage the patient to drink plenty of fluids and eat high-fiber foods.
• Consider prophylactic use of stool softeners or laxatives as prescribed.
• Educate the patient about the constipating effects of codeine and strategies to mitigate it.

✘Incorrect answer options:

Codeine acts as an antitussive in high doses. While codeine does have antitussive (cough suppressant) properties, it is effective at lower doses typically used for this purpose. High doses are not required for its antitussive effects, and higher doses are more commonly associated with its analgesic use.

Codeine causes more sedation than other opiates. Codeine does cause sedation, but it is generally less sedating compared to stronger opioids like morphine or oxycodone. Therefore, this statement is not accurate.

Codeine induces diarrhea, necessitating an additional medication to prevent it. This is incorrect. Codeine and other opioids typically cause constipation rather than diarrhea. Diarrhea is not a common side effect of codeine use.

EXPLANATION

✔Correct answer:

Halothane (Fluothane). Halothane (Fluothane), a volatile inhalational anesthetic, significantly increases the risk of arrhythmias when administered concurrently with catecholamines. Halothane sensitizes the myocardium to catecholamines, such as epinephrine and norepinephrine, making the heart more susceptible to arrhythmias.

Catecholamines stimulate the heart, increasing heart rate and contractility. Halothane, however, can increase myocardial sensitivity to these effects, leading to an increased risk of cardiac arrhythmias, such as ventricular fibrillation or other serious arrhythmias. This interaction can result in dangerous and potentially life-threatening cardiac events during surgery.

Think of the heart as an engine. Catecholamines are like adding high-octane fuel to make it run faster and stronger. Halothane acts like a turbocharger, which can cause the engine to overheat and malfunction if both are used together, leading to erratic and dangerous behavior.

Nurse Jamie should closely monitor the patient's cardiac status, including ECG, when catecholamines and halothane are used concurrently. She should be prepared to manage any arrhythmias that may occur and communicate with the anesthesiologist and surgical team about the increased risk.

• Continuously monitor the patient's ECG for any signs of arrhythmias during the procedure.
• Be prepared to intervene with antiarrhythmic medications or other measures if an arrhythmia occurs.
• Communicate with the anesthesiologist and surgical team about the increased risk of arrhythmias with the concurrent use of halothane and catecholamines.
• Ensure that emergency resuscitation equipment is readily available in the operating room.
• Document all observations, interventions, and communications regarding the patient's cardiac status.

✘Incorrect answer options:

Digoxin (Lanoxin) Digoxin can increase the risk of arrhythmias, particularly in patients with electrolyte imbalances, but the combination with catecholamines does not pose as significant a risk as halothane.

Bupivacaine (Marcaine) Bupivacaine is a local anesthetic that can cause cardiac toxicity at high doses, but it is not as closely associated with increased arrhythmia risk when combined with catecholamines as halothane.

Lidocaine (Xylocaine) Lidocaine is an antiarrhythmic agent and local anesthetic. It is often used to treat arrhythmias, not cause them, and does not significantly increase the risk of arrhythmias when used with catecholamines.

EXPLANATION

✔Correct answer:

An intravenous medication will be administered to calm the patient. During the induction of anesthesia, it is not uncommon for patients to exhibit hyperactivity and physical resistance due to the excitatory phase of anesthesia. This phase can cause involuntary movements, agitation, and confusion as the anesthetic agents take effect. To manage this situation and ensure the patient's safety, an intravenous medication, such as a benzodiazepine or another sedative, is often administered to calm the patient and facilitate a smooth transition into deeper anesthesia.

The excitatory phase of anesthesia is a stage where the central nervous system experiences a temporary imbalance as the patient transitions from consciousness to unconsciousness. This can lead to hyperactivity and resistance. Administering a sedative helps to depress the central nervous system further, allowing the patient to move into a more controlled state of anesthesia.

Think of anesthesia induction like easing into a hot bath. Initially, there might be some discomfort and agitation as the body adjusts to the temperature. Administering a sedative is like gradually adding more warm water to help the body relax and settle into the bath comfortably.

Nurse Riley should promptly administer the prescribed intravenous sedative or coordinate with the anesthesiologist to do so. She should continue to monitor the patient closely, ensuring that the anesthesia is progressing safely and effectively.

• Administer the prescribed intravenous sedative or coordinate with the anesthesiologist to do so.
• Monitor the patient’s vital signs and level of consciousness continuously during the induction process.
• Ensure that the patient’s airway is protected and that appropriate measures are in place to manage any complications.
• Communicate effectively with the anesthesia team to ensure the patient's safety and comfort.
• Document the patient’s response to the intervention and any medications administered.

✘Incorrect answer options:

The surgery needs to be rescheduled. This is not necessary. Hyperactivity during anesthesia induction can typically be managed with appropriate medications and interventions.

The anesthesia must be stopped immediately. Stopping the anesthesia abruptly is not recommended unless there are significant complications or contraindications. The focus should be on managing the patient's symptoms effectively.

The anesthesia process must be halted. Halting the anesthesia process is not the best approach. The situation can usually be managed by administering a sedative to help calm the patient and ensure a smooth induction.

EXPLANATION

✔Correct answer:

Morphine can cause respiratory depression, especially in higher doses. Morphine, an opioid analgesic, can cause respiratory depression by acting on the brainstem's respiratory centers. This effect is dose-dependent, meaning higher doses can significantly suppress the respiratory rate, which is a major concern in clinical use, especially in patients with compromised respiratory function.

Morphine binds to opioid receptors, primarily mu receptors, in the central nervous system. This binding inhibits the transmission of pain signals and alters the perception of pain. However, it also depresses the medullary respiratory centers, reducing the sensitivity to carbon dioxide and the drive to breathe, potentially leading to respiratory depression.

Think of the respiratory center in your brain as the driver of a car and carbon dioxide levels as the signals on the road. Morphine is like a strong sedative that makes the driver (respiratory center) drowsy and less responsive to the signals (carbon dioxide levels), causing the car (breathing) to slow down or potentially stop.

Nurses must carefully monitor patients receiving morphine for signs of respiratory depression, especially after initiating therapy or increasing doses. This includes regular assessments of respiratory rate, depth, and oxygen saturation.

• Monitor the patient’s respiratory status frequently, especially after administering morphine.
• Educate the patient and their family about the signs of respiratory depression and when to seek immediate help.
• Have naloxone (an opioid antagonist) available to reverse the effects of morphine in case of severe respiratory depression.
• Use caution when administering morphine to patients with underlying respiratory conditions, such as COPD or asthma.

✘Incorrect answer options:

Morphine has a ceiling effect, where increasing the dose does not increase the analgesic effect. Unlike some other analgesics, morphine does not have a ceiling effect. Increasing the dose can increase both the analgesic effect and the risk of adverse effects, such as respiratory depression.

Morphine is not addictive and has a low potential for abuse. This statement is incorrect. Morphine is highly addictive and has a significant potential for abuse. Its euphoric effects contribute to its potential for dependence and addiction.

Morphine primarily works by blocking sodium channels in nerves. Morphine does not work by blocking sodium channels. Local anesthetics, like lidocaine, act by blocking sodium channels. Morphine works by binding to opioid receptors in the central nervous system.

EXPLANATION

✔Correct answer:

Assessing the return of the gag reflex.  The priority assessment for Nurse Kelly after a patient receives lidocaine viscous before a gastroscopy is to assess the return of the gag reflex. Lidocaine viscous is a local anesthetic used to numb the throat and suppress the gag reflex, which facilitates the insertion of the gastroscope. However, until the gag reflex returns, the patient is at risk for aspiration if they attempt to eat or drink.

The gag reflex is an important protective mechanism that prevents aspiration of food, liquids, and saliva into the respiratory tract. Lidocaine viscous temporarily inhibits this reflex by numbing the oropharyngeal area. Before allowing the patient to eat or drink post-procedure, it is crucial to ensure that the gag reflex has returned to prevent the risk of aspiration and subsequent complications like pneumonia.

Think of the gag reflex as a security guard for your airway, preventing anything from entering the lungs. Lidocaine puts the guard to sleep for the procedure, and Nurse Kelly needs to make sure the guard is awake and alert before allowing any food or drink past the gate.

Nurse Kelly should perform a thorough assessment to ensure the gag reflex has returned. This can be done by gently touching the back of the patient's throat with a tongue depressor or asking the patient to swallow small amounts of water. The patient should not be given anything by mouth until the return of the gag reflex is confirmed.

• Gently touch the back of the patient's throat with a tongue depressor to check for the gag reflex.
• Ask the patient to swallow small sips of water and observe for any signs of difficulty or coughing.
• Monitor the patient for any signs of aspiration, such as coughing, choking, or difficulty breathing.
• Provide reassurance and explain the importance of this assessment to the patient.
• Document the return of the gag reflex and any other relevant observations in the patient’s medical record.

✘Incorrect answer options:

Checking the patient's ability to urinate. This is not directly relevant to the effects of lidocaine viscous or the immediate postoperative care following a gastroscopy. While urinary function is important, it is not the priority in this context.

Evaluating the patient's ability to stand. Although mobility is important, the primary concern after using lidocaine viscous for a gastroscopy is the patient's airway protection and ability to safely swallow.

Monitoring for any abdominal pain. While assessing for abdominal pain is important post-procedure, it is not the immediate priority compared to ensuring the patient’s gag reflex has returned to prevent aspiration.