Scenarios and items in this section represent situations that exemplify perianesthesia nursing practice. This specialty is defined by a set of knowledge and skills related to anesthetic medications, techniques, and surgical manipulations that significantly alter a patient’s organ systems. These concepts are considered together because the perianesthesia clinical nurse:
• Focuses on anesthesia-induced alterations of airway, circulation, consciousness, and neurologic function that require astute nursing consideration, whether for 5 minutes or 5 hours
• Practices this unique body of knowledge for varied and highly individual patient situations
• Synthesizes and applies concepts from multiple clinical disciplines to a diverse clinical population and spectrum, which includes infants, critically-ill patients, elderly individuals, and a vvariety of organ system or musculoskeletal procedures
• Distinguishes priorities from an assortment of wide-ranging and frequently simultaneous concerns
| ESSENTIAL CORE CONCEPTS | AFFILIATED CORE CURRICULUM CHAPTERS |
|---|---|
| Nursing Process | Chapters 3, 35, 56, 61 |
| Assessment | |
| Planning and Implementation | |
| Evaluation | |
| Perianesthesia Spectrum | Chapters 2, 4, 7; Section 5—Chapters 24-37 |
| Situational Applications | |
| Anesthetics | |
| Pharmacodynamics | |
| Pharmacokinetics | |
| Receptors and Blocks | |
| Regional, Local, General, or Balanced | |
| Conscious Sedation | |
| Standards and Safety | |
| Perianesthesia Units and Beyond | |
| Preanesthesia to Discharge Education | |
| Priorities: Imminent Need or Remote Potential | |
| Surgical Manipulations | |
| Cautery and Blood Loss | |
| Position, Injury, and Pain | |
| Clinical Continuums | |
| Airway: From Patency to Obstruction | |
| Awareness: From Delays to Delirium | |
| Cardiac: From Heartbeat to Heart Failure | |
| Consciousness: From Sedation to Self-Awareness | |
| Hemodynamics: From Hemorrhage to Hemostasis | |
| From Hypotension to Hypertension | |
| From Vessel Patency to Stagnation | |
| Immunity: From Allergy to Sepsis | |
| Nausea: From Retching to Relief | |
| Neurologic: From Deficit to Function | |
| Oxygenation: From Hypoxia to Toxicity | |
| Pain: From Angst to Comfort | |
| Pulmonary: From Ventilation to Apnea | |
| From Croup to Aspiration | |
| Temperature: From Shivers to Sweats |
ITEMS 5.1–5.22
5.1. A nurse caring for an ambulatory surgical patient in the main PACU rather than a PACU used exclusively for outpatients understands that this patient is most likely to experience:
a. a positive response to the technical environment.
b. a less stressful environment.
c. care delivered by a nurse who is more experienced in handling emergency treatment protocols.
d. a more rapid reunion with significant others.
5.2. Regular, frequent hand washing is a proven means of preventing cross-contamination in the perianesthesia setting, yet this practice is often overlooked. The best method to change behavior and ensure that hand washing is regularly performed by nursing staff is to:
a. install hand sanitizer dispensers at every bedside.
b. replace hand washing with use of protective gloves.
c. monitor hand washing compliance of personnel.
d. provide regular education regarding the importance of hand washing.
5.3. A PACU nurse accepts a 46-year-old male patient from the operating room. The anesthesia provider reports that a 1% mepivicaine lumbar epidural anesthesia was administered for the 20-minute lower extremity procedure, rather than 1% lidocaine lumbar epidural anesthesia because:
a. mepivicaine has a longer duration of action.
b. the patient is susceptible to hypotension.
c. the patient has a history of cardiac dysrhythmias.
d. mepivicaine has a low level of potency and toxicity.
5.4. A 7-year-old boy is admitted to the PACU after undergoing general anesthesia for orthopedic repair of a congenital foot anomaly. The child has had three prior surgeries related to this anomaly and arrives in the PACU sedate but responding appropriately to simple commands. The nurse applies oxygen, observes symmetric chest expansion, and auscultates the lungs, which are clear. The child exhibits inspiratory and expiratory throat sounds at a rate of 16 breaths per minute, a SpO2 of 96%, and a heart rate of 114 bpm. It is most important to closely monitor this child’s airway because:
a. there is an audible partial obstruction.
b. oropharyngeal suctioning is frequently indicated.
c. there is potential for rapid airway obstruction.
d. he is positioned in a ¾ prone position.
5.5. Family member visitation in the PACU should:
a. be limited to pediatric patients.
b. begin when a pediatric patient is admitted to the PACU.
c. only be determined by the individual nurse caring for a patient.
d. be based on practitioner guidelines developed within their perianesthesia practice setting.
NOTE: Consider the scenario and items 5.6-5.7 together.
An alert, oriented 60-year-old woman arrives in the PACU after a 2½-hour surgery for placement of a right total hip prosthesis. An 8-mg 0.75% bupivacaine (Marcaine) spinal anesthesia was administered 30 minutes preoperatively, and the patient received intraoperative IV doses of 3 mg of midazolam and 8 mg of morphine. Assessment reveals absence of sensation at the T7 dermatome, and she is unable to move both legs.
5.6. The patient tells the nurse that she is worried about being unable to move her legs. The PACU nurse calculates the known residual effects of bupivacaine and advises the patient not to worry because her leg movements:
a. could remain anesthetized for 3 to 6 more hours.
b. will return within 30 to 60 minutes.
c. will return entirely in 90 minutes.
d. should completely return to normal in 2 hours.
5.7. Twenty minutes after PACU admission, the patient verbalizes dizziness and says she is feeling very weak. The nurse examines the patient and notes that her blood pressure has dropped from 128/84 on admission to 90/54. The nurse’s next immediate action is to:
a. notify the attending anesthesia provider.
b. assess for surgical bleeding.
c. deliver a bolus of IV fluid.
d. place the patient in Trendelenburg position.
5.8. A male patient has been in the PACU for 30 minutes recovering from general anesthesia for a gastrectomy procedure for malignant tumor. A nasogastric tube is in place with small amounts of bright, bloody drainage present. He is now awake and oriented, lying on his left side, respirations are normal, and the lungs are clear and equal bilaterally. He reports a pain level of 4/10 at the incision area after the nurse administered a total of 3 mg of IV morphine 15 minutes ago for a reported pain level of 8/10. The nurse’s next action is to assist the patient with repositioning to a semi-Fowler position to:
a. enhance comfort of the indwelling nasogastric tube.
b. instruct the patient to perform coughing and deep breathing exercises.
c. promote comfort and decrease pressure on the suture lines.
d. check the wound dressing.
5.9. Unless a known contraindication exists, the preferred method of postoperative pain control for a Phase I gastrectomy procedure patient is:
a. patient-controlled analgesia (PCA) in the demand dose mode.
b. a low thoracic epidural analgesia delivery system.
c. PCA with a continuous infusion rate.
d. a mid-thoracic epidural analgesia delivery system.
5.10. A 39-year-old female patient is in Phase I PACU after receiving general anesthesia. Her cardiac monitor shows sinus bradycardia at a rate of 42 bpm. She easily arouses to verbal stimuli and states she feels fine except for 2/10 incision pain from her right breast biopsy site. Her preanesthetic blood pressure assessment was documented as 124/74 and is now 100/62 with a SpO2 of 98% on oxygen at 4 liters/minute by nasal cannula. The most appropriate action by the nurse caring for this patient is to consult the anesthesiologist and anticipate:
a. an IV fluid bolus of crystalloid solution.
b. administration of a 0.1-mg dose of IV atropine.
c. moving the emergency crash cart closer to the bedside.
d. continued stir-up regimen and observation.
5.11. The PACU nurse performs an assessment on an 80-kg, 72-year-old male patient admitted 10 minutes earlier after general anesthesia for transurethral resection of the bladder tumor, after a failed spinal anesthetic attempt. The nurse observes a very sedate patient who barely responds to loud verbal and touch stimuli with 8 breaths per minute, shallow respirations, clear breath sounds that are diminished throughout both lung fields, and a SpO2 of 82% on oxygen at 60% by facemask. The nurse confirms airway patency, increases the FiO2 to 100%, stimulates the patient to take deep breaths, and has a colleague immediately call the attending anesthesiologist. With regard to the respiratory parameters identified during this assessment, the nurse:
a. understands that hypoventilation is a significant postoperative problem.
b. retrieves the intubation tray and prepares to use a size 7.5-mm tube.
c. does not question the placement or accuracy of the pulse oximeter reading.
d. expects the normal tidal volume range for this gentleman to measure between 400 and 560 mL/kg.
5.12. The clinical characteristics of moderate sedation and analgesia include:
a. inability to control secretions, patent airway, and easy arousal.
b. maintenance of protective reflexes, patent airway, and response to verbal or light tactile stimulation.
c. partial loss of protective reflexes, not easily aroused, and patent airway.
d. maintenance of protective reflexes, partial loss of airway, and easy arousal.
5.13. Which of the following statements is true regarding assessment of the patient receiving moderate sedation/analgesia?
a. It is not always possible to predict an individual patient’s reaction to sedation.
b. It is possible to predict an individual patient’s reaction to sedation if following medication guidelines available in the Physician’s Desk Reference (PDR).
c. Spontaneous ventilation is frequently inadequate with moderate sedation; therefore the patient requires critical ventilatory assessment.
d. Airway intervention is often required when using moderate sedation.
NOTE: Consider the scenario and items 5.14-5.16 together.
A surgeon refers a 54-year-old female patient with Type 2 diabetes to the preanesthesia evaluation and testing unit for blood work, ECG, preanesthesia evaluation, and education. The preanesthesia nurse reviews the surgeon’s preoperative history and physical and related physician orders for this patient and then escorts the patient to a private area and begins the preanesthesia interview. The patient is scheduled for an outpatient laparoscopic cholecystectomy procedure in 7 days, arrives for her preanesthesia appointment alone, and states she lives alone. She follows a diabetic diet and takes daily Glucophage to successfully manage blood sugar readings in the desired range established by her endocrinologist.
5.14. Collaborative nurse and attending surgeon considerations regarding the preparation of a patient for outpatient surgery should include:
a. identifying the responsible adult caregiver for the postoperative period.
b. allowing the preanesthesia nurse to perform specific testing based on the history and physical findings.
c. reporting findings for all preoperative tests performed.
d. standing orders for all consents to be obtained in the preanesthesia unit.
5.15. The patient is closely monitored during the perianesthesia period involving general anesthesia. The perianesthesia nurse understands that in a perianesthesia diabetic patient:
a. glucose-free urine levels are a desired outcome.
b. the target serum glucose level is <200 mg/dL.
c. fluid losses are less significant because of increased cardiac stressors from anesthesia.
d. a preoperative or intraoperative infusion of 5% dextrose IV solution is contraindicated.
5.16. The patient arrives in the PACU awake and oriented with stable vital signs and denies any untoward symptoms. Soon after PACU admission, she has a blood pressure of 108/58 and exhibits shallow breathing, diaphoretic skin, pallor, and vertigo. The nurse notifies the attending anesthesia provider and anticipates:
a. treatment consistent with an impending myocardial infarction.
c. insulin administration to prevent further progression of early diabetic coma.
d. IV intravenous administration of a concentrated dextrose solution.
NOTE: Consider the scenario and items 5.17-5.20 together.
A 45-year-old female patient is admitted to the preoperative holding area for an elective abdominal hysterectomy under general anesthesia. She is a nonsmoker with no significant medical history or problems (American Society of Anesthesiologists [ASA] I). She has had no previous surgeries but does have a history of motion sickness. Postoperative pain management will include IV PCA with fentanyl. Based on the ASPAN Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV, answer questions 5.17-5.20.
5.17. Based on the presenting risk factors, the patient is at a ___________ risk for developing PONV.
a. low
b. moderate
c. severe
d. very severe
5.18. Based on the presenting level of risk for developing PONV, you can expect to work with the anesthesia and surgical team to implement at least _____ prophylactic measure(s).
a. 0
b. 1
c. 2
d. 3
5.19. Based on the patient’s presenting factors, which of the following prophylactic combinations are most likely to be administered?
a. Total IV anesthesia (TIVA), dexamethasone, scopolamine patch
b. TIVA, dexamethasone, metoclo-pramide
c. TIVA, scopolamine patch, metoclo-pramide
d. TIVA, 5-HT3 receptor antagonist, metoclopramide
5.20. If rescue therapy is indicated, which agent should the PACU nurse administer?
a. Dexamethasone
b. 5-HT3 antagonist
c. Promethazine
d. Metoclopramide
NOTE: Consider the scenario and items 5.21-5.22 together.
An anesthesiologist orders a continuous fentanyl epidural infusion for a 44-year-old female after a total abdominal hysterectomy procedure. The awake patient verbalizes 9/10 pain to the admitting nurse upon arrival in the PACU. The anesthesia provider immediately treats this pain report by administering a 100-mcg bolus dose of epidural fentanyl.
5.21. The PACU nurse expects this patient to experience an onset of pain relief from this fentanyl dosage within:
a. 5 to 10 minutes.
b. 10 to 20 minutes.
c. 15 to 25 minutes.
d. 20 to 30 minutes.
5.22. While connecting the epidural fentanyl infusion, the PACU nurse recognizes that this medication:
a. is less potent than epidural morphine.
b. has few undesirable side effects.
c. requires good catheter placement because of the medication’s properties.
d. requires infrequent dosing adjust-ments.
ITEMS 5.23–5.42
NOTE: Consider the scenario and items 5.23-5.24 together.
A male patient is admitted to the preanesthesia unit at 10 am for a 12 noon surgical procedure. The history and physical documents no known allergies for this patient. The patient is employed as an industrial environmental services worker and frequently wears latex gloves. During the admission interview he tells the nurse he “might be” allergic to latex because his hands have been breaking out in a rash every day lately after wearing the gloves. All operating rooms are actively running cases on this morning, and the hospital does not have a dedicated latex-free operating room.
5.23. The type of latex reaction described by this patient is classified as a:
a. Type I reaction.
b. Type II reaction.
c. Type III reaction.
d. Type IV reaction.
5.24. Based on the patient’s initial self-report, in addition to notifying the surgeon, surgical team, and anesthesia team, the preanesthesia nurse’s next most appropriate action is to:
a. immediately check vital signs using non-latex unit equipment.
b. collect a more detailed history from the patient.
c. initiate a latex-free IV infusion.
d. contact an allergist to examine the patient.
5.25. Which of the following is the most commonly occurring postoperative complication?
a. Postoperative hypothermia
b. Sinus tachycardia
c. Postoperative nausea and vomiting (PONV)
d. Postoperative wound infection
NOTE: Consider the scenario and items 5.26-5.27 together.
A postoperative femoral-popliteal graft procedure patient met criteria for discharge from the Phase I PACU to a cardiac observation unit. The PACU nurse coordinated the patient’s transfer by telephone with the accepting nurse, notified the nurse that this patient required continuous telemetry monitoring, and stated the patient would arrive to the assigned room in 5 to 10 minutes. The two nurses agreed that a verbal hand-off report would take place in person at the patient’s bedside.
5.26. To ensure safe transfer of care for this patient, the PACU nurse’s most appropriate action is to:
a. administer only small amounts of opioid medication just before discharge from PACU.
b. apply supplemental oxygen to prevent hypoxemia during the transport phase.
c. assign appropriate staff members to transport the patient.
d. position the portable cardiac monitor in plain view of the unit aide pushing the gurney.
NOTE: The scenario continues.
The PACU nurse arrives on the nursing unit with the patient, notifies the unit clerk of the patient’s arrival, requests the accepting nurse’s assistance, and then takes the patient directly to the assigned room. After a 9-minute wait and a second request for a relief nurse by the PACU nurse, no telemetry unit nurse has arrived in the room. The PACU nurse is paged to immediately return to the PACU because of limited staffing available in the PACU and the pending arrival of two critical care patients from the operating room.
5.27. The PACU nurse’s most appropriate action is to:
a. wait at the bedside until the accepting unit nurse comes for report.
b. attach the telemetry, give the alert patient a call light, and leave a written report for the nurse.
c. request immediate relief from the telemetry unit charge nurse or administrative supervisor.
d. have an experienced nursing assistant remain with the patient until the nurse can come.
5.28. A patient received a usual dose of succinylcholine during general anesthesia and is admitted to the PACU with previously undiagnosed atypical pseudocholinesterase deficiency. The nurse understands that this patient can have sustained apnea for up to:
a. 12 hours.
b. 24 hours.
c. 36 hours.
d. 48 hours.
5.29. During preanesthesia screening a 48-year-old female reports that she has been taking Maxzide 25 mg/day for treatment of hypertension for 1 year and Gingko biloba extract 120 mg/day for the beneficial antioxidant properties for the past 6 months. The surgery is scheduled for 3 weeks from the date of the preanesthesia appointment. Based on the patient’s self-report regarding medication and herbal supplement use, the preanesthesia nurse recognizes that Gingko biloba:
a. increases the platelet count.
b. should be discontinued for 7 days before surgery.
c. has no known interactions with thiazide diuretics.
d. should be discontinued for 2 weeks before surgery.
NOTE: Consider the scenario and items 5.30-5.31 together.
A patient unsuccessfully attempted vaginal birth after a previous cesarean delivery and was taken to the operating room for failure to progress during a difficult 22-hour labor period. The patient was admitted to the PACU after receiving general anesthesia for cesarean delivery of a healthy 4.2-kg boy. The nurse examines the patient on admission, performs a fundus check, and discovers her uterus is boggy and the perineal pad is completely soaked with blood.
5.30. The nurse most effectively performs external uterine massage by:
a. supporting the lower uterus.
b. applying a bimanual compression technique.
c. asking the patient to simultaneously tighten the abdominal muscles to promote uterine contraction.
d. instructing the patient to take shallow breaths to prevent increased diaphragmatic pressure during the massage.
NOTE: The scenario continues.
Oxytocin 20 units/1000 mL of normal saline is infusing at 500 mL/hour. Thirty minutes after PACU admission, the second perineal pad is completely soaked with blood and the patient’s blood pressure has dropped to 88/52 with the monitor showing sinus tachycardia at 126 bpm. The anesthesia record indicates that the estimated blood loss in surgery was 1050 mL with no blood replacement products administered. The bleeding remains uncontrolled in the PACU and the patient requires massive transfusion therapy.
5.31. While administering repeated units of packed red blood cells, the PACU nurse understands that massive transfusion therapy is defined as:
a. administering 8 or more units of packed red blood cells in a 24-hour period.
b. a 50% replacement of blood volume within 3 hours.
c. an estimated blood loss of more than 4000 mL.
d. replacing 75% of the patient’s circulating blood volume.
5.32. A female patient admitted to the PACU has blockade after spinal anesthesia assessed at the T4 dermatome. During Phase I recovery, this patient is at increased risk to develop:
5.33. The most accurate measure of the patient’s core temperature in the PACU is made with a:
a. pulmonary artery catheter.
b. oral thermometer.
c. tympanic thermometer.
d. bladder thermometer.
NOTE: Consider the scenario and items 5.34-5.35 together.
During the PACU admission assessment on a barely responsive elderly man, the nurse observes occasional premature ventricular contractions on the cardiac monitor. During the 150-minute surgery, the patient received oxygen with nitrous oxide and thiopental, then Tracrium, fentanyl, halothane, and dolasetron. Blood pressure is 84/50, measured by a noninvasive automatic device. The attending anesthesia provider orders an immediate 200-mL normal saline fluid bolus.
5.34. Considering the inhalation anesthetic used for this patient, the nurse determines that the presence of ventricular ectopy is most likely related to:
a. parasympathetic nervous system stimulation.
b. a decreased rate of SA node discharge.
c. a decrease in bundle of His–Purkinje and ventricular conduction times.
d. decreased ventricular automaticity.
5.35. The medication most likely to cause an increase in cardiac dysrhythmias as a result of pharmacokinetic interaction with the inhalation anesthetic used for this patient is:
a. furosemide.
b. chlorpromazine.
c. epinephrine.
d. gentamycin.
5.36. A patient receives midazolam in the PACU. Which of the following statements is true about midazolam?
a. Midazolam has a rapid onset of action, moderate amnesic effects, faster peak effect in elderly adults, and is contraindicated for patients with acute narrow-angle glaucoma.
b. Midazolam does not inhibit the activity of any known drugs, has excellent amnesic effects, and is water soluble.
c. Midazolam is metabolized by an agent in the blood and excreted through the urine, has excellent amnesic effects, and is contraindicated for patients with acute narrow-angle glaucoma.
d. Midazolam has a rapid onset of action, excellent amnesic effects, is water soluble, and is contraindicated for patients with acute narrow-angle glaucoma.
5.37. A patient received a single injection of 15 mg of extended-release epidural morphine (EREM) after repair of a severe orthopedic trauma to the left lower extremity. While giving a transfer-of-care report to the surgical unit nurse, the PACU nurse states that the patient may have effective pain relief from EREM for how many hours?
a. 24
b. 36
c. 48
d. 60
5.38. The primary investigator of a nursing research project invites perianesthesia staff member participation in data collection. The study’s purpose is to compare analgesic effects and patient responses to a nonsteroidal antiinflammatory drug (NSAID) and a narcotic medication. The perianesthesia nurses’ role is to document participants’ relevant physiologic data and reported pain level based on a 0-10 numeric pain scale before and after the medication is administered. Before participating in data collection, the perianesthesia nurse questions the researcher to ensure that:
5.39. The optimal postoperative positioning of the bariatric surgery patient is:
a. left side-lying with head of bed elevated 20° to 30°.
b. semi-recumbent.
c. supine until the patient is awake and responding appropriately to com-mands.
d. right side-lying with head of bed elevated 20° to 30°.
5.40. A visually impaired patient arrives for surgery. The preanesthesia nurse conducts the preoperative interview and facilitates care management while paying special attention to:
a. speaking in a normal tone and volume.
b. guiding the patient to the bathroom for preoperative voiding while giving directions from behind the patient.
c. ambient environmental sounds.
d. witnessing the patient’s signature on the surgical consent form.
5.41. A 36-year-old man had surgical repair of an inguinal hernia and is now in Phase II PACU. While performing discharge teaching, the postanesthesia nurse addresses postdischarge pain medication and treatment. The nurse instructs the patient to take pain medication:
a. when his pain level is self-rated at 5/10 to 6/10.
b. every 4 hours around the clock.
c. at early onset to maintain an acceptable pain goal.
d. only after trying other comfort measures.
5.42. Perianesthesia care of the immunosuppressed patient includes:
a. mandatory placement of the patient in protective isolation.
b. assessment for classic signs and symptoms of infection.
c. constant direct visualization of needle puncture and incision sites.
d. cleansing of common-use monitoring items before application.
ITEMS 5.43–5.60
NOTE: Consider the scenario and items 5.43-5.44 together.
A 90-kg male is being cared for in the PACU after general anesthesia for a three-level lumbar fusion procedure. The nurse observed sinus rhythm with occasional premature atrial contractions for the first 20 minutes of his PACU course and now responds to a monitor alarm indicating the high heart rate limit has been exceeded at 132 bpm. The nurse examines the patient who is breathing well, shows a blood pressure drop from 128/78 on admission to 108/62, responds to verbal stimuli, is oriented to place, and states he feels sleepy but fine. The nurse obtains and reviews the cardiac monitor strip, immediately notifies the attending anesthesia provider, and performs a 12-lead ECG. The anesthesiologist arrives and identifies the sustained ECG rhythm as supraventricular tachycardia.
5.43. The anesthesiologist orders an immediate dose of IV propranolol. The PACU nurse understands that propranolol:
a. is a beta adrenergic receptor antagonist.
b. dosing for this patient should not exceed a 9-mg total.
c. can be rapidly administered in a 1- to 2-mg IV dose.
d. has a peak action time of 3 minutes.
NOTE: The scenario continues.
The patient has a history of thrombolytic events; therefore the surgeon’s postoperative orders request anticoagulant therapy with a heparin-loading dose to be followed by a continuous heparin infusion.
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5.44. Regarding the heparin order, the PACU nurse’s most appropriate action is to:
a. initiate the order as soon as possible.
b. keenly assess for postoperative bleeding because of increased partial thromboplastin time associated with this anticoagulant therapy.
c. notify the surgeon and anesthesiologist of an associated risk related to this medication.
d. place a “Bleeding Precautions” sign on the patient’s bed.
5.45. A normal 7.3-kg infant’s total lung capacity is calculated to equal:
a. 438 mL.
b. 475 mL.
c. 511 mL.
d. 548 mL.
5.46. A new anesthesia provider group has recently taken over the contract services for a freestanding surgery center, completely replacing the previous anesthesia providers with new practitioners. The PACU nursing staff note an increased trend of emergence delirium in their pediatric surgical population manifested as thrashing, disorientation, and agitation. The nurses perform a retrospective review of the pediatric anesthesia records, which reveals increased use of which of the following inhalation agents associated with increased incidence of emergence behavioral changes in pediatric cases:
a. sevoflurane.
b. desflurane.
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