Perioperative Quiz

What is a perioperative nurse?
-A perioperative nurse is a term used to describe the nursing functions in the TOTAL surgical experience of the patient (pre-operative, intra-operative, and post-operative)

What does a perioperative nurse do?
-ADVOCATES FOR THE PATIENT (we are the eyes and the ears of the patient while they are sleeping)

Perioperative nursing is client oriented and must be geared to meet the clients ________
-psychosocial needs as well as immediate physical needs.

PNDS (Perioperative nursing data set): (2)
-Is a nursing language which describes nursing process in the perioperative setting by utilizing four domains. The focus of perioperative nursing is on SAFE surgical outcomes.
-Uses a structured vocabulary that includes the nursing process and representation of each phase.

Three phases of perioperative nursing: (3)
-Preoperative (doesn’t have to take place in the operating room for example doctor’s office)
-Intraoperative (inside the OR, there needs to be one RN in each OR room)
-Postoperative (recovery room, has to be an RN, PACU)

Pre-operative nursing:
-Takes place from the time the decision is made for surgical intervention to the TRANSFER of the patient to the operating room

Intra-operative nursing: (2)
-Begins from the time the patient is RECEIVED in the operating room until ADMITTED to the recovery room.
-The intraoperative phase of the surgical intervention is the PRIMARY FOCUS of perioperative nursing

Post-operative nursing:
-Begins when the patient enters the PACU and lasts through some degree of convalescence (the patient is still recovering even when the patient is home, or admitted back to the floor)

Types of surgery
-Surgery is scheduled completely at the preference of the patient (eg. cosmetic surgery)
-The approximate time for surgery is at the convenience of the patient; failure to have surgery is not catastrophic
-The condition requires surgery within a few weeks
-The surgical problem requires attention within 24-48 hours (cancer)
-Situation requires immediate surgical attention without delay (intestinal obstruction)

Pre-Operative Teaching: (3)
-DISCUSS PAIN MANAGEMENT (PCA pump, and oral pain medications)
-tubes, drains
-Reinforce physician’s explanation and insturction

Pre-op check list: (6)
-SURGICAL INFORMED CONSENT (make sure it is signed and filed)
-blood transfusion consent
-lab results
-current vital signs
-special needs

Pre-Op Lab Data: (4)
-Blood tests
-Urine tests
-Chest x-ray

First thing PACU nurse does when receiving patient from the OR:
-ABC’s (check airway, breathing, circulation)

Perioperative team:
-providing perioperative patient care is based entirely on MULTIDISCIPLINARY TEAMWORK.

Surgical team members: (5)
-Anesthesiologist/ Nurse Anesthetist
-Registered Nurse
-Scrub Person
-Surgical Assistant (MD, PA, RNFA)

Sterile members of the surgical team: (3)
-First assistant (assists surgeon, controls patient bleeding, provides wound exposure, suturing, requires additional education)
-Scrub nurse (prepares and maintains integrity, safety, and efficiency of the sterile field)

During the immediate postoperative period, the nurse should give highest priority to:
A. Observing for signs of infection
B. Maintaining a patent airway
C. recording the intake/output
D. Checking vital signs every hours
-Answer: B (maintaining airway)

True of False
The role of the circulating nurse in the OR is to handle the sterile equipment during surgery?

True or False
The preoperative phase ends when the patient is safely transported to the OR and care is assumed by the OR nurse?

What is the Nursing Diagnosis for the operative phase
-Anxiety r/t surgery and anesthesia

-Risk for injury r/t positioning

-Ineffective airway clearance r/t anesthesia.

A nurse who helped found the field of perioperative nursing during the Crimean War was:
a. Clara Barton
b. Florence Nightingale
c. Lillian Wald
d. Mary Breckinridge
e. Mary Ezra Mahoney
Answer: B

In 1920, an organization that developed a standard curriculum of OR techniques was:
a. AMA
c. Bellevue Hospital
d. The National League of Nursing
e. The Nightingale Society
Answer: D

In an environment of care, perioperative RNs should:
a. Always follow the instructions of surgeons
b. Maintain the patient as the focus of all team activities
c. Minimize communication in order to work efficiently
d. Never deviate from protocol, even if an error may result
e. Strive
Answer: B

Perioperative RNs primarily use checklists to ensure that:
a. Lawsuits from the patient and their family are avoided
b. New nurses perform their work as expected
c. Surgical supplies are not wasted before or after surgery
d. Staff begin shifts on schedule and relieve one another as needed
e. The plan of care is implemented correctly before, during, and after surgery
Answer: E

The pre-incision TIME OUT should be performed by which member(s) of the perioperative team?
a. All perioperative team members
b. All perioperative team members except anesthesia professionals
c. Perioperative RNs
d. Scrub nurses only
e. Surgeons only
Answer: A

This perioperative RN prepares the OR, helps with anesthesia induction if requested, and works outside the sterile field to ensure the perioperative team has everything it needs.
a. PACU nurse
b. Pre-admission nurse
c. RN circulator
d. Registered nurse first assistant (RNFA)
e. Scrub person
Answer: C

Which of the following best describes the semirestricted
surgical practice area?
a. Has work areas for processing and storing instruments
b. Includes the OR
c. Permits wearing of street clothes
d. Requires that all patients wear masks
e. Used for communication of information between the surgical suite and the rest of the health care facility
Answer: E

When updating the patient’s support person during surgery, a nurse should:
a. Call the surgeon away from the operation, but only if the support person demands it.
b. Discuss a projected time frame for completion of the surgery
c. Discuss the patient’s expected prognosis
d. Provide details of the surgery and describe any problems
e. Tell the patient that she is not allowed to talk to the support person
Answer: B

Advanced practice nurses in the perioperative setting may do all of the following except which one?
a. Direct patient care
b. Help implement improvements in healthcare systems
c. Perform surgery in an emergency without a surgeon being present
d. Serve as first assistant during surgery
e. Teach self-care to patients and their support team
Answer: C

Wrong-site surgical errors:
a. Almost never happen
b. Are the sole responsibility of the surgeon to prevent
c. Are usually due to incorrect information provided by the patient
d. Can result from failure to perform the TIME OUT before surgery
e. Should be concealed from the patient as much as possible
Answer: D

Approximately what percentage of serious medical errors are thought to associated with miscommunication during patient hand-offs?
a. < 1% b. 10% c. 50% d. 80% e. 100%
Answer: D

Which of these activities is NOT performed in the preoperative area?
a. Information is confirmed from the patient’s history
b. The circulating RN and scrub nurse count instruments, sponges, needles, and other sharps
c. The patient’s name, date of birth, procedure, and procedure site are confirmed
d. The anesthesia plan is confirmed, and consent for anesthesia is obtained
e. The surgical site is confirmed and marked
Answer: B

The postoperative period is defined as which of the
a. Admission to the PACU to transfer to a patient
care unit
b. Admission to the PACU to patient’s death
c. Closure of the incision to admission to the PACU
d. Discharge from hospital to patient’s return home
e. Leaving the OR to admission to the PACU
Answer: A

Fast tracking patients from the OR to the PACU Phase II due to rapid-onset, fast-emergence general anesthetics may require the increased use of which drugs?
a. Amphetamines
b. Anticoagulants
c. Anti-emetic and pain control drugs
d. Antihypertensives
e. Sedatives
Answer: C

The body’s most important barrier to infection is:
a. Saliva
b. Skin
c. Keratin
d. Tears
e. Vitamin C
Answer: B

Which activity is NOT recommended to reduce the risk of surgical infections?
a. Administer prophylactic antibiotics as directed
b. Keep the OR doors closed during the operative procedure
c. Minimize movement and talking during the operative procedure
d. Perform a TIME OUT before beginning the procedure
e. Perform a thorough skin prep and hand scrub
Answer: D

The primary responsibility of scrub nurses is to:
a. Help anesthesia professionals anesthetize patients
b. Perform the skin prep
c. Perform a thorough hand scrub before surgery
d. Providing needed instruments to the surgeon and first assistant during the surgical procedure.
e. Scrub dirty/used surgery instruments before
they are sterilized.
Answer: E

Which of the following is a role of a registered nurse first assistant (RNFA)?
a. Assist with the surgical procedure
b. Clean up the OR after surgery
c. Concurrently perform the duties of a scrub nurse
d. Perform the skin prep
e. Practice at the direction of a RN Circulator
Answer: A

Which of the following phases of anesthesia recovery is best described by the following description? The patient is more alert and functional and no longer requires intensive nursing care. The
focus is on preparing the patient for self-care, care by support persons, or care in an extended-care environment.
a. Phase I
b. Phase II
c. Phase III
d. Phase IV
e. Not possible to state based on this information
Answer: B

An instrument falls below the level of the back table during an operative procedure. Only the circulating RN sees this happen. The nurse should:
a. Try to catch the instrument before it touches the floor
b. Discard and replace the instrument with a sterile one
c. Pick up the instrument and return it to the table
d. Follow the 5-second rule (OK if not on floor for more than 5 seconds)
e. Inspect for visible particulate matter and use if clean
Answer: B

Monitor immunocompromised patient closely for ________
-S/S of infection before surgery

Pre-operative common anxieties:
-Fear of the unknown

Common Pre-operative Laboratory Tests:
-Hemoglobin and Hematocrit
-White blood cell count
-Blood typing and cross matching
-Serum electrolytes
-PT and PTT
-Liver enzymes
-Urine analysis (in women it is used to check for pregnancy)
-BUN and creatinine

Informed consent:
-It is the surgeon’s responsibility to explain the surgical procedure, alternatives, risks, and benefits.

Poor nutrition danger: (2)
-Increases the risk of infection and shock
-Greatly impairs wound healing

Fluid and Electrolyte Imbalance Danger:
-Dehydration and electrolyte imbalances can have adverse effects in terms of general anesthesia and the anticipated volume losses associated with surgery. This can cause shock and cardiac dysrhythmias.

Presence of Cardiovascular Disease Danger:
-Many surgical problems may be complicated in the presence of cardiovascular compromise and/or any comorbidities.

Presence of Diabetes Mellitus Danger:
-Hyperglycemia is potentiated by increased catecholamines and glucocorticoids due to surgical stress

Presence of Alcoholism Danger: (2)
-Additional problem of malnutrition
-The patient may also have an increased tolerance to anesthetics

Presence of Pulmonary and Upper Respiratory Disease Danger:
-Surgery may be contraindicated because it might potentiate a more serious illness such as pneumonia.

Universal Protocol
-Pre-operative verification (identifying/interviewing patients):
-Marking the operative site:
-To ensure the effective and safe transition of the operative patient through the pre-operative phase, beginning with the physician’s office and concluding upon the patient’s arrival to the operating room. It is the sharing of pertinent information to ensure appropriate verification of the correct patient, correct procedure and correct site.
-To identify the correct operative/procedure site. Clearly marking the surgical site to eliminate any ambiguity and ensures correct bilaterally/level.
-To prevent medical error by conducting a final verification of correct patient, procedure and site. Active two way communication among al surgical/procedural team members that is consistently preformed prior to all procedures.

1. Assessment data are collected
a. preoperatively.
b. intraoperatively.
c. postoperatively.
d. all of the above.
Answer: D

Assessment data may be collected from
a. the patient.
b. the patient’s family members.
c. other health care providers.
d. all of the above.
Answer: D

In the course of the preoperative assessment, the
perioperative nurse should
a. obtain informed consent from the patient.
b. ensure that a signed informed consent is in the patient’s chart.
c. explain the risks and alternatives of the planned procedure.
d. all of the above for this information.
Answer: B

When addressing the patient during the preoperative
interview, the nurse should
a. use the patient’s first name.
b. use the patient’s title and last name.
c. ask permission before using the patient’s first name.
d. wait for the patient to say how he or she wishes to be addressed
Answer: C

The information given by a patient during the
assessment interview
a. is always assumed to be correct.
b. may not always be correct and should be checked against another source if there is any question about its accuracy.
c. should always be checked against another source.
d. must be accepted; there is no other source for this information.
Answer: B

Use of the hands and fingertips on the patient’s skin to distinguish temperature variations, hard and soft, rough and smooth, and stillness and
vibration is called
a. auscultation.
b. percussion.
c. palpation.
d. inspection.
Answer: C

The patient’s identity should be verified
a. verbally (whenever possible).
b. by checking the patient’s chart.
c. by checking the patient’s identification bracelet or wristband.
d. all of the above.
Answer: D

Surgical sites should be marked preoperatively
a. when the surgery involves limbs.
b. when the surgery involves bilateral organs.
c. when the surgery involves multiple structures or levels.
d. all of the above.
Answer: D

When gathering information about medications
that the patient is taking, it is important to
a. physician prescribed medications.
b. over the counter medications and vitamins.
c. herbal medications that the patient may be taking.
d. all of the above.
Answer: D

When conducting a perioperative assessment of a
hearing impaired patient, it may be helpful to
a. have the patient face toward the light to facilitate lip reading.
b. shout at the patient.
c. ask short, direct questions.
d. let the surgeon conduct the assessment.
Answer: A

To assess the patient for “pitting edema,” depress the skin
a. over the shin for five seconds, and then release.
b. over the neck veins for five seconds, and then release.
c. over the shin for 15 seconds, and then release.
d. over the axilla for five seconds, and then release.
Answer: A

The lungs should be auscultated with the patient
a. sitting, with legs dangling over the side of the examination table.
b. sitting, with the legs up on the examination table.
c. supine, with the legs dangling over the side of the examination table.
d. supine, with the knees bent and the feet on the examination table.
Answer: A

Data about alcohol intake and recreational drug
use are
a. not necessary.
b. not reliable.
c. essential.
d. best obtained in the presence of family members.
Answer: C

Discharge planning begins during the
a. assessment phase.
b. planning phase.
c. implementation phase.
d. evaluation phase.
Answer: A

Cold, clammy skin may be a sign of
a. inadequate room heating.
b. poor circulation.
c. anxiety.
d. a febrile illness.
Answer: C

Destructive behavior toward self or others is a
sign of
a. anxiety.
b. depression.
c. poor coping mechanisms.
d. type A behavior.
Answer: C

A history of noncompliance with previous instructions for self-care may be indicative of
a. denial of illness.
b. a perception that recommended therapeutic
regimens are ineffective.
c. a lack of understanding of the seriousness of the patient’s health problems.
d. any of the above.
Answer: D

In the anthropological sense, prescribed ways of behaving to prevent actual or possible harm to self and others are called
a. myths.
b. taboos.
c. cultures.
d. philosophies.
Answer: B

By establishing preoperative evaluation clinics
for outpatients, hospitals have
a. increased laboratory use.
b. increased surgical cancellation rates.
c. decreased length of stay for surgical patients.
d. improved patient outcomes.
Answer: C

The perioperative period begins when the patient:
A. arrives in the holding area and ends in PACU
B. Arrives in the hospital and ends with discharge
C. Is informed of the need for surgery and ends with discharge from the hospital
D. Is informed of the need for surgery and ends with the patient’s return to his or her usual activities.
Answer: C

Which of the following is not a nursing focus during the preoperative period?
A. patient teaching
B. patient and family support
C. diagnostic testing
D. preparation for discharge
Answer: C

Intraoperative phase begins when:
A. the patient arrives at the hospital for surgery
B. The patient enters the operating room
C. The anesthesia provider induces the patient
D. The surgeon makes the initial incision
Answer: B

Initial nursing focus in the postoperative period focuses on:
A. transferring the patient to the PACU
B. Supporting the patient’s physiological systems
C. Preparing the patient for discharge
D. Making arrangements for the patient to return to normal activity
Answer: B

Why was the term “operating room nurse” changed to “perioperative nurse”
A. AORN decided it sounded more contemporary
B. To eliminate the “Or mystique” and encourage more nurses to join the specialty
C. The responsibilities of nurses in this specialty have expanded to support and care for the surgical patient through the continuum of care
D. Because PACU nurses wanted to be included.
Answer: C

AORN’s patient focused model includes which of the following domains?
A. patient safety, physiologic response, behavioral responses, the health system
B. patient teaching, patient safety, behavioral responses, discharge planning
C. patient safety, patient assessment, discharge planning, the health system
D. patient assessment, plan of care, discharge planning, the health system
Answer: A

Perioperative nurses provide patient care:
A. in collaboration with the surgeon and the anesthesia provider
B. that primarily focuses on patient and family education and support
C. within the framework of the nursing process: assessment, planning, intervention, and evaluation of the patient outcomes
D. that is focused primarily on the patient’s surgical diagnosis.
Answer: C

The perioperative nursing assessment of the patient
A. takes place in a number of settings and time frames
B. begins with a telephone call to the patient prior to surgery for teaching, support, and data gathering
C. is based on data collected by other healthcare professionals
D. usually takes place just prior to surgery and includes an interview, chart review, and physical inspection
Answer: D

Typical nursing diagnoses for the surgical patient include:
A. knowledge deficit and high risk for infection
B. prevention of adverse outcomes and patient teaching
C. high risk for infection and support of patient and family
D. maintenance of normothermia and anatomical body alignment
Answer: A

The perioperative nurses begins the patient’s care plan:
A. prior to the procedure, based on information about the patient from the surgeon and other healthcare providers
B. in the holding area based on interview and assessment data
C. prior to the procedure based on knowledge of the planned procedure, typical related nursing diagnoses, and resources required.
D. when the patient enters the operating room and all attention is focused on supporting the patient
Answer: C

The framework for the intervention stage of perioperative patient is based on
A. the surgeon’s preferences related to the surgical procedure
B. the patient’s medical diagnosis and comorbidities
C. the needs of the healthcare team participating in the surgical procedure
D. identified standards of clinical practice and professional performance.
Answer: D

The criteria upon which the final evaluation is make is the extent to which:
A. the goals of the surgical procedure were met and the patient was transferred to the appropriate recovery area.
B. The desired patient outcomes have been achieved
C. The hospital policy and professional standards were upheld.
D. the patient and family express satisfaction with the entire surgical experience.
Answer: B

The perioperative nursing data set (PNDS) is:
A. standardized nursing vocabulary used to describe perioperative nursing practice
B. A collection of recommended practices to guide patient care
C. Used by all electronic health record systems to standardize patient records
D. a set of evaluation tools to determine the extent to which patient care has been successful
Answer: A

Perioperative nursing is:
A. task oriented and designed to care effectively for surgical patient
B. nursing science related to surgical patients
C. patient oriented, using knowledge, judgment, and skill
D. a framework to evaluate patients’ responses to surgical and other invasive procedures.
Answer: C

Which of the following is not a standard of perioperative care?
A. the patient is free from signs and symptoms of electrical injury
B. the patient receives appropriately administered medications
C. the patient’s wound perfusion is consistent with or improved from baseline levels
D. the patient’s comorbidities are managed effectively during the operative or other invasive procedure
Answer: D

Which of the following facilitate(s) personal and professional growth?
A. participating in research activities
B. participating in professional organization activities
C. mentoring and precepting other perioperative nurses
D. all of the above
Answer: D

Which of the following is a true statement about the RNFA?
A. an RNFA is an advanced practice perioperative nurse, regardless of his or her academic levels of preparation
B. The RNFA position is an expanded role in perioperative nursing
C. The RNFA practices under the license of the physician
D. The RNFA must have an advanced degree in nursing
Answer: B

The transitioning of complex procedures form the traditional operating room to alternative settings in primarily the result of:
A. reimbursement guidelines
B. technological advances in surgical technique
C. Patient preference
D. The nursing shortage
Answer: B

Who may function in the scrub role? (select all correct responses)
A. perioperative registered nurse
B. licensed vocational or licensed practice nurse
C. surgical technologist
Answers: A, B, and C

Who or what determines who may function as an assistant to the surgeon during the procedure?
(select all that apply)
A. surgeon
B. facility policy
C. state board of medicine
D. state board of nursing
Answers: A, B, C, and D

What is the primary focus of the perioperative nurse?
A. managing the operating room environment
B. patient safety and achieving the desired patient outcomes
C. supervising the scrub person
D. documenting intraoperative patient care
Answer: B

Which of the following roles is not part of the sterile surgical team?
A. perfusionist
C. first assistant
D. surgical technologist
Answer: A

What is the purpose of the nursing diagnoses identified by the PNDS?
A. to serve as the basis for the plan of care developed by the perioperative nurse
B. to increase NANDA’s database of nursing diagnoses
C. to eliminate the need for the perioperative nurse to develop an individualized plan of care
D. to increase awareness of perioperative nursing
Answer: A

Preoperative preparation of the patient does not include:
A. clarifying expectations of the patient’s participation in recovery and rehabilitation
B. reinforcing the patient’s understanding of the risks delineated on the consent form
C. eliminating the patient’s anxiety and feet
D. clarifying the events anticipated in the preoperative and immediate postoperative periods
Answer: C

Preparing effectively for obese patients presents an additional challenge because they:
A. often have comorbid conditions
B. are at higher risk for surgical-site infection
C. do not respond well to antibiotics
D. are more fearful of surgery than nonobese patients
Answer: B

The dose and timing of prophylactic antibiotic administration is determined by
A. protocol, which states the dosage and specifies that it be given 1 hour before surgery
B. the attending surgeon
C. the anesthesia provider
D. the optimal level of antibiotic in the patient’s serum and tissue at the time of the surgery
Answer: D

Communication protocols such as SBAR and I PASS THE BATON are important because they:
A. determine which information must be communicated
B. provide a framework for comprehensive and concise communication
C. are mandated by TJC’s National Patient Safety Goals
D. become part of the patient’s record
Answer: B

The most common nursing diagnoses in the perioperative period are:
A. knowledge deficit and risk of injury
B. Risk of injury and risk of infection
C. risk of infection and anxiety
D. Knowledge deficit and anxiety
Answer: D

Which of the following statements about anxiety and fear is true?
A. the focus of fear is specific
B. the focus of anxiety is specific
C. it is more common for a patient to be fearful than anxious
D. it is more difficult to allay anxiety than fear
Answer: A

Which of the following measures is effective in addressing the patient’s anxiety?
A. providing all of the information the patient should know
B. reassuring the patient that there is nothing to worry about
C. listening attentively and providing emotional support
D. promising the patient that everything will go well
Answer: C

Which of the following is not a criterion for determining that the patient’s knowledge deficit has been addressed?
A. the patient confirms the consent
B. the patient describes the expected sequence of events
C. the patient denies anxiety or fear
D. the patient confirms procedures to be followed upon discharge
Answer: C

Anticipatory grieving is most frequently related to:
A. not waking up from anesthesia
B. waking up during the procedure
C. postoperative pain
D. possible changes in body images
Answer: D

The intraoperative period begins when the patient:
A. leaves the preoperative holding area
B. enters the actual operating room
C. is transferred to the operating room table
D. is induced by the anesthesia provider
Answer: B

Wrong-site surgery as defined by TJC includes surgery on the wrong:
A. side or wrong level
B. patient
C. procedure
D. patient, body part, side, level, or procedure
Answer: D

Three protocols that TJC implements in an effort to prevent wrong-site surgery are:
A. site marking, time-out, and better documentation
B. time-out, better documentation, and consent form
C. pre procedure verification, site marking, and time-out
D. site marking, consent form, and time-out
Answer: C

A priority for the perioperative nurse before bringing the patient into the operating room is:
A. verification of the patient’s identity and surgical procedure
B. ensuring that the surgeon is in the room
C. ensuring the scrub person has completed setting up the sterile field
D. ensuring that family members are present in the waiting area.
Answer: A

Which techniques can the nurse use to alleviate anxiety and fear?
A. telling the patient everything he or she needs to know
B. attentive listening and reassuring touch
C. giving information to the family instead of the patient
D. postponing patient teaching until after the procedure
Answer: B

Which factors interfere with learning in the elderly?
A. elderly patients are more frightened than anxious
B. they have difficulty with written materials
C. they do not need as much instruction because others will be caring for them.
D. their short-term memory may be impaired
Answer: D

Which of the following statements is true?
A. toddlers may feel that surgery is punishment for bad behavior
B. school-age children have a short attention span
C. becoming familiar with items they will encounter in surgery gives pediatric patients a sense of comfort
D. preschoolers will benefit from discussing the steps involved in the procedure
Answer: C

Which of the following statements is false?
A. adults learn best from printed materials
B. printed material must be tailored to the needs of the learner
C. the patient’s literacy level and health literacy influence the value of printed teaching materials
D. the nurse should solicit feedback to determine the degree the patient’s level of understanding of the printed material.
Answer: A

Health literacy is the patient’s:
A. level of health and well-being
B. highest level of education
C. ability to assimilate information from printed literature
D. capacity to obtain, process, and understand health information
Answer: D

TJC requires which of the following because patient injuries can result from poor communication among caregivers?
A. written communication using the SBAR or I PASS THE BATON format
B. a standardized hand-off protocol that includes the opportunity to ask and respond to questions
C. a communication competency checklist to be completed by all healthcare providers
D. the surgeon, perioperative nurse, and anesthesia provider to al be in the operating room before the patient can be brought it.
Answer: B

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