Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 01: Concepts Basic to Perioperative Nursing Test Bank MULTIPLE CHOICE 1. The Perioperative Patient Focused Model presents key components of nursing influence that

guide patient care. Select the statement that best describes the dynamic relationship within the model. a. The patient experience and the nursing presence are in continuous interaction. b. Structure, process, and outcome are the foundation domains of the model. c. The perioperative nurse is the central dynamic core of the model. d. The interrelated nursing process rings bind the patient to the model.

ANS: A

The Perioperative Patient Focused Model consists of domains or areas of nursing concern: nursing diagnoses, nursing interventions, and patient outcomes. These domains are in continuous interaction with the health system that encircles the focus of perioperative nursing practice—the patient.

REF: p. 3 2. The Association of Perioperative Registered Nurses’ (AORN) Standards of Perioperative

Nursing Practice that describes nursing interactions, interventions, and activities with patients falls under which standards category? a. Evidence-based b. Process c. Outcome d. Structural ANS: B

Process standards relate to nursing activities, interventions, and interactions. They are used to explicate clinical, professional, and quality objectives in perioperative nursing.

REF: p. 3 3. Which order best describes the process used to implement evidence-based professional

nursing? a. Literature search, theory review, data analysis, policy development b. Regional survey, literature search, meta-analysis, practice change c. Identify problem, scientific evidence, develop policy, evaluate outcome d. Identify issue, analyze scientific evidence, implement change, evaluate process ANS: D

Evidence-based practice is a systematic, thorough process by which to identify an issue, to collect and evaluate the best evidence to design and implement a practice change, and to evaluate the process.

REF: p. 15

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. The ambulatory surgery unit is planning to develop a standardized skin preparation practice

for their unit. The best process to gather scientific information is to: a. conduct a survey of skin prep policies at the next AORN chapter meeting. b. review their surgical site infection data from the last 6 months. c. conduct a literature search on antimicrobial agents and infection prevention. d. review the scientific literature from the leading manufacturers of prep solutions.

ANS: C

Perioperative nurses have an ethical responsibility to review practices and to modify them based upon the best available scientific evidence. Using research to guide practice is called evidence-based practice (EBP).

REF: p. 10 5. The cardiac team is developing a standardized sterile back table setup and is unable to find

sufficient research evidence for their project. Where might they look for information on best practices? a. Survey regional surgical technology programs for their back table models b. Review case studies and expert opinions on sterile back table setups c. Review AORN’s Standards and Recommended Practices on sterilization d. Consult with facility instrument vendor representatives for their advice ANS: B

When there is not enough evidence to guide practice, perioperative nurses should consider gathering information from varied trusted sources that reflect best practices.

REF: pp. 10-11 6. How do institutional standards of care, such as policies and procedures, differ from national

standards, such as AORN’s Standards of Perioperative Nursing Practice? a. They are written by nurses. b. They are written specifically to address responsibilities and circumstances. c. They are collaborative and collective agreement statements. d. They are rarely based on research.

ANS: B

Institutional standards apply to the system or facility that develops them and can be directive about specific actions in specific circumstances; national standards provide generalized authoritative statements that can be implemented in all settings.

REF: p. 10 7. Which of the following actions best describes an element of the perioperative nursing

assessment? a. Scanning the surgical schedule for the day before morning report b. Reading the pick/preference list attached to the case cart c. Reviewing the patient medical record d. Studying an on-line tutorial about the intended surgical procedure ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Assessment is the collection and analysis of relevant health data about the patient. Sources of data may be a preoperative interview with the patient and the patient’s family; review of the planned surgical or invasive procedure; review of the patient’s medical record; examination of the results of diagnostic tests; and consultation with the surgeon and anesthesia provider, unit nurses, or other personnel.

REF: p. 3 8. A frail 76-year-old diabetic woman is scheduled for major surgery. She is vulnerable and at

high risk for harm because of several factors related to her preexisting conditions and overall health status. As part of developing a plan to guide her care, the nurse uses standardized descriptive terms. This step of the nursing process is called: a. nursing diagnosis. b. nursing assessment. c. nursing outcome. d. nursing intervention.

ANS: A

Nursing diagnosis is the process of identifying and classifying data collected in the assessment in a way that provides a focus to plan nursing care.

REF: p. 5 9. During the admission interview, the nurse initiated the discharge teaching and demonstrated

crutch-walking activities. The teaching activities are what stage of the nursing process? a. Nursing assessment b. Nursing implementation c. Nursing outcome preparation d. Nursing evaluation ANS: B

Implementation is performing the nursing care activities and interventions that were planned and responding with critical thinking and orderly action to changes in the surgical procedure, patient condition, or emergencies. Implementation is the “work” of nursing.

REF: p. 6 10. While conducting the preoperative interview with a patient scheduled for a septoplasty, the

perioperative nurse learned that the patient was latex sensitive. Based on this knowledge, the nurse reviewed the pick/preference list and reassembled the surgical case cart setup to reflect this new information and change in care delivery. Which two phases of the nursing process are represented in the nurse’s actions? a. Assessment and planning b. Assessment and implementation c. Planning and implementation d. Nursing diagnosis and intervention ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Planning is preparing in advance for what will or may happen and determining the priorities for care. Planning is based on patient assessment results in knowing the patient and the patient’s unique needs. Implementation is performing the nursing care activities and interventions that were planned and responding with critical thinking and orderly action.

Implementation is the “work” of nursing.

REF: p. 6 11. The perioperative nurse implements protective measures to prevent skin or tissue injury

caused by thermal sources. Successful accomplishment of this intervention would meet which of the following desired nursing outcomes? a. The patient is free from signs and symptoms of injury from anxiety. b. The patient is free from signs and symptoms of impaired skin integrity. c. The patient is free from signs and symptoms of surgical site infection. d. The patient is free from signs and symptoms of hyperthermia.

ANS: B

Chemical and thermal sources used in surgery can cause skin and tissue burns (e.g., electrosurgery, povidine-iodine, radiation, lasers). The patient being free from signs and symptoms of chemical injury, radiation injury, and electrical injury are approved NANDAInternational nursing diagnoses.

REF: p. 5 12. The nursing diagnosis is derived from: a. patient data retrieved from the nursing assessment. b. synthesized clues from the admitting diagnosis and surgery schedule. c. the approved NANDA-International list attached to the patient medical record. d. the admission form on the front of the chart.

ANS: A

Nursing diagnosis is the process of identifying and classifying data collected in the assessment in a way that provides a focus to plan nursing care.

REF: p. 5 13. A 36-year-old woman was preoperatively admitted for laparoscopic cholecystectomy with

operative cholangiogram. She was then interviewed by her perioperative nurse in the preoperative intake lounge. The patient’s weight on admission was 245 lb. After the assessment, the nurse returned to the operating room (OR) and modified the standard plan of care by instituting risk reduction strategies that were derived from information from the preoperative assessment. A good example of this action would best be described by: a. replacing the regular OR bed with a bariatric-specific OR bed. b. providing protective lead aprons for all staff during the procedure. c. writing the patient’s name, allergies, and body weight on the white board. d. administering antibiotics to the patient 1 hour before the incision.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Planning is preparing in advance for what will or may happen and determining the priorities for care. Planning based on patient assessment results in knowing the patient and the patient’s unique needs so that alterations in events, such as positioning the patient on a bariatricspecific OR bed as opposed to a regular OR bed, can be readily accommodated. Replacing the OR bed with a larger OR bed is a nurse-sensitive preventive intervention that provides equipment based on patient need.

REF: p. 6 14. Accurate documentation is an integral part of all phases of the nursing process. For this

reason, perioperative nursing care documentation: a. should not include technical care. b. must include a description of patient care delivered and patient response to that care. c. must be aligned with appropriate Perioperative Nursing Data Set (PNDS) elements. d. will have PNDS integrated into all mandatory fields.

ANS: B

Documentation of the nursing care given should include more than the technical aspects of care, such as the sponge count or the application of the electrosurgical dispersive pad. Nursing care documentation should be associated with the assessment and nursing diagnoses, with preestablished outcomes against which the appropriateness and effectiveness of care may be judged.

REF: p. 9 15. When delegating a task, such as removing an intravenous (IV) catheter, to an unlicensed

individual, the perioperative nurse: a. still retains responsibility and authority for the outcome of the task. b. must comply with the seven “rights” of delegation. c. transfers the authority to perform the task to a competent person. d. transfers the supervision of the competent person to another competent person.

ANS: C

Delegation transfers to a competent person with the authority to perform a selected nursing task in a selected situation according to the five “rights” of delegation. When the perioperative nurse delegates a task, he or she retains accountability for that delegation.

REF: p. 8 16. A hospital nursing excellence center for education developed standards for nursing

advancement that would reflect high-level achievement of professional performance. They developed a clinical advancement ladder based on the leading skill and knowledge acquisition model and established worthy criteria for each level. Select the response that might best describe the highest level of achievement for a perioperative staff nurse. a. Certified nurse, OR (CNOR) credential, BSN, and chair of the nursing research committee b. Published article in the hospital newsletter and 15 years’ service pin c. BCLS instructor and weekend Emergency Medical Technician (EMT) transport d. Patient safety champion and nurses' union representative

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

Achieving certification (CNOR), pursuing lifelong learning, and maintaining competency and current knowledge in perioperative nursing are the hallmarks of the professional.

REF: p. 3 17. Performance improvement activities in the perioperative practice setting are designed to

promote: a. cost savings by eliminating fines for near-misses and never events. b. customer satisfaction and loyalty. c. time measurement activities. d. efficient, effective, and ethical quality care.

ANS: D

Performance improvement efforts encompass improvements in quality and effectiveness, based on ethical and economic perspectives. A performance measurement and improvement approach facilitates the delivery of safe, high-quality perioperative patient care.

REF: p. 10 18. Perioperative nursing diagnoses and interventions are directed toward, and guided by, the

tremendous risks for harm to the patient inherent in surgery and interventional procedures; therefore nursing actions can generally be categorized as: a. therapeutic/restorative. b. preventive/protective. c. caring/comforting. d. advocating/justifying.

ANS: B

Perioperative nurses possess a unique understanding of desired outcomes that apply to all patients. In contrast to some nursing specialties in which nursing diagnoses are derived from signs and symptoms of a condition, much of perioperative nursing care is preventive in nature, based upon knowledge of inherent risks to patients undergoing surgical and invasive procedures. Perioperative nurses identify these risks and potential problems in advance and direct nursing interventions toward prevention of undesirable outcomes, such as injury and infection. Much of the work of perioperative nursing involves patient safety, protecting patients from risks related to the procedure, positioning, equipment, and the environment.

REF: p. 2 19. A registered nurse first assistant (RNFA) is considered an advanced practice nurse (APN)

when he/she has achieved: a. RNFA certification. b. clinical performance ladder level 4 or above. c. graduate degree in nursing (MSN). d. facility practice privileges.

ANS: C

APNs must have graduate nursing education (at least a master’s degree).

REF: p. 13

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

20. Emerging perioperative nursing roles are defined by the tremendous growth in science and

technology combined with the increasing complexity of surgery and the interventional disciplines. An example of an emerging nursing role is: a. sterile processing clinical specialist. b. general surgery service liaison. c. weekend resource nurse. d. informatics nurse specialist.

ANS: D

Informatics is another specialty in which some perioperative nurses are focusing. Pressures for more efficient management of fiscal, material, and human resources have stimulated the development of electronic information systems for diverse functions in perioperative patient care settings.

REF: p. 13 21. The relationship between the Perioperative Patient Focused Model and the PNDS is

evidenced by their unique language and use of the nursing process to guide care. The most notable feature of their similarity is that the PNDS: a. promotes standardized perioperative documentation. b. fosters research on best practices. c. begins with outcome statements. d. promotes standardized perioperative documentation and begins with outcome statements.

ANS: C

Similar to the Perioperative Patient Focused Model, the PNDS begins with patient outcomes.

Each outcome is defined and interpreted and presents criteria by which to measure outcome achievement.

REF: p. 8 22. In a research study by Bandari and colleagues, of surgical briefings and debriefings, they

concluded that this communication model was a practical and effective means to: a. identify potential surgical defects in the OR. b. monitor central processing productivity. c. promote teamwork. d. quantify equipment and instrument issues.

ANS: A

Bandari and colleagues (2012) found a total of 6,202 reported defects over years—an average of 141 defects per month. The researchers concluded that briefings and debriefings are practical and effective strategies to identify potential surgical defects in the OR. REF: p. 7 23. In a research study by Steelman and colleagues, perioperative nurses were surveyed to

prioritize perioperative patient safety issues. The majority of nurses placed the highest priority and heightened awareness on preventing which patient safety risk? a. Surgical fires

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Wrong site/procedure/patient surgery c. Retained surgical items d. Medication errors ANS: B

The majority of nurses considered preventing wrong site, procedure, or patient surgery (69%) and preventing retained surgical items (61%) to be high-priority safety issues in need of heightened attention.

REF: p. 8 24. All anesthetized surgical patients are at risk for unplanned hypothermia. Select the most

effective preventative intervention. a. Forced air warming b. Prewarming prior to incision c. Heated cotton blankets d. Ambient room air above 98.6° F (37° C) ANS: A

Numerous clinical trials have demonstrated that intraoperative forced air warming (FAW) is an effective intervention for preventing perioperative hypothermia.

REF: p. 10 25. Researchers in Toronto (Wong J, et al, 2009) developed a research tool to evaluate recovery

after ambulatory surgery, focusing on functional abilities after discharge. Select the true statement about the benefits of a functional recovery index for ambulatory surgery patients. a. It determines readiness for discharge. b. It evaluates financial incentives for early discharge. c. It determines criteria for readmission. d. It determines criteria for extended observation.

ANS: A

Ambulatory surgery centers regularly perform complex procedures on higher-risk patients.

Therefore, it becomes important not only to determine patients’ readiness for discharge from the ambulatory surgery center but also how well patients fare in their recovery and rehabilitation after discharge.

REF: p. 12

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 02: Patient Safety and Risk Management Test Bank MULTIPLE CHOICE 1. Governmental and professional agencies and organizations, whether voluntary or involuntary,

have a significant influence on patient safety policies in the healthcare setting. Select the agency or organization statement that presents a true reflection of its focus or purpose. a. The Joint Commission (TJC): Nonvoluntary bureau that tests healthcare institutions against evidence-based elements of performance b. Surgical Care Improvement Project (SCIP): Trends surgical site infection statistics c. American Society of Anesthesiologists (ASA): Professional organization of anesthesia providers and technologists d. World Health Organization (WHO): United Nations (UN)–based and supported authority on health throughout most of the world ANS: D

The UN created WHO to function as its health oversight and coordination authority for all UN member nations who in turn have joined WHO. In 2004, WHO launched the World Alliance on Patient Safety, by which it began to examine patient safety in acute as well as in primary care settings relevant to all WHO member nations. WHO was created by and functions within the UN as the directing and coordinating authority for health throughout UN member nations.

REF: p. 21 2. Since its organization and establishment as a professional nursing association in the early

1950s, the Association of periOperative Registered Nurses (AORN) continues its endeavor to: a. promote guidelines influencing patient safety. b. create professional operating room (OR) nursing care delivery models. c. interpret healthcare statistics critical to perioperative nursing care. d. ensure risk reduction strategies are the foundation of perioperative education.

ANS: A

AORN provides an array of standards, recommended practices (RPs), guidelines, publications, videos, and tool kits that specifically address patient safety from the perioperative team’s point of view.

REF: p. 22 3. A healthy 32-year-old nursing student is scheduled for excision of a left-sided subglottal cyst

with frozen section and possible radical neck dissection. The preoperative verification process provides the opportunity to collect and verify information about the patient to ensure patient safety. Among the patient data that must be verified are: a. emergency contact name. b. laboratory and imaging results. c. advance directive on file. d. immunization records.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Preoperative verification process ensures that all relevant documents (e.g., the history and physical examination, surgical consent, required laboratory studies) and imaging studies (properly labeled and displayed) are available before the start of the procedure. Preprocedure verification is best conducted when the patient can be involved and should be completed before the patient leaves the preprocedure area.

REF: p. 24 4. A patient was positioned, prepped, and draped following general endotracheal anesthesia

induction. The team assembled to perform the time-out as described in the WHO surgical checklist. Successful employment of the time-out can only be ensured when: a. the time-out is initiated by the surgeon. b. the entire team stops and focuses active attention together. c. perioperative services has a physician champion and surgeon buy-in. d. someone simultaneously checks the patient ID band.

ANS: B

All members of the team must introduce themselves by name and role and participate in sharing critical elements of care. The team includes the surgeon, anesthesia provider, and nursing staff, plus any allied or ancillary care providers contributing to the procedure when the time-out is performed.

REF: p. 23 5. When unexpected events occur that have, or could have, compromised patient safety, a

systematic investigatory process takes place. Significant information is gained through this meticulous exploration. The primary motive for carrying out a root cause analysis is to: a. establish cause and trends based on who was involved. b. determine precisely what happened and why. c. find out what needs to take place to prevent a recurrence of the event. d. uncover factors that contributed to the environment and the event.

ANS: C

Root cause analysis is a systematized process to identify variations in performance that cause, or could cause, a sentinel event. The analysis phase of root cause analysis progresses from “why” questions to “what can be done to prevent this” questions that flow and ultimately result in an action plan. Root cause analysis concentrates on systems and processes, not individuals.

REF: p. 10 6. The National Patient Safety Goals (NPSG) are intimately aligned with the perioperative

nursing–sensitive interventions that define the daily role functions of the perioperative nurse.

In the early days of the twentieth century (1900s), as perioperative nursing evolved as a specialty of nursing practice, history was chronicled when someone remarked that: a. “Surgical nurses are the glue that holds surgical care together.” b. “A nurse is always there to be the patient’s advocate.” c. “The primary role of the surgical nurse is to protect the patient from the risks of surgery.” d. “Primum non nocere (first do no harm).”

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

Most perioperative nursing interventions are aimed at protecting patients from the unintended insults of regular surgical care and the risks inherent in surgery. Tightly coupled systems are most prone to accidents, and surgical suites, emergency departments, and intensive care units are examples of complex, tightly coupled systems.

REF: p. 17 7. A patient was transferred to the postanesthesia care unit (PACU) by the anesthesia provider

and perioperative nurse. A hand-off report was given, using situation, background, assessment, recommendation (SBAR) format, to the accepting PACU nurse. The first element of information that should be presented in the hand-off report is: a. the expected discharge criteria. b. the names and roles of the nurse and anesthesia provider. c. patient identification and procedure performed. d. pain management orders.

ANS: C

All patient encounters should begin with patient identification verification. The receiving healthcare provider bears the responsibility for obtaining all of the information needed to safely care for the patient before the transferring staff leaves the area. Time for clarification and questioning must be provided. The purpose of hand-off communication and reports is to provide essential, up-to-date, and specific information about the patient. Standardized handoff communication must include an opportunity to ask and respond to questions.

REF: p. 24 8. The OR is a danger-prone area for both patients and staff. Providing a safe environment of

care for the patient involves identifying, mitigating, and managing the hazards inherent in surgical care. Choose the answer below that completes the blanks in this sentence: The risk of the surgical hazard of _________________ can be mitigated through _______________________. a. wrong patient, wrong site, and wrong side surgery; site marking and presurgical checklists b. electrical and thermal burns; alcohol-free prep solution c. surgical site infection; flash sterilization d. surgical airway fire; fire extinguishers in every OR ANS: A

Evidence shows that wrong site surgery not only can devastate the patient and family but also can impact the perioperative team adversely. All institutions accredited by TJC must follow the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The surgical team must agree that this is the correct patient and that the planned procedure is on the specified side and site. Marking the surgical site must be done so that the intended site of incision or insertion is clear and unambiguous.

REF: p. 24

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 9. Laparoscopic procedures that emergently convert to open procedures place the patient at risk

for unintentional retained foreign objects (RFOs). What new and evolving risk reduction strategy could prevent RFOs and frustrating, time-consuming miscount adventures at the end of these procedures? a. Creating precounted laparotomy sets with only the few necessary instruments b. Performing radiologic surveillance on all conversion procedures at closure c. Counting all instruments including a laparotomy set before the laparoscopy d. Replacing or tagging sponges and laparotomy instruments with radiofrequency identification (RFID) chips ANS: D

New sponge-tracking technologies have emerged that enhance risk reduction strategies to prevent inadvertent retention of retained surgical items (RSIs). These include sequentially numbered sponges, bar coding, and RFID products. Researchers suggest that, given medical and liability costs of more than $200,000 per incident, sponge tracking technologies can substantially reduce the incidence of retained surgical sponges at an acceptable cost. At a minimum, all facilities should have a “count” policy that reflects AORN’s Recommended Practices for Sponge, Sharp, and Instrument Counts.

REF: p. 30 10. A 49-year-old long-distance runner with dysfunctional uterine bleeding was scheduled for a

hysteroscopy. During the procedure, sterile saline was used to expand the intrauterine compartment and enhance visualization. The perioperative nurse meticulously monitored fluid use and documented infiltration to the uterus and fluid collected as drainage from the uterus.

The perioperative nurse was concerned that approximately 500 mL of fluid was unaccounted for and alerted the surgeon. The nurse’s motive for this surveillance was to: a. determine the potential for intravascular uptake of fluid or third spacing. b. estimate the likelihood for fluid puddles on the floor, causing a fall hazard. c. determine the potential for dependent pooling under the patient and subsequent electrical burn. d. determine the potential for dependent pooling under the patient and sacral maceration.

ANS: A

Fluid and electrolyte imbalances may occur rapidly in the surgical patient and can be caused by numerous factors, including preoperative fluid and food restrictions, intraoperative fluid loss, or the stress of surgery. The surgical patient is unable to regulate body fluid and electrolyte requirements by normal activities of drinking, eating, excreting, and breathing unaided. It is therefore imperative that the perioperative nurse collaborate in monitoring the fluid and electrolyte status of the patient intraoperatively.

REF: p. 38 11. A 4-week-old frail neonate had a rectal exam and dilatation under anesthesia following prior

surgery for imperforate anus. When the drapes were removed, the perioperative nurse noted an area of redness, swelling, and abrasions on the buttocks of the patient. The patient had been positioned supine in the frog-leg position for 20 minutes. The nurse who noted the skin condition had relieved the circulating nurse and quickly reviewed the perioperative record and patient chart, but had not seen the patient before positioning. Which of the following safety factors may have contributed to this event?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

Neonates have extremely delicate skin that is prone to injury.

Preoperative skin condition was assessed and documented.

The relieving nurse received a hand-off report from the circulating nurse.

The patient was positioned and generously padded and supported by the team.

ANS: A

Leape and colleagues (1991) found that nearly half (48%) of adverse events were associated with surgery. Their results were consistent with those of earlier investigators, who had found half of all hospital-based, potentially compensable events (i.e., injuries from substandard care) arose from treatment in the OR. TJC findings from 2006 to 2012 (TJC, 2012b) are similarly consistent with those findings: Individual efforts of the best nurses, surgeons, and anesthesia providers, combined with a recognized need for teamwork, are not sufficient to prevent injury and are especially insufficient in the perioperative setting.

REF: p. 17 12. Weighing sponges is a valuable tool for meticulous calculation of blood and fluid loss when

conducted correctly and used in appropriate circumstances. Select the response that correctly reflects the best practice in weighing sponges. a. Calculate all sponge weight results at the end of the case. b. Use the following to calculate loss: 1.5 g = 1.2 mL = 1.5 cc. c. Consider saline-soaked sponges equal to blood-soaked sponges when urine is involved in the operative field. d. Keep a running total blood loss calculated from available sponges during procedure ANS: D

When blood loss estimates must be more accurate, weighing sponges provides a reliable means of judging the amount of blood lost and of gauging the need for transfusion. Add the amount of blood loss calculated from suction canisters to the total recorded from sponges to obtain accurate blood loss estimates.

REF: p. 35 13. During a particularly long and bloody spinal fusion procedure for scoliosis, the perioperative

nurse collected, monitored, and spun down the blood collected in the autotransfusion cell salvage system. She was able to provide the anesthesia provider with three units of packed red blood cells (PRBCs) by the end of the procedure. As the team calculated the estimated blood loss (EBL) as wound closure ended, the perioperative nurse also: a. added the total from the suction canister. b. excluded the suction canister since cell salvage returned blood to the patient. c. included suction content, subtracting irrigation amount used. d. requested hemoglobin and hematocrit levels to quantify EBL. ANS: C

Measure blood in the suction canister(s) at regular intervals, subtracting the amount of any irrigating solution used.

REF: p. 36

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 14. As the pediatric cardiac team prepared to cannulate for a coarctation repair, their neonate

patient presented with a sudden dysrhythmia, ectopy, and failure to respond to digitalis. Pointof-care serum electrolyte measurements revealed low potassium, sodium, and magnesium levels. On anesthesia induction, only 35 minutes earlier, these values were at normal levels, and the patient status was secure. The electrolyte levels were treated to normal and the patient was cannulated and placed on cardiopulmonary bypass. As the procedure continued the team pondered the cause to prevent a recurrence. What possible event could have caused, or contributed to, this loss of electrolytes? a. Unreported patient diarrhea before surgery b. Unnoticed arterial bleeding from disconnected arterial line c. Sterile water from back table switched with heparinized saline d. Missed breast-feeding 2 hours before procedure ANS: C

Intravascular infusion of a hypotonic solution would cause hypokalemia, hyponatremia, and hypomagnesemia. Signs and symptoms of hypokalemia include cardiac effects, such as ectopy, dysrhythmias, conduction abnormalities, and altered sensitivity to digitalis. Sterile water is a hypotonic solution.

REF: p. 39 15. Informed consent is both a requirement and a patient right. The perioperative nurse’s

responsibility in terms of informed consent is to: a. obtain verbal consent when the written consent is unavailable. b. ensure that the consent is in the medical record, correct, signed, and witnessed. c. withhold preoperative medication until the consent is witnessed. d. review the procedure and expected outcome with the patient.

ANS: B

On the patient’s arrival in the OR, the circulating nurse and anesthesia provider are responsible for verifying that documentation of the consent is in the chart and is correct, properly signed, and witnessed before the administration of anesthesia.

REF: p. 44 16. Which of the following situations requires informed consent from the patient/family? a. Urgent/emergent surgery b. Organ procurement c. Selection of cast color d. Selection of case cart picklist ANS: B

Except in emergencies, surgical procedures should not be performed without documentation of the patient’s consent on the chart. The patient also must be informed who will perform the procedure and when practitioners other than the primary surgeon will perform important parts of the procedure, even when under the primary surgeon’s supervision.

REF: p. 42 17. Select the appropriate order for administering blood and blood products. a. Verify informed consent for blood, separate blood bag from identification slips,

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock sign slips, verify ID numbers and expiration dates with second licensed person, verify patient with blood tag and requisition slips b. Verify informed consent for blood, verify patient identification and blood type and unit numbers against blood tag and requisition slip with second licensed person, sign slips c. Check blood bag for damage, clots, and bubbles with second licensed person; identify patient and blood expiration date against all slips and tags; remove slips and tags from blood bag d. Verify patient identification, blood unit number, and blood type between patient chart and blood tags and slips; check blood for bubbles and clots; spike blood bag with filtered tubing; sign blood slip while still on blood bag; remove when bag is infused without reaction ANS: B

A patient having an elective surgical procedure for which blood has been requested should not be anesthetized without verification that the requested blood products are typed, crossmatched, and available and that informed consent to receive blood products has been documented. Before administration of any blood product, the circulating nurse and anesthesia provider (or a second licensed individual) must confirm the following: (1) The unit number on the blood product corresponds with the unit number on the blood requisition. Facilities using electronic records will return a “transfusion card” or “cross-match card” as verification that this unit can be given to this patient in lieu of the requisition. (2) The name, birth date, and number on the patient’s ID band agree with the name, birth date, and number on the blood product. (3) The patient’s name on the blood product corresponds with the name on the requisition. (4) The blood group indicated on the blood product corresponds with that of the patient. (5) The date and time of expiration has not been reached. (6) The blood product bag is free of leaks, damage, or signs of possible bacterial contamination (e.g., presence of fine gas bubbles, discoloration, clots, or excessive air in the bag). Both individuals who verify this information must sign the slip that comes with the blood product.

REF: pp. 36, 38 18. Proper care and handling of surgical specimens is imperative for correct diagnosis, treatment,

and prognosis planning of the patient. Select the response that best reflects correct specimen care and handling. a. Label consecutive specimens in alphabetical order for laboratory efficiency. b. Send all specimens to the laboratory together as one pickup, including frozen sections. c. Avoid placing specimens for frozen section in formalin. d. Neutralize formalin/formaldehyde spills with glycerin sulfate, and call the hazmat team.

ANS: C

Specimens for frozen section should be sent fresh (e.g., without fixatives [formalin/formaldehyde]). Specimens for frozen section usually are placed on Telfa or into a dry specimen container. They are never placed in saline solution or formalin, nor are they ever transported on a counted sponge. They should be sent immediately to the laboratory.

Formalin, a combination of methanol, water, and formaldehyde, is frequently used to preserve specimens if they are not taken to the laboratory immediately.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: pp. 32-33 19. Proper handling of specimens is crucial for patient safety. What is the most serious negative

outcome that could occur as a result of the loss, mislabeling or mishandling of a surgical specimen? a. The medical facility could be sued for negligence. b. The patient might be unsatisfied with the treatment received. c. The patient’s condition could be misdiagnosed. d. The medical facility’s reputation could be damaged.

ANS: C

A mislabeled specimen may result in misdiagnosis and consequently inappropriate treatment of the patient. Communication errors pose significant risks to patients in the misidentification of a surgical specimen before its arrival in the pathology laboratory.

REF: p. 32 20. During a simulation on intraoperative counts in which peer “teams” competed, Team 2 was

determined to have demonstrated best practice in performing surgical counts. This team, whose members included a RN, CNOR, and CST, reviewed the unit practice standard and current AORN evidence-based guidelines. Select the appropriate order of counts that they demonstrated to their peers. a. The CST counted the back table, Mayo stand, and sterile field, while the RN counted the sponge bags and the items in the kick bucket. b. The RN and CST counted aloud together as RN pointed to the sponges in the sponge bag and then as the CST touched each sponge, moving from back table to Mayo stand to sterile field. c. The RN and the CST each counted aloud as the CST pointed to items on the floor and kick bucket, and back table. To expedite the count, the RN counted aloud as she pointed out the sponges in the sponge bag while the CST completed the back table. d. The surgeon searched the wound as the RN and the CST counted the floor, sponge bag, dip basin, kick bucket, back table, Mayo stand, sterile field, and the sponge wrapped around the new ostomy.

ANS: B

As the first layer of closure begins, the scrub person and circulating nurse count all items consecutively in a standardized routine (e.g., proceeding from the sterile field to the Mayo stand to the back table and then off the field, or vice versa). The count is done audibly, visibly, and concurrently.

REF: p. 30 21. As the placenta was delivered and the uterus prepared for closure, the scrub person gathered

up all of the sponges and dropped them in the kick bucket while the circulating nurse frantically stuffed them into sponge bag pockets. Sharps, sponges, and instrument counts were correct on closure of the uterus and again on closure of the peritoneum. On final sharps and sponge counts before skin closure, a needle was missing. Select the appropriate order of corrective action for the team. a. Count and verify suture packs, dump and count packs in sterile suture bag, check floor, check back table and Mayo stand, notify surgeon, and check linen and clean

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock and red trash bags. Open clean trash bags tied up in the corner from sterile table setup. b. Recalculate numbers on white board, check back table and Mayo stand, dump and check linen and trash, verify suture packs, notify team of possible missing needle. c. Notify team of needle discrepancy; recount needles on and off sterile field and white board; check sterile field, Mayo stand, and back table; check floor, under OR table, bottoms of shoes, pants’ cuffs, and sterile sleeve cuffs; check sponge bags and kick bucket. d. Recount needles on and off sterile field, check sterile field and Mayo stand and back table; check floor, wait to notify team until miscount verified; check red bag trash, compare empty suture packs, total number on white board.

ANS: C

All incorrect closure counts should be reported immediately, and attempts made to resolve every discrepancy. If the count remains unresolved, the circulating nurse again notifies the surgeon of the unresolved count. A search of the surgical wound, field, floor, linen, and trash is made for the missing item (thus, the rationale that linen and trash not leave the OR until the end of the procedure). All personnel direct their immediate attention to locating the missing item.

REF: p. 32 22. Early on, during the preliminary sponge count on closure of a repair of a ruptured abdominal

aortic aneurysm, the circulating nurse was unable to account for 2 lap sponges. He had meticulously maintained accountability for all sponges and instruments discarded from the sterile field and bagged each sponge carefully. He immediately turned and addressed the entire team in a clear voice. Select the appropriate communication that the circulating nurse must employ during this count discrepancy. a. “Stop everything. I’m missing a couple of sponges. They are not in the trash or back table. Check the wound.” b. “I think you are missing 2 sponges. Shall I call x-ray while the scrub person checks her table again? Doctor, please check the incision.” c. “We have a count discrepancy. We started with 70 sponges and find only 68. We are missing 2 lap sponges. Everyone, please check your areas. d. “I’ve called x-ray because we are short 2 sponges. I’ve called the charge nurse to get someone to help me check the trash and linen. The rapid response team is on their way.”

ANS: C

Note that the circulating nurse used SBAR format to alert the team of the critical situation. All incorrect closure counts should be reported immediately and attempts made to resolve every discrepancy. If the count remains unresolved, the circulating nurse again notifies the surgeon of the unresolved count. A search of the surgical wound, field, floor, linen, and trash is made for the missing item (thus, the rationale that linen and trash not leave the OR until the end of the procedure). All personnel direct their immediate attention to locating the missing item. If it is not found, an x-ray film may be taken and read by the radiologist or surgeon as specified in institutional policy.

REF: p. 32

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 23. A patient was presented with the prepared informed consent form during the discussion with

her surgeon concerning her scheduled vaginal-assisted laparoscopic hysterectomy. She demonstrated and verbalized that she understood all of the tenets of the procedure, risks, expected outcome, complications, and procedural process. Before she signed the consent form, she informed the surgeon that she did not want any medical students or surgical residents performing any parts of the procedure other than assisting and did not want any photographs of her body taken. The surgeon agreed, and she crossed out those portions of the form and initialed them before she signed. The patient was exercising her: a. understanding and rights under the Patient Self-Determination Act (PSDA). b. right to informed consent. c. autonomy to protect herself from negligence and malpractice. d. hope that everyone would honor the Health Insurance Portability and Accountability Act (HIPAA).

ANS: B

Every adult has the right to determine what happens to his or her body. In perioperative practice settings, these rights are protected via informed consent processes for the procedure itself and/or for any research interventions, and via patient wishes expressed in advance directives for healthcare. The patient also must be informed who will perform the procedure and when practitioners other than the primary surgeon will perform important parts of the procedure, even when under the primary surgeon’s supervision.

REF: p. 42 24. A female patient with end-stage pancreatic cancer was admitted from hospice for a celiac

plexus block to treat intractable pain. She had a Whipple procedure 18 months earlier and enjoyed a good quality of life until 3 weeks ago. She wanted to be able to complete “getting her things in order” and saying good-bye to her friends and family while enjoying her last days pain-free. The patient insisted that her Do Not Resuscitate (DNR) status NOT be rescinded. She was conscious and competent and knew what was best for herself. The patient was taking full advantage of what provision for her care? a. PSDA b. Advance directives c. Informed consent d. PSDA and advance directives ANS: D

Many individual states had statutes that allowed patients to dictate their future healthcare wishes in a legally recognized fashion if they were unable to do so when a life-threatening situation arose. Then, in the wake of the first U.S. Supreme Court case to deal with the issue —Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990)—the U.S. Congress in 1991 passed the PSDA to extend legal protection to all U.S. citizens and residents. Under the Act, patients have the legal right to accept or refuse medical treatment, including resuscitation, even if refusal will likely result in death.

REF: p. 44 25. Researchers in the area of patient safety have proposed an emphasis on transparent systems,

asserting that adverse patient events cannot be effectively prevented until the legal and professional licensure systems discontinue their focus on individual error and blame. In order for a transparent system to exist and thrive, it requires:

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

human factor reliance. confidentiality. open reporting. disciplinary guidelines.

ANS: C

They urged an emphasis on transparent systems that required open reporting, investigation, innovation, and dissemination. The aviation and nuclear systems’ parallel examination of human factors served as models for ideas that led to relative success in preventing injury attributable to human error.

REF: p. 16 26. A key factor in promoting patient safety is: a. communication and teamwork. b. adequately compensating healthcare workers. c. the standardized checklists. d. continuous monitoring.

ANS: C

Using surgical safety checklists is most important in promoting patient safety. Data suggests that checklist use may also improve adherence to lifesaving processes during OR patient crises such as cardiac arrest and massive hemorrhage. Studies confirm tangible improvements in safety outcomes after implementation of a checklist and found a nearly 75% reduction in failure to adhere to critical steps in management of a simulated surgical crisis.

REF: p. 24 27. Which nonprofit organization improves patient care through applied research into

effectiveness and safety of devices, drugs, procedures, and processes? a. The Joint Commission (TJC) b. National Institute for Occupational Safety and Health (NIOSH) c. Consumers Advancing Patient Safety (CAPS) d. Emergency Care Research Institute (ECRI) ANS: D

ECRI is a nonprofit organization dedicated to using the discipline of applied scientific research to discover which medical procedures, devices, drugs, and processes, including fire safety, best improve patient care.

REF: p. 17

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 03: Workplace Issues and Staff Safety Test Bank MULTIPLE CHOICE 1. What one factor describes the high incidence of musculoskeletal disorders (MSDs) among

surgical technologists and perioperative nurses? a. Pulling a large, heavy piece of equipment rather than pushing it b. The cumulative effect of repeated patient handling events c. The growing high obesity rate and heavier patients and care providers d. The cumulative effect of pushing, pulling, and carrying heavy instrument sets and rolling carts ANS: B

The high incidence of MSDs among nurses is the cumulative effect of repeated patient handling events, often involving unsafe loads. Nurses and surgical technologists often lift, transfer, or reposition patients on OR beds and transport vehicles, and assist with prepping with their arms outstretched or their bodies bent forward in awkward postures and positions, increasing the risk for injury.

REF: p. 47 2. The lifting equation provides a mathematical equation to determine the recommended weight

limit (RWL) and lifting index (LI) for selected two-handed manual lifting tasks. What is the recommended maximum weight limit for one person in a patient handling task, and what is the best option when the weight limit exceeds the recommendation? a. 25 lb; bend from the knees, not the waist b. 32 lb; use good body mechanics c. 35 lb; wear a support belt d. 37 lb; use assistive lift devices ANS: D

The concept behind the lifting equation is to start with a recommended weight that is considered safe for an ideal lift and then to reduce the weight as the task becomes more stressful. In general, the revised equation yields a recommended 35-lb maximum weight limit for use in patient handling tasks. When the weight to be lifted exceeds this limit, assistive devices should be used.

REF: pp. 49-50 3. Wet floors are a common hazard causing slips, trips, and falls (STFs). Select a prevention

strategy that is a best practice for preventing STFs from spills on wet floors. a. Transport liquids in covered containers with lids in place. b. Place bright yellow low-profile pop-up signs in areas where STFs are most likely to occur. c. Position highly visible yellow absorptive pads in areas where STFs are most likely to occur. d. Use a dripless, brush-free gel solution for surgical patient skin preps.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Planning to avoid wet spots can reduce the rate of falls. Providing lids for all cups or other open containers being transported helps to avoid spills.

REF: p. 50 4. An STF hazard is present when the scrub person stands on a lift, or foot stool, to reach an

acceptable height for ergonomic comfort with the sterile field. Whether the scrub person uses one stool, stacked stools, or a “runway” of stools, the danger exists that a fall could occur.

What classification of cause and prevention factor does this situation represent? a. Proper footwear b. Unobstructed pathways c. Uneven floor surface d. Lighting ANS: C

Falls on the same level also occur at transition areas, such as from dry to wet, on uneven surfaces, or from one type of floor surface to another. Healthcare facilities should ensure that there are no uneven surfaces, including thresholds, on floors. In stairwells with potentially low visibility, the nosing on the top and bottom steps can be painted to provide visual cues.

REF: p. 50 5. A sharps-safe area on the sterile field between the scrub person and the surgeon—where

sharps can be transferred to the surgeon from the scrub person and returned to the scrub person after use—is referred to as the: a. sharps zone. b. hands-free zone. c. neutral zone. d. safety zone.

ANS: C

The “neutral zone” has been defined as a location on the surgical field where sharps are placed in a predesignated sterile basin or tray or on a magnetic pad, from which the surgeon or assistant can retrieve them. After use, the items are returned to the neutral zone, and the scrub person retrieves them. This technique eliminates hand-to-hand passing of sharps between the surgeon and the scrub person, so that no two individuals touch the same sharp at the same time.

REF: p. 52 6. Select the appropriate nursing action that supports hands-free instrument passing and sharps

safety. a. Create a neutral hands-free area between the scrub person and surgeon with a basin or magnetic mat. b. Use a hands-free area for sharps and all small clamps or sponges. c. Announce the transfer of the sharp or clamp as soon as possible after it is placed. d. During the hand-off report, ask the relief scrub person if he/she will want to use the hands-free technique for passing sharps.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock A magnetic pad or basin may be used to create the neutral zone; if a basin is used, it should be placed on the field and not held by the scrub person. Dedicate the neutral zone to sharps only; these include suture and hypodermic needles, scalpels, and other sharp instruments. Place only one sharp at a time in the neutral zone. Announce the transfer of a sharp before placing it in the neutral zone (such as “knife down”). Include identification of the neutral zone during hand-off communications to relief scrub persons.

REF: p. 52 7. Select the true statement that best explains the Occupational Safety and Health Administration

(OSHA) exposure control plan (ECP). a. OSHA has developed the Hierarchy of Controls model, which protects the workplace from lawsuits stemming from worker injury from sharps and blood exposure. b. The OSHA ECP is similar to the Health Insurance Portability and Accountability Act (HIPAA) in that it protects the workplace from being exposed when a worker injury occurs that could harm the facility’s reputation. c. The OSHA ECP is designed to provide guidelines to control risks and protect workers from sharps injury and bloodborne pathogens. d. The OSHA ECP is a materials management strategy to explore replacements for sharps and other healthcare devices that can cause sharps injury and blood exposure.

ANS: C

OSHA regulations require healthcare organizations to protect their workers and to have a sharps injury and bloodborne pathogen ECP. At a minimum, the following must be included in the ECP: determination of employee exposure; implementation of exposure control methods, including universal precautions, engineering and work-practice controls, personal protective equipment (PPE) and housekeeping, hepatitis B vaccination, postexposure evaluation and follow-up, communication of hazards to employees and training, recordkeeping, and procedures to evaluate exposure incidents.

REF: pp. 54-55 8. Select the true statement that best describes a key component of the culture of safety in

regards to blood exposure. a. A goal of the culture of safety is to reduce the risk of blood exposure and sharps injuries to staff. b. The culture of safety is a model for ensuring The Joint Commission survey expectations are met. c. The culture of safety is mandated by regulatory agencies to structure environmental rounds. d. The ECP was designed to provide the framework for the culture of safety.

ANS: A

A healthcare institution’s culture of safety profoundly impacts its success or failure in reducing employees’ blood exposure risk. For sharps safety in particular, success factors include effective systematic review of exposure data, workers’ perceptions of exposure risk, availability and use of safety devices, and comprehensive education on bloodborne pathogen exposure risk and safety device use.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 55 9. Select the guideline that complements the design of the culture of safety model. a. Take advantage of a personal injury event to learn about future prevention

strategies. b. Comply with those policies that fit your current practice. c. Incorporate safe practices into your daily work when handling sharps. d. Observe local, state, and federal regulations as they fit your current practice.

ANS: C

You can take significant measures toward ensuring your personal safety and avoiding injuries from sharps if you do the following: Adopt and incorporate safe habits into daily work activities when preparing and using sharp devices. Observe local, state, and federal (OSHA) regulations. Comply with methods to protect yourself from disease transmission (e.g., get the hepatitis B vaccination). Participate in education about bloodborne pathogens, and follow recommended infection prevention practices. Know the location in your department of the ECP. Finally, follow the exposure control policy if injured, including immediate reporting of the incident and commencement of exposure response procedures.

REF: pp. 55, 61 10. What is the purpose of a Safety Data Sheet (SDS)? a. To recommend exposure limits of all chemicals in the workplace over a working

lifetime b. To inform all employees of the presence, characteristics, handling, and risks of

chemicals in the workplace c. To provide a structured design for inservices and skill stations on hazardous chemical safety d. To promote the development of manuals and log books for The Joint Commission (TJC) survey ANS: B

The purpose of the OSHA standards is to ensure that all hazards of chemicals produced or imported are evaluated and that information concerning hazards is transmitted to employers and employees. Responsibility to inform workers about chemical hazards and to use control measures, including providing PPE, rests with the employer. The OSHA hazard communication standard requires all manufacturers and importers of hazardous chemicals to develop SDSs for all chemicals and mixtures of chemicals.

REF: p. 62 11. Where are the sources of radiation exposure in an operating room setting? a. Ionizing sources (e.g., ultrasound machines) and nonionizing sources (e.g.,

magnetic resonance imaging [MRI] scanners) b. Nonattenuated fluorescent lights and portable X-ray machines without lead guards c. Radioactive seed implants not contained in a lead container and nonionizing lasers d. Nonionizing sources (e.g., lasers) and ionizing sources (e.g., X-ray machines and

C-arms) ANS: D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Sources of radiation exposure in the OR include ionizing sources, such as portable radiography (X-ray) machines and portable fluoroscopy units (C-arm), and nonionizing sources, such as lasers.

REF: p. 63 12. Which of the following may be a consequence of high-dose or full-body radiation? a. Contrast media reaction b. Perioral numbness and tingling c. Nausea, vomiting, and diarrhea d. Wheezing, dyspnea, and tachycardia ANS: C

Acute exposure to ionizing radiation can result in dermatitis and reddening of the skin (erythema) at the point of exposure, while large, full-body exposures can lead to radiation poisoning, symptoms of which may include nausea, vomiting, diarrhea, weakness, and death.

REF: p. 63 13. Latex allergy develops from exposure to natural rubber latex and plant cytosol, used

extensively to manufacture medical gloves and other devices, as well as numerous consumer products. Allergic reactions to latex range from skin disease to asthma and anaphylaxis that can result in chronic illness, disability, career loss, hardship, and death. Which signs and symptoms would be indicative of an allergic contact dermatitis response to contact with natural rubber latex? a. Pruritus, edema, erythema, and vesicles that develop 6 to 48 hours after exposure b. Dry, reddened, itchy skin with hives and peeling patches c. Cracked hands, nausea, vomiting, and perioral numbness and tingling d. Generalized urticaria, wheezing, dyspnea, and tachycardia ANS: A

Allergic contact dermatitis is a delayed reaction, usually appearing 6 to 48 hours after exposure. Symptoms are similar to those from irritant contact dermatitis (i.e., drying papules, crusting and thickening of the skin), except that the reaction may extend beyond the actual point of contact. Allergic contact dermatitis (also called chemical contact dermatitis) is a delayed cell-mediated type IV localized allergy caused by chemicals used to manufacture rubber products.

REF: p. 64 14. A nurse anesthesia provider has an allergy to latex. When she is at work, she always carries an

epinephrine autoinjector and a beta-agonist inhaler. What type of latex allergy does she have? a. Allergic contact dermatitis b. Irritant contact dermatitis c. Type I IgE-mediated hypersensitivity reaction d. Combined-effect latex allergy ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock A true latex allergy is a type I IgE-mediated hypersensitivity reaction that involves systemic antibody formation to proteins in products made from natural rubber latex. The allergic response is immediate and anaphylactic. Medications include epinephrine for reaction (may be autoinjector and carried by individual), beta-agonist inhaler, prednisone, and other anaphylactic life-supporting medications.

REF: pp. 64-65 15. Healthcare professionals should employ strategies to reduce their risk of allergic reaction to

latex in the perioperative environment. Which of the following represents a best practice for minimizing the risk of latex allergy development in nonallergic patients and the risk of a reaction in sensitive or allergic patients? a. Use powder-free gloves that have low levels of protein and chemical allergens. b. Use sterile oil-based hand creams before donning gloves if latex gloves must be worn. c. Before donning latex gloves, sprinkle hands with cornstarch to create a barrier between skin and gloves. d. Wear an OR hat without an elastic band and do not wear rubber tennis shoes.

ANS: A

Use powder-free gloves that are low in protein and chemical allergens. Use nonlatex gloves for activities that are not likely to involve contact with infectious materials.

REF: p. 65 16. Which list of medications best reflects medications indicated for latex sensitivity therapeutic

management? a. Epinephrine, prednisone, and a beta-agonist inhaler b. Atropine, dopamine, and beta-blockers c. Dopamine, mannitol, and sodium bicarbonate d. Dimethylxanthine, atropine, and mannitol ANS: A

Medications used during a reaction include epinephrine (may be autoinjector and carried by individual), beta-agonist inhaler, prednisone, and other anaphylactic life-supporting medications.

REF: p. 66 17. Perioperative personnel historically have relied on numerous types of precautions to protect

themselves and others from bloodborne pathogens and other infectious diseases. Select the statement that best differentiates between universal and standard precautions. a. Universal precautions and standard precautions are the same; however, standard precautions require more hand hygiene and prevention of sharps injuries. b. Many similarities and differences exist between universal and standard precautions; however, they both are equally effective against transmission-based disease. c. Standard precautions apply to blood; all body fluids, secretions, and excretions (except sweat), regardless of whether they contain visible blood; mucous membranes; and nonintact skin. d. Universal precautions is the same as blood and body fluid precautions.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: C

Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain visible blood; (3) mucous membranes; and (4) nonintact skin.

REF: p. 62 18. Contact with infected patients or infectious material places healthcare workers at risk for

occupational-acquired infection. Which communicable disease are healthcare workers at risk for acquiring or transmitting? a. Mumps b. Varicella c. Seasonal influenza d. Hepatitis C ANS: C

Patients transmit influenza to healthcare workers and, in turn, healthcare workers who are clinically or subclinically infected with influenza can transmit seasonal influenza to patients or others. Studies demonstrate seasonal influenza antibodies in healthcare workers who did not recall ever having a respiratory tract infection. By receiving the seasonal influenza vaccination, healthcare workers protect themselves, their patients, and their families.

REF: p. 63 19. What vaccine should healthcare workers receive if they are caring for immunocompromised

patients? a. Live attenuated influenza vaccine (LAIV) b. Inactivated influenza vaccine c. Immunoglobulin d. Bordetella vaccine ANS: B

Inactivated influenza vaccine and live attenuated influenza vaccine (LAIV) are widely available for workers in the healthcare professions. LAIV is approved only for nonpregnant healthy persons, ages 5 to 49 years. Healthcare workers caring for severely immunocompromised patients should not receive LAIV. Instead, the inactivated influenza vaccine is the preferred vaccine for workers who come into direct contact with this group of patients. Bordetella is a gram-negative coccobacilli of the phylum Proteobacteria and the most common cause of tracheobronchitis (kennel cough) in dogs.

REF: p. 63 20. Waste anesthetic gases are small amounts of gases that may leak either from the patient’s

anesthetic breathing circuit into the OR air while anesthesia is being administered or from exhalation of the patient during recovery. Both mechanisms of exposure create risks for OR personnel. What is an effect of short-term exposure for the healthcare worker? a. Spontaneous abortion b. Infertility c. Cancer d. Lethargy and fatigue

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: D

Short-term exposure causes lethargy and fatigue. Long-term exposure may be linked to spontaneous abortion, congenital abnormalities, infertility, premature births, cancer, and renal and hepatic disease. Today, perioperative staff members are exposed to trace amounts of waste anesthetic gas, and although this exposure cannot be eliminated, it can be controlled.

REF: p. 61 21. If a staff person receives a needlestick injury, what is the first corrective action? a. Immediately report to employee health, the emergency department (ED), or the

designated facility. b. Wash wound with soap and water; flush mucous membranes. c. Alert the supervisor of the injury. d. Undergo immediate testing; ensure confidentiality for human immunodeficiency

virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections.

ANS: B

If a needlestick or other occupational contact (e.g., splashing or spraying) that could result in a bloodborne pathogen exposure does occur, the injured person should wash with soap and water all wounds and skin sites that have been contacted by blood or body fluids. Procedures following include alerting the supervisor and initiating the injury reporting system used in the workplace; identifying the source patient; testing the patient for HIV, HBV, and HCV infections; immediately reporting to employee health, the ED, or the designated facility; and documenting the exposure in detail, for your own records as well as for the employer and for workers’ compensation purposes.

REF: p. 55 22. A neutral zone is a predetermined location on the surgical field where sharps are placed for

retrieval by the surgeon. Which of the following is a best practice for the use of the neutral zone? a. Place all sharps that will be used during surgery in the neutral zone before the start of the procedure. b. When a sterile basin is designated as the neutral zone, have the scrub person hold the basin. c. Announce the transfer of each sharp before placing it in the neutral zone. d. Use the neutral zone for non-sharp instruments when it is the most convenient location.

ANS: C

Guidelines for the best use of the neutral zone include the following: only one sharp at a time should be placed in the zone; if a sterile basin is used, it should be placed on the field and not held by the scrub person; transfers should be announced before a sharp is placed in the zone; the neutral zone should be dedicated to sharps only.

REF: p. 53 23. The Hierarchy of Controls model defines a method to control exposure to occupational

hazards as a fundamental approach to protect workers. Which control measure is of the highest priority of those listed? a. Engineering controls

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Substitution c. Elimination d. PPE ANS: C

Elimination is the highest priority. After elimination in the hierarchy comes substitution, then engineering control, administrative controls, and finally PPE. The concept of the hierarchy is that the control methods at the top of the list are potentially more effective and protective than those at the bottom.

REF: p. 55 24. A new graduate perioperative nurse was consistently verbally criticized and teased by her

preceptor. The ensuing stress caused her to make mistakes and contributed to lost time from work. She was experiencing: a. unlawful discrimination. b. physical violence. c. horizontal violence. d. psychological demise.

ANS: C

Horizontal (or lateral) violence occurs when nurses inflict psychologic injury on one another.

While patients are the main perpetrators of physical violence, staff members are the main perpetrators of psychological violence.

REF: p. 65 MULTIPLE RESPONSE 1. Exposure to bloodborne pathogens occurs during all phases of the perioperative process.

Observing safety precautions during all phases of surgery, from setup to cleanup, reduces the number of injuries and exposures for all OR personnel. For the prevention of sharps injuries in the preprocedure and postprocedure phases, which safe handling practices reflect appropriate nursing actions? (Select all that apply) a. Use standardized sterile field setups throughout the surgical services department. b. Organize the Mayo stand with all sharps visible and pointed toward the setup person. c. Transport reusable sharps in a safe, closed container to the decontamination cleanup area. d. Safely grasp the sharp tip with gloved fingers when disposing in sharps container. e. Do not place hands or fingers into a container to dispose of a device. f. Inspect the sharps container for overfilling before discarding disposable sharps in it.

ANS: A, C, E, F

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock During preparation for surgery, use standardized sterile field setups throughout the surgical services department. Organize the work area (Mayo stand, back table) so that sharps are always pointed away from the person setting up. During postprocedure cleanup, transport reusable sharps in a closed, secure container to the designated cleanup area. Inspect the surgical setup used during the procedure for sharps. Keep hands behind the sharp tip when disposing. Do not place hands or fingers into a container to dispose of a device. Inspect the sharps container for overfilling before discarding disposable sharps in it.

REF: p. 52

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 04: Infection Prevention and Control Test Bank MULTIPLE CHOICE 1. Surgical site infections (SSIs) are most often caused by gram-positive cocci and may arise

from the patient’s own endogenous sources. The most typical causative microorganism cultured from SSIs is: a. Staphylococcus epidermidis. b. Streptococcus pyogenes. c. Staphylococcus aureus. d. Enterococcus.

ANS: C

The organisms most commonly found in postoperative SSIs include staphylococcal, enterococcal, pseudomonal, and streptococcal species. S. aureus is the most frequently identified organism.

REF: p. 69 2. A swab of a fluid collection from an edematous, red, and suppurative postoperative wound is

sent to the microbiology lab for culture, sensitivity, and Gram stain. The surgeon expects that the result will show a gram-positive coccus. This Gram stain designation is based on the: a. ability to cause plasma to coagulate and form a microscopic clot. b. physical and chemical properties of the cell wall. c. formation of aerobic clustered spheres. d. appearance of a thicker and brownish-colored cell wall.

ANS: B

Gram stain is a procedure for staining bacteria; it is the first step in classifying and differentiating bacteria into two large groups (gram-positive and gram-negative) based on the chemical and physical properties of their cell walls. A gram-positive microorganism has a thicker cell wall than a gram-negative microorganism.

REF: p. 70 3. The hospital epidemiologist was alerted when several cultures had recently revealed

suspicious similarities. He was concerned about two unrelated patients with similar abscesses in similar body regions. A 72-year-old female diabetic patient taking immunosuppressive medications for chronic Crohn’s disease had an incision and drainage of a perianal fistula. A healthy 22-year-old male college student and motocross racer had an incision and drainage plus excision of a pilonidal cyst. Both patients cultured out a new subtype of S. aureus. The female patient's specimen results showed a significant colony growth of S. aureus plus differential growth of coagulase-negative S. epidermidis, while the male patient's specimen was a high colony growth coagulase-positive, similar subtype of S. aureus. The epidemiologist charged the department to be alert for this S. aureus subtype and cross-check for trends. They were most concerned about one of these patients in particular and pulled up the medical record for review. Which patient may be at higher risk with the more virulent strain and why? a. The female patient because she is immunocompromised and elderly and has

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Crohn’s disease b. The male patient because he has pilonidal sinus tracts from sacral pressure caused by racing c. The female patient because she has a mixed microorganism culture that is coagulase-negative d. The male because he has a high microbial load that is coagulase-positive ANS: D

Staphylococci are called coagulase-positive when they are capable of clotting plasma and coagulase-negative when the plasma clumps them. Coagulase-positive staphylococci are more virulent or pathogenic than coagulase-negative staphylococci. S. aureus is hemolytic, parasitic, pathogenic, and coagulase-positive.

REF: p. 69 4. While antibiotics have been credited with saving lives, misuse of antibiotics has contributed to

the evolution of multidrug-resistant organisms (MDROs). Select the antibiotic application that has evidence to support it as a best practice and not, potentially, a misuse of antibiotics. a. Antibiotics given intravenously within 1 hour of the incision for every procedure with an incision or entered body system b. Vancomycin paste applied to cut edges of the sternum in cardiac surgery c. Tobramycin and methylmethacrylate bead implants into deep orthopedic incisions at risk for osteomyelitis d. Bacitracin ointment on a clean subcuticular sutured incision as part of the dressing ANS: A

Drug resistance from treatment-related causes is often the result of misuse (e.g., incorrect use, overuse, or underuse) of antibiotics. It is believed that 50% of all antibiotic use in the United States can be characterized by misuse in one form or another, and efforts to reduce surgical site infections include appropriate prophylactic antibiotic use in surgical patients. It is estimated that half of all antibiotic prescriptions written are not warranted. During antibiotic therapy, the patient may have retained a few resistant organisms. By natural selection, as the susceptible organisms are killed, the resistant organisms multiply and become predominant.

Failure to perform sensitivity testing along with inappropriate dosing can contribute to resistance. Although some surgical complications are unavoidable, surgical care can be improved through decisions and subsequent care focusing on evidence-based practice recommendations. Research shows that delivering antibiotics to a patient within 1 hour of beginning surgery can dramatically decrease SSI rates, yet this practice is not followed in all situations.

REF: p. 76 5. The Centers for Disease Control and Prevention (CDC) have identified pathogens that could

pose a threat to national and world security and safety through bioterrorism. Select the four most probable agents that could be used to cause mass transmission, mortality, panic, and social disruption. a. Anthrax, tuberculosis, C. difficile, tularemia b. Smallpox, plague, botulism, tularemia c. Smallpox, monkeypox, avian influenza, anthrax d. Anthrax, H1N1 influenza, botulism, smallpox

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

The potential for bioterrorism is a reality. The CDC has identified agents that may pose a risk to the national security because of their (1) easy dissemination or transmission from person to person, (2) potential to cause high mortality and have a major public health impact, (3) potential to cause public panic and social disruption, and (4) necessity for special action for public health preparedness.

REF: p. 84 6. An 86-year-old male was admitted to the intensive care unit (ICU) 3 weeks ago for heart

failure and intractable atrial fibrillation. He has had diarrhea for 4 days that has cultured C. difficile. The transmission-based precautions sign on the door to his room alerts the staff to employ which practice precaution? a. Contact precautions with eye protection b. Both standard precautions and contact precautions c. Body substance isolation d. Droplet precautions with standard isolation technique ANS: B

Several interventions can assist in the prevention of C. difficile transmission in the healthcare environment, including following contact precautions, handwashing with antimicrobial soap and water, using personal protective equipment (PPE), cleaning and disinfecting all surfaces and equipment, and cleaning and disinfecting reusable devices in the perioperative suite.

Standard precautions should be applied to all patients receiving care regardless of their diagnosis or presumed infection status. They are considered the first and most important tier of precautions and as such are a primary strategy for successful infection prevention and control.

REF: p. 72 7. A 47-year-old man was admitted to the emergency department (ED) with respiratory

symptoms, facial and upper body abrasions, burns, and moist lesions after a small package, delivered to his office, exploded and sprayed him with dried powder and glass shards. In response to the reported mechanism of injury, the ED team sequestered him in a secluded area away from the rest of the patients. The team believed that this was highly suspicious of a bioterrorism event. The epidemiologist was called, and the patient was transferred to a negative-pressure isolation room and placed on standard, contact, airborne, and droplet precautions. Based on these actions, which microorganism agents might be suspected to be involved? a. Plague and tuberculosis b. Smallpox and tuberculosis c. Ebola virus and monkeypox d. Anthrax and smallpox ANS: D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Anthrax: Cutaneous lesions can occur from direct contact and inhalation from droplet aerosolization. Use standard precautions with special attention to protection and containment of any draining wounds, inclusive of cutaneous lesions. Smallpox: Inhalation of droplets, droplet nuclei, aerosols, and direct or indirect contact; standard, droplet, airborne, and contact precautions for patients with vesicular rash pending diagnosis. Avoid contact with organism while handling contaminated bedding. Wear protective attire to include gloves, gown, and N95 respirator.

REF: p. 85 8. Positive-pressure air handling systems with unidirectional flow of non-recirculated air from

the ceiling to the floor are designed to: a. create mild air turbulence to prevent dust from settling on surfaces. b. augment the oxygen-enriched environment with dust-free air. c. flow clean air over the patient and prevent corridor air intake. d. redirect and absorb ambient anesthetic gases.

ANS: C

Air pressure in the operating room (OR) should be greater than that in the surrounding corridor. This is called positive-pressure in relation to corridors and adjacent areas. This positive-pressure helps maintain the unidirectional airflow in the room and minimizes the amount of corridor air (less clean area) entering the OR (more clean area).

REF: p. 87 9. The design of the physical space within an OR attempts to minimize horizontal surfaces by

placing cabinets flush with the wall. This prevents dust settling on multiple surfaces and decreases the areas that have to be monitored and cleaned. Another concern with horizontal surfaces is that air turbulence from staff movement and activity plus door movement, when it opens and closes, can: a. mobilize resting dust from these surfaces. b. contaminate unsterile areas. c. disrupt the multidirectional airflow. d. mobilize material from the sterile back table.

ANS: A

Movement and activity in the OR can create a turbulent airflow and may recirculate settled bacteria. Doors to ORs should be kept closed to maintain correct ventilation, airflow, and air pressure. Cabinets should be recessed into the wall if possible. For noncabinet shelving, open wire shelves are preferred, because dust and bacteria do not accumulate, and air can circulate freely around shelf contents.

REF: p. 87 10. All surgical patients present with the risk for hypothermia from a variety of factors inherent in

the surgical experience. Hypothermia has been shown to be a factor that may place the surgical patient at risk for infection and delayed healing. Select the intervention that is an engineered control factor to protect the patient from hypothermia. a. Surround the patient with a forced air–warming blanket and foil head covering. b. Set the ambient room temperature between 68° and 73° F and limit exposure. c. Line the OR bed with a circulating fluid mat and insert a rectal temperature probe

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock in the patient. d. Cover and surround the patient with several warm bath blankets and change them at frequent intervals.

ANS: B

Maintaining the ambient room temperature and limiting patient exposure is the first line of defense in protecting the patient from hypothermia. Temperatures in ORs should be maintained at 68 to 73 F (20 to 23 C).

REF: p. 87 11. The mechanism of lethality (microbial death) with steam sterilization is achieved with this

event. a. Time, temperature, and steam pressure b. Reduced and limited mitosis within the bioburden c. Saturated vaporization of the microbial cytoplasm d. Denaturation and coagulation of enzyme proteins ANS: D

Microorganisms are believed to be destroyed by moist heat through a process of denaturation and coagulation of the enzyme-protein system when steam sterilized. This fact is based on the theory that all chemical reactions, including coagulation of proteins, are catalyzed by the presence of water.

REF: p. 91 12. Within a steam sterilizer, at a temperature of 100° C (212° F), the water condensation and the

steam are the same temperature. This scientific phenomenon is called ___________________ and will __________________. a. steam saturation; not kill microorganisms b. steam distribution; promote microbial kill c. sterilization; kill all microorganisms to 106 d. saturated steam; kill microbes at 106 ANS: A

When a cold item is introduced into the steam, some of the steam releases its latent energy to the object and changes back to liquid water. This phenomenon allows items to be heated much more rapidly in steam than in dry heat. The phenomenon of steam changing to liquid water is called condensation, and the steam and the liquid water are at a temperature of 212 F (100 C) when this occurs. At this point, the steam is said to be saturated. This 212 F (100 C) temperature is insufficient to kill microorganisms, however. To kill microorganisms, a saturation temperature of 250° F (121° C) is necessary.

REF: pp. 91-92 13. With the production of more steam in the sterilizer chamber, the pressure increases as well.

The steam should contain little or no entrapped liquid water. Steam quality is the term that describes the amount of water mixed with the steam. The constitution of high-quality steam would be measured by: a. 70% or greater. b. 55% or greater

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. <3% of the mixture is liquid water. d. <1% of the mixture is liquid water.

ANS: C

Steam entering the sterilizer chamber should contain little or no trapped liquid water. The term steam quality describes the amount of steam vapor and liquid water in the mixture. A steam quality of 100% indicates that no liquid water is present in the steam. A steam quality of 97% or greater (i.e., <3% of the mixture is liquid water) is recommended to achieve an efficient sterilization process.

REF: p. 92 14. Sterilization prepares instruments to be used within, and on, sterile tissues. It kills vegetative

microorganisms and endospores within a probability of 106. The process of decontamination prepares instruments to be: a. handled without PPEs. b. free of bioburden. c. clean at a high level of disinfection. d. Used on nonsterile ear, nose, and throat (ENT) procedures.

ANS: B

The efficacy of the sterilization process depends in part on lowering or limiting the amount of bioburden present on the item to be sterilized. Items to be sterilized should be precleaned to lower the bioburden to the lowest possible level. Items that were soiled with blood or body fluids and that have only been cleaned may not have been sufficiently decontaminated to allow handling by workers not wearing protective attire. If such an item tolerates highpressure water washing, it can be decontaminated further by processing through an unwrapped washer/disinfector cycle. It is then safe to handle. It is recommended that gloves be worn during preparation and wrapping until meticulous inspection has cleared the instruments to be handled without gloves.

REF: pp. 87, 100 15. Qualities of an effective packaging material must include several key characteristics. Select

the three most important qualities. a. Cost, good microbial barrier, lint-free writable surface b. Good steam penetration and removal, good microbial barrier, aseptic presentation c. Aseptic presentation, event-related sterility indicators, writable surface d. Stackable in sterilizer/storage shelf, comparable cost, low toxicity ANS: B

To be effective, packaging material should have the following characteristics: allows for adequate steam penetration and removal; provides an adequate microbial barrier; resists tearing or punctures; has proven seal integrity (i.e., does not delaminate when opened and does not allow a reseal after opening); allows for aseptic delivery of package contents; is free of toxic ingredients and nonfast dyes; is low-linting; is cost-effective by cost and value analysis.

REF: p. 89

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 16. The final step, after decontamination and before sterilization, is the prep, pack, and wrap

process. The sterile processing technologist has taken the laparotomy set from the washer/decontaminator to prepare for sterilization. Select the most appropriate order that the instrument set must travel before reaching the steam sterilizer. a. Air-dry, inventory, inspect, lubricate, assemble and string instruments, wrap and tape b. Inspect, unlock locked clamps, count and string instruments, place indicators, wrap and tape c. Inspect, unlock locked clamps, string instruments, inventory, replace missing items, wrap d. Inspect, inventory against list, assemble, place integrators, wrap and tape ANS: D

The final step before sterilization for reuse includes instrument preparation and packaging.

These activities occur in a clean area, separate from the area where decontamination occurred.

Instruments are inspected carefully for cleanliness and functionality. Soiled instruments are returned for further cleaning. Instruments with movable parts are treated with a water-soluble lubricant solution that contains an antimicrobial agent to retard growth in the lubricant solution. Broken or worn instruments are set aside for repair. Instruments are assembled into sets according to set content lists prepared by perioperative nursing staff.

REF: p. 89 17. Both sterilization and disinfection describe the elimination of microbial contamination and the

achievement of a state suitable for patient care in select situations. However, disinfection differs from sterilization in that the process for disinfection uses: a. contact precautions as well as universal precautions. b. hospital-grade disinfectant/sterilants. c. semicritical medical devices used for ambulatory procedures. d. agents to disinfect and eliminate most, if not all, pathogenic microbes.

ANS: D

Disinfection is defined as the process of eliminating many or all pathogenic organisms, except bacterial spores, from inanimate objects. In healthcare facilities, equipment is usually soaked in liquid chemicals for a specified period to achieve disinfection of the equipment or item. The disinfection process may destroy tubercle bacilli and inactivate hepatitis viruses and enteroviruses but usually does not kill resistant bacterial spores. The term disinfection also may refer to treatment of body surfaces that have been contaminated with infectious material.

Chemicals used to disinfect inanimate objects are referred to as disinfectants. Chemicals used for body surfaces are known as antiseptics. The term germicide refers to any solution that destroys microorganisms.

REF: p. 99 18. An integrator is a multiparameter indicator designed to measure: a. time and pressure. b. pressure, steam, and temperature. c. temperature, time, and presence of steam. d. sterility and pressure.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Chemical integrators are so named for their ability to integrate time, temperature, and the presence of steam. Chemical integrators are placed inside every package. They indicate that one or more of the parameters necessary for sterilization have been achieved.

REF: p. 94 19. The evening before the procedure was scheduled, the central sterile processing department

received two complete sets of an orthopedic spine fusion system that contained titaniumimplantable instrumentation, four flexible coated retractor blades, and an unsterilized internal paper inventory form. The sterilization instructions provided by the vendor representative recommended steam sterilization for the implants, but stated that the flexible coated blade retractors could not be exposed to temperatures higher than 220° F. The appropriate sterilization option for these instruments and devices would be: a. hydrogen peroxide gas plasma sterilization for everything. b. steam sterilization for the implant sets and paper inventory form, hydrogen peroxide gas plasma for the retractors, wrapped separately. c. steam sterilization for the implant sets, hydrogen peroxide gas plasma for the retractors and paper inventory form, wrapped separately. d. steam sterilization for everything with a shortened dry time.

ANS: B

Low-temperature hydrogen peroxide gas plasma sterilization should be used for moisture- and heat-sensitive items and when indicated by the device manufacturer. Cellulosic-based products, such as paper and linen, are not recommended for use with plasma systems, because they tend to absorb the vapor and cause the sterilization cycle to abort.

REF: p. 98 20. The scrub person is preparing to self-don a wraparound sterile gown before surgery. Select the

best practice to follow for the self-gowning procedure? a. Hold the gown away from the body and allow it to unfold with the outside toward the wearer b. Keep hands on the outside of the gown as it completely unfolds c. Slip one hand into an open armhole at a time, while using the other hand to hold the shoulder of the gown in place d. Push the hands and forearms into the sleeves, advancing the hands just to the proximal edge of the cuff.

ANS: D

The proper procedure for self-donning a wraparound sterile surgical gown includes the following best practices: Allow the gown to unfold with the inside (not outside) toward the wearer. The hands should be kept on the inside (not outside) of the gown while it unfolds.

Both hands should be slipped into the open armholes simultaneously (not while holding one shoulder in place with the other hand).

REF: p. 103 21. The skin preparation for a vaginal-assisted laparoscopic hysterectomy begins

______________ and _____________ before and after the procedure. a. at the vagina and perineum; the nurse should check with the anesthesia provider before touching the patient

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. at the incision site to the periphery of the abdomen; only the nurse should begin

and complete perioperative documentation of skin preparation, including wound classification c. at the cleanest area first and proceeds to less clean areas (abdomen then vagina/perineum); a skin assessment should be performed d. at the vagina and perineum first with urinary catheter insertion and then proceeds to the pelvic abdomen; a skin assessment should be performed ANS: C

Factors to be considered in skin disinfection are as follows: condition of the involved area, number and kinds of contaminants, general physical condition of the patient, characteristics of the skin to be disinfected, and patient allergies. The surgical principle followed when preparing the patient’s skin for surgery (“prepping”) is to prepare (“prep”) the cleanest area first and then move to the less clean areas (clean to dirty). The skin at the surgical site should be exposed and inspected before beginning the skin prep.

REF: pp. 115-116 22. Closed gloving is the technique of choice for the initial donning of sterile gloves by the

scrubbed team member; however: a. it can only be used for the initial gloving. b. it requires two people to execute without contamination. c. there is a risk of contamination if the thumbs are not extended. d. it is only used by scrubbed registered nurses (RNs) and surgical technologists.

ANS: A

The closed method of gloving is the technique of choice when initially donning a sterile gown and gloves. Because the cuffs of a sterile gown collect moisture, become damp during wearing, and are considered unsterile, the closed-gloving technique can be used only for initial gloving. Cuffs may not be pulled down over the wearer’s hand for subsequent gloving.

For subsequent gloving, an alternative technique must be used, such as assisted gloving or open gloving.

REF: p. 113 23. Which glove lubricant, used to facilitate easy donning, is considered a best practice? a. Sterile talcum powder b. Sterile corn starch powder c. Sterile silicone powder d. Glove lubricant is not recommended.

ANS: D

Using powder as a glove lubricant is not recommended because of three primary hazards: the potential for postoperative complication of powder granulomas; powder fallout from hands and gloves, which provides a convenient vehicle for dissemination of microorganisms throughout the OR; and the ability of powder to carry and disperse latex proteins, contributing to an increased latex sensitivity among healthcare workers and others. Powder-free gloves are widely available.

REF: p. 113

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 24. Which of the following lists the correct order of the proper steps in the removal of soiled

sterile attire when breaking scrub? a. Mask, gown, gloves, shoe covers b. Gown, lead apron, shoe covers, mask, gloves c. Mask, gown, hat, gloves d. Gown, gloves, mask ANS: D

Members of the scrub surgical team should use the following procedure to remove soiled sterile scrub attire: gowns, gloves, and then masks. Hands must be washed after removing soiled sterile attire.

REF: pp. 114-115 25. To protect the forearms, hands, and clothing from contacting bacteria on the outside of the

used gown and gloves, members of the scrubbed surgical team should use the following procedure to remove soiled gowns and gloves. Which choice lists the appropriate first three steps in the removal of the sterile gown? a. Wipe gloves clean, untie side gown closure, grasp gown at one shoulder seam b. Wipe gloves clean, grasp gown at both shoulder seams, pull over and off arms c. Unfasten gown back closures, grasp gown at one shoulder seam, pull down over both arms and gloves while everting glove cuffs d. Grasp both gown shoulders, slide gown down over arms, grasp gloves inside gown sleeves and pull gown and gloves off together.

ANS: A

Bring the neck and sleeve of the gown forward and off the gloved hand, turning the gown inside out and everting the cuff of the glove. Repeat the previous two steps for the other side.

Keep arms and gown away from the body while turning the gown inside out and discarding carefully in the designated receptacle.

REF: pp. 114-115 26. Describe the best practice for aseptic removal of sterile gloves after removal of the sterile

gown at the end of the procedure. Select the best practice to protect the wearer from crosscontamination. a. Remove both gloves together using the gloved fingers of one hand to secure the everted cuffs of the other hand, turning both gloves inside out. Discard gloves in regular trash since they are inside out. Remove mask by the ties and wash hands. b. Using the gloved fingers of one hand to secure the everted cuff, remove the glove, turning it inside out. Discard appropriately. Using the ungloved hand, grasp the fold of the everted cuff of the other glove and remove the glove, inverting the glove as it is removed. Discard in biohazard trash. Remove mask by the ties and discard. Wash hands. c. Remove both gown and gloves in the decontamination area and wash hands d. Remove the gown in the OR before transferring the case cart to the decontamination area, where the gloves are removed and discarded.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Using the gloved fingers of one hand to secure the everted cuff, remove the glove, turning it inside out. Discard appropriately. After leaving the restricted area, remove the mask by touching the ties or elastic only. Discard in the designated receptacle. Wash hands and forearms.

REF: pp. 113-114 27. The surgical hand scrub is designed to: a. render the hands, nails, and arms surgically clean. b. target a narrow range of microorganisms. c. work slowly and depend on cumulative action. d. fully sterilize the skin on the hands and arms.

ANS: A

The purposes of surgical hand hygiene are as follows: to remove dirt, skin oil, and transient microorganisms from the nails, hands, and forearms; to reduce the resident microbial count to as near zero as possible; and to leave an antimicrobial residue on the skin to prevent regrowth of microbes for several hours. Hand hygiene has been recognized as a primary method of decreasing healthcare-associated infections. The skin can never be rendered sterile, but it can be made surgically clean by reducing the number of microorganisms present.

REF: p. 108 28. Decontamination of the hands can be done by a variety of methods. Facility infection control

procedures govern the selection of materials and the methods used for surgical hand hygiene.

Select the best practice for surgical hand hygiene. a. Use an alcohol-based hand lotion. b. Use an anatomic scrub, with a prescribed number of strokes plus friction. c. If using a brush, its bristles should be as stiff as can be tolerated by the skin. d. Sponges are no longer recommended for surgical hand hygiene because they have been linked to skin cell shedding.

ANS: B

For the traditional, standardized surgical scrub, individually packaged disposable brushes and sponges or synthetic sponges without a brush may be used. The use of synthetic sponges in place of brushes has gained wide acceptance, especially when long and repeated scrubbing may be traumatic to the skin. Disposable brushes or sponges are available with a variety of antimicrobial soap or antiseptic solutions impregnated into the sponge. Soft brushes or sponges are preferred to reduce damage to the skin and skin cell shedding. When hand rubs are used for surgical hand antisepsis, the only acceptable products are alcohol-based antiseptic surgical hand rubs with documented persistent and cumulative activity that have met the Food and Drug Administration (FDA) regulatory requirements for surgical hand antisepsis. An anatomic scrub, using a prescribed amount of time or number of strokes plus friction, is used to effectively cleanse the skin. When using the timed approach, the product instructions for use and the institution’s policies and procedures should be followed.

REF: p. 109 29. Which of the following choices reflects the appropriate order of four of the steps in preparing

for the surgical hand scrub procedure? a. Wash hands and wrists, remove jewelry, replace mask and eye protection, contain

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock hair b. Contain hair and earrings in hat, wash hands and clean under nails, place mask and eye protection, remove jewelry c. Remove jewelry, contain hair, don fresh mask and eye protection, wash hands and forearms d. Don fresh mask, contain hair, place eye protection, clean under nails ANS: C

Remove all jewelry, including rings, watches, and bracelets, from the hands and forearms.

Cover all head and facial hair. Don a surgical mask. If other personnel are at the scrub sink, a surgical mask should be worn in the presence of hand scrub activity. Protective eyewear, such as goggles with side shields or a full-face shield, should be adjusted to ensure clear vision and to avoid lens fogging. Scrub shirts are tucked into the trousers to prevent potential contamination of the scrubbed hands and arms from brushing against loose garments. Wash hands and forearms with soap and running water immediately before beginning the scrub procedure, if visibly soiled.

REF: p. 109 30. If a sterile glove becomes contaminated during the procedure, the best practice for corrective

action is: a. regloving with open-glove or assistive glove technique. b. regloving with closed-glove technique. c. removing gown and gloves and regowning and regloving. d. placing a new sterile glove over the contaminated glove.

ANS: A

Cuffs may not be pulled down over the wearer’s hand for subsequent gloving. For subsequent gloving, an alternative technique must be used, such as assisted gloving or open gloving.

REF: p. 113 31. In several studies, it was determined that the risk of contamination and subsequent infection to

the wearer can be reduced by wearing two pairs of sterile surgical gloves, as opposed to wearing one pair. Select the correct statement that refers to double gloving in terms of a best practice. a. The CDC endorses double gloving only when nonlatex gloves are worn. b. Wearing two glove layers permits regloving using the closed-glove technique for a contaminated glove. c. Wearing a glove liner between both layers of gloves may eliminate the risk of perforation to the inner glove, protecting the wearer from sharps injury. d. Double gloving is the best practice that can protect both the healthcare provider and the patient.

ANS: D

Double gloving can reduce the number of breaks to the innermost glove that might allow cross-infection between the healthcare provider and patient. Increasing evidence supports and recommends double gloving as being the best practice to protect both the healthcare provider and patient.

REF: p. 113

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

32. Sterile surgical drapes are used to create the sterile field, protecting the patient from

endogenous and exogenous sources of contamination. Which action is essential to maintaining the sterile field? a. Providing barrier protection from microorganisms, fluid, and particulate matter b. Limiting environmental impact and flammability c. Ensuring a fiscally responsible cost/benefit ratio and reducing glare d. Selecting drapes that do not exhibit “memory” folds ANS: A

Commercially packaged and sterilized synthetic single-use disposable drapes are widely used.

They reduce the hazards of contamination in the presence of known infectious microorganisms from body fluids and excretions and in situations in which laundering of grossly contaminated textiles may be problematic. They prevent bacterial penetration and fluid breakthrough, also known as strikethrough. They create an appropriate barrier to microorganisms, particulate matter, and fluids.

REF: p. 118 33. When applying sterile drapes to create the sterile field on the patient, which of the following

principles is most important? a. The circulating nurse should monitor the scrub person’s gowned arms when reaching over the sterile parts of the patient. b. Gently shake and fan out the drapes to open up the folds before approaching the patient. c. Drape the patient starting with the incision area and proceeding to the periphery. d. Drape the far side first.

ANS: C

The draping procedure should begin at the area of the intended incision and proceed outward to the periphery. Always drape from a sterile area to an unsterile area by draping the near side first. Never reach across an unsterile area to drape. When draping the opposite side of the OR bed, go around the bed to drape.

REF: pp. 119-120 34. The transplant team received the liver from the procurement team moments after it arrived by

medical air lift. The OR was ready with a scrubbed team of a surgical nurse, scrub person, transplant surgeon, and surgical resident and with a sterile back table setup and counted to prepare the liver for transplant. As the surgeon began to dissect out the liver vessels, he realized that the liver could reasonably serve two recipient patients and he had another suitable donor candidate. The surgeon was aware that all of the available OR rooms were blocked and running until midnight, and the second patient could not be scheduled until this case was finished. As he carefully segmented and split the liver, the second patient was contacted to come to the medical center. The anesthesia provider transported the original intended recipient patient into the room and proceeded to prepare and induce the patient with a general anesthetic. The circulating nurse suddenly realized the sterile technique violation dilemma after the patient was asleep. Which option best reflects appropriate sterile technique and the best care for both patients? a. The patient should have been taken to a second available OR, not the room with the liver dissection underway, since it was being split for two patients.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. The patient should have been held in preoperative holding until the liver was split

and the second segment placed back into the cooler. c. The back table should have been covered with sterile drapes and moved to a

second available room. d. The surgeon should proceed with splitting the liver, replacing the segment for the

second patient back into the cooler, and storing the cooler in the back of the OR for the second transplant patient, whose procedure will follow in the same OR. ANS: B

The presence of the patient in the OR while the liver is being split to provide a transplant organ for a second patient is a sterile technique violation as the probability of contamination of the liver segment from microbes from the first patient could affect the segment to be transplanted to the second patient. All surgical patients should be considered to be potentially infected with bloodborne or other infectious material.

Contamination in the OR can occur from various sources. The patient, healthcare workers, and inanimate objects are all capable of introducing potentially infectious material onto the surgical field. The patient should be provided a clean, safe environment. Techniques have been established to prevent the transmission of microorganisms into the surgical area, such as wearing proper surgical attire and establishing controlled traffic patterns in the surgical suite.

During the surgical procedure, traffic within and through the room should be kept to a minimum to reduce air turbulence and to minimize human shedding.

REF: pp. 120-121 35. Effective instrument decontamination is dependent on a particular sequence designed to lower

bioburden to the lowest level. What is the first step in processing a basic set of laparotomy instruments through decontamination? a. Rinse with cold water in deep sink. b. Remove and discard all disposable sharps. c. Wipe instruments with sterile water during surgical procedure. d. Transport in closed container to decontamination area.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Instruments should be kept as free as possible from gross soil and other debris during the surgical procedure. Throughout the surgical procedure, the scrub person should wipe used instruments with sponges moistened with sterile water. All instruments that can be immersed are disassembled, and box locks are opened to allow solution to contact all soiled surfaces.

These instruments should be placed in a basin, solid-bottom container system, or bin with a lid. Scissors and lightweight instruments should be placed on top. Heavy retractors should be placed in a separate tray. Sharp instruments must not be placed in a basin or tray in such a way that a worker would have to reach into the container to retrieve the instrument, risking injury.

An enzyme solution, foam or spray, or a towel moistened with water can be added to the instruments to begin the process of breaking down any proteinaceous materials that may remain on the instruments and is useful in preventing debris from drying. Either should be used if there will be a delay in processing. Soiled instruments should be contained within leak-proof containers or trays inside plastic bags when they are transported from the OR for cleaning and decontamination. Contaminated instruments should be transported to and cleaned only in a dedicated decontamination area. If sharps are being transported, the container should be puncture-resistant. In the decontamination area an initial cold water rinse with tap water or a soak in cool water with a protein-dissolving and blood-dissolving enzyme helps remove blood, tissue, and gross debris from device lumens, joints, and serrations. After completion of this pretreatment, the instruments should be processed in a mechanical washer or manually washed if a mechanical system is not available or if the device cannot tolerate mechanical washing.

REF: p. 88

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 05: Anesthesia Test Bank MULTIPLE CHOICE 1. The anesthesia department at a small medical center has a total staff of 102 people. These

employees serve in many roles as care providers, technical assistants, materials management, clinical engineers, and clerical staff. Select the list of direct-care anesthesia providers. a. Certified registered nurse anesthetist (CRNA), anesthesia technician, anesthesia provider b. CRNA, certified nurse assistant (CAN), anesthesia scheduler c. Anesthesia technician, anesthesiologist assistant (AA), anesthesia scheduler d. Anesthesia provider, AA, CRNA ANS: D

In the United States, anesthesia care usually is provided by an anesthesiologist, by a CRNA working in collaboration with or under the direction of an anesthesiologist or a physician, or by an anesthesia provider’s assistant (AA) working under the direct supervision of an anesthesia provider.

REF: p. 124 2. The potential for intraoperative awareness (IOA) can exist for patients in all modes of

anesthesia. Select the anesthesia modality that presents the least likely opportunity for IOA. a. Regional anesthesia b. General endotracheal anesthesia c. Monitored anesthesia care (MAC) d. Local anesthesia ANS: B

Remaining conscious during anesthesia is a concern of both patients and anesthesia providers.

Some patients are so anxious about being aware of anything during surgery that it may affect their reasoning when discussing the options for anesthesia. Many procedures, such as biopsies, inguinal hernias, or procedures on the lower extremities, can be done under regional anesthesia or MAC. These patients may want general anesthesia, however, because they do not want to be aware of anything during the procedure.

REF: p. 125 3. At a regional malignant hyperthermia (MH) testing center a 14-year-old male is undergoing a

muscle biopsy for suspected genetic predisposition to malignant hyperthermia. The anesthesia provider will provide light intravenous (IV) sedation while the surgeon infiltrates the biopsy site with a local anesthetic. This will facilitate the patient’s tolerance of the procedure and minimize his risk for an MH episode. What is the current correct name for this anesthesia modality? a. Local with anesthesia standby b. MAC c. Basal narcosis d. Moderate sedation

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

MAC is infiltration of the surgical site with a local anesthetic and is performed by the surgeon (note that local standby and anesthesia standby are older, less accurate terms frequently used interchangeably with MAC). The anesthesia provider then supplements the local anesthesia with IV medications that provide sedation and systemic analgesia, monitors the patient’s vital functions, and may use additional medication to optimize the patient’s physiologic status.

REF: p. 130 4. A 38-year-old endoscopy nurse in a busy free-standing ambulatory surgery center is a

registered nurse (RN) with additional documented competency in providing an anesthesia modality to healthy patients having screening colonoscopies, bronchoscopies, and upper gastrointestinal (GI) endoscopies. This modality will allow this patient population to tolerate potentially uncomfortable procedures while maintaining their own airway and be easily aroused from light sleep. The nurse is competent and legally qualified to provide which modality of anesthesia? a. MAC b. Local infiltration c. Moderate sedation/analgesia d. Procedural narcosis ANS: C

Moderate sedation/analgesia (conscious sedation) is administered for specific short-term surgical, diagnostic, and therapeutic procedures performed within a hospital or ambulatory center. It is defined as “a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.” No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. The demand for this modality in the ambulatory surgical setting has resulted in increased use of non–anesthesia providers (usually professional RNs with additional training in administering conscious sedation/analgesia medications and monitoring these patients) for these functions.

REF: p. 130 5. The instillation of a local anesthetic into the subarachnoid space is termed: a. spinal anesthesia. b. epidural anesthesia. c. perfusion block. d. stellate ganglion block.

ANS: A

Common regional anesthesia techniques include spinal anesthesia (subarachnoid block [SAB]), epidurals, caudals, and major peripheral nerve blocks. For epidural anesthesia, the local anesthetic usually is injected through the intervertebral spaces in the lumbar region (lumbar epidural), although it also can be injected into the cervical or thoracic regions. For caudal anesthesia, the local anesthetic also is injected into the epidural space, but the approach is through the caudal canal in the sacrum. For peripheral nerve blocks, the anesthetic is injected along the nerve pathway.

REF: p. 1345

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 6. A 4-year-old preschool student was telling his friend about his operation. He had a hernia

fixed and told his friend that the nurse put “magic cream on his hand before she stuck the ivy in” and then the doctor “gave him surgery sleep medicine that was like milk in his ivy” and “another doctor put a little needle stick in his back near his butt after he was asleep so he would not hurt when he woke up.” Based on the child’s self-report of his surgery experience, what three types of anesthesia, in the correct order of his story, did he receive? a. Local, general, spinal b. Local, regional, general c. Local, general, caudal d. Regional, general, caudal ANS: C

Local anesthesia refers to the administration of an anesthetic agent to one part of the body by local infiltration or topical application, usually administered by the surgeon. General anesthesia is a reversible, unconscious state characterized by amnesia (sleep, hypnosis, or basal narcosis), analgesia (freedom from pain), depression of reflexes, muscle relaxation, and homeostasis or specific manipulation of physiologic systems and functions. Common regional anesthesia techniques include spinals (SAB), epidurals, caudals, and major peripheral nerve blocks.

REF: pp. 129, 130, 149 7. Local anesthetic medications, such as lidocaine hydrochloride, have more than one indication

for use as an anesthetic. Which three anesthesia modalities use local anesthesia? a. Plastics; ear, nose, throat (ENT); dental b. Local, spinal, MAC c. General, plastics, spinal d. MAC, ENT, GenET ANS: B

Regional anesthesia is defined broadly as a reversible loss of sensation in a specific area or region of the body when a local anesthetic is injected to block or anesthetize nerve fibers in and around the operative site. Local anesthesia refers to the administration of an anesthetic agent to one part of the body by local infiltration or topical application, usually administered by the surgeon. MAC is infiltration of the surgical site with a local anesthetic and is performed by the surgeon (note that local standby and anesthesia standby are older, less accurate terms frequently used interchangeably with MAC).

REF: p. 130 8. A 2-year-old scheduled for bilateral myringotomy with tube placement, was calm and giggling

as her mother stood by her side stroking her cheek. Operating room (OR) policy permitted parents to be present during the initial administration of anesthetic. The anesthesia provider explained her actions and what they would experience as she gently placed the mask over the patient's nose and mouth and turned on the flow of sevoflurane and oxygen. The child calmly slid into unconsciousness. The anesthesia provider told the mother that the child would soon begin to squirm and possibly thrash around a bit restlessly, but it is a normal effect and the child would soon be in a quiet sleep. What phase of anesthesia is the patient in and what stage is about to occur? a. Maintenance and stage 1 b. Induction and stage 1

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. Induction and stage 2 d. Maintenance and stage 3 ANS: C

Stage 1 is from initial administration (induction) of anesthetic agents to loss of consciousness.

Stage 2 is from loss of consciousness to onset of regular breathing and loss of eyelid reflex.

Stage 2 also is called the delirium or excitement stage, and thrashing movements may occur.

No auditory or physical stimulation should occur during this stage, especially in children.

Induction begins with administration of anesthetic agents and continues until the patient is ready for positioning or surgical prepping (surgical prep), surgical manipulation, or incision.

REF: pp. 135-136 9. The physiologic effects resulting from the inhalation of gaseous anesthetic agents and

intravenous infusion of anesthetic drugs inhibit several areas of the central nervous system (CNS). The processes by which they occur are explained by several proposed theories. Which of the options describes a plausible anesthetic mechanism of action? a. Inhaled opiates are absorbed by dopamine antagonist receptors in the CNS. b. Sodium channels trade places with potassium ions in the cerebral cellular cytoplasm. c. Endorphins undergo biotransformation into protein-soluble compounds. d. Synaptic transmission of nerve impulses in the CNS is inhibited.

ANS: D

Numerous proposed theories explain the action of general anesthetics. Investigations have involved inhalation anesthetics (volatile anesthetic, potent agent, and inhaled or inhalational anesthetic are virtually synonymous with inhalation anesthetic and used interchangeably).

Evidence suggests that synaptic transmission of nerve impulses is reversibly inhibited in several areas of the CNS. The extent of inhibition and consequent progressive depression of function correlate with partial pressure of the inhaled anesthetic at various sites. Inhibition is believed to occur at a lipophilic site on the biologic membrane of synapses and possibly on small, unmyelinated nerve fibers.

REF: p. 135 10. A frail 92-year-old was positioned in lithotomy for a 90-minute rectal procedure under SAB.

At the end of the procedure, when the circulating nurse and surgeon gently removed her legs from the position and placed her in a supine position, she experienced a common side effect of spinal anesthesia, ____________. a. numbness of both legs and feet b. paralysis with bilateral popliteal pain c. hypotensive episode d. esophageal reflux ANS: C

Hypotension may occur rapidly after an SAB. It results from vasodilation because the sympathetic nerves that control vasomotor tone are blocked. Peripheral pooling of blood occurs, resulting in reduced venous return to the heart and decreased cardiac output.

REF: p. 145

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 11. A 24-year-old tennis coach was scheduled for an arthroscopy for recurrent knee pain. This was

his first surgical experience, and he was determined to optimize his chances for a successful outcome by complying with all his preoperative orders. He has a family history of anesthesia and surgery complications and did his best to provide a thorough preanesthetic assessment history. He denied any history of allergies, musculoskeletal abnormalities, obstructive sleep apnea, or reflux disease. He admitted to eating a cheese steak and drinking two cans of beer the night before at 11:30 PM, but promised that he finished food and fluid intake before midnight and did not eat or drink anything else. He stated that he felt calm even without preoperative sedation. The induction was smooth. On attempt at intubation, it was evident that total muscle relaxation had not been achieved. The circulating nurse gently restrained his arms as he began to move and gag on the laryngoscope. The patient vomited undigested stomach contents. His nasopharynx was suctioned and cleared, intubation was achieved, and a nasogastric tube was inserted and connected to suction. The patient experienced respiratory distress on extubation and was transferred to the intensive care unit (ICU) with acute respiratory distress syndrome. Based on his preanesthetic history, aspiration could have been prevented by which measure? a. The perioperative nurse applying cricoid pressure during induction through intubation b. The anesthesia provider inserting a nasogastric tube to suction before induction c. Intravenous proton pump inhibitors and an oral antacid being given 1 hour before induction d. Intubating with a nasotracheal tube instead of per ora ANS: A

The perioperative nurse assists the anesthesia provider in emergent procedures and when a surgical patient is at risk for aspiration (as in cases of a full stomach, intestinal obstruction, hiatal hernia, or significant esophageal reflux). The perioperative nurse must be ready to assist by applying cricoid pressure—exerting downward pressure on the cricoid cartilage with the thumb and index finger of one hand (Sellick maneuver).

REF: p. 152 12. A basic anesthesia monitoring device that is used during general anesthesia to confirm

successful endotracheal tube placement and determine the presence of gas exchange is the: a. pulse oximetry device placed on the finger, toe, or ear lobe to measure oxygen saturation. b. stethoscope to listen to breath sounds in all lung fields. c. capnometer/end-tidal CO2 monitor to identify expired CO2 in the breathing circuit. d. postintubation arterial blood gas monitoring with a point-of-care testing device.

ANS: C

A capnometer measures CO2 concentration; it produces a capnograph that displays the CO2 waveform. The capnograph provides a continuous display of the CO2 concentration of gases from the airways. CO2 concentration at the end of normal exhalation (ETCO2, PETCO2) is a reflection of gas from the distal alveoli; it therefore represents an estimate of alveolar concentration (PACO2). For patients with normal circulation and pulmonary function, capnography is an excellent method to evaluate alveolar ventilation, because the gradient between arterial and alveolar CO2 pressure is small.

REF: p. 133

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 13. Two monitoring devices that are commonly used to determine ventilatory status are required

by some insurance providers as reflective of high-quality care and by anesthesia provider professional organizations as a recommended standard of care. These two devices are: a. pulse oximetry and capnography. b. oxygen analyzer and low-limit alarm system. c. electrocardiography and capnography. d. electrocardiography and pulse oximetry.

ANS: A

Significant advances continue in perioperative monitoring. Among medical specialties, anesthesiology has been a pioneer in review and analysis of perioperative mishaps and implementation of improved monitoring techniques and guidelines. These monitors include pulse oximetry, which measures oxygen saturation in a pulsating vessel (SpO2), and capnography, which measures end-tidal carbon dioxide (ETCO2) level. These advances have resulted in significant decreases in morbidity and mortality.

REF: p. 130 14. Perioperative nurses should be familiar with all basic anesthetic monitors and normal ranges

of physiologic parameters in order to: a. relieve the anesthesia provider for short periods of time during long procedures with stable patients. b. be familiar with the setup, operation and leak testing of the anesthesia machine. c. safely monitor a patient under MAC. d. be familiar with the principles and practices of anesthesia and the perioperative functions of the anesthesia provider.

ANS: D

As integral members of the patient care team in operative and other invasive procedure settings, perioperative nurses need to be familiar with the principles and practices of anesthesia and the perioperative functions of the anesthesia provider.

REF: p. 130 15. Somatosensory evoked potential (SEP) monitoring assesses neuromuscular transmission

pathways during procedures where ischemia may occur because of surgical manipulation, resulting in sensory and motor function. This surveillance is most often employed in: a. lumbar puncture with chemotherapeutic agent injection. b. carpal tunnel release. c. posterior spinal fusion. d. nerve biopsy when a nerve stimulator is used.

ANS: C

SEP monitoring may be used during some neurosurgery procedures. It is used widely to assess the integrity of the spinal cord during surgery in which the spinal cord is manipulated. Upper and lower extremities may be monitored.

REF: p. 132

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 16. The pulse oximeter is used during perioperative anesthesia monitoring. The “pulse ox”

reading can be adversely affected by a number of events. Pulsatile blood flow to the distal extremities may be inadequate because of: a. hyperthermia. b. increased cardiac output. c. hypervolemia. d. malpositioning.

ANS: D

Pulsatile blood flow in the extremity may be inadequate because of hypovolemia, decreased cardiac output, malpositioning, constriction by the blood pressure cuff, or hypothermia. As a final step the nurse can place the sensor on his or her own finger to verify satisfactory function of the pulse oximetry unit, cable, and sensor.

REF: p. 132 17. Whenever regional anesthesia is used, resuscitative equipment and drugs must be immediately

available and the patient monitored for any substantial change in vital signs or untoward reactions. An example of a risk with regional anesthesia is: a. temporary numbness distal to the injection. b. temporary loss of motor function distal to the injection. c. intravascular injection of the anesthetic agent. d. diminished pain along nerve pathways.

ANS: C

Intravenously injected bupivacaine is associated with cardiac arrest. Toxicity from other local anesthetics can cause sudden and profound hypotension, convulsions from effects on the CNS, and tachycardia if the solution contains epinephrine.

REF: p. 147 18. A 19-year-old male received an intravenous peripheral nerve block (PNB/Bier block) for an

open reduction internal fixation (ORIF) of an ankle fracture. The anesthesia provider injected a distal dorsal vein of his right foot with 2% lidocaine, after placing a single cuffed pneumatic tourniquet circumferentially around his upper right thigh. The surgeon looked through the OR window to check on anesthesia progress as he scrubbed at the sink outside of the OR. The circulating nurse had his leg elevated and was prepping his ankle. The surgeon noticed that the cuff seemed to be deflating and that the anesthesia provider was turned away from the patient.

The circulating nurse also noticed the movement under the protective towel placed over the cuff, and saw the tourniquet tubing fall to the floor. The nurse’s first response should be to: a. alert the anesthesia provider, run for the code cart, and tell the scrub person to wrap the Esmarch bandage around the deflated cuff. b. alert the anesthesia provider, reconnect the tubing to cuff and reinflate. Send the surgeon for the code cart. c. send the scrub person for the code cart, alert the anesthesia provider to reconnect the tubing and reinflate the cuff, and continue the skin prep. d. alert the anesthesia provider, reconnect the tubing and reinflate the cuff, and send the surgeon for a replacement cuff.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Although problems can occur from an overdose or toxic reaction to lidocaine, these are rare if the tourniquet has been inflated more than 20 minutes. In this case, however, loss of pneumatic pressure in the tourniquet can cause a toxic reaction and loss of anesthesia.

REF: p. 148 19. An experienced CRNA administered MAC to a 29-year-old female undergoing local scar

revision surgery for an old abdominal incision. She titrated midazolam and propofol to dull the patient’s level of consciousness. She was alerted by the dropping SpO2 reading and the patient’s loss of chest movement. The patient did not respond to a head tilt–chin lift maneuver.

The CRNA’s next response to this event is to: a. alert the surgeon and ventilate the patient’s lungs with a self-inflating bag/valve/mask. b. increase the O2 to 10 L/min, gently tap the patient’s shoulder, and call the patient’s name. c. begin chest compressions. d. call for the code cart and difficult airway cart.

ANS: A

During MAC, vital signs, respiratory and cardiovascular status, and positioning are carefully monitored, and supplemental low-flow O2 often administered. In the described scenario, when the patient did not respond to head tilt-chin lift maneuver, the next response would be to alert the surgeon and to ventilate the patient’s lungs with a bag/valve/mask.

REF: p. 149 20. Patient and family education are crucial for successful preanesthesia preparation. Which of the

following information about regular medications should be provided as part of the preoperative preparation? a. Oral hyperglycemic medications should be discontinued 3 days before surgery b. Aspirin and aspirin-containing products can be taken until the evening before the surgery. c. NSAIDs should be discontinued 4 days before surgery. d. Warfarin should be discontinued 1 week before surgery.

ANS: C

Patients should take any necessary medications, such as antihypertensive, cardiac, seizure, and asthma medications, with minimal sips of water, before they leave their homes to come to the facility. Patients with diabetes should continue taking oral hypoglycemic agents until the evening before surgery. Aspirin and aspirin-containing products should be discontinued 1 week before surgery. NSAIDs should be discontinued 4 days before surgery. If the patient is taking warfarin, it is usually discontinued 3 days before surgery, if appropriate.

REF: p. 127

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 21. A 78-year-old female is scheduled for compression nail insertion of a left fractured hip. She

was positioned for a spinal injection to induce spinal anesthesia. During the process, the anesthesia provider inadvertently inserted the spinal needle into the subarachnoid space, not noticing the error until the entire syringe of lidocaine was emptied into the patient. The patient immediately experienced rapid onset of hypotension, bradycardia, and apnea. This unintentional condition is called ______________ and now must be managed with _____________. a. total subarachnoid syndrome; mechanical ventilation b. hypotensive apnea episode; tracheostomy and humidified positive end-expiratory pressure (PEEP) c. cardiogenic shock; advanced cardiovascular life support (ACLS) protocol d. total spinal anesthesia; general endotracheal anesthesia ANS: D

Subarachnoid injection occurs if the needle or catheter is unintentionally inserted into the subarachnoid space. If a large volume of local anesthetic is injected as a bolus, it causes “total spinal” anesthesia. This condition is associated with a rapid onset of hypotension caused by vasodilation and profound bradycardia as the sympathetic nerves to the heart are blocked, causing a totally paralyzed patient. Treatment includes intubation, control of ventilation, support of blood pressure and the cardiovascular system, and administration of amnestic medications until the block resolves.

REF: p. 147 22. Which anesthetic agent could not be given if an IV-only anesthesia plan was employed? a. Thiopental b. Desflurane c. Diazepam d. Diphenhydramine ANS: B

Desflurane (Suprane) is an inhalation agent.

REF: p. 134 23. Which inhalational anesthetic agents have the fastest onset of induction, emergence, and

recovery? a. Nitrous oxide and sevoflurane b. Isoflurane and cycloflurane c. Desflurane and isoflurane d. Nitrous oxide and cyclopropane ANS: A

Nitrous oxide and sevoflurane promote rapid induction, emergence, and recovery.

REF: p. 137 24. Postoperative nausea and vomiting (PONV) is often a side effect of the analgesic

___________. a. morphine b. acetaminophen

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. chloral hydrate d. meperithan ANS: A

Nausea and vomiting are side effects of morphine.

REF: p. 137 25. What is the primary purpose of premedication before anesthesia? a. Tranquilize the patient and reduce stomach acidity (pH) b. Sedate the patient and reduce anxiety c. Elicit desirable amnesia and prevent awareness under anesthesia d. Promote rapid induction and airway management ANS: B

The primary purpose of premedication before anesthesia is to sedate the patient and reduce anxiety. Medications that may be given preoperatively include sedatives and hypnotics, anxiolytics, amnestics, tranquilizers, narcotics or other analgesics, antiemetics, and anticholinergics.

REF: p. 153 26. Which statement best explains the mechanism of action of general anesthetic agents? a. Inhibition of synaptic transmission of nerve impulses b. Regional depression of the CNS with resultant narcosis c. Suppression of myoneural and musculoskeletal junctions d. Analgesia, amnesia, anesthesia, and systemic hyporeflexus ANS: A

Numerous proposed theories explain the action of general anesthetics. Investigations have involved inhalation anesthetics (volatile anesthetic, potent agent, and inhaled or inhalational anesthetic are virtually synonymous with inhalation anesthetic and used interchangeably).

Evidence suggests that synaptic transmission of nerve impulses is reversibly inhibited in several areas of the CNS. REF: p. 135 27. A desired anesthesia experience for a child is an anesthetic agent that offers a rapid and

smooth induction with good relaxation, followed by rapid emergence. Which of the listed inhalational agents is the best choice for pediatric anesthesia? a. Isoflurane b. Nitrous oxide c. Sevoflurane d. Halogen ANS: C

Sevoflurane (Ultane) is used for induction and maintenance. It provides rapid induction and emergence and good relaxation; it is desired for rapid and smooth mask induction in children and adults.

REF: p. 137

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 28. Which of the following medications is a specific depolarizing muscle relaxant than can

produce generalized fasciculations? a. Succinylcholine b. Mivacurium c. Pancuronium d. Rocuronium ANS: A

The standard depolarizing agent is succinylcholine (Anectine), which was introduced in 1952.

It has a chemical structure similar to that of acetylcholine (ACh) and depolarizes the postjunctional neuromuscular membrane. Administration is followed by a brief period of muscle fasciculations that corresponds to initial membrane depolarization and muscle fiber activation.

REF: p. 140 29. The term balanced anesthesia is described as: a. a combination of IV medications and inhalation agents. b. nitrous oxide, air, and oxygen. c. Premedication, induction agents, and reversal agents. d. Induction agent, muscle relaxation, and analgesics.

ANS: A

In the past, the term balanced anesthesia was used when various combinations of IV medications were “balanced” to provide complete anesthesia. Today the term is often used to describe a combination of IV medications and inhalation agents used to obtain specific effects tailored to each patient and procedure.

REF: p. 136 30. Many factors have contributed to the evolution and progressive growth of ambulatory surgery.

Select the three anesthetic agents that promote fast induction, rapid emergence, and minimal side effects and have been credited as a significant factor in this trend. a. Propofol, desflurane, sublimaze b. Ketamine, sevoflurane, propofol c. Desflurane, midazolam, halothane d. Sevoflurane, propofol, desflurane ANS: D

Goals for anesthesia in an ambulatory setting include minimal physiologic changes secondary to the anesthetic, fast induction, rapid emergence while maintaining patient comfort, intraoperative amnesia and analgesia, suitable operating conditions, minimal perioperative side effects, and minimized postoperative side effects, such as nausea. Use of a laryngeal mask airway (LMA), awareness monitoring, and certain anesthetics (such as propofol, sevoflurane, and desflurane) contribute to attaining these goals.

REF: p. 128 31. Multiple studies have found that IOA occurs in a small percentage of patients undergoing

general anesthesia. Which high risk populations have more incidence of IOA? a. Emergent trauma and obstetric patients

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Pediatric patients c. Ambulatory surgery patients d. Elderly patients ANS: A

In rare cases, during general anesthesia for emergent procedures or trauma, the patient may be paralyzed, aware of what is occurring but unable to tell anyone. IOA is reported with multiple and differing anesthetic techniques. Several factors may contribute to its occurrence. Overall, 20,000 to 40,000 patients each year experience awareness during general anesthesia. The incidence of awareness may increase to 1% to 1.5% in higher-risk patient populations, such as patients requiring anesthesia for obstetrics, major trauma, and cardiac surgery.

REF: p. 125 32. Ketamine is a short-acting induction and IV or intramuscular (IM) maintenance agent.

Patients are able to maintain their airways. It is a suitable agent to use with small children and burn patients. The concern with this agent is that in large doses it may cause: a. hallucinations. b. thrombocytopenia. c. respiratory depression. d. hallucinations and respiratory depression.

ANS: D

Ketamine, in large doses, can cause hallucinations and respiratory depression. The patient needs a darkened, quiet room for recovery.

REF: p. 138 33. During a surgical procedure using ketamine as the induction and maintenance agent, the

perioperative nurse should: a. promote a safe, quiet, and low-stimulus environment of care. b. maintain close proximity to the patient and anesthesia provider in case the patient has hallucinations. c. have the difficult airway cart in the room in case of respiratory distress. d. monitor the dosage and amount of ketamine used.

ANS: A

The perioperative nurse should minimize noxious stimuli that might trigger hallucinations or respiratory distress when large doses of ketamine are used.

REF: p. 138 34. While hypothermia was historically credited as a therapeutic modality benefitting all surgery

because it decreases metabolism and reduces oxygen demand, inadvertent hypothermia is now recognized as impacting many critical physiologic functions and patient outcomes. Which of the following impairments can contribute to surgical site infections? a. Altered drug uptake b. Impaired wound healing c. Impaired platelet function d. Cardiac rhythm disturbances ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Vasoconstriction from hypothermia can interfere with skin perfusion and delay wound healing processes. Unintentional hypothermia can cause patient discomfort, untoward cardiac events, adrenergic stimulation, impaired platelet function, altered drug metabolism, delayed emergence from anesthesia, and impaired wound healing.

REF: p. 151 35. Pediatric, geriatric, and physiologically compromised patients have impaired thermal

regulatory mechanisms that place them at risk for hypothermia. The perioperative nurse should prepare the OR bed before patient arrival by placing: a. an infrared warming lamp 18 inches from the OR bed surface. b. hot bath blankets over the OR bed surface as the patient transport vehicle enters the room. c. a forced air–warming hose towel clipped under the lifting sheet. d. a patient-sized forced air–warming blanket on top of the OR bed surface.

ANS: D

Forced air–warming devices that blow heated air onto the upper or lower body surface are commonly used to keep patients warm and maintain normothermia. These units are effective in maintaining body temperature even during a long abdominal procedure and can be used later in the postanesthesia care unit (PACU). Forced air–warming devices must be used according to manufacturers’ instructions. They must be used with appropriate disposable blanket and should not have the hose inserted under surgical drapes to warm the patient (this directs the heat on the patient, with the risk of a burn, rather than filtering it through the blanket).

REF: p. 151 36. MH is a rare, multifaceted syndrome with an increased incidence in individuals with central

core diseases such as: a. spinal cord injury. b. muscular dystrophy. c. congenital myopathies. d. muscular dystrophy and congenital myopathies.

ANS: D

The incidence of MH increases in patients with central core disease (a congenital myopathy) and some muscular dystrophies.

REF: p. 151 37. In the past, MH mortality ranged up to 80%, but the immediate infusion of dantrolene

(Dantrium) and proper treatment have reduced the death rate to about 7%. What is dantrolene’s mechanism of action that reverses the hypermetabolic state and crisis? a. It is a succinylcholine reversal agent. b. It is a skeletal muscle relaxant. c. It is a metabolic antagonist. d. It has diuretic properties.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Dantrolene is a hydantoin skeletal muscle relaxant that also has effects on vascular and heart muscle.

REF: p. 152 38. During a hypermetabolic MH crisis, the patient will require major modalities of treatment. In

addition to dantrolene what is another priority intervention? a. Giving mannitol b. Cooling the patient c. Reversing the malignancy d. Calling the Malignant Hyperthermia Association of the United States (MHAUS) ANS: B

In addition to dantrolene, the major modalities of treatment include cooling the patient with ice packs and cold IV solutions, administering diuretics, treating cardiac dysrhythmias, correcting acid–base and electrolyte imbalances, and monitoring fluid intake and output and body temperature.

REF: p. 152 39. As a member of the surgical team, the perioperative nurse advocates for the surgical patient

during the surgical experience. Which nursing activity would positively influence patient safety and desired patient outcomes? a. Assisting the anesthesia provider during anesthesia induction and IV insertion b. Monitoring and documenting physiologic parameters on the anesthesia electronic system c. Maintaining balanced drug levels of hypnotics, analgesia, and muscle relaxants d. Never leaving the operating room (OR) ANS: A

Care of the surgical patient is a cooperative effort, and perioperative personnel should function as a smooth, well-coordinated team. A patient should never be left alone in the OR. When an anesthetized patient is in the OR, a perioperative nurse should always be immediately available to provide assistance if needed. During insertion of IV, arterial, central venous, or pulmonary arterial catheters, the nurse assists as required. During induction of anesthesia, particularly with urgent and emergency surgical procedures, the patient presumptively has a “full stomach.” The perioperative nurse should be ready to apply cricoid pressure to prevent regurgitation of stomach contents and to assist the anesthesia provider in visualizing the vocal cords.

REF: p. 152 40. A 72-year-old morbidly obese male patient with uncontrolled diabetes is examined by the

anesthesia nurse practitioner in the preoperative holding area for physical status and airway assessment prior to surgery. His most likely American Society of Anesthesiology (ASA) physical status is: a. P1 b. P2 c. P3 d. P4

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

The ASA defines a P3 status as a patient with a severe systemic disease that limits activity but is not incapacitating. Examples include cardiovascular or pulmonary disease that limits activity; severe diabetes with systemic complications; history of myocardial infarction, angina pectoris, poorly controlled hypertension, or morbid obesity renal failure on dialysis or class 2 congestive heart failure. There is a significant impact on daily activity. These conditions likely have an impact on anesthesia and surgery.

REF: p. 126 41. Which inhalation anesthetic gas can cause retinopathy in premature infants? a. Oxygen b. Sevoflurane c. Desflurane d. Nitrous oxide ANS: A

There are advantages and disadvantages to the use of any anesthetic gas. Although oxygen is essential for life and is commonly administered in supplemental form during surgical procedures, a drawback is the fact that it can cause retinopathy in premature infants.

REF: p. 137

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 06: Positioning the Patient for Surgery Test Bank MULTIPLE CHOICE 1. A 325-pound male is scheduled for a 6-hour abdominal surgery. While assessing the patient in

the preoperative holding area, the perioperative nurse is concerned about the risk for pressure injury because of the weight of the patient’s body pressing against the surface of the operating room (OR) bed for a long surgery. Which of these other factors may also produce pressure? a. The scrub person leaning with his or her forearm on the Mayo stand b. A self-retaining retractor post clamped to the OR bed rail and tightened against the patient’s side c. A Deaver retractor and two right angle clamps placed on the patient’s thighs when draped d. Full-leg sequential compression wraps on both legs throughout the entire surgery ANS: B

Pressure comes from the weight of the body as gravity presses it downward toward the surface of the bed. Pressure also comes from the weight of equipment resting on or against the patient, such as drills, Mayo stands, surgical instruments, rigid edges of the OR bed or its attachments, or vertical posts for self-retaining retractors. Positioning devices, such as stirrup bars, leg or arm holders, and edges of laminectomy frames, can rest or press against the patient under tension.

REF: p. 155 2. A 325-pound male is undergoing a 6-hour abdominal surgery. While asleep and intubated, the

surgeon requests the patient to be placed in lithotomy position for a sigmoidoscopy before the open procedure. The team of five nonscrubbed persons lifts the patient with the lift sheet, slides the patient down toward the foot of the OR bed, and places him into position. After the sigmoidoscopy, the perioperative nurse has the team roll the patient to his side for a skin assessment of his back before he is repositioned supine. What injury is the perioperative nurse concerned that she might see? a. A shearing force injury to the tissue from having been slid into position b. Skin creases from wrinkled sheets c. Incontinence from an inadequate bowel prep d. Side-to-side striations across his back and buttocks from the lifting sheet ANS: A

Shear is the folding of underlying tissue when the skeletal structure moves while the skin remains stationary. A parallel force creates shear, unlike the perpendicular force created by pressure. As gravity pulls the skeleton down, any stretching, folding, and tearing of the underlying tissues, as they slide with the skeleton, can occlude vascular perfusion, which can lead to tissue ischemia.

REF: p. 155

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 3. The perioperative nurse noticed abrasions on a patient’s elbows when she visited him in the

intensive care unit (ICU) the day after his 6-hour abdominal surgery. The patient told her that the ICU nurses had difficulty pulling him back up in bed every time he slid down toward the bottom, and he was not able to be much help in moving himself. This skin injury was probably the result of which physical force? a. Heat and moisture from prolonged bed rest b. Pressure of his elbows resting on the bed for 2 days c. Friction from his elbows rubbing over the sheets when slid up in bed d. Negativity from the bath blankets the nurses stacked to make arm rests for the patient ANS: C

Friction is the force of two surfaces rubbing against one another. Friction on the patient’s skin can occur when the body is dragged across bed linen instead of being lifted. Friction can denude the epidermis and make the skin more susceptible to higher stage pressure ulcer formation, pain, and infection.

REF: p. 155 4. Select the nursing activity that would reduce the impact of an extrinsic factor that could cause

a pressure injury to the patient. a. Assisting the anesthesia provider with checking and hanging albumin before anesthesia induction b. Washing the patient’s back, heels, scapulae, and elbows with chlorhexidine gluconate (CHG) wipes before transfer to the OR bed c. Fluffing the surface of the OR bed with warm bath blankets and eggcrate foam before patient transfer to the OR bed d. Removing all but one layer of linen from the dry polymer elastomer gel mattress surface of the OR bed before patient transfer ANS: D

Negativity can override the pressure-relieving properties of mattresses and padding. Placing a warm blanket under a patient may be soothing initially, but if a surgical procedure is long, pressure to the bony prominences resting on the blanket will be higher than if only a sheet and draw sheet are used. Additionally, wrinkles and folds can cause further pressure points.

REF: pp. 155-156 5. A 92-year-old frail female nursing home patient was admitted for dehydration, anemia, and

respiratory symptoms. She has type 2 diabetes and low albumin levels, is underweight, and continues to smoke cigarettes. The patient is on complete bed rest in a hospital bed with an alternating pressure mattress overlay. She is not able to turn herself in bed and must be assisted to change position. Based on this description of the patient, which factor classification dominates her vulnerability and risk for injury? a. Shearing force factors b. Intrinsic factors c. Bed rest precaution factors d. Extrinsic factors ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Intrinsic factors lower a patient’s tissue tolerance to pressure and decrease the time and pressure required for tissue breakdown. Certain preexisting conditions are regarded as intrinsic risk factors for OR-induced pressure ulcer development. These conditions include diabetes mellitus, smoking, peripheral vascular disease, cerebral vascular disease, urinary or fecal incontinence, anemia, malignancy, sepsis, steroid use, morbid obesity, malnutrition (serum albumin levels less than 3.5 g/dL), advanced age, body size (obesity as well as thin, frail build), and impaired mobility.

REF: pp. 157-158 6. Recent studies on the relevance of the Braden pressure ulcer risk scale in the perioperative and

critical care setting are inconclusive. In which perioperative setting would the Braden scale be most predictive as a baseline metric? a. Postoperative b. Intraoperative c. Preoperative d. Ambulatory ANS: C

Studies have concluded that not all Braden scale risk factors are predictable in these patients and that other significant risk factors are not identified on Braden or other pressure ulcer predictive scales used in hospital settings. The Braden score may be used as a preoperative baseline, but the OR is unique when compared with other areas of the hospital.

REF: p. 158 7. A patient undergoing a laparoscopic Nissen fundoplication procedure will be positioned in

both high and low lithotomy during the procedure. After the patient is repositioned into low lithotomy, the perioperative nurse should: a. position the patient back in supine before repositioning in low lithotomy. b. reposition as quickly as possible to avoid pressure latency. c. reprep and redrape after repositioning. d. reassess the patient for body alignment, tissue integrity, and pressure areas.

ANS: D

The patient should be reassessed after any adjustment of the position and at appropriate intervals during long procedures as is possible with a draped patient. Assessment for pressure ulcer risk factors and development occurs during three periods: preoperative, intraoperative, and postoperative. Periodically recheck position, straps, and padding to ensure that nothing has slipped or moved. Reassess tissue integrity; document and verbally communicate any changes during hand-off report.

REF: p. 169 8. A 14-year-old patient with marked scoliosis is in prone position with gel bolster rolls, gel

pads, and pillows for a spinal fusion. Before the skin prep is begun, the perioperative nurse should check the positioning for pressure areas on the: a. genitals, knees, toes, and eyes. b. breasts, forehead, and knees. c. genitals, breasts, toes, eyes, and all areas in contact with the OR bed or accessories. d. forehead, toes, and knees.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: C

A final check of all areas of vulnerability should be conducted before the prep begins and the patient is draped. The male genitals, female breasts, and eyes are vulnerable to injury in the prone position. Eyes should be checked to ensure that they are not under pressure when the prone or lateral position requires the face to be in a dependent position.

REF: p. 155 9. The circulating nurse instructed the new anesthesia resident in the proper positioning of the

arm and hands on the OR bed armboards. She cautioned him to avoid pressure on the elbow to prevent: a. ulnar nerve injury. b. radial artery tension. c. radial nerve compression. d. pressure sore of the elbow.

ANS: A

The most common OR-related nerve injuries are to the ulnar nerve and brachial plexus. There is a good reason for this. As the ulnar nerve circles behind the elbow, it lies superficially in the shallow cubital tunnel of the humerus, where it is subject to pressure and to stretching from flexion of the elbow.

REF: p. 161 10. Prolonged lithotomy positioning can result in neuropathies of the legs. The most frequently

injured nerves are the obturator, sciatic, femoral, and _____________ nerve, which can result in injury from ______________. a. tibial; hyperextension b. common peroneal; full leg pneumatic compression sleeves c. iliopsoas; hyperabduction and contact with candy cane stirrup pole d. patellar; deep tissue injury from contact pressure with underside of Mayo stand ANS: B

The common peroneal nerve branches from the sciatic nerve behind the knee and becomes superficial as it wraps around the lateral head of the fibula. At this level, it is vulnerable to direct compression by stirrup bars. This risk may be increased in extremely thin patients who have minimal overlying tissue in this area. It is important to ensure that the lateral head of the fibula does not rest against stirrup bars or any other rigid surface. Compressive leg wraps (i.e., intermittent pneumatic compressive devices, graduated compression stockings) also can put pressure on this nerve if the wrapping is too tight in this area.

REF: p. 164 11. The lateral kidney position allows approach to the retroperitoneal area of the flank. To render

the kidney region readily accessible, the _______________ is raised, and the bed flexed so that the area between the twelfth rib and the iliac crest is elevated. Compression of the ____________ can occur when the flank is raised too high. a. head; vena cava b. foot; dependent ureter c. kidney bridge; vena cava

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. kidney bridge; renal artery ANS: C

Raising the kidney bridge depends on the cardiovascular response of the body to increased pressure transmitted from this area. It should be raised slowly, and the anesthesia provider should monitor blood pressure frequently. The OR bed is flexed to lower the patient’s head and legs. The patient’s affected side thus presents a straight horizontal line from shoulder to hip. In this position the gravitational force on the head and torso opposes that on the extended limb to facilitate operative exposure. Increased intra-abdominal pressure evoked by the kidney bridge and by flexion of the lower limbs toward the abdomen limits diaphragmatic movement.

The acute angulations of the body in the lateral kidney posture and the effect of gravity also may decrease blood return to the right side of the heart.

REF: pp. 183-184 12. While Fowler’s position offers the best respiratory excursion for the patient, the patient is at

higher risk for ____________________ because of dependent pooling in the hips and legs. a. venous thromboembolism (VTE) b. sacral ischemia c. restless leg syndrome d. compartment syndrome ANS: A

This position poses significant circulatory compromises and risks. Blood pooling occurs in the lower torso and legs, which in turn causes significant orthostatic hypotension and diminished perfusion to the brain. Venous return from the lower extremities also lessens, and such hindrance increases the threat of venous thrombosis.

REF: p. 179 13. Lateral, lateral chest, and lateral kidney positions all place pressure on structures of the

dependent side: ears, shoulder, ribs, hips, greater femoral head, knees, and ankles. The potential for injury to the patient is significant, based on these pressure areas. Which resultant injury or harm could be related to these lateral positions? a. Diminished lung capacity of nondependent lung b. Celiac plexus injury c. Decreased blood return to the right side of the heart d. Scalene node rupture ANS: C

A respiratory effect of lateral chest position is that the dependent lung is more perfused because of gravitational pooling of blood. The nondependent lung is more easily ventilated, however, because it is less compressed. This results in a ventilation-perfusion mismatch.

Increased intra-abdominal pressure evoked by the kidney bridge and by flexion of the lower limbs toward the abdomen limits diaphragmatic movement. The acute angulations of the body in the lateral kidney posture and the effect of gravity also may decrease blood return to the right side of the heart REF: pp. 183-184

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 14. While tucking the arms at the sides of the patient in supine position offers comfort, safety, and

easy access to the patient by the scrubbed team, improper positioning and securing of the arms can result in significant injury. Injury can be avoided by tucking the draw sheet ________ the arm and under the _________. a. around; body b. under; mattress c. over; mattress d. around; OR bed rail ANS: A

Many OR-induced peripheral upper extremity nerve injuries can be avoided by properly securing the arms if there are procedure-related reasons to tuck them at the patient’s side. The arms should be tucked in such a way as to prevent them from sliding down the side of the OR bed and contacting the bed edge or rigid bed attachments. An effective technique to prevent arm slippage during surgery is to wrap the draw sheet smoothly around the arm, extending to above the elbow, and then tuck the draw sheet under the patient’s body instead of under the mattress.

REF: p. 163 15. A 52-year-old 425-pound male patient is scheduled for surgery at the bariatric surgery center

in 3 days. He has osteoarthritis and had a spinal fusion when he was 13. His long-time neighbor, a perioperative nurse at the bariatric center, has asked to be the patient's circulating nurse and is contemplating his plan of care. He shared his concern that he would not be able to move himself over to the OR bed and would be embarrassed if the nurses could not lift him.

Based on this information, the nurse has identified this nursing diagnosis: ___________________ and these three positioning-relevant nursing interventions: _______ _______ _______. Select from the options to fill in the blanks. a. impaired transfer ability; lock OR bed and transport vehicle during transfer; use at least four people to assist with lift and transfer; use OR bed to accommodate patient weight and size b. anxiety; reassure patient with calm and appropriate touch; remain at patient’s side during induction; use at least four people to assist with lift and transfer c. impaired physical mobility; reassure patient with calm and appropriate touch; remain at patient’s side during induction; use OR bed to accommodate patient weight and size d. impaired physical mobility; lock OR bed and transport vehicle during transfer; reassure patient with calm and appropriate touch; remain at patient’s side during induction ANS: A

He will not be able to transfer himself to the OR bed from the transport vehicle without considerable assistance. The encompassing nursing diagnosis related to the care of the patient during surgical positioning is the risk for perioperative positioning injury. Other potentially applicable nursing diagnoses are: impaired comfort, impaired transfer ability, and risk for falls. During transfer the OR bed and transport vehicle should be next to each other and locked. At least one individual should stand on either side to assist the patient in the transfer.

Beds and accessories must accommodate the width and weight of morbidly obese patients.

REF: p. 168

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 16. A frail and thin 91-pound, 83-year-old woman is scheduled for a right pneumonectomy for

non–small cell lung cancer. She will be positioned in left lateral position for her procedure.

Based on the perioperative nurse’s preoperative assessment, identify three position-related nursing diagnoses for this procedure and four relevant nursing interventions. Select from the options to fill in the blanks. a. Falls; pain; impaired physical mobility; remain at patient’s side during induction; use under- and over-body forced air–warming blanket; prevent fluid pooling under dependent areas; pad all bony prominences with foam or gel pads b. Hypothermia, impaired skin integrity; impaired comfort; use under- and over-body forced air–warming blanket; prevent fluid pooling under dependent areas; pad all bony prominences with foam or gel pads; unlock OR bed and transport vehicle after transfer c. Impaired skin integrity; falls; pain; remain at patient’s side during induction; use at least four people to assist with lift and transfer; pad all bony prominences with foam or gel pads; unlock OR bed and transport vehicle after transfer. d. Hypothermia; impaired skin integrity; falls; remain at patient’s side during induction; use under- and over-body forced air–warming blanket; use at least four people to assist with lift and transfer; pad all bony prominences with foam or gel pads ANS: D

The patient is at risk for hypothermia because of her age, weight, and amount of skin that will be exposed in the skin prep before draping. Falls are a risk during all stages of patient transfer and positioning and for a patient positioned in lateral position if not properly secured. A team member must stand on either side of the patient until the safety strap is applied. The patient’s thin frame is at risk for pressure injury and requires padding of all dependent bony prominences including her left hip, lateral knee, and ankle.

REF: p. 168 17. Positioning devices should be used according to the original equipment manufacturer’s

instructions to reduce the capillary interface pressure to below: a. 40 mm Hg. b. 32 mm Hg. c. 50 mm Hg. d. 100 mm Hg. ANS: B

Pressure is the major physical force responsible for pressure ulcer formation. Its intensity and duration affect the ultimate outcome of whether the tissue suffers damage. An inverse relationship exists between pressure and time: the greater the pressure, the shorter time it takes to cause ischemic changes. Pressures greater than 32 mm Hg (capillary interface pressure) can occlude flow of the arterioles, which nourish and oxygenate the tissue at the capillary level.

REF: p. 156 18. Select three basic criteria requirements that an OR bed mattress must meet. a. Nonallergenic, pressure-reduction capabilities, radiolucent b. Electrically conductive, latex-free, black c. Nonflammable, compatible with warming/cooling devices, black d. Fluid resistant, bactericidal, pressure-reduction capabilities

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: A

OR mattresses should be durable, versatile for many uses, nonflammable, resistant to bacterial growth, radiolucent with low x-ray attenuation, compatible with warming and cooling devices, and covered with flexible nonallergenic antistatic fabric. Many mattress pads are now made without latex. OR mattresses should also have pressure-reduction capabilities.

REF: p. 172 19. Select the positioning device and accessory commonly used for neurosurgical procedures. a. Cavitron ultrasonic surgical aspirator (CUSA) head positioner b. Crutchfield cranial tongs c. Mayfield head positioner d. Cushing head stabilizer ANS: C

Pin fixation of the head (e.g., Mayfield head positioner) is frequently used for craniotomies in prone position (as well as in other positions). The head is supported by three pins that are tightened into the skull. This allows complete stabilization of the head without the risk of pressure to the eyes or other facial structures.

REF: p. 181 20. Select the positioning devices and accessories commonly used for bariatric surgery. a. Air-filled, roller, or slider transfer device b. Lower body ramp c. Elevated padded heel supports with foot board d. Abduction pillow ANS: A

Bariatric patients present a higher risk of injury to both patient and staff during transfers.

Special air-assisted transfer devices enable the patient to “float” on a small cushion of forced air. These devices may be placed deflated under the patient on the OR bed. After the procedure they can be inflated and used to transfer the patient onto the PACU bed.

REF: p. 167 MULTIPLE RESPONSE 1. A 68-year-old, American Society of Anesthesiologists (ASA) physical status (PS)-2 male with

early-stage prostatic cancer, was intubated and positioned for a robotic-assisted laparoscopic radical prostatectomy. The initial position for insertion of the trocars was supine with arms tucked and secured within under-mattress sled arm positioners padded with gel. His hands were placed in a natural position with the fingers wrapped around gauze rolls and touching his lateral thighs. The new anesthesia provider, who had never seen a robotic prostatectomy, was concerned about anesthesia implications when the patient would be repositioned into extreme Trendelenburg for the dissection and anastomosis. The circulating nurse assured her that they would implement protective measures and work together to ensure the best patient outcome.

Select all of the potentially harmful effects of extreme 45-degree Trendelenburg in a robotic procedure. (Select all that apply) a. Respiratory compromise and ventilation resistance

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Pelvic pressure from abdominal organs c. Shearing injury to soft tissues d. Heel pressure injury from stirrup boot ANS: A, C

Positioning can compromise the respiratory system. In almost all types of positions, except semi-Fowler, sitting, and reverse Trendelenburg, the abdominal viscera shift upward toward the diaphragm. Subsequently, the diaphragm shifts upward and outward such that it contributes only about two-thirds of the ventilatory force and significantly reduces tidal volume. Although the head-down position facilitates drainage of secretions from the bases of the lungs and the oropharyngeal passages, the weight of the abdominal viscera further impedes diaphragmatic movement; as abdominal viscera push the diaphragm up and compress the lung bases, pulmonary compliance and tidal volume diminish. Fluid shifts into the alveoli, causing edema, congestion, and atelectasis. Shearing is a significant risk in this position. The skeletal structure slides up toward the head of the bed. If the patient is draped, lifting the patient to realign the tissue cannot be done.

REF: p. 165 2. A circulating nurse and anesthesia provider employed protective measures for a 68-year-old,

ASA PS-2 male with early-stage prostatic cancer positioned in extreme 45-degree Trendelenburg for a robotic-assisted laparoscopic radical prostatectomy. These measures included (Select all that apply.): a. Locking the remote control for the OR bed and placing it in a secured area. b. Place patient directly on gel overlay without a sheet c. Use a vacuum-packed positioning device (beanbag) d. Padded cross-chest straps secured to the bed ANS: A, B, C, D

Accidental deployment of the remote can cause significant injury and death; therefore the remote should be removed or locked. A vacuum-packed positioning device (i.e., beanbag) that is approved for use in lithotomy position with steep Trendelenburg is used to prevent sliding while protecting the nerves of the brachial plexus. Another method is to place the patient directly on a gel overlay (without a sheet) to create a high friction coefficient and to counteract some of the effects of shear and pressure. Additionally, padded cross-chest straps secured to the bed after the arms have been padded and tucked at the sides can further secure the patient.

REF: p. 175

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 07: Sutures, Needles, and Instruments Test Bank MULTIPLE CHOICE 1. The primary use for suture is essentially to: a. strengthen, reform, and close tissue. b. ligate, suture, and close tissue. c. ligate, strengthen, and stop bleeding. d. clamp, divide, and attach tissue.

ANS: B

Suture is a generic term for all materials used to repair and reapproximate incised or torn tissues. The primary goal is to encourage wound healing of the injured tissue to reduce the risk of infection. To suture is to stitch together cut or torn edges of tissue. A ligature is a strand of suture material used to tie off or occlude blood vessels to prevent bleeding, or to isolate a mass of tissue for excision. A variety of suture materials are available for ligating, suturing, and closing the wound.

REF: p. 186 2. The ideal suture material is one that has handling characteristics such as: a. memory. b. slickness. c. ease of tying. d. removable knots.

ANS: C

Handling characteristics of suture material are related to pliability (e.g., how easily the material bends) and the coefficient of friction (e.g., how easily the suture slips through tissue and can be tied).

REF: p. 186 3. Nonabsorbable sutures are strands of material that effectively resists enzymatic digestion in

living animal tissue. The USP categorizes nonabsorbable surgical suture into classes. A suture composed of monofilament or multifilament metal wire would be a: a. Class I suture. b. Class II suture. c. Class III suture. d. Class IV suture.

ANS: C

Class I suture is composed of silk or synthetic fibers of monofilament, with a twisted or braided construction. Class II suture is composed of cotton or linen fibers or coated natural or synthetic fibers, in which the coating significantly affects thickness but does not contribute significantly to strength. Class III suture is composed of monofilament or multifilament metal wire. There is no Class IV category of suture.

REF: p. 189

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

4. The surgeon needs a suture material that will not degrade over time but becomes encapsulated

and supports a tissue structure that will continue to be exposed to pressure and stretching forces throughout the patient’s life. These physical properties are best described by a suture that: a. is nonabsorbable, has good tensile and knot strength, and is the appropriate diameter for the tissue. b. has a large diameter, is nonabsorbable, is highly reactive, and is a monofilament. c. is a monofilament, is synthetically manufactured, is absorbable, and has a large diameter. d. has good tensile strength, memory, and ease of tying and is absorbable.

ANS: A

Physical characteristics of sutures can be measured or visually determined and include the following properties: Diameter (size) is measured in millimeters, and expressed in USP sizes with zeroes. The finer diameter (smaller size) provides better handling qualities and small knots. Improved suturing techniques are possible with sutures of finer diameter. Tensile strength is defined as the amount of weight (breaking load) necessary to break a suture (breaking strength); it varies according to the type of suture material. Knot strength is the force necessary to cause a given type of knot to slip, either partially or completely. The most common nonabsorbable suture materials are silk, nylon, polyester fiber, polypropylene, and stainless-steel wire.

REF: p. 186 5. A surgeon was teaching the new residents as he closed the muscle and fascia layer following

an open cholecystectomy. He stated that he liked the tensile strength of this monofilamented synthetic suture, but it was hard to manage with its memory and slipperiness and normally needed six surgeon’s knots to hold. He was using: a. Ethilon. b. Prolene. c. Sofsilk. d. Monocryl.

ANS: B

Prolene (polypropylene) is a clear or pigmented polymer. This monofilament suture material (Prolene, Surgilene, Surgipro, Dermalene) is used for cardiovascular, general, and plastic surgery. Because polypropylene is a monofilament and is extremely inert in tissue, it may be used in the presence of infection. It has high tensile strength and causes minimal tissue reaction. Sizes range from 10-0 to #2.

REF: p. 190 6. An older surgeon explains his justification for his suture choice to the new perioperative nurse

in the scrub role. He prefers to suture his intestinal anastomosis with a suture that has multiple filaments braided together because it ties well and holds the knot, which tightens when the thread absorbs the tissue fluids. He also needs a strand that is easy to see and only needs to retain its tensile strength for about 1 year, at which time the intestinal junction will be healed, even though this suture is considered nonabsorbable. He will ask the nurse for a 24-inch 4-0: a. Vicryl. b. Prolene.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. Monocryl. d. Sofsilk.

ANS: D

Silk (Sofsilk) is prepared from thread spun by the silkworm larva while making its cocoon.

Top-grade raw silk is (1) processed to remove natural waxes and gum, (2) manufactured into threads, and (3) colored with a vegetable dye. The strands of silk are twisted or braided to form the suture, which gives it high tensile strength and better handling qualities. Silk handles well, is soft, and forms secure knots. Because of the capillarity of untreated silk, body fluid may transmit infection along the length of the suture strand. Silk is not a true nonabsorbable material. When buried in tissue, it loses its tensile strength after about 1 year and may disappear after several years.

REF: p. 189 7. A male patient had a vasectomy in his urologist’s office. The small incision was closed with

sutures that are synthetic and will “dissolve and fall out” after 2 to 3 weeks. As the procedure ended, he heard the doctor ask the nurse for 5-0: a. silk. b. polyglactin. c. plain gut. d. chromic gut.

ANS: B

To produce synthetic absorbable sutures, specific polymers are extruded into suture strands.

The base material for synthetic absorbable sutures is a combination of lactic acid and glycolic acid polymers (Vicryl, Dexon, and Polysorb). The molecular structure of these products has a tensile strength sufficient for approximation of tissues for 2 to 3 weeks, followed by rapid absorption. These sutures are dry-packaged in sizes 10-0 to #3.

REF: p. 188 8. A veteran perioperative nurse remembers a time when all suture needles had eyes, and she

even had her own needle rack. She hand-threaded all sutures according to the surgeon’s preference. The newer sutures were originally called “atraumatic” sutures because they did not double back through a needle eye and cause tissue trauma during pulling or suturing through the tissue. Today, we call this manufacturing process of connecting the suture thread to the needle: a. engineered crimp. b. controlled release. c. reverse cutting. d. swaged.

ANS: D

The swaged needle is the most universally used needle type, eliminating threading eyed needles before and during surgery. A single strand of suture material is drawn through the tissue, and tissue damage is minimized (atraumatic). The swaged needle may need to be cut off with suture scissors or swaged for controlled release of the suture (semi-swaged).

REF: p. 191

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 9. When creating a vascular or intestinal anastomosis (connecting two tubular structures

together), the surgeon will typically suture one-half of the anastomosis with one half of the suture and the other half of the anastomosis with the other half of the suture. This technique minimizes the drag and wear on the suture material and needle. The correct name for this type of suture and needle is: a. controlled release. b. retention. c. double-armed. d. multi-strand cardiovascular.

ANS: C

A double-armed suture is a strand of suture material with a needle on each end. Double-armed sutures are most commonly used for vascular procedures such as anastomoses and vessel repairs.

REF: p. 192 10. This hemostatic device offers a rapid and secure method of clamping arteries, veins, nerves,

and other small structures. It will remain in the patient, is not counted, and is made of a metal that is compatible with magnetic resonance imaging (MRI). Select the correct hemostatic device that fits this description. a. Hemostat b. Alligator forcep c. Ligating clip d. Bulldog clamp ANS: C

Ligating clips are small V-shaped staple-like devices that are placed around the lumen of a vessel or structure to close it. They may be made of one of several metals, such as stainless steel, tantalum, or titanium. Stainless steel clips are the most economical to use. Although more expensive, titanium clips are used frequently in specific surgical procedures, because the starburst reflection on postoperative radiographs is less with titanium than with other metals.

Absorbable clips made of synthetic absorbable suture material also are available.

REF: p. 198 11. These hemostatic devices date back to a period in time when they consisted of a product that

was harvested from the ocean. They continue to be used today in every surgical procedure where a considerable amount of bleeding may be encountered and are still made of a natural product, but not from the ocean. Select the appropriate hemostatic device that fits this description. a. Laparotomy sponges b. Oxidized cellulose polymer c. Bovine thrombin d. Fibrillar gelatin fibers ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Surgical sponges are used to affect hemostasis via direct pressure, absorb intraoperative blood loss and drainage, act as aids to blunt dissection, pack the viscera from the field, and keep areas of the wound moist. Laparotomy sponges (also referred to as laps, lap pads, or tapes) are either square or oblong and have a loop of colored twill tape with a radiopaque marker sewn to one corner. Used for major surgical procedures with large incisions, laparotomy sponges are presented to the surgeon either moist or dry.

REF: p. 207 12. The instrument devices depicted below are designed to ligate, divide, resect, suture, and

anastomose tissue. They are commonly called:

a. b. c. d.

endomechanical clamps. stapling anastomosers mechanical suturers mechanical staplers

ANS: D

Mechanical staplers (both nondisposable and disposable) use cartridges of tiny stainless steel staples or absorbable nonmetallic staples that are commercially preloaded, prepackaged, and presterilized.

REF: p. 205 13. Surgical instruments that are not considered in the category of clamps, retractors, or cutting

instruments, but are used in most procedures, are typically included within the category of: a. specialty instruments. b. microsurgical instruments. c. endomechanicals. d. accessory and ancillary instruments.

ANS: D

Accessory and ancillary instruments are designed to enhance the use of basic instrumentation or to facilitate the procedure. These include suction tips and tubing; irrigators-aspirators; electrosurgical devices; and special-use devices, such as probes, dilators, mallets, and screwdrivers.

REF: p. 203 14. The surgeon decided to convert to an open abdominal instead of the laparoscopic approach for

the colectomy, because the patient was morbidly obese and he needed a larger incision. He asked the circulating nurse to bring the largest self-retaining retractor in the sterile storage room. Select the appropriate retractor. a. Large wide Deavers b. Bookwalter c. Weitlaner

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Balfour ANS: B

Retractors are self-retaining or manually held in place by a member of the surgical team. The two types of self-retaining retractors are (1) retractors with frames to which various blades may be attached, and (2) retractors with two blades held apart with a ratchet. An example of the latter is a Weitlaner retractor. Other very large self-retaining retractors, such as the Omni or Bookwalter, are equipped with multiple blades and attachments of varying lengths and sizes.

REF: p. 203 15. During the draping procedure, the anesthesia provider asked the scrub person for two towel

clamps to secure the top of the unsterile edge of the drape to the intravenous (IV) poles. The scrub person had two penetrating and two nonpenetrating clamps on the back table. She knew she would need to secure the suction and electrosurgical pencil to the sterile field as soon as draping was finished. How should the scrub person respond to the anesthesia provider's request for towel clips? a. Refuse to give him any towel clamps because they are counted b. Give him two Allis clamps instead c. Give him the penetrating towel clamps d. Give him the nonpenetrating towel clamps ANS: C

Towel clamps also are considered holding instruments. Of the two basic types, one is a nonpenetrating towel clamp used for holding draping materials in place. The other has sharp tips used to penetrate drapes and tissues, and it is damaging to both. The use of sharp towel clamps to secure drapes is highly discouraged because they penetrate the sterile field.

REF: p. 202 16. The circulating nurse received the trauma call from the emergency department (ED) and

called sterile supply to assemble the instruments for an abdominal trauma case with possible aortic rupture. When the cart arrived, she saw the vascular set; however, the most important instrument set was missing. What important instrument set was needed for this procedure besides the vascular set? a. Sternal saw and blades b. Basic laparotomy set c. Basic laparoscopy set d. Minor set ANS: B

Tray/set names and instrument composition vary by institution, but three basic OR instrument sets are the minor/plastic, the basic laparotomy, and the dilation and curettage (D&C). A basic laparotomy set includes instruments to open and close the abdominal cavity and repair any gross defects in the major body musculature.

REF: p. 205

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. The scrub person was precepting a surgical technology student on her first orthopedic case, a

tibial intramedullary (IM) rodding. The scrub person explained to the surgical technology student the importance of keeping the instruments free of blood and bioburden during the procedure and demonstrated the best practice and how to: a. dip and agitate the instruments in saline after the surgeon returns them. b. wipe the instruments with a sponge moistened with sterile water after each use. c. rinse or soak the instruments in sterile water and dry them before placing on the back table. d. wipe the instruments with a sponge moistened with sterile water after each use and rinse or soak the instruments in sterile water and dry them before placing on the back table ANS: D

During the procedure the scrub person should wipe the used instruments with a damp sponge or place them in a basin of sterile water to prevent blood from drying on the surfaces and in the box locks. Saline solution should never be used on instruments because the salt is corrosive and accelerates rusting or deterioration of the metal. As time allows during the procedure, the scrub person should rinse and dry the used instruments and replace them on the back table to facilitate closing counts.

REF: p. 206 18. The safest practice for passing sharps and instruments is to: a. use a “no-touch” technique by passing all instruments and sharps with a sponge

forceps. b. establish a neutral zone on the closest corner of the Mayo stand. c. employ a robotic arm designed to deliver sharps and instruments to the surgeon. d. Adopt a hands-free technique with safety scalpels and blunt needles ANS: D

Because sharp instruments used in surgery are a frequent cause of injury, recommendations for eliminating hand-to-hand passing have been established, and numerous engineering controls, such as safety scalpels and blunt suture needles, have been developed. The Association of Perioperative Registered Nurses (AORN) and the American College of Surgeons (ACS) have made statements and recommendations for the adoption of a hands-free technique (HFT), and use of engineered sharps injury prevention (ESIP) devices along with double-gloving and blunt needles.

REF: p. 209 19. The perioperative nurse and the scrub person have a responsibility to maintain a safe

environment of care for the surgical patient. A surgical complication concerning surgical counts that poses serious harm for the patient and potential consequences for the involved staff is called: a. a malpractice suit. b. a retained extraneous object. c. res ipsa loquitur. d. criminal negligence.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Retained foreign bodies after surgery are a complication with serious potential consequences for the people involved. The surgical count process is undertaken to ensure that needles, sharps, soft goods, and instruments are not retained in the patient. One of the patient outcomes identified in the Perioperative Nursing Data Set (PNDS) is that “the patient is free from signs and symptoms of injury due to extraneous objects.”

REF: p. 207 20. Careful counting (according to established policy), situational awareness, and conscientious

and meticulous attention to the field are believed to prevent miscounts and lost items. A recent patient safety statement about preventing retained foreign objects recommends which of these practices? a. Two circulators must conduct the count. b. Verbal handoff must include count status at time of relief. c. Call for a "pause for the cause" when ready for closing count. d. Keep all used sponges on the sterile back table for a comprehensive final count.

ANS: B

In situations in which personnel may be relieved on a temporary basis, the verbal hand-off should include a discussion about counted items. In all situations it is imperative that two individuals be involved in the count—one counting and the other witnessing that the count is correct. Rushing at the end of a surgical procedure can result in incorrect or incomplete counts. When the scrub person and perioperative nurse are rushed, it may be necessary to call for a “pause for the count,” enabling counts to be carried out in an orderly manner.

REF: p. 207 21. Wound tissue healing is enhanced by the use of stapling instruments that mechanically apply

internal staples for ligation and division, resection, and anastomoses. What feature of the mechanical process reduces tissue manipulation, edema, and inflammation? a. The noncrushing B shape of the staples allows nutrients to pass through. b. The titanium staples are highly reactive to tissue. c. The staple line is contiguous and evenly spaced. d. The staple line has consistent tension.

ANS: A

Used in many surgical specialties, the mechanical application of these instruments reduces tissue manipulation and handling. The edema and inflammation that usually accompany anastomoses are minimized because the noncrushing B shape of the staples allows nutrients to pass through the staple line to the cut edge of the tissue.

REF: p. 205 22. According to a 2010 article published in The Journal of the American College of Surgeons and

citing data from a 1998 study, where do more than half of needlestick injuries involving suture needles occur? a. During the suturing of fascia or muscle tissue b. During the suturing of epithelial tissue c. During the suturing of loose connective tissue d. During the passing of the needle between surgical personnel

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

According to a 2010 article published in The Journal of the American College of Surgeons and citing data from a 1998 study, more than half of needlestick injuries involving suture needles occur during the suturing of fascia or muscle.

REF: p. 208 23. There are many different types of suturing techniques (stitches) in wound closure and tissue

approximation. Which type of stitches is used to reinforce the primary suture line with heavy, strong suture material in an obese patient with high tension on the wound closure? a. Interrupted stitches b. Retention stitches c. Purse-string stitches d. Subcuticular stitches ANS: B

Retention stitches are used to reinforce the primary suture line. Heavy, strong suture material is used. Other types of stitches include interrupted stitches, in which each stitch is made with a separate piece of suture material and tied separately; continuous or “running” stitches, in which the stitch is made with one uninterrupted length of suture material; subcuticular stitches, in which a stitch is placed completely under the epidermal layer of the skin; and purse-string stitches, where a stitch runs parallel to the edge and encircles a circular wound.

REF: p. 194 24. Flat neurosurgical patties are flat sponges composed of soft compressed cotton or rayon with

an embedded radiopaque element and string attached. They are often used in neurosurgical procedures. While used for hemostasis and exposure, what other use would be important in surgery? a. Application of topical steroids b. Marking of suspicious site on a specimen for frozen section c. Filter for suction tip to prevent underlying tissue damage d. Permanent packing to fill cranial defect ANS: A

Flat neurosurgical patties are often used in neurosurgical procedures. These sponges are available in a multitude of sizes and widths. They may be used as a filter for a suction tip to prevent damage to the underlying tissue, or as a vehicle for the application of topical anesthetic to the nasal mucosa.

REF: p. 207 25. Tissue adhesives, such as cyanoacrylate may be used for skin closure by applying on

approximated and dry skin edges. When the monomer comes into contact with moisture on the skin’s surface, it chemically changes into a polymer that binds to the top epithelial layer.

Select the true statement about tissue adhesive skin closures. a. Topical skin adhesives are best used in areas not subjected to high tension. b. They can be used to replace subcuticular sutures on obese patients. c. They provide a protective coating that lasts 14 to 20 days. d. They must be removed with acetone on the patient's postop visit.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

Cyanoacrylate tissue adhesives combine cyanoacetate and formaldehyde in a heat vacuum along with a base to form a liquid monomer. Some tissue adhesives include an initiator, which speeds up polymerization. Topical skin adhesives are best used in areas not subject to high skin tension or across areas in which tension may increase (such as knuckles, elbows, or knees) and can be used to replace subcuticular sutures that are 4-0 or smaller in diameter, as long as the skin edges are tension free and well approximated. They provide a flexible waterresistant protective coating that naturally sloughs off the incision in 7 to 10 days and may offer equivalent wound cosmesis to sutures.

REF: p. 198

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 08: Surgical Modalities Test Bank MULTIPLE CHOICE 1. An endoscope is a diagnostic or therapeutic instrument that enters the body through: a. a straight catheter via a paraumbilical incision. b. a large incision into a body compartment. c. an internalized sinus tract. d. a natural orifice.

ANS: D

An endoscope is a tube inserted into a natural body orifice or through a small incision to access internal organs or structures. Endoscopes are flexible, rigid, or semirigid. Flexible endoscopes include angioscopes, mediastinoscopes, ureteroscopes, and ureteropyeloscopes.

Rigid endoscopes include cystobronchoscopes, choledochoscopes, colonoscopes, cystonephroscopes, laparoscopes, sinuscopes, arthroscopes, bronchoscopes, laryngoscopes, and hysteroscopes.

REF: p. 211 2. The light transmission through an endoscope is achieved by way of: a. a charge-coupled device chip in the tip of the scope. b. a chain of small connected micro light bulbs. c. bundles of fiberoptic glass rods. d. electrified silicon cables.

ANS: C

There are two types of flexible endoscopes: fiberoptic endoscopes and videoscopes. Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers.

REF: p. 211 3. Endoscopic instruments are designed to perform the intervention at the target tissue site

through the tubular endoscope. The endoscopic instrument is considered: a. an instrument on a stick. b. an extension of the surgeon’s hand. c. a means to perform hands-free surgery. d. surgery without tactile sensation.

ANS: B

Endoscopic minimally invasive surgery (MIS) instrumentation has been designed to correspond with the surgical site and the technique used while functioning as an extension of the surgeon’s hand. The length and working end of the instrument must be adequate to perform surgery at the target site.

REF: p. 214

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. Flexible fiberscopes and flexible videoscopes share many of the same components; however,

in a video gastroscope, the eyepiece and lens of the fiberscope are replaced by a: a. charge-coupled device (CCD) image intensifier. b. high-definition video monitor. c. video chip. d. light-guided sensor.

ANS: C

There are two types of flexible endoscopes: fiberoptic endoscopes and videoscopes.

Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers. Videoscopes have, at their distal end, a video chip that provides an image that is directly viewed on a monitor; a videoscope does not have an eyepiece for direct viewing; the eyepiece is replaced with an endoscopic video camera.

REF: p. 211 5. The design of laparoscopic instruments aims to provide a clamping, cutting, dissecting,

electrocoagulating, suturing, or stapling instrument on the tip of a shaft that is long or short enough to reach the target tissue. The hand control on the surgeon’s end of the instrument is engineered to provide: a. ergonomic comfort and control. b. smooth operation of the lubricated instrument tips to prevent tissue adherence or entrapment. c. a perception of haptic and tactile sense to prevent crushing or losing tissue. d. adaptors for monopolar electrosurgery connection and laser fibers.

ANS: A

The length and working end of the instrument must be adequate to perform surgery at the target site. The hand control is ergonomically designed for the operator’s maximum comfort and reduced fatigue. Graspers and other instrumentation used by the assistant in surgery often are built for a shorter hand span because many women function in this role.

REF: p. 214 6. The instrument tips in laparoscopic instruments are designed to produce the same tissue

effects as a traditional instrument used for open surgery. Because of the process challenges of the laparoscopic approach, it is time-consuming to insert and withdraw instruments repeatedly during the procedure. Instrument manufacturers have attempted to make their products efficient by combining functions. An appropriate combined function for a laparoscopic instrument would be: a. ultrasound capability in a suturing forceps. b. electrosurgery conduction through the tips of a Babcock grasper. c. scissors that cut, blunt dissect, and coagulate tissue. d. suction and irrigation combined with an argon beam coagulation handpiece.

ANS: C

Scissors usually have a rounded tip when closed so that they can also be used to manipulate tissue without trauma. When open, both blades of the scissors should be visualized to prevent inadvertent injury. Some scissors are designed to be connected to an electrosurgical energy source so that coagulation can be provided during cutting.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 216 7. The challenge of suturing intra-abdominally is not as great as the process needed to tie and

tighten the surgical knot. The knot-tying process can be achieved within or outside of the abdominal compartment. The intracorporeal suture technique uses the suture-tying process analogous to the: a. instrument tie. b. two-handed tie. c. one-handed tie. d. stapled ligature.

ANS: A

Intracorporeal sutures are a suture ligature that can also be passed through the obturator sleeve to be tied while it is inside the body. The tissue is approximated in the same fashion but tied intracorporeally (i.e., inside the abdomen) using grasping forceps or laparoscopic needle holders.

REF: p. 218 8. To help visualize abdominal structures and to enhance safety during laparoscopic procedures,

a pneumoperitoneum is created. After Veress needle confirmation, insufflation tubing is connected and the process begun. CO2 gas is used to insufflate the abdominal cavity at an ideal flow rate of ___________ to achieve an ideal intra-abdominal pressure of ____________. a. <9 L/min; 10 to 12 mm Hg b. 10 L/min; 10 to 12 mm Hg c. 9 L/min; 14 to 16 mm Hg d. 14 to 16 L/min; 9 mm Hg ANS: C

The peritoneal cavity is filled, first at a low flow rate that is increased to a high flow rate of at least 9 L/minute ideally. Flow rate refers only to how quickly a predetermined intraabdominal pressure can be reached. Intra-abdominal pressure is the actual measure that must be closely monitored and should be maintained between 14 and 16 mm Hg. REF: p. 230 9. The new general surgery fellow placed the three trocar ports for the laparoscopic

appendectomy. She was focused on the concept of exact geometric triangulation of the three port accesses, to avoid the concept of sword fighting after inserting her instruments. She knew she had to proceed with caution and determination since this hospital was not able to provide the protected blade trocars she was used to using at the university medical center. The procedure was completed without incident; however, on postoperative day 1, the patient demonstrated signs and symptoms of sepsis. What might have been the unusual occurrence that could have resulted in patient sepsis? a. Unrecognized appendiceal rupture b. Significant break in sterile technique c. Inadvertent trocar puncture through the bowel on insertion d. Recent H1N1 outbreak on the surgery unit at the hospital

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

To help visualize abdominal structures and enhance safety during laparoscopic procedures, a pneumoperitoneum is created. Although rare, bowel perforation is a risk because this is a relatively blind procedure and no scope can be introduced until pneumoperitoneum is established.

REF: p. 229 10. The OR was trialing a new insufflation system and the vendor representative was out of the

room taking a phone call. The perioperative nurse was concerned that the flow rate was well above 14 L/min, and the pressure had risen to 17 mm Hg. She alerted the surgeon and reduced the rate and pressure because she feared that the elderly patient was at high risk for: a. gastroesophageal reflux. b. hypocarbia. c. postoperative nerve damage and shoulder pain. d. carboxyhemoglobinemia.

ANS: D

Overpressurization can be extremely hazardous to the patient. Excess pressure can force CO2 to diffuse into the blood, resulting in hypercarbia. End-tidal CO2 monitoring becomes a crucial assessment parameter to detect increased CO2 absorption. Excess pressure also increases diaphragmatic pressure, which can cause gastric regurgitation and aspiration of stomach contents. It also can reduce intrathoracic space, resulting in decreased respiratory effort and cardiac output. The phrenic nerve innervates the diaphragm and is responsible for some motor activity associated with respiration. CO2 gas can irritate this nerve, causing postoperative pain in the shoulder and neck. Excessive pressure could cause tremendous postoperative discomfort and severe nerve damage.

REF: p. 230 11. High-pressure insufflation rates can cause increased intra-abdominal pressure that can result

in life-threatening sequelae. The perioperative nurse reduces the flow rate in collaboration with the surgeon, while monitoring the patient for signs of: a. CO2 gas embolism. b. hemostasis. c. deep vein thrombosis (DVT). d. hypoxia.

ANS: A

CO2, highly soluble in blood, generally is not hazardous when used during laparoscopic insufflation, because it is rapidly absorbed in the splanchnic vascular region. Excessive intraabdominal pressure or any anesthetic technique that reduces splanchnic blood flow, however, could increase the potential for CO2 gas emboli.

REF: p. 231 12. The surface tissue effect of the CO2 laser has a shallow penetration of 0.1 to 0.2 mm

photothermal effect which serves as the laser of choice for: a. urologic lithotripsy. b. plastic surgery or dermatologic removal of tattoos and hemangiomas. c. laparoscopic cholecystectomy.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. endoscopic ablation of Barrett’s esophageal dysplasia.

ANS: B

The CO2 laser is characterized by its superficial tissue interaction (0.1 to 0.2 mm), because the beam is highly absorbed by water. The degree of tissue response is related to the photothermal effect (the amount of heat buildup) from absorption of the CO2 laser beam. The longer the CO2 beam is in contact with tissue, as with other laser wavelengths, the more destruction occurs. With the CO2 beam a greater depth of penetration can be achieved. Tissue reaction is visible and has been described as “what you see is what you get.”

REF: p. 239 13. A female patient arrived at the endoscopy center 2 days before her scheduled interventional

bronchoscopy to receive an injection of a photosensitive intravenous dye that the pulmonologist explained would highlight the dysplastic tissues of her bronchi that were precancerous. He scheduled her for an ablative procedure called photodynamic therapy (PDT), where the highlighted tissues would be affected by the laser light that is color-specific for uptake of the dye. Select the laser tissue interaction that describes the patient's treatment. a. Photosynthesis b. Absorption c. Transmission d. Scattering ANS: B

Absorption of laser light results when tissue is altered from the absorption of the beam. As the amount of energy delivered to tissue (fluence) increases, different tissue effects can be produced. The lowest level of energy produces a photochemical reaction. Then as fluence increases, a photothermal reaction occurs. With the highest level of fluence, a photoacoustic effect occurs.

REF: p. 239 14. The nursing research and practice committee searched the scientific literature for information

on smoke evacuation, because they planned for a unit-wide initiative to use this safety measure on all procedures where smoke or plume is generated. Their main concern was that the surgeons will not be as willing to comply as the staff. Select the safety measure that will be the most critical and most challenging to enforce. a. Change the smoke evacuation filter according to the manufacturer’s written instructions. b. Hold the smoke evacuation suction tube close (<1 inch away) to the tissue interaction site to remove as much plume as possible. c. Evacuate surgical smoke generated during endoscopic or laparoscopic procedures. d. Wear a surgical mask that provides adequate filtration to protect against residual smoke particulate that has not been evacuated.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Use the appropriate smoke evacuation system, depending on the amount of plume generated.

Hold the smoke evacuation suction tube close (<1 inch away) to the tissue interaction site to remove as much plume (odor and particulate matter) as possible. The surgeon may perceive that the close proximity of the smoke evacuation to active electrosurgery unit (ESU) or laser electrode is obstructive. Continuing education helps healthcare personnel to understand the hazards of surgical smoke and encourages the use of appropriate methods for evacuation.

REF: p. 246 15. Lasers, dependent on their wavelength, can produce absorption, reflection, transmission, and

scatter. The effect of laser wavelength scatter does not have any therapeutic benefit at this time and can be destructive to both staff and instruments. Select a safety measure that would prevent inadvertent scatter or heating of the endoscope channel from laser energy during a surgical procedure. a. Ebonize the surface of laser mirrors that are used in laparoscopic cholecystectomies. b. Surround the surface drapes and endoscope trocar with moist sterile towels and cover the glass windows. c. Advance the laser fiber at least 1 cm beyond the tip of the endoscope within operator’s view. d. Cover the laser fiber with medical-grade tubing along its entire length.

ANS: C

Special precautions should be followed when using the laser during an endoscopic procedure.

When a laser fiber is introduced through the biopsy port of a flexible or rigid endoscope, the operator must view at least 1 cm of the tip of the fiber before activating the laser. If the end of the fiber is still within the sheath of the endoscope, and the laser is fired, the heat from the laser energy quickly damages the optics and channel of the endoscope.

REF: p. 246 16. A 9-year-old female softball player has arrived in the OR for emergency repair of superficial

facial and deep arm lacerations when she ran into the chain link fence during practice after school. The perioperative nurse discovers that the patient has diabetes and has an insulin pump that should remain connected during the short procedure. The best option for energygenerated hemostasis is: a. battery-generated eye electrosonic cautery. b. bipolar electrosurgery. c. hemoelectrocoagulated plasma capacitor. d. monopolar electrosurgery.

ANS: B

In a bipolar system a dispersive electrode is not needed because electrical energy flows from one tine (or prong or blade) of the bipolar instrument to the other tine as it passes through the tissue located between the tines. Energy returns directly through the instrument to the generator to complete the circuit, eliminating flow of current through the patient or implanted devices.

REF: p. 233

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. The surgeon used the ESU in monopolar mode to cut and coagulate through the subcutaneous

tissue on opening the abdomen during a bariatric bypass procedure. As she began to proceed through the muscle and fascia layer, she asked the circulating nurse to increase the cut and coagulation modes on the ESU. Which measure could the scrub person take to enhance energy delivery? a. Unwrap the ESU cord from around the towel clamp handle b. Clean the charred tissue from the active electrode blade c. Remind the surgeon that adipose tissue offers less impedance than muscle d. Replace the active electrode blade with a coated blade ANS: B

Electrosurgical tips on the active electrode must be kept clean and free from debris (eschar) to function properly. Eschar is less conductive and impedes the flow of electrons, requiring more power to be used to achieve the desired tissue effect. Electrode tips with nonstick coating make removal of eschar easier.

REF: p. 233 18. The surgeon prefers the argon beam coagulator for dissection in his liver procedures, because

the liver bleeds easily, and traditional monopolar electrosurgery often causes more bleeding than it stops. What is the application characteristic of the argon beam coagulator that enhances liver tissue hemostasis? a. Combined argon gas with electrosurgical energy with rapid coagulation b. Argon gas is heavier than air, inert, and noncombustible and does not tear tissue. c. Decreased chance of combustion, formation of surgical smoke, and burned tissue d. Noncontact tissue coagulation with reduced risk of rebleeding ANS: D

An argon-enhanced ESU device combines argon gas with electrosurgical energy to improve the effectiveness of the electrosurgical current. Because argon gas is heavier than air, inert, and noncombustible, it creates an efficient pathway for electrosurgical energy to travel from electrode to target tissue. The flow of argon gas also clears the surgical site of blood and fluids, allowing for greater visibility of the bleeding site or target area, and disperses oxygen, decreasing the chance of combustion and formation of surgical smoke. Benefits of argonenhanced electrosurgery include: rapid coagulation of diffuse bleeding site with reduced blood loss, reduced risk of rebleeding, noncontact tissue coagulation, reduced depth of penetration by electrical energy, and less adjacent tissue damage.

REF: p. 237 19. A 72-year-old man with a single early-stage liver tumor has an implanted automatic internal

defibrillator that the anesthesia provider has decided not to disarm for the procedure. What energy-generated dissection device should the doctor use to replace the argon beam coagulator? a. An ultrasonic dissector b. A monopolar suction-irrigator c. A monopolar hydrodissector d. A CO2 laser with articulating arm and handpiece ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Vibrating energy devices provide a safe option for cutting and coagulation. High-frequency sound waves are propagated to a blade tip to produce ultrasonic energy. The following are advantages of using an ultrasonic device to cut and coagulate: No surgical plume or odor is generated; only a small amount of aerosolization is created. Less adjacent tissue is damaged compared with laser and ESU devices. Tactile feedback is retained. No nerve or muscle stimulation occurs, because no electrical current is delivered to the target area. No stray electrical or laser energy is produced. Precise cutting and control are offered.

REF: p. 249 20. The original equipment manufacturer (OEM) instructions that came with the new rigid

endoscope system did not recommend a particular sterilization modality; however, high temperatures and ultrasonic cleaning were discouraged, and the facility recently removed the ethylene oxide sterilizers from the sterile processing department. The minimally invasive surgery (MIS) team collaborated on developing a processing procedure for their new equipment. What modality is their best option? a. Outsource to a facility that uses ethylene oxide or gamma radiation b. Sterilize the entire set in the low-temperature plasma sterilization system c. Perform high-level disinfection in glutaraldehyde d. Steam-sterilize the metal components and soak the nonmetal components in glutaraldehyde ANS: B

The low-temperature plasma sterilization system uses hydrogen peroxide gas plasma, which sterilizes within 50 to 75 minutes and dissociates into nontoxic by-products. Understanding the advantages and limitations (e.g., lumen restrictions) of this system is important when determining if it would meet the needs of endoscope or instrument sterilization. Generally, flexible endoscopes cannot be sterilized in this system, but shorter rigid scopes with larger lumens can. The low-temperature requirement for this system could also address the lenses of the rigid telescopes and video components.

REF: p. 222 21. The new physician-owned endoscopy and surgery center opened with ample-sized procedure

rooms and a larger sterile storage core than the former unit. The gastroenterologists had a busy and financially profitable practice. They used the best and most expensive reusable endoscopic biopsy forceps on every gastroscopy and colonoscopy. The endoscope processing and decontamination room used the same manufacturer’s endoscopic cleaning brushes on every scope. These devices received considerable use and abuse and were often discarded after one or a few uses. Based on the characteristics of the new center and the gastroenterology practice, what would be the best option for the biopsy forceps and cleaning brushes? a. Disinfect the forceps and brushes in the same high-level cycle with the scope for efficiency b. Secure a contract with a repair company to facilitate ongoing repair of the brushes and forceps c. Buy more reusable brushes and biopsy forceps and only open them when needed d. Trial several manufacturers’ single-use biopsy forceps and cleaning brushes ANS: D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Advantages of single-use items include sharpness, reliability related to function, guaranteed sterility, and safety. Indirect advantages include no reprocessing, no repair costs, and comparable levels of patient care. Upgraded designs are more easily brought to market when the device is labeled for single use. Disadvantages include the need for increased storage space, budgetary implications, and environmental concerns related to disposal of biohazardous waste.

REF: p. 222 22. A neutral plasma coagulator is an energy source that produces pure plasma to provide

coagulation. Why is patient risk reduced with this directed energy source? a. The plasma is formed from activated carbon dioxide, an inert gas. b. The plasma approximates tissue with a low heat welding process. c. No electrical current passes through the patient. d. The coagulation results in minimal tissue eschar.

ANS: C

Patient risk is reduced because no electrical current passes through the patient. Plasma is created when a low flow of argon gas is excited within the handpiece, consisting of an anode (where current enters) and cathode (where current exits). The gas, in the plasma state, emerges from the handpiece tip as an electrically neutral pale blue jet stream that coagulates tissue.

When the plasma reaches bleeding tissue, it releases its kinetic energy as heat and causes coagulation of the bleeding surface as well as cutting capabilities. Because the electrodes are contained within the handpiece, no dispersive pad is used.

REF: p. 250 23. A neonate has burns over 45% of his body from a scalding incident. He was prepared for

surgical fasciotomy for ensuing compartment syndrome of his legs and trunk. In planning for the use of electrosurgery, the perioperative nurse's assessment revealed a limited surface area for the dispersive electrode, and the appropriate choice was made to use the: a. dispersive pad cut in half to the upper unburned back. b. large capacitive coupling pad under the neonate. c. adhesive pad wrapped circumferentially around the arm. d. battery-operated eye cautery and silver nitrate sticks.

ANS: B

The large capacitive pad eliminates the need for an individual adhesive dispersive electrode pad, which is problematic if an ESU is used without dispersive electrode monitoring capabilities, and the pad tents during a procedure. The bulk resistivity of this unique capacitive pad ensures that current densities are kept to a clinically safe level such that pad site burns rarely occur. Adhesive pads also can irritate sensitive skin, may require a shaved area for placement, or may become a hazard if not placed on the patient appropriately.

REF: p. 234 24. Direct coupling during the use of monopolar electrosurgery is caused by __________ and is

usually within the control of the ______. a. metal-to-metal sparking; the scrub person b. metal to tissue; the scrub person c. active burns; the surgeon

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. metal-to-metal sparking; the surgeon ANS: D

Direct coupling occurs when the active electrode accidentally touches a noninsulated metal instrument, allowing the electrical energy to flow from one to the other (metal-to-metal sparking). Direct coupling may also occur if an active electrode is activated while in contact with a clip. When the metal instrument or clip receives electrical energy, a burn can easily result. This coupling is often called “pilot error” because it is within the surgeon’s control to avoid. The surgeon should not activate the active electrode until the target site is within the field of vision, and the active electrode is in proximity or direct contact with target tissue and not a metal object.

REF: p. 235 25. The sterile processing department technician checks each fiberoptic light cord for

transmission of light before decontamination and again before it is prepared for sterilization.

What would indicate that the cord must be replaced? a. Peppering spots of 20% of the bright light b. Peppering spots of 35% of the bright light c. Opacity with peppering spots of 1% of the outer ring of the bright light d. An opacity crescent of 1% of the outer ring of the bright light ANS: A

To check the transmission of light within a fiberoptic cable, one end of the cable is held pointing toward a bright light while the other end is checked for any peppering, which indicates broken fibers. When approximately 20% of the fibers are broken, the cable must be replaced.

REF: p. 252 MULTIPLE RESPONSE 1. Select the statement(s) that best reflect the benefits of laser surgery for the surgical services

department. (Select all that apply) a. Decreases postoperative scarring that could lead to stenosis b. Reduces operative and anesthesia use of antibiotics c. Sterilizes tissue from the heat generated at the laser-tissue impact site d. Promotes a shift to more laparoscopic surgery procedures ANS: A, C

Following are some advantages that have been associated with laser technology, depending on the procedure performed: • Seals small blood vessels (less intraoperative and postoperative blood loss) • Seals lymphatics (decreases postoperative edema and potential spread of malignant cells in the lymphatic system) • Seals nerve endings (on selective procedures, decreases postoperative pain) • Sterilizes tissue (from the heat generated at the laser–tissue impact site) • Decreases postoperative stenosis (by decreasing the amount of scarring that could lead to stenosis) • Produces minimal tissue damage (from precision of the laser beam) • Reduces operative and anesthesia time

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock • Allows a shift to more ambulatory surgery procedure • Allows more use of local anesthetics instead of general anesthetics • Provides quicker recovery and return to daily activities REF: p. 242 2. The new endoscopy and surgery center called in an outsource company to present the options

and advantages of reprocessing single-use devices at their staff meeting. Select the appropriate question(s) that the staff should ask before making their decision. (Select all that apply) a. Can the disposable device be adequately cleaned? b. Is the device tested and checked for form and function after cleaning? c. Can the device withstand disinfection or sterilization? d. How many times can a device be reprocessed and reused?

ANS: A, B, C, D

Questions to ask when determining whether to reprocess single-use devices include the following: • Can the disposable device be adequately cleaned?

• Can the device withstand disinfection or sterilization?

• Can it be adequately aerated if ethylene oxide sterilization is used?

• Is the device tested and checked for proper form and function after cleaning has been completed?

• Has device integrity been destroyed during reprocessing, or is equipment available to test the integrity of the device?

• How is the integrity of insulation checked on an electrosurgical instrument?

• Can the device be returned to its original intended use?

• Will cost savings be passed on to the patient, if appropriate?

• What is the maximum number of safe reuses, as determined through comprehensive testing?

• How is the number of reuses indicated on the device?

• Should the patient be informed that a reprocessed device may be used?

REF: p. 223 3. The perioperative educator is teaching the OR assistant to change the smoke evacuation filters

when they have met their usage life. Which priority teaching element(s) must be taught?

(Select all that apply) a. Change the filters on all generators on a regular monthly schedule b. Treat the used filter as contaminated waste c. Place used filter back in its original container before disposal d. Dispose of the used filter as regulated biohazard waste.

ANS: B, D

Standard precautions should be used when changing a contaminated filter because of the possibility of bacterial and/or viral contamination. Many manufacturers recommend that the contaminated filter be treated as infectious and disposed of as regulated medical waste (biohazardous).

REF: p. 246 4. The diode laser is most often used in which specialties? (Select all that apply) a. Ophthalmology

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Dermatology c. Hepatopancreatic surgery d. Podiatry ANS: A, B

The diode laser is a compact, reliable laser system most often used for ophthalmology and dermatology procedures.

REF: p. 240

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 09: Wound Healing, Dressings, and Drains Test Bank MULTIPLE CHOICE 1. Identify the primary substance that composes a layer of the epidermis, is responsible for

hardening nails and hair, and protects the body from fluid loss and invasion by pathogens. a. Lipids b. Keratin c. Dermis d. Collagen ANS: B

The epidermis is composed of several layers consisting of keratin and lipids. Keratin is the primary substance that hardens nails and hair and protects the body from fluid loss and invasion by pathogens.

REF: p. 253 2. There are many factors that influence surgical wound healing. Some are helpful, and some are

beyond the scope of the surgical team. Select the response below that reflects a factor with high influence over wound healing and is within the control of the surgical team. a. Use of a local anesthetic with epinephrine at the incision site b. Antibiotic sensitivity studies conducted on wound culture results c. Selection of wound closure materials, dressings, and drains d. Positive cultures from a chronic wound beyond the patient’s incision site ANS: C

The causes of wounds can be described as follows: surgical—caused by an incision or excision; traumatic—caused by mechanical, thermal, or chemical destruction; chronic— caused by an underlying pathophysiologic condition (e.g., pressure ulcers or venous leg ulcers) over time. The amount of tissue loss, the existence of contamination or infection, and the degree of damage to tissue are some factors that determine the type of wound closure selected by the surgeon. The healing process is inherently related to whether the wound is closed or left open.

REF: p. 253 3. Cosmetic elective plastic surgery, on healthy patients, is based on the expectations that healthy

healing and ideal cosmesis will be achieved. On which phase or phases of healing is considerable emphasis placed during the procedure? a. Inflammatory phase b. Proliferative phase c. Remodeling phase d. Proliferative phase and remodeling phase ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Clean, full-thickness wound healing is an intricate biologic process that occurs in three overlapping phases. In cosmetic surgery a clean incision with early suturing will produce a “hairline” scar, healing by first intention. An aseptically made wound with minimal tissue destruction and minimal tissue reaction begins to heal as the edges are approximated by close sutures or staples. No open areas or dead spaces are left to serve as potential sites of infection.

In the inflammatory phase, an exudate containing blood, lymph, and fibrin begins to clot and loosely binds the cut edges together. Blood supply to the area increases, and the basic process of inflammation begins. Inflammation is a prerequisite to wound healing and is a vascular and cellular response to dispose of bacteria, foreign material, and dead tissue.

REF: p. 256 4. A 24-year-old female sought the consult of a plastic surgeon to repair a large 2-year-old

surgical scar on her right leg that was healed but remained darkly pigmented, uneven, and raised. The plastic surgeon reviewed the operative report from the patient’s prior surgery, which revealed an uneventful procedure, wound classification I, closure with uninterrupted 40 nylon, and no drain. The underlying cause of the uneven healing was probably due to: a. failed remodeling phase resulting from inadequate skin care after initial healing. b. unknown interruption in the normal healing process during proliferative and remodeling phases. c. failed proliferative phase caused by improper postoperative dressings. d. failed inflammatory phase caused by delayed suture removal.

ANS: B

Unknown factors can interrupt or impact the normal healing process; these factors are not influenced by the surgical team or the patient. The proliferative phase, beginning within hours of the injury, allows new epithelium to cover the wound. Epithelial cells migrate and proliferate to the wound area, covering the surface of the wound to close the epithelial defect.

Epithelialization also provides a protective barrier to prevent fluid and electrolyte loss and to reduce the incidence of infection. While reepithelialization takes place collagen synthesis and wound contraction are occurring. Contraction begins approximately 5 days after the wound onset and peaks at 2 weeks, gradually shrinking the entire wound.

REF: p. 256 5. A 62-year-old man had surgery 6 days ago for a ruptured diverticula. He is back in the OR for

a debridement and washout. The patient’s fever has subsided, and the drainage is clear. The surgeon will schedule the patient to return to the OR in 3 days for: a. one more final debridement and washout. b. packing with antibiotic-impregnated gauze before final closure. c. sutured closure of the peritoneum and muscle fascia layer and secondary closure with granulation of the subcutaneous and skin layers. d. delayed primary sutured closure.

ANS: D

As the name delayed primary closure implies, this healing process occurs when approximation of wound edges is intentionally delayed by 3 or more days after injury or surgery (see Figure 8-2). These wounds may require debridement and usually require a primary and secondary suture line, such as when retention sutures are used. The conditions leading to a decision to delay closure are removal of an inflamed organ or heavy contamination of the wound.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 256 6. A 60-year-old man had surgery 6 days ago for a ruptured diverticula. What was the wound

classification at the time of his emergency surgery? a. Clean wound, classification I b. Clean/contaminated wound, classification II c. Contaminated wound, classification III d. Infected wound, classification IV ANS: C

The diverticulum rupture exposes, or contaminates, the peritoneal cavity with bowel contents and bowel organisms that can cause infection.

REF: p. 259 7. A patient recently operated on for a ruptured appendix had a temperature of 103° F and

returned to the OR for a debridement and washout of purulent drainage from his wound on postoperative day 3. What was the wound classification at the time of his debridement and washout surgery? a. Clean wound, classification I b. Clean/contaminated wound, classification II c. Contaminated wound, classification III d. Infected wound, classification IV ANS: D

His wound is now infected as evidenced by purulent drainage and a fever. Infected wounds include old, physically induced (traumatic) wounds with retained devitalized tissue and wounds that involve an existing clinical infection or perforated viscera. Examples are excision and drainage of abscess and delayed primary closure of a wound after appendectomy for ruptured appendix.

REF: p. 259 8. Surgical site infections (SSIs) account for 14% to 16% of all hospital-acquired infections. The

surgical team is responsible for understanding the factors that contribute to SSIs and preventive measures. Which of the following is a true statement about preparation of the patient? a. Hair removal should be accomplished in the OR with a sterile razor or depilatory. b. The patient should bathe or shower the night before surgery with chlorhexidine gluconate (CHG). c. The antimicrobial skin prep should be a slow-acting antibiotic. d. Diabetic patients are recommended to have a short hospital stay to control glucose levels.

ANS: B

An understanding of the guidelines for preventing SSIs enables perioperative nurses to weigh factors that are viewed as effective in preventing SSIs. The following guidelines from the World Health Organization (WHO) are based on a review of evidence and research:

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock • Hair should not be removed unless it will interfere with the procedure. If hair is removed, it should be clipped less than 2 hours before the procedure. Shaving is not recommended because it increases the risk for SSI. If hair is to be removed, the use of depilatories is discouraged.

• The skin at the surgical site should be prepared with an appropriate antiseptic agent before surgery. The antimicrobial agent should decrease the microbial count of the skin rapidly and have persistent efficacy throughout the procedure.

• Patients should take up to three preoperative showers or baths with antiseptic soap such as CHG. REF: p. 261 9. Surgical team members have control of many of the factors that have been shown to

contribute to SSIs. Which statement below reflects a best practice for surgical scrub/surgical hand asepsis? a. Apply the alcohol-based surgical hand rub to wet hands and arms. b. Keep nails short and do not wear artificial nails or nail wraps. c. The first 10 minute scrub of the day must include a brush and CHG. d. Wear a surgical mask only when colonized with S. aureus or group A streptococcus.

ANS: B

Artificial nails are prohibited. Brushes are not recommended for surgical hand preparation.

When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, typically 2 to 5 minutes.

Long scrub times (e.g., 10 minutes) are not necessary. When using an alcohol-based surgical hand rub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to dry hands only.

REF: p. 258 10. An experienced perioperative nurse was precepting a new perioperative nurse in the

circulating role. She watched and coached as the new nurse prepared to perform the skin prep on a patient for closure of a colostomy. The new nurse had never had the opportunity to prep a patient with an existing colostomy and was concerned about the potential of her actions contributing to an SSI. After the successful prep and the onset of the procedure, the experienced nurse and the new nurse had an opportunity to discuss SSIs in this patient population and preventive measures. What combinations of topics should they have discussed? a. The role of the wound ostomy care nurse b. Sterile technique during skin prep procedure and protection from crosscontamination c. Wound classification and surgeon technique d. The best antibiotics for bowel microbes ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The WHO provides SSI prevention guidelines for consideration in planning and implementing nursing interventions to optimize successful patient outcomes. The nurse assesses the patient’s susceptibility for infection, classifies the wound on the intraoperative record, implements sterile technique, protects the patient from cross-contamination, collaborates in administration of antibiotic prophylaxis, and performs other responsibilities to create and control the environment of care.

REF: pp. 260-261 11. A perioperative nurse returns back to work in a busy OR tomorrow after a 3-week vacation.

She is certain she will be assigned to scrub in cardiac surgery in the morning. Select the infection prevention measures she must accomplish before she returns to the OR. a. Home launder her hats and scrubs b. Remove her artificial nail tips and cut her nails to 1/4 inch past her finger tips c. Take a bath with antimicrobial foaming soap gel d. Drink an antibiotic herbal tea before bedtime ANS: B

Artificial nails are prohibited. Do not wear artificial fingernails or extenders when having direct contact with patients. Brushes are not recommended for surgical hand preparation.

REF: p. 258 12. A 48-year-old tetraplegic with a chronic sacral wound is scheduled for another wound

debridement. What is the purpose of doing a wound debridement on a chronic wound? a. The debridement will stimulate circulation and promote healing. b. The debridement will prevent the growth of parasitic maggots. c. The debridement will remove dead tissue that could support infection. d. Debridement creates a nidus that nourishes and supports healing.

ANS: C

Debridement is the act of removing dead and devitalized tissue from a wound. It is necessary because dead tissue in the wound provides a nidus for wound infection.

REF: p. 260 13. Which statement about surgical dressings is true? a. Surgical dressings cushion and protect the wound from trauma and gross

contamination and absorb drainage. b. Surgical dressings cover the wound to maintain moisture to promote granulation. c. Surgical dressings maintain tension on the suture line to prevent dehiscence. d. Surgical dressings protect surrounding drapes, linen, and clothing from contamination.

ANS: A

The dressing may serve one or more of the following purposes: • Cushioning and protection of the wound from trauma and gross contamination • Absorption of drainage • Debridement of the wound • Support, splinting, or immobilization of the body part and incisional area

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock • Assistance in hemostasis and minimization of edema and dead space, as in a pressure dressing • Promotion of the patient’s physical comfort and aesthetic appearance • Maintenance of a moist environment and prevention of cell dehydration • Application of medications REF: p. 266 14. Which statement best reflects the appropriate purpose of a surgical drain? a. Drains can prevent the development of deep wound infections. b. Drains provide pockets through which air and fluids can collect in the surgical site. c. Drains provide a portal for antibiotic irrigation. d. Drains can provide opportunities for wound aeration.

ANS: A

Drains control ecchymosis and provide exits through which air and fluids, such as serum, blood, lymph, intestinal secretions, bile, and pus, can be evacuated from the operative site.

Drains also may be used to prevent the development of deep wound infections.

REF: p. 268 15. Before the patient leaves the OR for transport to the postanesthesia care unit (PACU) or

intensive care unit (ICU), the circulating nurse empties the closed drain reservoir. What important information must the circulating nurse document and communicate about the drain to the PACU or ICU nurse during hand-off report? a. The name and manufacturer of the drain b. The location and type of drain, description and amount of drainage c. The amount of negative pressure in the collection bulb d. The instructions for reinfusing the autologous drainage collection ANS: B

The perioperative nurse documents the location and type of drain and ensures the drain is working properly before the patient leaves the OR. This information is important for the handoff report to nurses caring for the patient in the PACU and postoperative nursing units. Some wounds yield significant drainage and must be monitored closely during the postoperative course.

REF: p. 269 16. The perioperative nurse practitioner received a call from a patient 2 days after she was

discharged to home. The patient related that her drains were not working or drawing in fluid, and she had red, hot-to-touch skin and swelling around the left drain exit site. She also noted some yellowish fluid seeping around the drainage tube that smelled bad. What indications convinced the nurse practitioner that the patient followed her postoperative teaching? a. The patient called the right person, the nurse practitioner. b. The patient communicated the appropriate descriptive information about her incision. c. The patient was on her way to the emergency department for pain medication. d. The patient stated that she took better care of her incision by coating the 44 gauze pads with antibacterial spray.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

Patients or their designated support person need to demonstrate knowledge of wound management. In a patient-centered care framework, that involves knowledge (the patient repeats the instructions correctly), skills (the patient demonstrates wound care measures), and affect (the patient cooperates and verbalizes ability to cope with managing the surgical wound). Patient discharge information instructs the patient to seek help right away if: • a yellowish white fluid (pus) comes from the wound.

• medicine does not lessen the pain.

• there is a red streak going away from the wound.

• you cannot move your finger or toe (if an extremity is the surgical site).

• you have a fever.

REF: p. 262 17. What term represents a fibrous band between serous membranes that can cause obstructions

and subsequent surgical emergencies? a. Evisceration b. Adhesion c. Dehiscense d. Keloid ANS: B

Adhesions are an adherence of serous membranes to one another, causing fibrous tissue to form; sometimes occur in healing and inflammatory processes; and commonly occur in or around the gastrointestinal tract, where adhesions may form bands and cause obstructions and subsequent surgical emergencies.

REF: p. 259 18. Hydrotherapy for wound care was traditionally accomplished in an immersion bath whirlpool

system. Because immersion in a tank is not practical from an intraoperative perspective, the hydrotherapy method most frequently used in the OR is: a. hyperosmosis b. hydro irrigation c. pulsatile lavage d. water pik pressure-washout ANS: C

Because immersion in a tank is not practical from an intraoperative perspective, the hydrotherapy method most frequently used in the OR is pulsatile lavage. Hydrosurgery is a form of wound debridement and irrigation that uses a powered handpiece system with narrow nozzle through which pressurized saline (up to 15,000 pounds psi) is used to excise necrotic tissue.

REF: p. 263 MULTIPLE RESPONSE 1. Which of the criteria below are appropriate when determining whether an incisional SSI is

superficial or deep? (Select all that apply.)

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

Where the purulent drainage comes from, superficial or deep Where the positive wound culture comes from, superficial or deep Whether the wound dehisces and/or is deliberately opened by a surgeon The diagnosis by the surgeon or attending physician

ANS: A, B, C, D

Superficial incisional SSI involves only the skin and subcutaneous tissue of the incision and at least one of the following: purulent drainage from the superficial incision, organisms isolated from a culture from the superficial incision, signs or symptoms of infection and deliberately opened by the surgeon, or diagnosis by the surgeon or attending physician. Deep incisional infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following: purulent drainage from the deep tissue, incision spontaneously dehisces or is deliberately opened by a surgeon, abscess or other evidence of infection involving the deep incision, or diagnosis of a deep incisional SSI by a surgeon or attending physician.

REF: p. 257 2. Infection control and prevention surveillance was underway in the cardiac ICU because of an

alarming prevalence of sternal wound infections. The infection preventionist and perioperative clinical nurse specialist reviewed the criteria in order to define the SSI and develop strategies for further investigation and prevention. The infectious signs and symptoms arose on postoperative day 2 with edema, redness, and purulent exudates that appeared to be isolated to the subcutaneous plane above the sternum. What two important criteria must be met to conclusively define this SSI? (Select all that apply) a. Physician examination for wound separation with cultures of superficial and deep tissues b. Positive wound cultures from deep tissues, but not the organ space, with cultures of drainage c. Positive wound cultures obtained from the deepest accessible source of wound drainage d. Positive diagnosis of the SSI by the surgeon or attending physician ANS: C, D

These three criteria were met: evidence of signs of infection, purulent drainage, and less than 3 postoperative days. Superficial incisional SSI involves only the skin and subcutaneous tissue of the incision and at least one of the following: purulent drainage from the superficial incision; organisms isolated from a culture from the superficial incision; signs or symptoms of infection and deliberate opening by the surgeon; or diagnosis by the surgeon or attending physician. Deep incisional infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following: purulent drainage from the deep tissue; incision spontaneously dehisces or is deliberately opened by a surgeon; abscess or other evidence of infection involving the deep incision; or diagnosis of a deep incisional SSI by a surgeon or attending physician.

REF: p. 257 3. In post discharge home care of the postoperative patient, which statements reflect best practice

by the patient? (Select all that apply.) a. Clean the wound daily with soap and water b. Change dressings as instructed by your nurse or physician c. Take showers; do not swim or put your wound under water

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Keep your physician visit as planned ANS: A, B, C, D

Wound care helps prevent pain and infection. Patient discharge information instructs the patient to: • Only take medicine as told by your physician.

• Clean the wound daily with mild soap and water.

• Change any bandages (dressings) as told by your physician. Put medicated cream and a bandage on the wound as told by your physician. Change the bandage if it gets wet, dirty, or starts to smell.

• Take showers. Do not take baths, swim, or do anything that puts your wound under water until your physician says you may.

• Rest and raise (elevate) the wound until the pain and puffiness (swelling) is better (as applicable).

• Keep all physician visits as told.

REF: p. 262 4. A 76-year-old male patient has been approved as a candidate for hyperbaric oxygenation as a

management therapy for his chronic sacral wound. He responded well to his surgical debridement and the nurse is planning to explain the next course of therapy. He will describe to him how hyperbaric oxygenation (Select all that apply.): a. increases the ability of the blood to carry oxygen to the tissues. b. restores cells and kills bacteria that thrive without oxygen. c. decreases white blood cell migration, which lowers inflammation. d. slows but strengthens the healing process.

ANS: A, B

Hyperbaric oxygenation has been used to enhance healing in problem wounds for many years.

It increases the capacity of blood to carry oxygen to the tissues. The increased oxygenation assists in cellular restoration, is directly bactericidal to anaerobes, and improves leukocyte migration and phagocytosis to the wound bed.

REF: p. 261 5. A 70-year-old male patient was fitted with a negative-pressure wound therapy system

(NPWT), also called vacuum-assisted closure, after his most recent surgical wound debridement. This device works by (Select all that apply.): a. suctioning lymphatic drainage from the wound and decreasing inflammation. b. promoting microscopic bleeding and releasing cellular cytoplasm to cleanse the wound. c. creating mechanical tension on the tissues and pulling wound edges together. d. causing macro-deformation and wound contraction.

ANS: C, D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Also known as vacuum-assisted closure (VAC), NPWT is used for difficult to manage wounds that do not respond to traditional wound care methods. NPWT works by using a device to apply constant controlled negative pressure to a wound that is filled with a drainage sponge (polyurethane foam) and sealed with an occlusive dressing. The VAC system has three main mechanisms of action that promote wound healing. First, the negative pressure results in mechanical tension on the tissues, causing a reduction in edema and fluid removal. The second action is macro-deformation and wound contraction. The third action is microdeformation and mechanical stretch perfusion. VAC therapy may be used for acute and traumatic wounds, subacute wounds, pressure ulcers, chronic open wounds, meshed skin grafts, and skin flaps.

REF: p. 262

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 10: Postoperative Patient Care and Pain Management Test Bank MULTIPLE CHOICE 1. The initial primary assessment by the perianesthesia nurse, on the patient’s admission to the

postanesthesia care unit (PACU), begins with which criterion? a. Patient’s level of consciousness and hanging intravenous (IV) fluid level b. Patient identification using attached identification (ID) band with two identifiers c. Vital signs and ABCs, beginning with the respiratory system d. The surgical/interventional procedure performed and operating room (OR) number ANS: C

After the immediate primary assessment of the ABCs and completion of the hand-off report, the PACU nurse begins a more thorough postanesthesia assessment. The assessment is performed quickly and is specific, in part, to the type of operative procedure. Recommended elements of an initial assessment in the PACU are presented in Box 10-2.

REF: p. 270 2. A 32-year-old female patient has been admitted to the PACU after a bilateral bunionectomy.

During the hand-off report from the anesthesia provider and circulating nurse, the patient began to awaken, crying in drowsy garbled speech that she was thirsty and wanted water.

What would be the perianesthesia nurse’s appropriate response? a. Explain to the patient in a comforting manner that she cannot have anything to drink until phase II b. Check the patient’s intake and output, her return of gag reflex, and offer her sips of water c. Ask the anesthesia provider if the patient may begin oral intake d. Review the patient’s intake and output and cardiac status and increase her IV flow rate ANS: D

Thirst is a symptom of dehydration. Because hypovolemia is the most common cause of postoperative hypotension, the initial intervention is to administer IV fluids (physiologic saline or lactated Ringer’s solution) at a maximum rate while making a specific diagnosis.

REF: p. 275 3. A 33-year-old female, who had a dilation and curettage (D&C) with laparoscopic tubal

ligation and has been in phase II recovery for 3 hours, collapsed while sitting on the toilet.

The perianesthesia nurse had recently finished giving the patient her discharge instructions and helped her dress. The patient was assessed for loss of consciousness and ineffective breathing patterns and lifted to a transport vehicle. What action should the phase II nurse take next? a. Transfer the patient back to phase I PACU and begin airway interventions b. Determine if the patient has resedated and is a candidate for a dose of naloxone c. Begin airway interventions; revert to phase I criteria d. Initiate a cardiac arrest call and get the code cart; prepare to intubate

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

While phase II PACU prepares the patient for discharge, phase I activities focus on primary assessment, breathing, and circulation and facilitating the patient to a level of physiologic stability. The patient’s current status requires advanced care at the phase I level.

REF: p. 270 4. A patient, who collapsed while sitting on the toilet, admitted that she had been straining while

seated on the toilet. The anesthesia provider and perianesthesia nurse surmised that the patient experienced a vagal response, which led to bradycardia and syncope (fainting). The patient’s heart rate and blood pressure are less than 20% of her admission parameters; she is awake and lucid and is able to appropriately follow commands. What phase of the nursing process will impact the patient’s next step and what can she expect? a. The assessment phase will pursue laboratory diagnostic chemistry panels and arterial blood gases to determine oxygenation and potential for internal bleeding. b. The planning phase will review her current vital signs and symptoms compared to admission values, and she will continue to be monitored with IV fluids. c. The implementation phase will administer a titrated IV atropine until her blood pressure and heart rate are at or above preadmission values. d. The evaluation phase supports a period of watchful waiting while she receives IV fluids and sips juice.

ANS: B

The patient’s outcome is that she will maintain adequate cardiac output on discharge from the PACU as evidenced by blood pressure within preoperative range, her skin will be warm and dry, she will be oriented to person and place, and her pulse will be strong and regular. The nurse will monitor vital signs and physiologic parameters, level of consciousness, surgical site, intake and output; administer fluid and medication if indicated to improve depressed myocardial contractility, increase cardiac output, and promote diuresis. The patient will be monitored through phase I and phase II criteria until discharge.

REF: p. 272 5. A 49-year-old healthy male is beginning to emerge from general endotracheal anesthesia after

a transurethral laser lithotripsy of the left ureter. He is restlessly turning side-to-side and moaning. During the hand-off report from the anesthesia provider and circulating nurse, the perianesthesia nurse learned that the patient will probably continue to pass “sludge” (small granular ureteral stone material) for the next hour. As the surgical team rushes back to the OR to start the next case, the perianesthesia nurse thanks them and tells them they can go, because she knows what is wrong with the patient and will take care of him. The perianesthesia nurse’s comment reflects which phase of the nursing process and what will be her next actions? a. Her nursing diagnosis will prompt her to ask the patient to describe his pain. b. She is in the implementation phase as she checks the patient record for analgesia orders. c. She is in the assessment phase because she is not confident that the patient is awake enough to experience pain and continues to review vital signs and arouse him enough to speak. d. She has established a nursing diagnosis and is going to press the button on his patient-controlled analgesia pump to get medication circulating before he is fully awake.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

The nurse’s statement reflects that she has formulated a nursing diagnosis based on a few objective signs and the report about further ureteral sludge passage: acute pain related to operative procedure. His outcome goal is to exhibit a decreased level of pain or pain at a tolerable level on discharge from the PACU. The nurse’s next response is to assess for subjective signs of pain: patient reports pain; patient is given a visual analogue or numeric scale to rate pain level and assess for objective signs of pain—protective guarding behavior, moaning, crying, whimpering, restlessness, irritability, diaphoresis, dilated pupils, facial expression of pain, changes in vital signs (blood pressure, respiratory rate, or pulse).

REF: p. 273 6. A healthy 18-year-old was admitted to the PACU spontaneously breathing through his

endotracheal tube. Shortly after the perianesthesia nurse extubated the patient, he stopped breathing and his color changed to pale, dusky-beige. What is the most ideal action that should occur immediately? a. Administer oxygen 5 L/min by nasal cannula b. Administer oxygen 5 L/min by bag-valve-mask c. Perform head tilt–chin lift with gentle stimulation d. Reintubate and manually ventilate with bag-valve-mask at 4 L/min oxygen ANS: C

The patient had an airway obstruction. The first priority in the care of the postanesthesia patient is to establish a patent airway. A common cause of airway obstruction is the tongue, which is relaxed because of anesthetic agents and muscle relaxants used during surgery. The nursing action taken may be simple, such as stimulating the patient to take deep breaths, positioning the patient on the side, or providing supplemental oxygen. If the patient is still unresponsive, the nurse may need to open the airway with a chin tilt or jaw thrust.

REF: p. 273 7. Laryngospasm is a common but serious complication in the immediate postoperative pediatric

tonsillectomy and adenoidectomy patient. What is the ideal immediate and last resort response by the anesthesia provider or perianesthesia nurse in an emerging patient who has been in spasm for over 1 minute, is not responding to positive-pressure ventilation, and is in significant distress? a. Gentle stimulation and bag-valve mask ventilation with oxygen b. Suctioning, IV succinylcholine administration, and reintubation c. Emergency tracheostomy with a cricothyrotomy approach d. IV bronchodilator administration and nebulized oxygen treatment in the PACU ANS: B

Laryngospasm is a serious complication, usually the result of an irritable airway. The muscles of the larynx contract and partially or completely obstruct the airway; the patient can become hypoxemic quickly. If symptoms last longer than 1 minute and are unrelieved by positive pressure, administration of a muscle relaxant, such as succinylcholine, is required to relax the muscles of the larynx. Reintubation is undesirable and used only as a last resort.

REF: pp. 274-275

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 8. A 12-year-old developmentally delayed male scheduled for dental rehabilitation became

agitated on admission to the preoperative holding unit. In spite of sedation and the calming attention of the nurses and his parents, he was screaming and rapidly turning his head from side-to-side. He vomited and choked twice before he fell into a light but restless sleep. During the short procedure, the anesthesia provider was aware of rigidity and difficulty with ventilation in the patient’s chest, yet his oxygen saturation was between 96% and 100% throughout the procedure. On extubation, he presented with coughing, wheezing, dyspnea, use of accessory muscles, and tachypnea. The patient is presenting with ____________ probably caused by ____________. a. aspiration; vomiting b. bronchospasm; aspiration c. hypoxia; laryngospasm d. laryngospasm; traumatic intubation ANS: B

The patient has bronchospasm caused by aspiration of vomitus. Aspiration is the passage of regurgitated material into the lungs and can occur during the perioperative period, with most aspirations occurring during tracheal intubation or extubation. Prevention of aspiration postoperatively includes responding quickly to reports of nausea and vomiting, avoiding conversations that could elicit nausea and vomiting, and preventing rapid movement of the head. Bronchospasm is a lower airway obstruction caused by spasms of the bronchial tubes.

The patient presents with wheezing, dyspnea, use of accessory muscles, and tachypnea.

Bronchospasm can result from aspiration, pharyngeal suctioning, or histamine release secondary to allergic response or related to medication use.

REF: p. 275 9. Hypotension is a blood pressure reading that is 20% less than the patient’s normal baseline

pressure. Hypovolemia is the most common cause of hypotension; however, hypotension may also be caused by cardiac dysfunctions. Which triad of cardiac conditions will present with hypotension? a. Myocardial infarction, myocardial tamponade, and pulmonary embolism b. Cardiac ischemia, subaortic stenosis, and pericarditis c. Congestive heart failure, valvular dysfunction, and tachypnea d. Certain anesthetic agents and cardiac stimulants, conduction defects, and endocarditis ANS: A

Hypotension has been defined as a blood pressure reading that is 20% less than baseline or preoperative blood pressure measurement. It indicates either relative or absolute hypovolemia.

Cardiac output and vascular resistance determine blood pressure. Hypotension may be caused by cardiac dysfunction (such as myocardial infarction, tamponade, embolism, ischemia, dysrhythmias, congestive heart failure, valvular dysfunction) or by medications (including anesthetic agents).

REF: p. 275 10. Select the patient that is the most vulnerable and at high risk for hypothermia in the

perianesthesia phase based on diagnosis or surgical procedure. a. A 62-year-old patient who recently lost 80 pounds after a gastric sleeve and is scheduled for a cataract extraction.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. A 3-year-old child with otitis media having bilateral myringotomy with tube

placement c. A 3-week-old neonate undergoing surgery for a cardiac anomaly d. A 26-year-old patient undergoing escharotomy (fasciectomy) of an ankle with

second- and third-degree burns ANS: C

In many surgical services departments, postoperative cardiac surgery patients are transferred directly to the cardiac intensive care unit (ICU) rather than the PACU; however, their thermic needs must be met during this perianesthesia phase. Cardiac patients have considerable skin exposed during surgery and are often cooled to therapeutic hypothermic levels in order to decrease metabolic rate and oxygen demands during cardiopulmonary bypass. Especially vulnerable to the effects of hypothermia are the elderly and children 2 years old or younger.

There are four major risk factors for hypothermia; this includes three patient populations— neonates less than 1 month of age, burn patients, and patients whose surgery included general anesthesia with neuraxial anesthesia—along with low ambient temperature of the OR. Other risk factors include female gender, extreme age, length and type of surgical procedure, cachexia, significant fluid shift, and use of cold irrigants.

REF: p. 276 11. Select the statement below that best reflects the effects of hypothermia in the perianesthesia

period. a. Hypothermia causes physiologic stress and prolongs recovery time, primarily as a result of shivering. b. Hypothermia has often been shown to cause life-threatening morbidities. c. Shivering can increase the need for oxygen by 300% to 400%. d. Hypothermia causes fluid shift from the intracellular space, resulting from vasodilation.

ANS: C

Often hypothermia is not life-threatening; it does, however, cause physiologic stress.

Hypothermia can prolong recovery time and contribute to postoperative morbidity. In the PACU, tremendous demands are made on the body when the patient shivers. Shivering can increase the need for oxygen by 300% to 400%. Other problems associated with hypothermia include intravascular volume loss attributable to a fluid shift from the extracellular space, probably related to vasoconstriction.

REF: p. 276 12. A 46-year-old healthy male, admitted for a diagnostic arthroscopy, was prewarmed in the

preoperative holding lounge wearing a specialized patient gown with inlets for a forced air– warming device hose. After transfer to the OR bed, he was covered with an over-body adapted blanket of the same device. IV fluids cycled through a fluid warmer and the irrigation bags of sterile saline cycled through a warming device during the procedure. The perioperative nurse had preset the OR ambient temperature to 75° F. Select the statement that best reflects the justification for these practices. a. The patient will not produce heat when administered a general anesthetic. b. The patient will require more pain medication in the PACU if he is cold while recovering. c. The patient is at high risk for fever and shivering because of the possibility of an

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock abscessed knee. d. The patient is at high risk for malignant hyperthermia. and shivering is one of the triggers.

ANS: A

Prevention of heat loss continues in the OR. Under general anesthesia patients do not produce heat and depend on ambient temperature. Prevention of heat loss includes increasing the ambient temperature in the OR, providing the patient with warm blankets on arrival in the OR, and using draping techniques that minimize exposure during the procedure. Heated humidifiers and fluid warmers add heat. A common device to prevent hypothermia in the OR is a forced air–warming device.

REF: p. 276 13. Select the appropriate example of physiologic symptoms of pain. a. A proxy pain rating by someone who knows the patient well b. Facial grimacing and crying c. The patient’s self-report of pain d. Physiologic indicators, such as elevated vital signs ANS: C

Pain is a subjective experience and may or may not be verbalized. Often healthcare providers require objective signs of discomfort in addition to subjective reports of pain from the patient, which can lead to undertreatment of pain. The guiding principle in pain care is that pain is whatever the patient says it is; the most reliable indicator of the existence and intensity of pain is the patient’s self-report.

REF: p. 280 14. Evidence indicates that early analgesia reduces postoperative problems. Recent studies

endorse the multimodal approach to both preemptive (preventative) and postoperative analgesia customized to patient needs based on meticulous preoperative assessment. A 72year-old physically active woman was seen in the preoperative admission center in preparation for her total knee replacement surgery on Thursday. She has not had any opioid medications in her lifetime that she can remember. She has inflammatory bowel and gastric disease and was told she cannot take ibuprofen in any form. Select a multimodal analgesic treatment plan that would best serve the patient's perianesthesia experience. a. Intraoperative: Preincision—IV opioids, local lidocaine injection into the incision site before skin closure. Postoperative: Patient-controlled analgesia (PCA) with opioids and nonsteroidal antiinflammatory drugs (NSAIDs) b. Intraoperative: Preincision—regional block, IV opioids during the procedure.

Postoperative: PCA with opioids and nonsteroidal antiinflammatory drugs (NSAIDs) c. Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative: Systemic analgesia with COX-2–selective inhibitors, IV PCA with strong opioids d. Intraoperative: Spinal anesthesia with femoral nerve block. Postoperative: Systemic analgesia with COX-2–selective inhibitors, IV PCA with strong opioids (titrated to effect), and IM meperidine ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock See Figure 10-12. During preadmission testing/preparation, staff should identify candidates for PCA and teach its use, including the benefits of effective pain control, use of the pain scale, and the importance of reporting pain early. Evidence indicates that early analgesia reduces postoperative problems. Nonsteroidal antiinflammatory drugs (NSAIDs) and opiates are the analgesics of choice. Generally, they are used in combination (multimodal therapy) in the PACU. Using NSAIDs in combination with opiates can reduce opioid requirements by 20% to 40%. Traditionally, pain was treated with intramuscular (IM) injections of opioids at intervals from 3 to 6 hours as needed. Avoid meperidine except for treatment of shivering or allergy to other opioids. Contraindications to NSAIDs are aspirin-sensitive asthma, bleeding, coagulopathy disorders, history of gastrointestinal bleeding, renal compromise, and hypovolemia.

REF: p. 288 15. Postoperative nausea and vomiting (PONV) is a problem that affects approximately 30% of

PACU patients. Patients with four or more risk factors have a higher incidence of PONV. Select the option that best reflects relevant risk factors for PONV. a. Reaction to nitrous oxide, atopy, postmenopausal, use of volatile anesthetics b. Latex sensitivity, male gender, use of halogenated gas induction c. Predisposition to malignant hyperthermia, night sweats, motion sickness, male gender d. Nonsmoker, female gender, postoperative opioids, use of nitrous oxide ANS: D

Primary risk factors associated with PONV are female gender, nonsmoker, history of PONV or motion sickness, use of volatile anesthetics, use of nitrous oxide, postoperative use of opioids, duration of surgery, and type of surgery. Patients with four or more risk factors have a higher incidence of PONV. REF: p. 277 16. A key component of postoperative discharge instructions requires verification of

patient/family understanding of the instructions. A recent study found that only 67% of the discharge instruction comprehension was retained by day 3 postdischarge. What strategy best ensures patient/family understanding and comprehension of the discharge instructions? a. Written and signed instruction sheet with emergency and information contact numbers b. Follow-up e-mailed video clip of the patient/family teaching encounter c. Follow-up e-mail or telephone review of the discharge instructions on day 1 post discharge d. Patient/family teach-back of the discharge instructions to the nurse ANS: D

Review with the patient before discharge the interventions used and their efficacy, and provide specific discharge instructions regarding pain and its management. Have patient “teach back” or repeat instructions in his or her own words.

REF: p. 283

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. There are many therapeutic management strategies that have been successful in treating

PONV. What evidence-based practice best improves patient comfort, readiness for discharge, and satisfaction with care? a. Administration of promethazine as soon as the patient complains of nausea b. Pharmacologic prophylaxis c. Prophylaxis paralleled with anesthesia induction d. There is no single method to treat PONV ANS: B

Management of nausea and vomiting begins preoperatively and continues into the intraoperative period. Preventive therapy for patients at high risk of PONV is effective in reducing its incidence. There is no single method to prevent or treat PONV. Many causative factors relate to anesthesia and surgery. Pharmacologic prophylaxis improves patient comfort, readiness for discharge, and satisfaction with care.

REF: p. 277 18. It is estimated that 9% of women and 24% of men in the United States show disordered

breathing while asleep, and 2% of women and 4% of men show overt symptoms of obstructive sleep apnea (OSA). Postanesthesia management concerns with OSA patients include use of analgesia, appropriate oxygenation, patient positioning, and monitoring. What additional therapy is recommended for OSA patients during postoperative recovery? a. Incentive spirometry every 30 minutes while awake b. Coughing and forced deep breathing c. Continuous positive airway pressure (CPAP) d. Use of telemetry for monitoring pulse oximetry ANS: C

Supplemental oxygen should be used immediately postoperatively. Patients who use CPAP or noninvasive positive-pressure ventilation at home should continue to use these therapies during the postsurgery stay. The patient’s position can be changed based on the type of surgery to decrease the chance of airway obstruction. Lateral, prone, and sitting positions result in better airway management for the OSA patient compared to supine. Patients with OSA may require extended monitoring in the postoperative period.

REF: p. 286 19. Unfortunately, patients who are managed with opioids as part of their analgesic program can

have adverse events related to the medication. What are two of the most serious opioid-related adverse events? a. Pruritis followed by anaphylaxis b. Unintended advancing sedation and respiratory depression c. Respiratory depression and alveolar collapse d. Urticaria followed by anaphylaxis ANS: B

Two of the most serious opioid-related adverse events are unintended advancing sedation (which generally precedes respiratory depression) and respiratory depression. Education of the perioperative health care team and use of multimodal pain management are of utmost importance in decreasing these events.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 286 20. An opioid-naïve patient, one who has not used short-acting opioids in the last 60 days,

resedated on admission to the PACU and received which opioid antagonist to reverse the respiratory depression? a. Romazacon b. Ropivicaine c. Naloxone d. Pavulon ANS: C

Naloxone is the opioid antagonist used most frequently to reduce opioid-induced respiratory depression. It is administered slowly, never as a bolus, while the nurse observes the patient’s response. The patient should be able to open his or her eyes and talk to the nurse within 1 to 2 minutes of administration; naloxone is discontinued when the patient can take deep breaths on instruction and respond to physical stimulation.

REF: p. 285 MULTIPLE RESPONSE 1. Select three appropriate components of the hand-off report from the perioperative nurse to the

perianesthesia nurse as the patient is received in the PACU. (Select all that apply) a. Allergies, incisions, dressings and drains b. Use of radiologic shielding of the patient in the OR c. For pediatric patients, mother’s perinatal history d. Prognosis and presumed discharge date or time e. Patient’s identity and procedure performed f. Opportunity for clarification and questions ANS: A, E, F

The perioperative nurse may report in her hand-off: identity of patient; preoperative diagnosis; procedure performed; location of incision(s), dressings, drains, catheters, tubes, packing, stomas; surgical complications; allergies and reactions; medications, fluids, irrigations delivered by surgeon or registered nurse (RN); positioning during surgery; communication of other pertinent issues; questions and answers.

REF: p. 271 2. The perianesthesia nurse completes a systematic and comprehensive secondary assessment of

the patient (e.g., head-to-toe assessment or major body systems’ approach). Select the responses that best reflect the parameters of a comprehensive respiratory assessment. (Select all that apply) a. Rate, rhythm, and breath sounds b. Evidence of unabsorbed residual anesthetic vapors c. Artificial airway and oxygen delivery system d. Patient’s ability to take deep breaths on command ANS: A, C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Some PACUs use a head-to-toe assessment to organize the data obtained (Figure 10-1). Other PACUs take a major body systems’ approach (Figure 10-2). In any case, the PACU nurse assesses admitting vital signs and the ABCs, beginning with the respiratory system.

Respiratory assessment comprises rate, rhythm, auscultation of breath sounds for ventilatory adequacy, and oxygen saturation level. Any artificial airway and the type of oxygen delivery system are noted.

REF: p. 271 3. What parameters and questions will the perianesthesia nurse investigate while assessing

neurologic status? (Select all that apply.) a. Position of the patient’s arms at rest b. Pupillary reaction to light c. Orientation to person and place d. Level of consciousness ANS: C, D

The PACU nurse assesses neurologic function by asking questions such as the following: Has the patient reacted (awakened from anesthesia)? Can the patient follow commands? Is the patient oriented, at least to name and hospital? Can the patient move all extremities?

REF: p. 271 4. Hypothermia is a common side effect of surgery and the perianesthesia setting. Which of the

following interventions is most effective in normalizing and maintaining body temperature?

(Select all that apply.) a. Prewarming patients in normothermia b. Warming patients in hypothermia c. Setting ambient OR and PACU temperatures to 65° to 75° F and placing patient within forced air–warming blankets d. Using warmed skin prep solution during surgery e. Using continuous fluid-circulating blankets or warm-water mattresses f. Reapplying warmed cotton blankets every 10 minutes ANS: A, B, C

Postoperative hypothermia, defined as a temperature less than 36° C (96.8° F), continues to be a widespread PACU problem. Hypothermia can prolong recovery time and contribute to postoperative morbidity. Preventive warming measures are begun for normothermic patients and active warming measures instituted for hypothermic patients. A common device to prevent hypothermia in the OR is a forced air–warming device (Figure 10-5). Prevention includes increasing the ambient temperature in the OR and providing the patient with warm blankets on arrival in the OR. REF: p. 276

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 11: Gastrointestinal Surgery Test Bank MULTIPLE CHOICE 1. Select the statement that best describes the functional components of the gastrointestinal (GI)

tract. a. The GI tract is a continuous pathway from mouth to rectum. b. Peristaltic waveforms produce agitation, which digests large food particles. c. The alimentary canal extends from the mouth to the anus. d. The microscopic ecosystem of the GI tract is an unbalanced colony of germs.

ANS: C

The GI tract, or alimentary canal, is a continuous, tubelike structure that spans the human torso. It includes the mouth; pharynx; esophagus; stomach; small intestine, consisting of the duodenum, jejunum, and ileum; and large intestine. The large intestine consists of the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus.

REF: p. 295 2. A patient whose neck has been slashed and has a severed lower trachea may also have injury

to the: a. aorta. b. esophagus. c. duodenum. d. bronchial merge.

ANS: B

The esophagus begins at C6 and passes through the neck posterior to the trachea.

REF: p. 295 3. Exposure of intra-abdominal anatomy is crucial to safe surgery and employs varied

instruments, applications of highly technical energy sources, patient manipulations, light, and imaging. Review the list below and select the technique that is initiated to promote exposure. a. Insertion of self-retaining retractors b. Employing the Hasson technique c. Establishing pneumoperitoneum d. Insertion of fan retractor ANS: C

The general progression of a laparoscopic procedure includes gaining abdominal access, establishing pneumoperitoneum, exposing the targeted organ, completing the critical steps of the procedure, extracting a specimen, irrigating the wound, and closing the incisions.

REF: p. 311 4. When compared with open and laparoscopic techniques, the potential benefits of NOTES

include no visible scars, possibly less pain, and potentially shorter hospital stays. Select a complication that is the most typical risk associated with NOTES.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

Colitis Peritonitis Paralytic ileus Intestinal obstruction

ANS: B

NOTES appears to be a promising alternative approach for GI surgery in the future. However, the surgeon must open a closed viscera intentionally to access the abdomen. Complications related to the failure of that opening to heal after closure can result in peritonitis.

REF: p. 314 5. As the surgeon prepared to clamp and transect the bowel during a small bowel resection for

tumor, the scrub person transferred instruments from the Mayo stand to the back table and prepared the sterile field for bowel isolation technique. Review the list below and select the nursing diagnosis that is most closely related to bowel isolation technique. a. Risk for infection b. Risk for metastasis c. Risk for tissue injury d. Risk for positional injury ANS: A

Bowel technique, also referred to as contamination or isolation technique, prevents crosscontamination of the wound or abdomen with bowel organisms. To implement proper technique, the surgical team must keep clean and dirty items separate during open bowel procedures. Instruments used for bowel resection and anastomosis are kept separate from the rest of the sterile back table. Contaminated GI tract instruments are handed off or left on a separate Mayo stand. After wound irrigation, the surgical team dons fresh gowns and gloves.

Clean instruments are used for closure. Planning during preoperative setup includes having additional drapes, towels, gowns, gloves, and the necessary extra instruments to accommodate bowel technique.

REF: p. 304 6. During a laparoscopic colectomy, the scrub person carefully placed the endoscopic

electrosurgery instruments on the Mayo stand after inspecting the integrity of the insulation along the shaft. This practice is designed to meet the expectation for the following nursing outcome: The patient will be free from injury due to: a. fluid and electrolyte imbalance. b. thermal burns and adhesions. c. impaired tissue integrity. d. thermal burns and adhesions and impaired tissue integrity.

ANS: C

The patient is at risk for impaired tissue integrity due to lasers, thermal devices, electrosurgery, radiation, or chemical solutions. To protect the patient from impaired tissue integrity, follow institutional practice guidelines.

REF: p. 300

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 7. A 72-year-old male is scheduled for a total colectomy with ileostomy in the morning. The

wound ostomy care nurse (WOCN) has consulted the patient to initiate his ostomy teaching, answer his questions, and mark the site on his abdomen that would be the ideal placement for the ileostomy. An appropriate nursing diagnosis for the patient at this time would be: a. impaired comfort. b. deficient knowledge related to surgical energy modalities. c. disturbed body image related to intestinal diversion. d. acute pain.

ANS: C

The patient may have body image concerns about his postoperative appearance. This is a nurse-sensitive condition that can be addressed with education and caring behaviors.

REF: p. 300 8. Which statement about the McBurney incision is most correct? a. It is an oblique inguinal incision in the left lower quadrant. b. It is the incision of choice to repair a direct inguinal hernia. c. It is an oblique inguinal incision in the right lower quadrant. d. The direction is more transverse than oblique.

ANS: C

Use of the McBurney muscle-splitting incision is common for open appendectomy. In the lower right abdomen the surgeon incises the skin along the skin tension lines at a point onethird of the distance between the anterior iliac spine and the umbilicus.

REF: p. 308 9. Triangular orientation is a term used to describe the method used to provide instrument access

to the anatomy during abdominal surgery. It is uniquely associated with which surgical incision? a. Mid-epigastric transverse incision b. Left paramedian incision c. Thoracoabdominal incision d. Laparoscopic port incisions ANS: D

Traditional laparoscopic port placement, via triangulation, is the fundamental concept of laparoscopic surgery. It places the instruments on planes where they meet to effectively support dissection with adequate visualization and identification of anatomy and pathology.

Incorrectly placed ports can cause sword-fighting instruments and indirect access to the operative anatomy.

REF: p. 313 10. When setting up for a Billroth I gastrectomy, the scrub person will ensure that the appropriate

vascular instruments are available to clamp and ligate the: a. epiploic branches of the peritoneal artery. b. gastric branches of the gastroepiploic vessels c. gastric branch of the peritoneal artery. d. Treitz arterial stump.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

In a Billroth I gastrectomy, the surgeon opens and explores the abdomen through an epigastric midline incision. A self-retaining retractor is positioned to optimize exposure. Mobilization of the greater curvature of the stomach begins with sharp entry into the gastrocolic ligament, midway along the greater curvature. Working toward the duodenum, the surgeon frees the stomach from the gastrocolic omentum by ligating and dividing the gastric branches of the gastroepiploic vessels close to the gastric wall, leaving the gastrocolic omentum. This occurs with clamps and ties, hemostatic clips, ultrasonic sheers, or with a sealing bipolar instrument.

REF: p. 324 11. Two patients are scheduled to have a gastrojejunostomy for obstruction. How will

perioperative planning differ for a patient weighing 280 lb as compared to that for a 120 lb patient? a. The ligament of Treitz will not need to be identified in a lighter person. b. Forced air–warming devices are more important for a lighter patient. c. The anastomosis will require sutures rather than staples for the heavier patient. d. Deaver retractors will replace Richardson retractors with the heavier patient.

ANS: D

All larger patients undergoing surgery need special consideration because they usually have associated serious comorbidities that place them at heightened risk during the procedure. The larger patient will require longer instruments, deeper retractors, and extra large blood pressure cuffs.

REF: p. 330 12. A 42-year-old woman has been diagnosed with severe gastroesophageal reflux disease

(GERD) without the dysplastic changes of Barrett’s esophagus. Her GERD is unresponsive to proton pump inhibitors and histamine blockers. She also has a history of endometriosis with multiple surgeries for ablation of endometrial implants on her small bowel and adhesiolysis.

Her surgeon is hesitant to pursue an open or a laparoscopic Nissen fundoplication surgical approach. Which procedure might her surgeon consider in lieu of a Nissen? a. Thoracoabdominal partial esophagectomy b. Endoscopic mucosal resection c. Intraluminal plication of the lower esophageal segment d. Heller’s myotomy ANS: C

Intraluminal plication is an antireflux procedure that can be performed endoscopically. The EsophyX technique endoscopically creates a 260-degree internal plication of the gastric fundus to create a neogastroesophageal valve.

REF: p. 317 13. Pure NOTES procedures are transluminal procedures performed using flexible endoscopes

and instruments passed through the scopes’ working channels. Many surgeons use a hybrid NOTES technique. What is the difference between the pure NOTES and hybrid technique? a. Pure NOTES does not use the rectal approach. b. Hybrid NOTES is laparoscopic assisted. c. Pure NOTES does not use the vaginal approach.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Hybrid NOTES considers the umbilicus a natural orifice.

ANS: B

Many surgeons use a hybrid NOTES technique that combines laparoscopic visualization with natural orifice access. Using a transvaginal hybrid NOTES technique, the surgeon inserts a 3or 5-mm access port at the umbilicus to create a pneumoperitoneum. The surgeon next inserts a rigid laparoscope into the abdominal access port to visualize entry of the vaginal access port from inside the abdomen and then moves the laparoscope to the vaginal access port.

REF: pp. 314-315 14. Select the diagnosis/procedure option that pairs the correct surgical diagnosis with the

surgical/endoscopic procedure for diseases of the esophagus. a. Barrett’s dysplasia of the distal esophagus/endoscopic mucosal resection (EMR) b. GERD/photodynamic therapy (PDT) c. Zenker’s diverticulum/Ivor Lewis esophagectomy d. Esophageal varices/Heller myotomy ANS: A

EMR is the excision of dysplastic lesions related to Barrett’s esophagus (BE).

REF: p. 317 15. Review the list below and select the answer that reflects the correct match between the

procedure and the disease. a. Duodenoscopy for gastric reflux disease and hiatal hernia b. Roux-en-Y for gastritis c. Esophagogastroduodenoscopy (EGD) for gastric ulcer disease d. Small bowel enteroscopy for ulcerative colitis ANS: C

Common GI endoscopy procedures used to establish a diagnosis or monitor gastric disease include EGD (also referred to as gastroscopy or upper endoscopy).

REF: p. 315 16. A 12-year-old girl with a history of weight loss and stomach upset and pain after eating is also

small for her age. Her pediatrician suspects celiac disease. The patient has arrived at the pediatric endoscopy unit for a procedure that is less invasive and will also have the benefit of spending the next few hours in the mall across from the hospital with her mom until the procedure is over. What is her scheduled procedure? a. GI manometry b. Small bowel enteroscopy c. Capsule endoscopy d. Stretta procedure ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Capsule endoscopy is a noninvasive diagnostic test that uses a small wireless camera in the shape of a capsule about the size of a large vitamin. It is swallowed with a few sips of water and propelled along the GI tract by normal peristalsis. The capsule glides down the esophagus, taking two color digital pictures per second, which it transmits to a recording device worn by the patient. This device is suitable for imaging the mucosal surface of the esophagus, stomach, and small intestine.

REF: p. 316 17. Select the option that pairs the correct surgical diagnosis with the surgical/endoscopic

procedure for diseases of the abdomen. a. Colon cancer/laparoscopic Roux-en-Y (RNY) b. Ascites/hyperthermic intraperitoneal antibiotic therapy (HIAT) c. Obesity/laparoscopic adjustable gastric banding (LAGB) d. Esophageal varicies/photo dynamic therapy (PDT) ANS: C

Bariatric surgery, also termed weight loss or weight reduction surgery, is surgical treatment of obesity. There are three categories of bariatric procedures: restrictive (such as laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy), malabsorptive, or a combination of both. Restrictive procedures reduce the size of the stomach.

REF: p. 329 18. A 38-year-old female has been admitted through the emergency department (ED) for severe

abdominal pain, distended abdomen, and fever. The surgery service has been consulted and has scheduled her for exploratory surgery. The patient has undergone two open abdominal surgeries in the past for “female problems” and states that she has a tendency to form keloids.

Review the list below and select the most likely preoperative diagnosis for the patient based on her surgical history and symptoms. a. Keloidal mass of the mesentery b. Endometriosis plaques on the small bowel c. Small bowel obstruction with torsion d. Ruptured appendix ANS: C

Adhesions can form between the peritoneal surfaces of the abdominal wall and its underlying abdominal structures, or they can form between adjacent structures within the abdomen such as the omentum, small bowel, and colon. Adhesions may be asymptomatic but often result in complications that can occur in the early postoperative stage or years after an abdominal surgery. Complications include small bowel obstruction, abdominal/pelvic pain, and infertility.

REF: pp. 331-332 19. A 55-year-old woman has arrived for an outpatient Stretta procedure. She is assessed by the

perioperative nurse to be in good health and is listed as American Society of Anesthesiologists (ASA) class I. The patient changes into her gown and awaits transfer to the procedure room when she is informed that she will not be transferred to the procedure room until __________ and must wait for ________: a. she is typed and screened; type and crossmatch b. her ride home arrives; a responsible adult

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. she is NPO for 2 more hours; a bowel prep d. her esophagus is cleansed; return of gag reflex ANS: B

The patient will be sedated during the Stretta procedure, so she will need a responsible adult to accompany her to the facility, drive her home, and remain with her for 24 hours.

REF: p. 317 20. A patient consulted a noted colorectal surgeon after experiencing episodes of rectal bleeding

over the last 2 weeks. The patient had a screening colonoscopy 5 years ago with several adenomatous polyps and mild diverticular disease. She presents to the endoscopy suite after a successful bowel prep and NPO since midnight. The GI endoscopist is confident that he will find tumor growth in the rectum and decides to employ further diagnostic applications to determine potential for metastasis. Which of the following endoscopic procedures best describes the patient’s procedure? a. Endoscopic retrograde cholangiopancreatoscopy (ERCP) with biopsies b. Rectal manometry with dilatation c. Flexible sigmoidoscopy with chromotherapy d. Colonoscopy with endoscopic ultrasound (EUS) ANS: D

Colonoscopy provides endoscopic visualization of the colon from the rectum to the ileocecal valve. The clinician inspects the mucosa for abnormalities such as sites of bleeding, polyps, inflammation, ulceration, or tumors during both insertion and withdrawal of the colonoscope.

Colonoscopy can be diagnostic and therapeutic. An endoscopic ultrasound (EUS) combines endoscopy and ultrasound, using sound waves to generate an image of the histologic layers of the esophageal, gastric, and intestinal walls. EUS is critically important in staging GI malignancies and determining surgical options and potential for therapeutic resection. The frequencies used, higher than those used in traditional ultrasound, provide highly accurate depths of any mucosal invasion.

REF: pp. 316-317 21. A 19-year-old male has suffered from subsacral pain and swelling for 2 weeks and finally was

referred to a colorectal surgeon for care. He is currently in the ambulatory surgical center operating room (OR) bed positioned in the jackknife position. The perioperative nurse has gently but firmly taped his buttocks laterally to the rails of the OR bed to promote exposure to the surgical site. Which procedure is the patient prepared to undergo based on his symptoms and the surgical preparation? a. Internal hemorrhoidectomy b. External hemorrhoidectomy c. Removal of rectal foreign body d. Pilonidal cystectomy ANS: D

Excision of a pilonidal cyst and sinus is removal of the cyst with sinus tracts from the intergluteal fold on the posterior surface of the lower sacrum. A pilonidal cyst and sinus, which may be congenital in origin, rarely become symptomatic until the individual reaches adulthood, most commonly in young men. The patient is placed in the jackknife position with the buttocks taped open laterally and secured to the sides of the OR bed.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 346

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 12: Surgery of the Liver, Biliary Tract, Pancreas, and Spleen Test Bank MULTIPLE CHOICE 1. The liver, pancreas, and spleen share many similarities. Select the statement about these

organs that is true. a. All three are solid organs and very vascular. b. All three are metabolic organs. c. All three organs have terminal attachments to the duodenum. d. All three can be donor or recipient transplant organs.

ANS: A

A pathologic condition in the liver, biliary tract, pancreas, or spleen often requires surgical intervention. These organs are highly vascular and control many of the body’s metabolic and immune functions. Solid organ transplantation, such as for the liver and pancreas, is a common means to treat primary hepatic tumors, end-stage liver disease, and insulin-deficient diabetes.

REF: p. 350 2. The functional units of the liver are the lobules. The functional cells of the liver are the

______________, and they manufacture _______________. a. Kupffer cells; phagocytes b. sinusoid cells; lymphocytes c. hepatocytes; bile d. portal triad cells; ductal epithelium ANS: C

Lobules are the functional units of the liver. Each lobule contains a portal triad that consists of a hepatic duct, a hepatic portal vein branch, and a branch of the hepatic artery, nerves, and lymphatics. The hepatic cords consist of numerous columns of hepatocytes—the functional cells of the liver. The hepatic sinusoids are the blood channels that communicate among the columns of hepatocytes. The sinusoids have a thin epithelial lining composed primarily of Kupffer cells—phagocytic cells that engulf bacteria and toxins. Bile is manufactured by the hepatocytes.

REF: p. 350 3. The liver is essential in the metabolism of carbohydrates, proteins, and fats, generating

nutrient stores of which substance that supplies energy sources to the brain and body? a. Carbohydrate glucose substrate b. Glycogen c. Serum glucosamine d. Bile salts ANS: B

The liver is essential in the metabolism of carbohydrates, proteins, and fats. It metabolizes nutrients into stores of glycogen, used for regulation of blood glucose levels and as energy sources for the brain and body functions.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 350 4. The biliary system (also called the biliary tree) drains bile from the gallbladder to the ampulla

of Vater. The primary function of the gallbladder is to: a. manufacture bile. b. convert bile salts into bile enzymes. c. store and concentrate bile. d. contract to secrete bile into the hepatic duct.

ANS: C

The gallbladder, which lies in a sulcus on the undersurface of the right lobe of the liver, terminates in the cystic duct. This ductal system provides a channel for the flow of bile to the gallbladder, where it becomes highly concentrated during storage. The liver produces about 600 to 1000 mL of bile each day. The gallbladder’s average storage capacity is 40 to 70 mL. As the musculature of the gallbladder contracts, bile is forced into the cystic duct and through the common duct. As the sphincter of Oddi in the ampulla of Vater relaxes, bile is released, flowing into the duodenum to aid in digestion by emulsification of fats.

REF: pp. 351-352 5. The head of the pancreas is fixed to the: a. spleen. b. duodenum. c. stomach. d. biliary tree ANS: B

The pancreas is a fixed structure lying transversely behind the stomach in the upper abdomen.

The head of the pancreas is fixed to the curve of the duodenum.

REF: p. 352 6. While the pancreas’ function is carbohydrate metabolism with the production of insulin and

digestive enzymes, the spleen’s function is primarily ___________ with the production of _______________. a. immunologic; leukocytes b. metabolic; granulocytes c. anabolic; plasma cells d. as a blood reservoir; phagocytes ANS: A

The spleen has many functions. Among them are defense of the body by phagocytosis of microorganisms, formation of nongranular leukocytes and plasma cells, and phagocytosis of damaged red blood cells. It also acts as a blood reservoir. The pancreas contains groups of cells, called islets, or islands, of Langerhans, that secrete hormones into the blood capillaries instead of into the duct. These hormones are insulin and glucagon, and both are involved in carbohydrate metabolism.

REF: p. 352 7. An example of an indication for liver transplantation would be:

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

end-stage liver disease resulting from advanced hepatic cancer with metastasis. acute fulminant biliary disease of unknown origin. infection caused by untreated cystic anomalies. primary hepatic cancer.

ANS: D

Liver transplant procedures include entire organ transplants as well as living-related organ donations. Liver transplantation is indicated for patients with chronic hepatocellular disease, chronic cholestatic disease, metabolic liver disease, primary hepatic cancer, acute fulminant liver disease, and inborn errors of metabolism.

REF: p. 376 8. A 9-year-old boy is admitted to the emergency department (ED) after a sledding accident in

which he lost control of his sled and crashed into a tree. He is pale and in pain; his abdomen is tender and firm to palpation. The computed tomography (CT) scan suggests rupture of the spleen with internal bleeding. The scheduled surgery will most probably be a(n): a. laparoscopic splenic resection with sutured mesh overlay. b. open splenic lobectomy with vascular ligation. c. open total splenectomy. d. open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.

ANS: C

Splenectomy is removal of the spleen. It is performed for multiple reasons, including trauma to the spleen. For these patients an open approach is indicated.

REF: p. 379 9. The Whipple procedure is the removal of the head of the pancreas, the entire duodenum, a

portion of the jejunum, the distal third of the stomach, and the ____________ as a surgical treatment for____________. a. left lobe of the liver; metastatic hepatocytoma b. distal segment of the spleen; pancreatic metastasis c. inferior margin of the ligament of Treitz; pancreatic cancer d. lower half of the common bile duct; pancreatic cancer ANS: D

Pancreaticoduodenectomy (Whipple procedure) is the most common procedure for those with pancreatic cancer. In the Whipple procedure, the head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the common bile duct are removed, with reestablishment of continuity of the biliary, pancreatic, and GI tract systems.

REF: p. 371 10. Open common bile duct (CBD) exploration may be indicated in some cases where: a. the patient has undergone prior biliary surgery. b. a positive cholangiogram shows an obstruction in the pancreatic duct. c. endoscopic, percutaneous, or laparoscopic techniques are possible. d. the patient’s insurance will only reimburse for an open approach.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

With the advent of endoscopic, percutaneous, and laparoscopic techniques, open exploration of the CBD is rare. However, when these methods are not available, when they are not possible because of prior surgery, or when an open procedure is otherwise necessary, open CBD exploration is performed.

REF: p. 367 11. An example of a potential risk associated with pneumoperitoneum would be: a. tachycardia caused by peritoneal irritation from the CO2. b. CO2 absorption into the peritoneal capillaries, causing decreased oxygen saturation. c. bradycardia from CO2 pressure lower than 15 mm Hg. d. gas embolus into an exposed blood vessel during the procedure.

ANS: D

The gas of choice for pneumoperitoneum is CO2. Elevated CO2 levels and respiratory acidosis may occur because CO2 diffuses into the patient’s bloodstream during laparoscopy. Intraabdominal pressure is normally between 8 and 10 mm Hg, and the surgeon commonly uses that range as an indicator for proper Veress needle placement. The perioperative nurse should set the insufflation unit to a maximum pressure of 15 mm Hg. When intra-abdominal pressure reaches 15 mm Hg, flow will stop. Pressure higher than 15 mm Hg may result in bradycardia or a change in blood pressure, or it may force a gas embolus into an exposed blood vessel during the operative procedure.

REF: pp. 361-362 12. A 51-year-old male with hepatobiliary disease is scheduled for surgery. The perioperative

nurse, during the preoperative assessment, questions and examines the patient for signs and symptoms of jaundice, petechiae, and lethargy and: a. reviews his chart for bleeding and coagulation times and the platelet count. b. asks his blood type and when he last donated blood. c. palpates his abdomen for left upper quadrant tenderness and liver margins. d. reviews the findings of his endoscopic retrograde cholangiopancreatoscopy (ERCP).

ANS: A

The patient with hepatobiliary disease may have extreme jaundice, urticaria, petechiae, lethargy, and irritability. Depending on the extent of the disease, bleeding and coagulation times may increase and the platelet count may decrease, contributing to intraoperative concerns with achieving hemostasis. A thorough nursing history is necessary for proper assessment of the health status of patients with dysfunctions of the hepatobiliary system, pancreas, or spleen.

REF: pp. 352, 381 13. A 39-year-old, 248-pound mother of four children is assisted with transfer from a transport

vehicle to the OR bed for laparoscopic cholecystectomy, operative cholangiogram, and possible CBD exploration. The perioperative nurse identifies that the patient is at risk for positional injury related to her size and the positional requirements and OR bed manipulations required for this procedure. An appropriate nursing implementation for positioning this patient would be to:

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. place two safety belts over the thighs and lower legs to prevent the patient from

sliding out of position when the surgeon tilts the table for better exposure and access. b. place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant of the abdomen. c. abduct the patient’s right arm on an armboard at less than 90 degrees to allow an assistant to stand near the patient’s right upper quadrant and retract the liver with a wide Deaver retractor. d. Place the patient on a radiolucent OR bed and place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant.

ANS: D

For biliary surgery the patient is placed in a supine position. Arms are placed on padded armboards with the palms up and fingers extended. A small positioning aid may be placed under the lower right side of the thorax to elevate the lower rib cage, providing better exposure and access to the viscera in the right upper quadrant of the abdomen. When anticipating an operative cholangiogram, the perioperative nurse must ensure that the OR bed has been equipped and positioned so that C-arm image intensification can be accomplished efficiently.

REF: p. 356 14. The circulating nurse approaches the preoperative holding lounge to see her next patient, a 57-

year-old nurse, newly diagnosed with pancreatic cancer. He had an endoscopic retrograde cholangiopancreatography (ERCP) 1 week ago and, based on the findings, was scheduled for surgery at the comprehensive cancer center, where he works in the interventional endoscopy unit. He is aware of the poor prognosis for this disease, and the nurse has recorded his nursing diagnosis as anxiety related to impending surgical procedure, perioperative events, and surgical outcome. An appropriate nursing action for the patient would be to: a. encourage verbalization of his fears and reinforce the standardized age-appropriate coping mechanisms. b. describe for him the steps of the operative procedure. c. offer emotional reassurance by using touch, assisting him to a position of comfort on the OR bed, and offering warm blankets (thermal comfort). d. share with him his nursing diagnosis and reinforce the desired nursing outcome related to anxiety.

ANS: C

When patients are anxious, the perioperative nurse should speak slowly and clearly, using terminology the patient can understand. Offer emotional reassurance by using touch, assisting the patient to a position of comfort on the OR bed, and offering warm blankets (thermal comfort).

REF: p. 355

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 15. A perioperative nurse was the scrub person during a robotic-assisted laparoscopic

cholecystectomy. She locked the robotic endoscissor into the adaptor on the robotic arm and positioned the tip end into the trocar port in order for the surgeon to dissect the cystic duct and artery, while the surgical assistant placed the clips on the cystic duct and artery. As she reached across the sterile field to insert the cholangiocatheter through the port, the anesthesia provider accidentally made contact with the distal end of the catheter as he stood up to reach the monitor controls. The contaminated end of the catheter touched the endoscopic clip applier, the endoscissor connector that the surgeon was using, the glove of the assistant, and the perioperative nurse’s gown sleeve. The surgeon ordered everyone to change their gown and gloves and covered the port area with a sterile towel. What was the rationale for the surgeon to continue to dissect and not change his attire? a. The tip of the dissector that was in the patient’s abdomen was not contaminated. b. The surgeon planned to remove the dissector after he finished dissecting and then dispose of it. c. The surgeon’s gown was not touched, just the dissector connection to the robotic arm. d. The surgeon was not in contact with the sterile field because he worked from the robotic console.

ANS: D

The surgeon manages the robotic system from a console away from the operative field. With current robotic systems, the surgeon sits at an operative console with three-dimensional imaging and handheld controls. Movement of the controls follows the movement of the instrument’s tip. Robotic arms function just like a surgeon’s hands.

REF: p. 364 16. During an emergent total open splenectomy on a patient with blunt force trauma to the

abdomen, the circulating nurse and anesthesia provider noticed rust-colored urine in the urinary collection container. They had just hung the third unit of whole blood. What nursing action is the first priority? a. Send a sterile urine sample for stat cytologic studies. b. Notify the scrubbed team of the urine color change and check the bladder for trauma. c. Stop the blood transfusion. d. Check the blood unit for patient-specific identification and expiration date.

ANS: C

The first response is to stop the transfusion. The surgical team had just started transfusing another unit of blood, and the probability of a transfusion reaction is likely. There would be no immediate harm to the patient from stopping the blood transfusion. Instead, the surgical team should increase the IV flow rate of saline or lactated Ringer’s. When additional blood or blood products are required, the perioperative nurse communicates with blood bank personnel so that products are readily available, and then in conjunction with the anesthesia provider completes the required steps to verify blood/blood products before transfusion. Autologous blood or donor-directed blood products may be used in elective procedures involving the liver, pancreas, spleen, and biliary tract. Cell saver devices may be used.

REF: p. 359

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. What technologic characteristic of robotic surgery provides a superior indication for robotic-

assisted laparoscopic cholecystectomy? a. The surgeon controls two instruments plus a camera while an assistant suctions and retracts. b. Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage. c. It provides a 360-degree range of motion, extending surgeon skill. d. Robotic stapler and suture devices promote intracorporeal anastomotic techniques.

ANS: C

Robotic surgery offers multiple benefits: less blood loss, faster recovery, less scarring, and reduced postoperative pain. The robot extends the surgeon’s skills by providing a 360-degree range of motion that is not possible with traditional laparoscopic instruments. It also allows access to all the fine structures of the liver and better visualization of delicate blood vessels.

REF: p. 364 18. A 29-year-old man with paraplegia caused by a spinal cord injury from a diving accident 4

years ago is scheduled for an open cholecystectomy. The perioperative nurse conducts a preoperative assessment to prepare for his procedure. The patient tells the nurse that he is latex-sensitive, because he was told that as a spinal cord injured person he should always be considered latex-allergic. An appropriate risk reduction strategy for the patient’s latex sensitivity/allergy would be to: a. advise the anesthesia provider to premedicate with an H2 blocker, diphenhydramine, and prednisolone. b. alert the OR and postoperative recovery areas of his latex allergy, check the setup for latex-containing items, and replace those items with nonlatex alternatives. c. transfer his care to the pediatric OR in the adjoining hospital where everything in the OR is latex-free. d. position code and latex carts outside of the OR and watch for signs of latex reaction; tape an epinephrine-filled syringe to the head of his transport vehicle.

ANS: B

Notify healthcare providers in other perioperative areas of the patient’s latex sensitivity status.

Plan for a latex-safe environment of care: Remove all latex products from the room unless no alternative exists.

REF: p. 367 19. A 42-year-old woman from India is visiting her daughter and new grandson. She is a devout

follower of Hindu religious practices and has been diagnosed with splenomegaly, possibly from idiopathic thrombocytopenia. The patient is scheduled for a total splenectomy. During the preoperative assessment, the perioperative nurse, an observant practitioner of Hinduism, is concerned about the possibility of significant bleeding because of the patient’s coagulopathy and the need for hemostatic agents that are typically used to stop bleeding. Many of these products are manufactured from bovine source products, and it would be in conflict with the patient’s religion to use products from a cow. An appropriate risk-reduction strategy for selection of hemostatic agents that would not be in conflict with the patient’s belief system would be: a. substitute absorbable gelatin and oxidized collagen products; soak in thrombin. b. substitute absorbable gelatin and oxidized collagen products; use high ESU settings.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. substitute absorbable gelatin and oxidized collagen products; use regular ESU

settings. d. substitute microfibrillar collagen soaked in thrombin; add epinephrine 1:1000.

ANS: C

These hemostatic products do not contain bovine products: absorbable gelatin, powder, or compressed forms (Gelfoam); purified porcine gelatin, beaten, dried, and heat-sterilized; and oxidized cellulose (Surgicel, Surgicel Nu-Knit); absorbable oxidation product of cellulose.

These products are manufactured from bovine products: absorbable collagen (Collastat, Superstat, Helistat); bovine collagen origin. Collagen activates the coagulation mechanism, aggregation of platelets; microfibrillar collagen (Avitene, Instat), hydrochloric acid salt of purified bovine corium collagen; thrombin enzyme extracted from bovine blood.

REF: p. 357 20. The donor liver OR is prepared for an open laparotomy procedure with basic laparotomy and

vascular instruments and accessories. A second sterile, draped medium-sized instrument table is set up to receive and prepare the procured liver away from the main sterile field. Select the additional instruments and accessories needed on the donor organ preparation table. a. Flushing solution, sterile plastic containers, and in situ flush tubing b. Flushing solution, ice chest, sterile ice, powered sternal saw, and long Kocher clamps c. Culture tubes, Wisconsin University forceps, Deaver retractors, and slush machine d. Toothed forceps, vessel loops, two sterile plastic draw-string bags, and flushing solution ANS: A

The donor OR is set up for a major laparotomy procedure. Basic instrumentation and equipment include a basic laparotomy set, cardiovascular instruments, power sternal saw, and nephrectomy instruments. A sterile, draped, medium-size instrument table is needed for preparation of the liver away from the main sterile field and instrument tables. The procurement team provides special Collins solution for flushing the organs, sterile plastic containers and ice chests for organs, and in situ flush tubing. The liver is generally placed in two Lahey bags immediately after procurement.

REF: p. 376 21. The recipient liver OR is arranged for a major laparotomy and vascular procedure with

customized instruments, supplies, and sutures according to the transplant surgeon’s preference. In addition to the general patient care accessories, equipment, and supplies needed for any large surgery, also included are intraoperative laboratory testing and an autotransfusion system. Describe the boundaries of the surgical skin prep for the patient about to receive a liver transplant. a. From neck to midthigh; midaxillary line to midaxillary line b. From nipple line to pubis; bedline to bedline c. From the neck to midthigh; bedline to bedline d. From nipple line to midthigh; midaxillary line on the patient’s left side, and bedline on the right ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The patient is prepped from the neck to midthigh, bedline to bedline. Prep solution should not pool at the bedline or wet the sheets on the OR bed. Fire safety precautions for prep solutions must be followed.

REF: p. 377 22. Review the list below and select the first step the perioperative nurse must accomplish as a

best practice for donor organ identification. a. Sign receipt for organ b. Ensure crossmatch and ABO reports from human leukocyte lab and bloodbank have been received c. Verify the recipient’s preliminary crossmatch and ABO report d. Identify the recipient ANS: B

Before the transplant surgical procedure, a process of nine checkpoints is implemented to ensure identity and matching between the organs/tissues of the donor and the recipient. Before the patient enters the OR, the following must occur: (1) Once a transplant has been posted, preliminary transplant crossmatch reports are faxed from the human leukocyte antigen (HLA) lab to the transplant OR. The blood bank will fax ABO reports. (2) The OR charge nurse verifies the posted recipient’s preliminary crossmatch report and the ABO report. (3) The organ arrives at the OR. (4) The circulating nurse applies an addressograph label to the box with the organ. (5) The circulating nurse and another registered nurse together do the following: (a) verify the tag on the organ with the preliminary transplant crossmatch report to ensure the following match: (i) the recorded ABO type of the recipient is the same or is compatible with the recorded ABO type of the donor, (ii) the United Network for Organ Sharing (UNOS) number on the organ is the same as the UNOS number on the preliminary transplant crossmatch report; (b) identify the patient according to usual hospital policy; (c) sign the transplant verification form. In the OR the following must occur: (6) Preliminary anatomic checks are done by the surgeon. The transplant surgeon verifies that the UNOS number on the preliminary transplant crossmatch report is the same as the UNOS number on either the organ container or the paperwork provided and verifies the compatibility of the organ and the patient by ABO blood type. The transplant surgeon signs the transplant verification form. (7) Once the patient is taken into the OR, a time-out is taken with the OR team according to OR policy and procedure. (8) The transplant verification form and preliminary transplant crossmatch report are a permanent part of the patient’s medical record.

(9) The transplant verification form (deceased donor) is attached to the record.

REF: p. 373 MULTIPLE RESPONSE

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 1. Both Maryanne and Charles Rigler had surgery 6 days ago. Charles had a living-related donor

liver transplant and Maryanne, the matched donor, provided a segment of her healthy liver for her husband. They have both recovered as expected and are preparing for discharge. They are concerned about who will be the primary caregiver, because they are both recovering at the same time and rate. They also realize that they will need clear and realistic instructions and support because of their unique situation. They are most concerned about incision care, side effects that could mean complications, nutrition, and activity restrictions and escalation. An appropriate risk reduction strategy for Maryanne and Charles would give first priority to (Select all that apply.): a. secure an order for social services consult. b. secure an order for a physical rehabilitation plan. c. provide Maryanne and Charles with the standard discharge education with emphasis on their concerns. d. elicit their abilities to provide for themselves and their resources of support.

ANS: C, D

The patients should be included in the decision-making about their postdischarge care and have the opportunity to discuss, with the nurse or other healthcare services, their resources for support in order for them to mutually make a decision about professional assistance and needs that are in the best interest of their recovery. After receiving their discharge expectations, they can better compare the expectations and events with their capabilities and resources. The general discharge instructions for liver surgery patients include the following: keep the incision area clean and dry; solid foods should be added gradually; chew solid foods well, and avoid gulping, eating fast, or swallowing large and bulky portions; avoid carbonated beverages for 3 to 4 weeks to help prevent gas bloating; eat small, frequent meals; follow medication instructions, and conduct medication verification; increase exercise gradually to return to normal activities of daily living; exercise regularly; and make an appointment for follow-up care with the surgeon.

REF: pp. 359-360

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 13: Hernia Repair Test Bank MULTIPLE CHOICE 1. Identify the triad of anatomic sites of abdominal wall weakness with a potential for hernias. a. Groin, ventral line, umbilicus b. Inguinal rings, femoral canal, incision c. Inguinal canal, femoral rings, umbilicus d. Ventral line, aponeurosis, inguinal canal ANS: C

A hernia can occur in several places in the abdominal wall, with protrusion of a portion of the parietal peritoneum and often a part of the intestine. The weak places or intervals in the abdominal aponeurosis are: (1) the inguinal canals, (2) the femoral rings, and (3) the umbilicus.

REF: p. 383 2. What is the anatomical component of the lining of the herniated abdominal weakness and the

hernia sac? a. Fascia b. Peritoneum c. Muscularis d. Rectus abdominis muscle ANS: B

A hernia is a sac lined by peritoneum that protrudes through a defect in the layers of the abdominal wall. Generally, a hernia mass is composed of covering tissues, a peritoneal sac, and any contained viscera.

REF: p. 383 3. Select the triad of the boundaries of the Hesselbach triangle. a. Inguinal ligament, rectus abdominis muscle, deep epigastric vessels b. Rectus abdominis muscle, Cooper ligament, aponeurosis c. Scarpa’s fascia, deep epigastric vessels, external oblique muscle d. Inguinal ligament, inguinal canal, Cooper ligament ANS: A

The deep epigastric vessels (inferior epigastric) arise from the external iliac vessels and enter the inguinal canal just proximal to the internal ring. The triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially is referred to as the Hesselbach triangle.

REF: p. 385 4. Select the most common hernia that occurs in both men and women. a. Direct femoral hernia b. Indirect inguinal hernia

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. Indirect femoral hernia d. Direct inguinal hernia ANS: B

Hernias may be direct, indirect, femoral, umbilical, or occur at previous sites of surgical incisions (incisional hernia). Although hernias occur most often in men, the indirect inguinal hernia is the most common hernia in men and women.

REF: p. 385 5. Contributing factors to hernia formation include age, gender, previous surgery, obesity,

nutritional status, and pulmonary and cardiac disease. The formation of the hernia at a site of weakness is due to any number of conditions that cause: a. impaired healing and defective collagen formation. b. thinning and stretching of muscle fibers. c. increased pressure within the abdomen. d. loss of tissue elasticity.

ANS: C

Any number of conditions causing increased pressure within the abdomen can contribute to the formation of a hernia. Contributing factors to hernia formation include age, gender, previous surgery, obesity, nutritional status, occupation, and pulmonary and cardiac disease.

REF: p. 383 6. Femoral hernias occur more frequently in which group of individuals? a. Postoperative obese patients b. Newborns c. Weight lifters d. Women ANS: D

Femoral hernias occur much more frequently in women, and only 2% of women will develop inguinal hernias in their lifetime.

REF: pp. 384-385 7. While direct and indirect hernias both protrude into the inguinal canal and represent tears in

the transversalis fascia, which one of the two occurs within the Hesselbach triangle? a. Direct inguinal hernia b. Indirect inguinal hernia c. Both direct and indirect d. Umbilical hernia ANS: A

The triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially is referred to as the Hesselbach triangle. Hernias that occur within the Hesselbach triangle are called direct inguinal hernias. Indirect inguinal hernias occur laterally to the deep epigastric vessels. Both direct and indirect hernias represent attenuations or tears in the transversalis fascia. Direct hernias protrude into the inguinal canal but not into the cord, and therefore rarely into the scrotum.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 385 8. Ryan has an indirect hernia that is characterized by a small neck, thin walls, and close

attachment to the cord structures. Marc has a hernia with a short, wide neck, and a thickwalled sac. Based on this description, Ryan has a(n) ____________ hernia and Marc has a(n) __________ hernia. a. acquired; congenital b. reducible; nonreducible c. congenital; acquired d. pantaloon; sacular ANS: C

Indirect hernias may be either congenital, representing a persistence of the processus vaginalis, or acquired. In a congenital hernia, the hernia sac has a small neck, is thin-walled, and is closely bound to the cord structures. In an acquired indirect hernia, the neck is wide and the sac is both short and thick-walled. When both direct and indirect hernias are present, the defect is called a pantaloon hernia after the French word for pants, which this situation suggests.

REF: p. 385 9. Hernia-entrapped viscera, typically loops of small intestine, will result in intestinal obstruction

with resulting pain, vomiting, and distention. What is the appropriate descriptive diagnosis of this condition? a. Nonreducible hernia b. Incarcerated hernia c. Torsion of the hernia sac d. Gangrenous bowel ANS: B

Patients with incarcerated hernias may have signs of intestinal obstruction, such as vomiting, abdominal pain, and distention. The greatest danger of an incarcerated hernia is that it may become strangulated. In a strangulated hernia, the blood supply of the trapped sac contents becomes compromised and eventually the sac contents necrose.

REF: p. 383 10. An 86-year-old retired plumber states that he has suffered from a groin hernia all of his adult

life; he states, “as far back as I can remember.” Sometimes he has to push the bulge back into his abdominal muscle and then he is fine until he has a coughing spell. This morning the bulge was large and tender when he woke up, and he could not reduce it. As the pain increased, he felt weak and nauseated. His daughter took him to the emergency department (ED). The patient was diagnosed with a strangulated incarcerated hernia and scheduled for emergency surgery. If the contents of the patient’s hernia sac become compromised, with strangulation of the bowel, the probable label on his surgical specimen will be: a. compromised bowel. b. strangulated bowel. c. necrotic bowel. d. intestinal obstruction.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock In a strangulated hernia, the blood supply of the trapped sac contents becomes compromised, and eventually the sac contents necrose. When the bowel is strangulated in such a hernia, resection of necrotic bowel, in addition to repair of the hernia defect, becomes necessary. This is a surgical emergency.

REF: p. 383 11. Depending on their location, hernias are classified as direct inguinal, indirect inguinal,

femoral, umbilical, incisional, or epigastric. Hernias in any of these groups are either reducible or nonreducible. The characteristic “reducible” hernia can best be described as a hernia: a. that does not require surgical repair. b. that is an emergent diagnosis. c. with visceral contents that can be returned to the abdomen. d. with a narrow sac neck that is closed with adhesions.

ANS: C

Hernias in any of these groups are either reducible or nonreducible; that is, the contents of the hernia sac either can be returned to the normal intra-abdominal position or are trapped in the extra-abdominal sac (incarcerated). The conditions preventing the return of the hernia contents to the abdomen can result from (1) adhesions between the contents of the sac and the inner lining of the sac, (2) adhesions among the contents of the sac, or (3) narrowing of the neck of the sac.

REF: p. 383 12. A 37-year-old physically active male is getting dressed to return home from the emergency

department (ED) after he experienced a large, tender bulge in his scrotum while straining at the toilet. The ED physician reduced the patient’s indirect inguinal hernia and referred him to a general surgery practice for elective herniorrhaphy. The ED nurse prepared the patient for his discharge. An appropriate nursing intervention by the ED nurse would be to: a. explain the signs and symptoms of an incarcerated hernia and appropriate action. b. demonstrate how to reduce the hernia until he can see the surgeon. c. advise him on the best surgeon for this hernia and give contact information. d. measure him for a hernia belt to wear until his surgery is scheduled.

ANS: A

The ED nurse should provide the patient with information about his hernia and corrective actions in anticipation of complications, such as incarceration and strangulations. Patients with incarcerated hernias may have signs of intestinal obstruction, such as vomiting, abdominal pain, and distention. This is a surgical emergency.

REF: p. 387 13. A 37-year-old physically active male arrived at the preoperative receiving and waiting lounge

of the ambulatory surgery center for an elective herniorrhaphy. His perioperative nurse introduced herself and began his preoperative nursing assessment. The patient wanted to know when he would be able to get back to work and resume his place as pitcher on his softball team. He also told the nurse that he planned to do some yard work today as soon as the anesthesia “wears off.” Which one of the following nursing diagnoses is given priority in both preoperative and postoperative education?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

Risk for urinary retention related to anesthesia Activity intolerance related to pain and early postoperative ambulation Risk for ineffective tissue perfusion related to scrotal swelling Deficient knowledge related to disease process and convalescence

ANS: D

The patient was not well-informed before his surgery about the planned postoperative recovery expectations. He needs information and reinforcement about the disease process of his hernia, pain management, incision care, dietary needs, and activity; the information should span from the patient’s immediate postoperative phase to his progression to activities of normal daily living. His appropriate nursing outcome is the following: The patient and family or significant others will verbalize an understanding of the disease process (hernia) and convalescence.

REF: p. 387 14. Of the open hernia procedures listed below, which classic hernia procedure is considered, by

some surgeons, to not be anatomically correct because the superior transversalis fascia is sutured to the inguinal ligament instead of to the inferior portion of the transversalis fascia or the Cooper ligament? a. Shouldice repair b. Bassini repair c. McVay repair d. Cooper repair ANS: B

The Bassini repair procedure was introduced in 1887 and was formerly the standard of repair.

In this procedure the conjoined tendon and the shelving edge of the inguinal ligament are sutured together up to the internal ring. The major difference with this repair is that the superior transversalis fascia is sutured to the inguinal ligament with no attempt made to approximate it to the inferior portion of the transversalis fascia or the Cooper ligament. Critics of this procedure claim that it is not anatomically correct because layers that normally are not integrated (transversalis fascia and inguinal ligament) now are approximated.

REF: pp. 394-395 15. Which two similar hernia repair approaches reestablish the integrity of the transversalis fascia

and simultaneously reestablish and strengthen the posterior inguinal floor by sewing the transversalis fascia to the Poupart ligament? a. The Shouldice and the McVay ligament repair b. The Bassini and the Shouldice repair c. The McVay and the Cooper ligament repair d. The Shouldice and the Cooper ligament repair ANS: C

Approaches that reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor are favored. A surgical repair in which transversalis fascia is sewn to the Poupart ligament accomplishes this goal. A McVay or Cooper ligament repair approximates transversalis fascia superior to the inferior insertion of the transversalis fascia along the Cooper ligament.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 393 16. The mesh-plug open hernia repair technique is indicated for which type(s) of hernias? a. Umbilical hernias b. Indirect gastroesophageal hernias c. Direct and indirect inguinal hernias d. Strangulated scrotal hernias ANS: C

The mesh-plug technique has been recommended for the treatment of primary and recurrent direct and indirect inguinal hernias. Various hernia types have been classified by Gilbert (Kulacoglu, 2011) and have a corresponding relationship to the use of mesh plugs. Types I, II, and III are indirect hernias.

REF: p. 395 17. The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and

muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin. The key landmark of the _____________ designates the roof of the inguinal canal, and the key landmark of the __________ designates the floor of the inguinal canal. a. external oblique aponeurosis; transversalis aponeurosis and fascia b. lateral rectus abdominis; transversalis aponeurosis and fascia c. external oblique aponeurosis; Poupart ligament d. transversalis aponeurosis and fascia; Cooper ligament aponeurosis ANS: A

The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin. The roof of the inguinal canal is formed by the external oblique aponeurosis, and the floor is formed by the transversalis aponeurosis and fascia. Essential to an understanding of inguinal hernia repair is an appreciation of the central role of the transversalis fascia as the major supporting structure of the posterior inguinal floor. The inguinal canal is covered by the aponeurosis of the external abdominal oblique muscle, which forms a roof.

REF: pp. 383-384 18. Laparoscopic inguinal hernia repair is another method of tension-free mesh repair, with

several repair options. The most popular techniques include a totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approach. Which of the two techniques provides access to the preperitoneal space without entering the peritoneum? a. The TEP technique b. The TAPP technique c. Both the TEP technique and the TAPP technique if the hernias are recurrent d. Neither the TEP technique nor the TAPP technique; preperitoneal access is only possible with an open surgical approach ANS: A

TEP provides access to the preperitoneal space without entering the peritoneal cavity (Research Highlight). The TAPP uses intraperitoneal trocars and the creation of a peritoneal flap over the posterior inguinal region.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 397 19. A 49-year-old male had a laparoscopic hernia repair with good results and an uneventful

recovery. Weeks later, as he reviewed his hospital bill, he noted that he had been charged for a very expensive preperitoneal distention balloon, polypropylene mesh, an endomechanical stapler, fibrin glue, and three endosurgical trocars. Which hernia repair technique was most likely performed on the patient? a. TAPP repair b. Laparoscopic Bassini repair c. TEP repair d. Mesh-plug insertion repair ANS: C

The totally extraperitoneal patch (TEP) laparoscopic hernia repair technique was used on the patient. Access to the posterior rectus sheath is gained by trocar insertion in the periumbilical region. A balloon dissector is placed on the anterior surface of the posterior rectus sheath and inflated, thereby creating an optical cavity. The proximal peritoneal sac is closed with loop ligature to prevent pneumoperitoneum from occurring. A piece of polypropylene mesh is inserted; unfolded to cover the direct, indirect, and femoral spaces and rest over the cord structures; and carefully secured with a tacking stapler.

REF: pp. 397-398 20. A 37-year-old active male is in the postanesthesia care unit (PACU) recovering from a hernia

repair and preparing for discharge. The perianesthesia nurse, after reading the nursing assessment from the preoperative documentation, prepares to complete the patient’s discharge education. Based on the perioperative nurse’s nursing diagnosis of “deficient knowledge related to disease process and convalescence,” an appropriate risk reduction strategy that is a best practice in ensuring that the patient understands the information would be to: a. reinforce the discharge education by giving him written instructions. b. place a copy of the instructions that he has signed into the patient chart. c. include his wife in the teaching session. d. provide an opportunity for him to “teach back” his discharge instructions.

ANS: D

There is considerable evidence that many patients leave medical encounters with a poor understanding of their disease and the recommended treatment. Provide written discharge instructions. Review these with the patient and family or significant others to validate understanding. Provide opportunity for “teach back” by the patient or family. Have them repeat discharge instructions in their own words. Allow time for questions.

REF: pp. 388, 390 21. A 4-year-old preschooler is scheduled for bilateral inguinal hernia repair. He is in the

preoperative waiting lounge with his mother, while his father looks for a parking space. The mother does not speak English, and she seems confused and intimidated as the perioperative nurse approaches. The surgeon has just marked both inguinal sites with his initials. The mother appears to indicate that the surgery will take place only on the right side; however, the consent states bilateral and is signed by the father. The perioperative nurse’s first appropriate response should be to: a. attempt to explain the notation on the consent with hand signals and her best

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Spanish until the father returns. b. sit down next to the mother and convey calming behaviors until the father returns. c. stay with the mother and patient while someone calls back the surgeon and a medical interpreter. d. page the father.

ANS: C

Informed consent is a central element of safe surgical patient care. Informed consent forms should be written in simple sentences and in the primary language of the patient or legal surrogate. A recommended element of safe practice for informed consent includes providing an interpreter or reader to assist non–English-speaking patients or legal surrogates, visionimpaired, or hearing-impaired patients, and low-literacy patients.

REF: p. 390 22. Bupivacaine and ropivacaine are look-alike/sound-alike drugs. Adverse drug reactions

(ADRs) can occur if a clinician confuses these two drugs. Both drugs promote nerve conduction blockage analgesia when given locally, but bupivacaine is cardiotoxic. When selecting a local anesthetic to fill an elastomeric pain pump, what is one contraindication that should be considered? a. If the patient is hypersensitive to amide local anesthetics b. If the patient has cardiovascular disease c. If the patient is confused or unconscious d. If the patient had a local injection of lidocaine during the procedure ANS: A

Lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin) all have similar actions. They are contraindicated in patients with hypersensitivity to amide local anesthetics.

Compared to other local anesthetics, bupivacaine is markedly cardiotoxic. However, ADRs are rare when it is administered correctly. Most ADRs relate to systemic exposure, such as with pain pump failure. Systemic exposure to excessive quantities of bupivacaine mainly results in central nervous system (CNS) and cardiovascular effects. CNS effects may include nervousness, perioral tingling, tinnitus, tremor, dizziness, blurred vision, confusion, dyspnea, apnea, light-headedness, and loss of consciousness.

REF: p. 392 23. An example of a common postoperative complication related to inguinal hernia surgery is: a. delayed return to activity. b. inguinal nerve entrapment c. femoral canal adhesions. d. hernia recurrence.

ANS: D

A successful herniorrhaphy is measured by the percentage of recurrence, the number of complications, the total costs, and the ability to return to normal activities of daily living.

REF: p. 383

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 24. Regardless of the hernia type, the mesh-plug technique is performed on an ambulatory basis,

through a small incision, often laparoscopically. Which advantage of the mesh-plug technique increases patient comfort, speeds rehabilitation, and contributes to a low recurrence rate? a. Involves minimal blood loss b. Has a decreased chance of nerve injury c. Ensures a high-tension hernioplasty d. Is performed under local anesthesia ANS: B

Repair of inguinal hernias with the mesh-plug technique provides advantages when compared with conventional suture techniques—a plug repair requires less overall dissection, has a decreased chance of nerve injury, and ensures a tension-free hernioplasty. These factors increase patient comfort, speed rehabilitation, and contribute to a low recurrence rate.

REF: p. 395

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 14: Gynecologic and Obstetric Surgery Test Bank MULTIPLE CHOICE 1. When catheterizing the female patient the nurse must locate the urethra. The correct order of

the external organs of the vulva listed anterior to posterior is: a. mons pubis, labia majora, labia minora, urethra, clitoris, vaginal opening. b. labia majora, labia minora, clitoris, urethra, vaginal opening, mons pubis. c. mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal opening. d. labia majora, labia minora, urethra, mons pubis, clitoris, vaginal opening.

ANS: C

The external organs, referred to collectively as the vulva, include the mons pubis, the labia majora and labia minora, the clitoris, the vestibular glands, the vaginal vestibule, the vaginal opening, and the urethral opening, in that order.

REF: p. 405 2. An example of perineal glands that secrete mucus is: a. Skene’s glands. b. Bartholin’s glands. c. perineal glands. d. labial glands.

ANS: B

Bartholin’s glands and ducts are located on each side of the lower end of the vagina at the 5 and 7 o’clock positions. The narrow ducts open into the vaginal orifice on the inner aspects of the labia minora. The glands secrete mucus and can become infected or inflamed.

REF: p. 405 3. Ova travel through the fallopian tubes toward the uterus by which type of action? a. Peristalsis b. Gravity c. Brownian motion d. Intra-abdominal pressure ANS: A

It has been theorized that transfer of the ova from the ruptured follicles into the uterus is accomplished through vascular changes that occur during contraction of the smooth muscle fibers of the tube. The peristaltic action of the muscular layer and the ciliary movement propel the ova toward the uterus.

REF: p. 407

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. A 55-year-old woman with uterine cancer is scheduled for an open panhysterectomy. After the

incision is made and primary dissection accomplished, she will be positioned in Trendelenburg position to facilitate exposure of the lower pelvis and displacement of the small bowel from the operative area. The patient is at risk for compromise and injury related to prolonged Trendelenburg tilt, which promotes: a. decreased pulmonary compliance and functional residual capacity. b. increased popliteal congestion and peripheral vascular collapse. c. shearing force injury from sliding toward the head of the operating room (OR) bed. d. avascular ischemic changes to the lower leg and feet from gravitational devascularization.

ANS: A

Patients placed in Trendelenburg position for prolonged gynecologic procedures are at increased cardiovascular risk because of decreased pulmonary compliance and functional residual capacity (FRC).

REF: p. 415 5. A 55-year-old woman with uterine cancer is undergoing an open panhysterectomy. She is

positioned in Trendelenburg position to facilitate exposure of the lower pelvis and displacement of the small bowel from the operative area. The surgical team gently abducted the patient’s arms into position on padded armboards at less than 90 degrees with palms facing up. Extra padding was placed under her elbows, and an armboard strap was secured over her forearm. The armboards were locked into place to prevent inadvertent abduction. This important maneuver is designed as a risk reduction strategy to prevent: a. axillary tension. b. brachial plexus injury. c. celiac plexus injury. d. elbow torsion with displacement.

ANS: B

Whenever possible the nurse positions the patient’s arms on padded armboards with the palms up and fingers extended. Armboards are maintained at less than a 90-degree angle to prevent stretching of the brachial plexus. Care should be taken to protect all patients from integumentary, musculoskeletal, and nerve injuries while ensuring adequate circulatory, renal, and respiratory functions.

REF: p. 415 6. A 55-year-old woman with uterine cancer is undergoing an open panhysterectomy. During the

procedure, a moment of light anesthesia causes the patient to move slightly. The perioperative nurse prepared to assist while the anesthesia provider titrated drugs to a deeper anesthetic level. What would be the next priority intervention by the perioperative nurse? a. Document an “awareness under anesthesia” occurrence b. Tuck the patient’s arms anatomically at her sides c. Reassess padding, protection, and positioning security d. Refine the nursing diagnosis to include risk for falls ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Reassess padding and protection after this movement by the patient to ensure that she will remain free from injury related to surgical positioning. The patient should be secured to the OR bed without friction or pressure from the restraining straps. Assess and document the condition of dependent skin areas. Use pressure-reducing positioning devices. Pad and protect bony prominences and dependent pressure sites and maintain proper body alignment.

REF: p. 416 7. From the list below, select the statement that is true about fallopian tube cancer. a. Fallopian tube cancer metastasizes to the ovaries and cervix. b. Fallopian tube cancer is fast-growing in women with genital herpes. c. Fallopian tube cancer is very rare, with an incidence of less than 1%. d. Fallopian tube cancer is seen primarily as a metastasis from the small intestine.

ANS: C

Fallopian tube cancer is very rare, with an incidence of less than 1%. Symptoms include vaginal bleeding, vaginal discharge, and lower abdominal pain.

REF: p. 414 8. A 56-year-old postmenopausal obese woman is seen for her routine gynecologic exam. Which

statement by the patient might prompt her physician to suspect that she may have endometrial cancer? a. “I think I am having the normal symptoms of menopause, just a few hot flashes.” b. “I have vaginal bleeding and problems controlling my diabetes, but no other problems or pain.” c. “I am having intense genital itching and slight vaginal discharge.” d. “I often have feelings of abdominal fullness and bloating, even when I have not eaten.”

ANS: B

Patients with endometrial cancer may be asymptomatic or they may experience postmenopausal bleeding as their primary symptom. Most women diagnosed are older than 50 years of age.

REF: p. 414 9. A 57-year-old patient’s assessment and examination has revealed a family history of

endometrial cancer. She has never been pregnant and has been taking hormone replacement therapy for 4 years. Her physician has scheduled her for a surgical procedure to obtain visual and pathologic information and provide treatment as indicated. The patient was sure that she would have to have a dilatation and curettage (D&C). Her surgery, on the operative schedule, would most probably be written as: a. D&C with endometrial biopsies. b. hysteroscopy with endometrial ablation. c. D&C with endometrial and cervical biopsies. d. D&C with endometrial washings, frozen section, total abdominal hysterectomy.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock D&C is done for diagnostic purposes for a variety of pelvic conditions, such as abnormal uterine bleeding. D&C is also performed to obtain tissue for diagnosis when carcinoma of the endometrium is suspected, in the study of infertility, or for removal of uterine polyps.

Fragments of endometrium or other dislodged tissues may be removed with warm, moist radiopaque gauze sponges on sponge-holding forceps. The surgeon may take multiple punch biopsies of the suspected cervical lesions with a cervical biopsy forceps to supplement the diagnostic studies.

REF: p. 429 10. A 46-year-old para 2 gravida 2 returned to her gynecologist’s office for a second Pap smear

when her routine exam showed dysplastic cells in her cervical cytology test. She has a family history of cervical cancer and had laser ablation within the last 2 years for vulvar condylomata. She can expect her gynecologist to perform another Pap smear and: a. colposcopy with endocervical biopsy. b. hysteroscopy with cervical biopsy and frozen section. c. colposcopy with cervical stripping procedure performed using a local anesthetic. d. second-look vaginal exam with cervical Pap smear.

ANS: A

A colposcopy, with binocular magnification, is often performed in the surgeon’s office.

Patients who have an abnormal Pap smear suggestive of dysplasia undergo this examination.

Colposcopy identifies cellular abnormalities involving the vulva, vagina, or cervix and helps to identify localized areas of dysplasia and carcinoma in situ (CIS). Endocervical curettage samples can be obtained during the colposcopic procedure to rule out invasive carcinoma or to detect early adenocarcinoma of the cervix.

REF: p. 411 11. A 72-year-old patient with multicentric CIS of the vulva, without evidence of leukoplakia and

pruritus is scheduled for surgery. She has a history of prior papillomavirus infection. Select the most appropriate surgical option. a. Radical vulvectomy with inguinal lymph node dissection b. Skinning vulvectomy c. CO2 laser surface ablation of the vulvar lesions d. Simple vulvectomy ANS: D

Simple vulvectomy is removal of the labia majora and labia minora, possibly but not preferably the glans clitoris, and occasionally tissue from the perianal area. A simple vulvectomy is usually done to treat CIS of the vulva when it is multicentric. Rarely a superficial vulvectomy is necessary for the treatment of either leukoplakia or intractable pruritus.

REF: p. 419 12. A middle-aged mother of nine children from an orthodox community is seen in the

gynecologic clinic for heavy vaginal bleeding. She is anxious and shy and timidly asks the nurse if she may be seen only by a female doctor. An appropriate nursing action by the female nurse would be to: a. demonstrate strategies for the patient to verbalize, reduce, and control her anxiety.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. maintain the patient’s privacy and convey empathy and respectful regard for her

culture. c. inform the patient that all of the doctors are male, but they treat many of the

women from her community. d. suggest the patient reschedule her appointment for a day when a female physician

has clinic hours.

ANS: B

The patient is expressing feelings about her body image and cultural belief tenets of modesty.

The nurse should acknowledge the influence of cultural beliefs, norms, and values on the patient’s feelings regarding her body image. The patient’s heavy bleeding may have serious health implications, and treatment should not be postponed until a cause or diagnosis is determined.

REF: p. 409 13. A 67-year-old former competitive track athlete with debilitating osteoarthritis is scheduled for

a laparoscopic-assisted vaginal hysterectomy (LAVH). During the preoperative assessment, she tells the perioperative nurse that, while she is in excellent health for her age, her hip and leg joints are tender, and her movement is limited. The nurse explains that during the procedure she will be “up in stirrups” but will be handled gently and protected from further discomfort. An appropriate nursing action, after the patient is transferred to the OR bed and before anesthesia induction, is to: a. place her in the preferred lithotomy position and adjust to her position of comfort. b. discuss muscle relaxation and analgesic medication options with the anesthesia provider. c. discuss nonlithotomy positioning options with the surgeon. d. use unpadded straight-leg stirrups.

ANS: A

Note and document any preexisting patient considerations (e.g., limitations in mobility or range of motion, neurovascular impairments) that place the patient at risk for positioning injury. The nurse may anticipate that patient positions may be modified based on the surgical procedure and surgeon’s preference. The patient is placed in the lithotomy position for most vaginal and vulvar surgery. Careful attention must be focused on placing the patient in the lithotomy position in a manner that prevents injury and vascular changes.

REF: p. 438 14. A 55-year-old woman with a possible latex sensitivity is scheduled for a panhysterectomy. She

is at risk for postoperative urinary retention related to edema, anesthesia, opioids, or pain. An appropriate intraoperative nursing action would be to: a. insert an indwelling silicone catheter using aseptic technique. b. secure the tubing and collection container on top of the bed to prevent inadvertent stretching or stress on the catheter. c. discuss with the patient the importance of limiting fluids in the postop period until the risk for urinary retention is no longer a concern. d. employ the manual Credé’s technique to empty the bladder prior to prep and drape.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Before surgery, explain to the patient that an indwelling or temporary (straight) catheter will be inserted (if applicable). Verify the absence of any latex allergy; a latex-free catheter will be required for latex-allergic patients. Insert indwelling or straight catheter using aseptic technique. Secure tubing to prevent inadvertent stretching or stress on the catheter. Lastly, document size of catheter inserted.

REF: p. 416 15. A 32-year-old woman, recently an unemployed and uninsured college professor, is diagnosed

with an early ectopic pregnancy. Her obstetrician has given her the option of surgical or medical therapy. The patient is well-informed about the details of each medical and surgical option, but her primary concern about her condition is that her decision will be based upon her strong cultural belief system that will not sanction the destruction of the fetus. The patient’s treatment decision will most likely be: a. the medical therapy of intramuscular (IM) methotrexate for 5 to 7 days. b. laparoscopic injection of methotrexate to the extrauterine gestational sac. c. emergency laparotomy for a ruptured ectopic pregnancy. d. salpingectomy.

ANS: C

Ectopic pregnancy, a devastating complication that affects up to 2% of all pregnancies, may be treated medically with methotrexate or surgically through salpingostomy, segmental resection, fimbrial expression, and salpingectomy. Methotrexate destroys rapidly dividing cells and is often administered in conjunction with the surgical procedure to destroy any residual trophoblastic cells that might remain. Laparoscopic and/or ultrasound-guided application of methotrexate to the extrauterine gestational sac may also be used as an alternative therapy. The more cost-effective medical treatment for ectopic pregnancy is considered a front-line therapy in many major medical centers. Ruptured ectopic pregnancy is considered a surgical emergency and is associated with severe abdominal pain, tachycardia, and hypotension.

REF: pp. 429, 435 16. Surgical and nonsurgical options exist for endometriosis. Select the triad that best reflects

nonsurgical and nonhormonal options. a. Cul-de-sac obliteration, nonsteroidal antiinflammatory drugs (NSAIDs), and danazol b. Nerve block, analgesics, and acupuncture c. NSAIDs, acupuncture, and RH-486 d. NSAIDs, watchful waiting, modifications to diet and exercise ANS: D

Nonhormonal options include NSAIDs, analgesics, and opioids for severe pain. Other nonsurgical, nonhormonal options include watchful waiting, biofeedback, and lifestyle changes.

REF: p. 441

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. Many gynecologic conditions and diseases cause chronic pelvic pain. Both surgical and

nonsurgical therapies include invasive manipulations. Select the least invasive treatment option for chronic pelvic pain that is recommended by the Agency for Healthcare Research and Quality (AHRQ). a. Nerve block with biofeedback b. Ureterosacral nerve ablation c. Target point injections and acupuncture d. Oral contraceptives and physical therapy ANS: D

Oral contraceptives, NSAIDs, watchful waiting, physical therapy, nutritional counseling, and psychological counseling are all recommended therapies by the AHRQ. Oral contraceptives and physical therapy are the least invasive techniques.

REF: p. 441 18. A 29-year-old woman is in the emergency department (ED) with a ruptured appendix. Before

the ED room nurse and surgical resident transported her to the OR, the nurse called to inform them that the patient is 27 weeks’ pregnant. What special considerations must the perioperative nurse and anesthesia provider address with this new information? a. The fetal heart rate will have to be monitored in the postoperative recovery unit. b. The patient may need rapid induction of general anesthesia or spinal anesthesia. c. There is a possibility that tocolytic drugs may need to be administered to induce labor. d. A lateral tilt or wedge under the left hip may be required.

ANS: B

Special considerations for the obstetric surgical patient include continuous monitoring of the fetal heart rate, administration of a regional anesthetic before placing the patient in the supine position, rapid induction for general anesthesia, and preparation for the possible use of tocolytics (e.g., medications to decrease uterine activity) to prevent labor. Ready access to neonatal resuscitative drugs and equipment should be established when performing surgery on pregnant women in the second trimester and beyond. If permitted by the surgical approach, the pregnant woman should be positioned with a lateral tilt or with a wedge or pillow under her right hip to provide uterine displacement and relieve pressure on the maternal vena cava.

This position promotes blood flow to the placenta.

REF: p. 452 19. During cesarean delivery, which is the priority instrument or device needed as soon as the

fetal head is delivered? a. Broad Deaver or bladder blade retractor b. Umbilical cord clamp c. Bulb syringe or aspirator tip d. Sponge forceps with folded gauze sponge ANS: C

As soon as the head is delivered, the surgical assistant provides transabdominal fundal pressure to aid in the delivery of the shoulders and extremities. A bulb syringe and aspirator tip is used to aspirate the exposed nares and mouth to minimize aspiration of amniotic fluid and its contents.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 458 20. During the preoperative nursing assessment in the ambulatory surgery receiving unit, the

nurse notices bruises and abrasions in various stages of healing on her patient’s abdomen, arms, and breasts. In a quiet and respectful manner the nurse says, “The staff at our facility are concerned about your safety. We know that many things can happen in our lives that affect our mental and physical health.” This technique is an appropriate method of establishing a sense of __________ with the patient while conveying caring and concern. a. intimacy b. normalizing c. catharsis d. trust and confidentiality ANS: B

Nurses and other healthcare providers may represent the first and only contact that an isolated woman will seek outside of the abusive relationship and are a primary source of relief. A variety of screening tools are available. Characteristics common to the tools include trying to normalize the conversation with neutral opening statements, such as, “The staff at our facility are concerned about your safety. We know that many things can happen in our lives that affect our mental and physical health.” In addition, healthcare providers should use direct questions when violence is suspected, such as, “Are you with a partner who threatens or physically harms you?”

REF: p. 411 21. What classification of drugs are gynecologic/obstetric-related medications that require

monitoring of blood pressure, assessment for continued bleeding, and monitoring of fundal response to the drug? a. Oxytocics b. Tocolytics c. Antimetabolites d. Cytotoxics ANS: A

Oxytocics are medications that increase motor activity within the uterus by hormonal stimulation or by direct stimulation on the smooth muscles, usually resulting in uterine contractions. They may be used intraoperatively and postoperatively. The following are some nursing considerations after their administration: monitor blood pressure, assess for continued bleeding, and monitor fundal response to the drug.

REF: p. 452 MULTIPLE RESPONSE 1. During the skin preparation for a gynecologic procedure that requires both an abdominal and a

vaginal prep, the perioperative nurse must ensure that cross-contamination does not occur.

Select two nursing interventions that support cross-contamination prevention. (Select all that apply) a. Tuck sterile towels under the patient’s buttocks and both sides of the abdomen.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Insert the urinary catheter to drainage before beginning the prep. c. Prep the abdomen before beginning the vaginal prep. d. Use two separate prep trays (one for the abdomen, one for the vagina).

ANS: C, D

Care must be taken not to cross-contaminate when prepping multiple areas, such as for an abdominal hysterectomy. The nurse always preps the abdomen before beginning the vaginal prep, using the principle “clean to dirty.” Two separate prep trays should be used, and the prep setups should be kept separate. The perioperative nurse should take care when performing vaginal preps on patients who have been experiencing vaginal bleeding and may have clots in the vaginal vault. The clots and any gross blood on the thighs or vulva should be removed before beginning the prep to allow full contact of the prepping solution.

REF: pp. 415, 417 2. A 32-year-old para 2 gravida 2 is scheduled for a hysteroscopy for heavy bleeding of 2 weeks’

duration and possible retrieval of a displaced intrauterine device (IUD). She is tired and weak from blood loss and has marked anemia. During the vaginal prep, the perioperative nurse noted several large blood clots. The nurse communicated an estimated blood loss amount to the anesthesia provider and surgeon. After the patient was draped, the circulating nurse connected the hysteroscopic insufflator, pressure-infusion pump, and a video camera, light source, and monitor. The uterine cavity was distended with 32% dextran 70 in dextrose (Hyskon) at a continuous pressure through the hysteroscopic pump into the irrigating channel of the hysteroscope. The circulating nurse was relieved for lunch after she gave a hand-off report to her relief nurse. What patient safety information relevant to the hysteroscopy should be given to the receiving relief nurse before the circulating nurse leaves for lunch? (Select all that apply.) a. A review of the amount of hysteroscopy fluid infused and fluid received back b. A reminder to monitor for discrepancies of 1 to 1.5 L c. A reminder to monitor for signs of tachydysrhythmias d. A review of current fluid loss calculations based on sponge weights e. A request to soak instruments in sterile saline as soon as the procedure is finished f. A reminder to palpate the patient’s abdomen for signs of compartment syndrome before transfer to the postanesthesia care unit (PACU) ANS: A, B

The perioperative nurse is responsible for accurately monitoring hysteroscopy fluid intake and output during the procedure. Monitoring may be manual (i.e., calculating the difference between inflow and outflow) or may be automatically calculated on commercially available hysteroscopy pumps, which decrease the chance of human error. If a discrepancy of 1 to 1.5 L or more occurs (less for patients who have compromising medical conditions), the surgeon and anesthesia provider are alerted, and consideration is given to terminating the procedure.

At the end of the procedure the hysteroscopy deficit should be communicated to the surgeon, anesthesia provider, and the PACU nurse during the hand-off report, and documented in the patient’s perioperative record.

REF: p. 434

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 3. An experienced perioperative nurse has recently been hired at the new ambulatory surgery

center to lead their endometrial ablation and fibroid embolization program. She has created a patient education booklet with relevant postprocedure care information for patients and caregivers and is developing a training module for the nurses to learn techniques for teaching patients before surgery and before discharge. She is teaching the nurses how to encourage patients and caregivers to reflect on what they have just learned in order to elicit a “teachback” scenario. Select the reflective statements and questions appropriate for a post– endometrial ablation patient, to determine their understanding of her discharge instructions.

(Select all that apply.) a. “Tell me what you know about vaginal bleeding.” b. “What do you do and who do you call if you notice more than a tablespoon’s worth of bleeding?” c. “Do you feel that you are ready to take care of yourself?” d. “What are your most troubling concerns about going home right now?” e. “What are the activities that you must avoid for at least 2 weeks?”

ANS: B, D, E

Whenever possible, provide the patient and caregiver with verbal and written instructions.

Provide them with the phone number of the physician to call if questions arise. Use visual aids to enhance instruction. Encourage the patient to verbalize any concerns she may have regarding her condition and surgery. The following instructions are relevant to endometrial ablation patients: Spotting and vaginal drainage are normal for several days (even weeks or months) after the procedure. Use a heating pad or hot water bottle to relieve abdominal cramping if it occurs. You can return to your normal activities within 2 to 3 days. Avoid sexual intercourse, tub baths, and the use of tampons for 2 weeks to allow healing and prevent infection.

REF: pp. 418-419

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 15: Genitourinary Surgery Test Bank MULTIPLE CHOICE 1. The renal artery and vein enter and exit the kidney on the medial side of the organ through a

concave area known as the: a. calyces. b. pedicle. c. hilum. d. renal pelvis.

ANS: C

On the medial side of each kidney is a concave area known as the hilum, through which the renal artery and vein enter and exit.

REF: p. 461 2. Select the statement about the prostate that best reflects its location. a. The prostate sits adjacent to the urethra. b. The prostate sits below the urethra. c. The prostate is anterior to the bladder. d. The prostate is interposed between the bladder neck and the urethra.

ANS: D

The prostate gland is a donut-shaped organ composed of fibromuscular and glandular components. It is located at the base of the bladder neck and completely surrounds the urethra.

In the male the prostate gland is interposed between the bladder neck and the urethra.

REF: pp. 463-464 3. The kidneys are highly vascular organs. Approximately how much of the entire circulating

blood volume do the kidneys process at any one time? a. One-fifth b. 1 mL per kg body weight c. One-third d. 30 mL per hour ANS: A

The kidneys are highly vascular organs that process approximately one-fifth of the body’s entire volume of blood at any one time.

REF: p. 461 4. The adrenal glands lie retroperitoneally beneath the diaphragm, capping the medial aspects of

the superior pole of each kidney. The adrenal medulla secretes ______________, while the adrenal cortex secretes ____________ and ____________. a. epinephrine; steroids and hormones b. steroids; adrenaline and hormones c. epinephrine; pituitary-stimulating hormone and adrenaline

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. pituitary hormones; cortisol and norepinephrine ANS: A

Each adrenal gland has a medulla, which secretes epinephrine (adrenaline), and a cortex, which secretes steroids and hormones.

REF: p. 461 5. Which action best reflects the movement of urine from the renal pelvis to the bladder? a. Normal intra-abdominal positive pressure promotes renal drainage. b. Slight distention of the renal pelvis initiates a wave of peristaltic contractions. c. Distention of the proximal ureter facilitates gravity drainage through signaling

channels. d. Urine is propelled into the bladder when adrenal hormones bind with ureteral

receptor sites.

ANS: B

As urine accumulates in the renal pelvis, slight distention initiates a wave of muscular contractions. This peristaltic activity continues down the ureter, propelling urine into the bladder.

REF: p. 461 6. Patients having genitourinary surgery are at risk for impaired urinary elimination. Select the

statement that best reflects a desired outcome for an adult patient. a. The patient will be able to urinate before the bladder exceeds 350 mL of fullness. b. The patient will regain his or her normal pattern of urinary elimination. c. The patient will excrete 50 mL of urine per hour. d. The patient will be able to ambulate to the bathroom following surgery.

ANS: B

The patient outcome related to the risk for urinary retention could be stated as follows: The patient will demonstrate or regain a normal pattern of urinary elimination. Normal urinary output for an adult is 0.5 to 1 mL/kg body weight/hour. Full bladder capacity is 350 to 700 mL. REF: p. 461 7. The lead perioperative nurse in the robotic prostatectomy division of the urology service has

developed a standardized plan of care that the nurses will use to deliver individualized patient care and education according to recognized standards of care. Interventions include the following: clarifying the patient’s understanding of the risks and benefits of the surgical procedure; providing an open, accepting environment for the patient to discuss potentially embarrassing issues; and maintaining patient privacy and dignity. Which desired outcome is addressed by this plan? a. The patient will be free from injury related to the surgical position. b. The patient will discuss fears and concerns regarding sexual function. c. The patient will demonstrate or regain a normal pattern of urinary elimination. d. The patient will maintain normothermia throughout the perioperative experience.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The outcome statement, “The patient will discuss fears and concerns regarding sexual function” is sensitive to the following nursing interventions: clarifying the patient’s understanding of risks and benefits of the surgical procedure; providing an open, accepting environment for the patient to discuss potentially embarrassing issues; maintaining patient privacy and dignity; and considering making a referral for the patient to discuss options available to achieve sexual function.

REF: p. 466 8. During urologic surgery large quantities of irrigating fluids are infused intraoperatively. An

appropriate nursing intervention would include: a. monitoring and recording the volume of intravenous (IV) and irrigating fluids instilled. b. maintaining a closed urinary drainage system. c. providing the patient with information on preventing recurrent urinary tract infections. d. monitoring blood loss and volume replacement.

ANS: A

Large amounts of irrigating fluids are often used during urologic procedures, which may impact the patient’s electrolyte status. Irrigating fluids should be monitored both for fluid infused and for fluid returned. Thorough knowledge of the potential hazards encountered intraoperatively is extremely important, and close observation is essential. A sudden change in signs and symptoms may be suggestive of transurethral resection of the prostate (TURP) syndrome, a severe hyponatremia caused by systemic absorption of irrigating fluid used during surgery. Minimum amounts of fluids should be given and urine output carefully monitored. Irrigation fluid should be under as little pressure as possible and the bladder emptied before it reaches full capacity to prevent intravesical pressure.

REF: p. 469 9. A perioperative nurse relieved the circulating nurse in OR 5, where they were about to begin a

circumcision on a 17-year-old patient under general anesthesia. After she received the handoff report from the circulating nurse, she noticed an empty vial of lidocaine 1% with epinephrine 1:100,000 by the computer, where she had signed herself in as the relief nurse.

During the hand-off report the scrub person showed her the medication cup on the sterile field.

It was labeled “lidocaine 1%.” The scrub person had drawn up 10 mL in a syringe to hand to the surgeon for a penile block. Her immediate response should be to: a. say nothing; the epinephrine will minimize bleeding and prolong the anesthetic action. b. tell the scrub person to write epinephrine 1:100,000 on the syringe and cup label. c. alert the team that lidocaine with epinephrine was accidentally placed on the back table. d. empty the cup and syringe and refill with 1% lidocaine without epinephrine.

ANS: C

Local anesthetics that contain epinephrine should be used with caution in urology. Many urologic interventions involve “end-organs,” for example, the scrotum, testicles, and penis.

The use of epinephrine in these areas can result in an ischemic situation and should be avoided.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 468 10. A 26-year-old man with a ureteral stone is transferred to the urology bed for a cystoscopy,

ureteroscopy, and laser lithotripsy under fluoroscopy of a left ureteral stone. The circulating nurse assists the patient into a position of comfort and positions his arms, tucking them at his sides, with the lift sheet over his arm and under his body. With the patient’s assistance, the nurse ensures that his sacrum is positioned just above the break in the OR bed and that his legs and feet are safely and securely supported for anesthesia induction and intubation. From the interventions below, what important nursing action should the nurse perform as soon as he is asleep, intubated, and positioned into lithotomy? a. Slide an under-buttocks drape below his buttocks and pull out the fluid collection tray of the bed b. Place leaded shields over his thyroid and chest and document their placement on the perioperative nursing record c. Check, monitor, and document his position and body alignment d. Initiate the time-out briefing with the surgeon and anesthesia provider ANS: B

In some procedures involving stones of the kidneys or ureters, intraoperative fluoroscopy may be required. When fluoroscopy (C-arm) is to be used, the patient must be placed on an OR bed compatible with its use. Whenever possible, the perioperative nurse takes measures to protect the patient from undue radiation exposure to the thyroid and chest areas by using small leaded shields. In urologic procedures it generally is not feasible to shield the reproductive organs.

REF: p. 468 11. A 68-year-old retired school teacher is recovering on postoperative day 2 from a robotic-

assisted laparoscopic prostatectomy. The perioperative lead nurse for the urology surgery division has arrived in the patient’s room to complete his discharge instructions, which she began 3 days ago on his admission to the preoperative unit. Although the patient has been taught that it is normal to go home with a catheter after this type of procedure, he expresses concerns about his ability to care for his urinary catheter at home. After the nurse assures him that he will soon demonstrate or regain a normal pattern of urinary elimination, which statement would best ensure that the patient will be able to accomplish his outcome? a. He should learn catheter care and measures to facilitate voiding after catheter removal. b. The nurse should teach him about catheter care and how to void when it is removed. c. He should be able to “teach back” proper catheter care to the nurse. d. The nurse should demonstrate proper catheter care techniques.

ANS: C

Information provided should be presented in language the patient can understand (lay terms) and clarified with the patient by having the patient repeat back and/or teach back in his or her own words the information provided. Nursing interventions for the outcome statement, “The patient will demonstrate or regain a normal pattern of urinary elimination” include recommending that the nurse teach catheter care and measures to facilitate voiding after catheter removal as part of preoperative patient and family education and discharge planning.

The nurse should then have the patient teach back proper catheter care and provide time for questions and clarification about home care.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 472 12. Prostate cancer is the most frequently diagnosed cancer in men and is the second leading

cause of cancer death in men. Select the triad that best reflects the individual with the highest risk for prostate cancer. a. 65+ years old, African descent, father had prostate cancer b. 50+ years old, Pacific Islander descent, brother has prostate cancer c. 36 years old. Jamaican descent, low-fat diet, no family history d. 45 years old, African descent, low-fat diet ANS: A

Early detection is important in the diagnosis and management of prostate cancer. Information relating to a patient’s profile includes the following risk factors. Age: After 50 years of age, the risk increases rapidly; about 64% of all prostate cancer cases are diagnosed in men age 65 and older. Race: African-American men and Jamaican men of African descent have the highest prostate cancer incidence rates in the world. Diet: High dietary fat is associated with a greater risk for developing cancer. Family history: Risk is increased for men who have firstdegree relatives with prostate cancer.

REF: p. 489 13. The PSA test is a serum lab test for prostate-specific antigen. If the test value is elevated, the

patient is at risk for carcinoma of the prostate; a PSA value greater than 10 ng/mL is highly suggestive of prostatic carcinoma. Tissue from a transrectal prostate biopsy provides the cellular information to confirm the diagnosis. The American Urological Association (AUA) prostate cancer staging tool essentially provides which important information about the tissue specimen? a. Prostate cancer stages of severity b. Indications for selecting appropriate intervention c. Prognosis and potential for recovery d. Men who are at the greatest risk for prostate cancer ANS: A

The AUA recommends that starting at age 40 the PSA test and digital rectal examination (DRE) be offered to men at average risk. Clinical evaluation and an elevated PSA usually indicate the need for a transrectal ultrasound needle biopsy to confirm the diagnosis. When the results of the biopsy are positive for cancer, the AUA score measures the severity of the cancer: stage A is clinically unsuspected disease; stage B means a tumor confined to the prostate gland; stage C refers to a tumor localized to the periprostatic area; and stage D means metastatic prostate cancer.

REF: p. 488 14. The Gleason score is similar to the AUA score, because it also needs to be measured against

microscopic samples of prostatic tissue. Select the statement that best defines the assignment of the Gleason score. a. A Gleason score between 8 and 10 is associated with indications for curative surgery. b. The first and second most common cell types are each given a score of 1 to 5, and the numbers are combined for a total score. c. The number of cells in a given space determines the score; the lower the number,

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock the more aggressive the cancer. d. The Gleason score is determined by doubling the AUA score.

ANS: B

The most commonly used system to grade prostate cancer is the Gleason score. To calculate the Gleason score, the pathologist evaluates the prostatic tissue to determine which type of cell is the most common and which type is the second most common and gives each of the two cell types a score from 1 to 5. The two scores are combined to determine the total score.

Higher numbers are an indication of more abnormal, aggressive cancer cells after surgery.

Additional prostate cancer staging tools are the tumor, node, metastasis (TNM) system and the AUA system.

REF: p. 488 15. An 84-year-old retired musician was seen by his family practice physician for urinary

problems. His physician performed a DRE, which was abnormal, ordered a PSA, and referred him to a urologist. The patient’s PSA was 12 ng/mL. His transrectal prostatic biopsy was positive. The biopsy specimen determined a Gleason score of 10, and his AUA score was D2.

Based on this clinical diagnostic information, what is the best treatment plan for the patient? a. TURP b. Simple perineal prostatectomy c. Radical open prostatectomy with lymph node dissection d. No surgery, because he is probably not a candidate for surgery ANS: D

PSA values greater than 10 ng/mL are highly suggestive of prostatic carcinoma. Gleason scores between 8 and 10 indicate highly aggressive tumors and are associated with a poor prognosis after surgery. An AUA score of stage D2 indicates (1) metastatic prostatic cancer with pelvic lymph node metastases or ureteral obstruction causing hydronephrosis, or both, and (2) bone, soft tissue, organ, or distant lymph node metastases.

REF: pp. 488-489 16. An orthotopic neobladder is surgically created as a bladder substitute after a cystectomy,

prostatectomy, or hysterectomy is performed for bladder cancer. Bladder substitution relies on meticulous dissection with preservation of the urinary sphincter and neurovascular bundles, as well as a watertight urethral anastomosis. Also termed the Le Bag continent diversion, which segments of the bowel and/or small intestine are used in this technique to create the neobladder? a. Segment of sigmoid colon b. Right colon and ileum c. Proximal right colon segment with cecum d. Transverse colon ANS: B

The orthotopic ileocolic neobladder, or Le Bag continent diversion technique, uses the right colon and ileum as an orthotopic bladder replacement. Contraindications include previous radiation therapy, bowel disease (e.g., diverticulosis, Crohn’s disease, colitis), and other major medical problems.

REF: p. 521

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

17. In TURP, the surgeon passes a resectoscope into the bladder through the urethra and resects

successive pieces of tissue from around the bladder neck and the lobes of the prostate gland, leaving the capsule intact. TURP is traditionally indicated for patients with benign obstructive disease of the prostate. A TURP would be indicated for a patient with malignant prostatic disease under which of the following conditions? a. For palliative relief of obstruction for end-stage disease b. For symptom relief of obstruction before initiating other treatments c. For specimen retrieval for diagnostic cancer staging d. For men who cannot tolerate, or who are not candidates for, high-intensity focused ultrasound ANS: B

TURP is one surgical method of treating benign obstructive enlargement of the prostate gland.

Several factors influence the surgical approach: size of the gland and location of the pathologic condition, age and condition of the patient, and presence of associated diseases.

TURP may also be used in men who cannot have a radical prostatectomy or to relieve symptoms caused by prostate cancer before other treatments begin.

REF: p. 492 18. During a robotic-assisted laparoscopic prostatectomy, the patient, positioned in steep

Trendelenburg, exhibited signs of deteriorating oxygenation and loss of secured airway requiring immediate intervention. What is the next priority in order to respond to the emergency? a. Place the patient back in supine position b. Extubate and reintubate c. Remove the instruments from the patient d. Create a surgical airway ANS: C

Once the procedure begins, the anesthesia provider places the patient in the Trendelenburg position to displace the viscera from the pelvis into the upper abdomen to improve visualization. Once the patient is positioned and draped, the patient instrument cart is docked, and instruments are inserted into the patient. If the patient’s condition deteriorates and something needs to be done that involves moving the patient, the patient cannot be moved until the instruments are removed or it could cause serious damage to the internal organs.

REF: p. 508 19. A wide variety of drains, stents, and other catheters are designed and used for specific

urologic procedures. A commonly used catheter is described by its tip. What catheter type is described as open-ended tip, whistle tip, cone tip, and olive tip? a. Irrigation catheter b. Urethral catheter c. Ureteral catheter d. Pigtail catheter ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The most commonly used ureteral catheters include the open-ended, whistle tip, cone tip, and olive tip. When a retrograde ureterogram is indicated, a cone-tipped ureteral catheter may be helpful in occluding the ureteral orifice to accomplish the X-ray study effectively. A variety of urethral and ureteral catheters are designed for specific procedures. Ureteral catheters are manufactured of polyurethane material and are graduated so that the urologist may determine the exact distance the catheter has been inserted into the ureter.

REF: pp. 469, 471 20. A kidney transplant entails transplantation of a living-related or cadaveric donor kidney into

the recipient’s iliac fossa. It is performed in an effort to restore renal function and maintain life in a patient who has end-stage renal disease. Select the statement that best reflects the ideal living-related donor candidate. a. An identical twin or spouse, young, ABO and Rh factor compatibility b. An identical twin or parent, good health, and large right kidney c. An identical twin or sibling, no family history of diabetes, Rh factor compatibility d. An identical twin, sibling, or parent; ABO and human leukocyte antigen (HLA) compatibility; good health ANS: D

The kidney donor must be in good health. ABO (blood typing) and histocompatibility (HLA tissue typing) along with a negative white cell (lymphocyte) crossmatch determine donorrecipient compatibility. It is not necessary to match the Rh factor. If there is a family history of diabetes, a 5-hour glucose tolerance test is also performed. The ideal living donor is an identical twin, although any immediate family member (usually a sibling or parent) may be a donor. Usually the right kidney is chosen for removal because of its smaller size, leaving the donor patient with the left and larger kidney.

REF: p. 531 21. Each potential kidney transplant recipient is judged individually as a candidate. Which

condition would most likely eliminate a patient as a candidate for kidney transplant? a. Mild systemic disease b. Diabetes c. Post-treatment cancer in remission d. Active cancer ANS: D

Each potential recipient is judged individually in regard to kidney transplantation. Most people younger than 55 years are acceptable; older patients are less tolerant of postoperative complications. Contraindications for renal transplantation include: (1) systemic disease that precludes major surgery, (2) oxalosis (a metabolic disorder), (3) a positive HLA cytotoxic antibody screen, (4) untreatable cardiovascular disease, (5) active cancer, and (6) noncompliance.

REF: p. 533 22. TURP syndrome is a state of severe hyponatremia, caused by systemic absorption of irrigating

fluid during the procedure. Select the sign/symptom that the anesthesia provider would report in a patient experiencing TURP syndrome. a. Hypertension

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Hyperthermia c. Hypocalcemia d. Hypokalemia ANS: A

Signs and symptoms such as sudden restlessness, apprehension, irritability, confusion, nausea, slow pulse rate, seizures, dysrhythmias, and rising blood pressure may be suggestive of TURP syndrome. This syndrome results in severe hyponatremia caused by systemic absorption of irrigating fluid used during surgery.

REF: p. 469 23. Select the appropriate triad of corrective actions for the management of TURP syndrome in

the intraoperative patient. a. Determine electrolyte levels, measure irrigation fluid volume deficits, administer hypertonic IV saline b. Administer hypertonic IV saline, administer IV diuretics, terminate surgery if reaction is severe c. Evaluate electrolyte values, give IV diuretics, listen to breath sounds for signs of pulmonary edema d. Determine the irrigation fluid volume deficit, reduce pressure on irrigation bag system, administer IV diuretics ANS: B

IV diuretics such as furosemide (Lasix) may be required to prevent possible pulmonary edema associated with administration of hypertonic saline. If the patient’s reaction is severe, surgery may have to be terminated. The nurse monitors the amount of irrigation fluid recovered and subtracts it from the amount of irrigation fluid used. The total of the irrigation used minus the irrigation recovered is referred to as the volume deficit. If the cause for the deficit cannot be identified, it should be considered reabsorbed.

REF: p. 469 24. Endoscopic examination of the urinary tract, with a sterile cystoscope, is typically designated

as which wound classification category? a. Class I (clean) b. Class II (clean-contaminated) c. Class III (contaminated) d. Class IV (infected) ANS: B

Endoscopy of the genitourinary tract is considered a class II (clean-contaminated) procedure and, according to the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines, presently requires disinfection rather than sterilization.

REF: p. 475 MULTIPLE RESPONSE

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 1. The flexible cystoscope is a delicate and valuable endoscopic instrument indicated for

diagnostic bladder evaluation for patients with obstructive symptoms from prostatic hyperplasia and a rigid prostatic urethra. It has valuable benefits because of its small diameter and flexibility. Select benefits that support the use of flexible endoscopy in the outpatient setting. (Select all that apply.) a. It may be accomplished using a local anesthetic. b. It can be used for patients unable to assume the lithotomy position. c. It can be performed on the patient’s bed on the nursing unit. d. The cystoscope can be processed between patients without manual cleaning and disinfection.

ANS: A, B, C

The flexible cystoscope is used for patients with obstructive symptoms resulting from prostatic hyperplasia and rigid prostatic urethra. In addition, the flexible cystoscope can be used for patients who cannot assume a lithotomy position, such as those with spinal cord injuries or severe arthritis. Flexible cystoscopy may be accomplished with the use of a local anesthetic. It affords the patient a higher degree of comfort, is less traumatic to the urethra, and can be performed in the patient’s bed on the nursing unit. The flexible cystoscope must be reprocessed with manual cleaning and high-level disinfection or sterilization.

REF: p. 475

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 16: Thyroid and Parathyroid Surgery Test Bank MULTIPLE CHOICE 1. The pyramidal lobe of the thyroid is described as: a. a small lobe often involved in 30% of cases of thyroid dysfunction. b. a protrusion of an immature thyroglossal duct cyst overgrowth. c. a thin upward protrusion of thyroid tissue from the isthmus. d. a vestige of an embryonic thyroid cyst.

ANS: C

The pyramidal lobe, a long, thin projection of thyroid tissue protruding cephalad from the isthmus, is found in about 30% of patients at surgery; it is the vestige of the embryonic thyroglossal duct and migrates from the foramen cecum at the base of the tongue.

REF: p. 538 2. The primary function of the three thyroid hormones is to regulate: a. energy metabolism. b. body growth and development. c. calcium storage in the bones. d. the decrease in blood calcium levels.

ANS: A

The thyroid gland produces three hormones: thyroxine (T4) and triiodothyronine (T3) (together known as the thyroid hormones [THs]) and calcitonin. T3 and T4 cannot be synthesized without iodine and regulate energy metabolism and growth and development. Calcitonin inhibits calcium resorption from bone and increases calcium storage in the bone. In addition, calcitonin increases renal excretion of calcium and phosphorus and decreases serum calcium levels. When elevations in serum calcitonin are found in the patient’s blood work, medullary thyroid cancer is suspected.

REF: p. 539 3. Postoperative hoarseness, obstructed airway, and paralysis of the vocal cords are serious

complications of thyroid surgery. During surgery, care is taken to identify and protect which nerve? a. Superior branch of the vagus nerve b. Intrinsic cricothyroid nerve c. Recurrent tracheoesophageal nerve d. Recurrent laryngeal nerve ANS: D

The recurrent laryngeal nerve, a branch of the vagus nerve, innervates the intrinsic muscles of the larynx. During surgery, care is taken to identify and protect this nerve. Immediate hoarseness occurs if the nerve is divided on one side. If the recurrent nerve is injured bilaterally, acute paralysis of both vocal cords may obstruct the airway and require emergency tracheotomy. Injury to the external branch of the superior laryngeal nerve, which innervates the cricothyroid muscle, results in difficulty shouting or singing high notes.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 538 4. What is the mechanism by which the parathyroid glands maintain calcium homeostasis? a. They secrete parathyroid hormone (PTH), which promotes calcium storage in the

intestines. b. They produce a hormone that, with calcitonin, takes calcium from the bones and

promotes calcium absorption by the intestines. c. They stimulate the pituitary to produce PTH and calcitonin, which elevates serum

calcium levels. d. They secrete hormones that stimulate the production of calcium in the bones and

small intestines when serum calcium levels fall below 4.5 mg/dL. ANS: B

The parathyroid glands secrete PTH, an antagonist to calcitonin. Both PTH and calcitonin work together to maintain calcium homeostasis by increasing calcium removal from storage in bone and increasing absorption of calcium by the intestines.

REF: p. 539 5. The preoperative testing regimen for diagnosing thyroid disorders follows a structured plan of

history taking, neck palpation, imaging scans, and fine needle aspiration. Select the statement that is an appropriate reflection of a thyroid diagnostic study. a. Palpation determines size, contour, swallowing function, lymph nodes, and bruits. b. Fluoroscopy-guided fine needle aspiration is typically performed for frozen section. c. Ultrasonic scans are the treatment of choice to evaluate thyroid nodules. d. Magnetic resonance imaging (MRI) and computed tomography (CT) scans evaluate local invasion of the tumor nodules within the thyroid capsule.

ANS: C

Ultrasonic scans evaluate thyroid nodules and are useful to determine the size and number of nodules within the thyroid as well as to monitor size progression during follow-up. In addition to palpation of the thyroid gland for size, contour, consistency, lymph nodes, fixation, tenderness, and bruits, scans are used to clarify thyroid anatomy. CT and MRI scans are used to assess a thyroid with suspected malignancy for encroachment of the tumor outside the thyroid capsule into the adjacent tissue of the neck. Scans are the most effective means to evaluate local invasion of surrounding tissue. Fine needle aspiration is usually performed under ultrasound guidance. Several samples are aspirated from various parts of the nodule.

REF: p. 543 6. Hypothyroidism results from undersecretion of thyroid hormone. Select the set of symptoms

that is most commonly associated with hypothyroidism. a. Dry scaly skin, patchy hair, muscle cramps, and depression b. Irritability, mood changes, visual disturbances, and diarrhea c. Heat intolerance, anorexia, hair loss, and menstrual irregularity d. Bradycardia, hypotension, hypoxia, and poor concentration ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Symptoms of hypothyroidism include fatigue, weight gain, cold intolerance, hair dryness or loss, dry skin, depression, hoarse voice, poor concentration, muscle stiffness and pain, edema, bradycardia, constipation, and menstrual irregularity (especially heavy menses and/or infertility).

REF: pp. 540,548 7. The patient with hyperthyroidism most likely has received appropriate drug therapy that has

returned thyroid hormone levels and metabolic state to normal; however, the perioperative nurse should assess for any symptoms that relate to accelerated metabolism. Select the set of symptoms that is most commonly associated with hyperthyroidism. a. Atrial fibrillation, anxiety, weight gain, and cold intolerance b. Tachypnea, dry mouth, systemic pruritus, and heavy menses c. Fatigue, vision changes, disturbed concentration, and vertigo d. Increased sweating, insomnia, tremor, and muscle weakness ANS: D

Symptoms of hyperthyroidism include vision changes (e.g., myopathy, ophthalmopathy, such as extraocular muscle enlargement or visual loss with prolonged optic nerve compression), emotional lability, mood changes, irritability, exercise intolerance, fatigue, weight loss, heat intolerance and flushing, hyperactivity (especially children), increased sweating, insomnia, tremor, muscle weakness, dyspnea, frequent bowel movements, and menstrual irregularity (oligomenorrhea, infertility).

REF: p. 540 8. A 62-year-old woman with a 4-year history of Graves’ disease has not responded to medical

therapy. She is scheduled for a subtotal thyroidectomy. Which condition, a complication of Graves’ disease, is her probable indication for a subtotal thyroidectomy? a. Tracheal obstruction b. Diffuse unilateral enlargement of a lobe c. Hyperthyroidism with cricothyroid compression d. Autoimmune hypothyroidism ANS: A

Graves’ disease, the most common cause of hyperthyroidism, is associated with diffuse, bilateral enlargement of the thyroid gland. Surgery is reserved for those patients who fail medical therapy (antithyroid drugs and radioactive iodine) or have a contraindication to medical therapy. Surgery may be indicated to relieve tracheal or esophageal obstruction or to rule out a malignant nodule of the thyroid.

REF: p. 549 9. A 61-year-old woman with nontoxic nodular goiter is scheduled for a subtotal thyroidectomy

to relieve esophageal obstruction and rule out a malignant nodule. Select the statement that best describes the patient’s thyroid dysfunction and cause. a. Hypothyroidism resulting from inflammatory impairment of cells that produce hormones b. Hyperthyroidism resulting from overproduction of enlarged normal thyroid cells c. Hypothyroidism resulting from insufficient hormone production, increasing thyroid tissue proliferation

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Hyperthyroidism resulting from malignant spread of mutated hormone-producing

tissue ANS: C

Nontoxic nodular goiter involves production of insufficient hormones and is noninflammatory; in such cases thyroid tissue proliferates in an apparent attempt to produce the minimal hormonal requirement. Surgery may be indicated to relieve tracheal or esophageal obstruction or to rule out a malignant nodule of the thyroid.

REF: p. 549 10. A 19-year-old woman is scheduled for a thyroidectomy. She is significantly underweight as a

result of her thyroid disease. The perioperative nurse considers her to be at high risk for pressure and shearing injury to skin and tissues. Of the following, which is the high-priority nursing action in the preoperative phase for this patient? a. Perform a preoperative assessment of dependent pressure areas. b. Encourage the patient to discuss any issues with body image. c. Assure the patient that she will be carefully positioned and padded. d. Suggest a wound ostomy nurse referral for the patient for postoperative skin care.

ANS: A

Proper patient positioning on the operating room (OR) bed is crucial for optimal exposure of the thyroid gland. The perioperative nurse should consider a patient who is not at optimal weight at high risk for pressure ulcer development and plan on padding pressure areas to prevent skin and tissue damage.

REF: p. 545 11. Thyroid storm can occur in patients whose hyperthyroidism is partially controlled or

untreated. Thyrotoxic crisis can be precipitated by a stressful event, such as surgery. An example of nursing action(s) to reduce the risk of thyroid storm is to: a. administer potassium iodide before transfer to the OR. b. provide a quiet, calm atmosphere and help the patient relax. c. provide comfort measures, including a cooling blanket. d. provide a quiet, calm atmosphere and help the patient relax, and provide comfort measures, including a cooling blanket.

ANS: D

By planning a quiet, calm atmosphere and helping the patient relax, the perioperative nurse can reduce the risk of thyroid storm. Collaborating with the surgical and anesthesia team, the perioperative nurse can plan for appropriate interventions to assist in reducing body temperature and heart rate, provide oxygen and intravenous (IV) solutions, and administer medications as prescribed in the event thyrotoxic crisis occurs.

REF: p. 545 12. Thyroid surgery is considered surgery of the head and neck. There is a high risk for surgical

fires because of the proximity of all three components of the fire triangle. Select the statement that best reflects an appropriate nursing action to prevent a surgical fire. a. Do not use self-adherent tape strips; they do not adequately seal the operative site from anesthetic vapors that may have leaked.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. If bed sheets or towels become soaked with flammable prep solution, allow them

to dry completely before surgery begins. c. Ensure that the patient’s skin is totally dry and all fumes from the prep solution

have dissipated before draping. d. Determine fire risk score during the postprocedure debriefing.

ANS: C

When an alcohol-based prep solution is used around the head and neck, risk for surgical fire is increased. The patient’s skin should be totally dry and all fumes from the prep solution should be dissipated prior to draping. Bed sheets or towels that become soaked with a flammable prep solution should be removed from the OR. Self-adherent tape strips or drapes reduce the risk of intraoperative fire hazard by sealing off the operative site from anesthetic vapors that may have leaked and become trapped under the drapes.

REF: p. 545 13. Patients with hyperthyroidism should be assessed and monitored for an abnormally elevated

resting pulse rate, elevated systolic blood pressure, and cardiac symptoms. Atrial fibrillation is the most common cardiac complication of hyperthyroidism. An example of a nursing action during the nursing assessment phase would be to: a. ask the patient if he/she is a vocalist and concerned about the postoperative effect of surgery on the voice. b. confirm whether anticoagulation medication is being taken. c. note the patient’s muscle strength, elimination patterns, and history of weight loss. d. note signs of anxiety and issues related to body image concerns with neck surgery.

ANS: B

Studies show that patients with overactive thyroid conditions have an increased risk of various heart problems, particularly atrial fibrillation, that may lead to premature death. Atrial fibrillation can cause blood clots to form from the continuous blood turbulence in the atria.

The perioperative nurse should determine whether anticoagulant and thyroid medications are being taken by the patient. The patient’s baseline vital signs should be noted for an abnormally elevated resting pulse rate, elevated systolic blood pressure, and cardiac symptoms, such as palpitations or atrial fibrillation. The patient’s cardiac and respiratory rates, muscle strength, elimination patterns, history of weight loss, heat intolerance, and emotional status should all be noted.

REF: p. 540 14. A 32-year-old thin and pale patient with hypothyroidism is met by the perioperative nurse for

her preoperative assessment. The nurse notes the patient’s thin frame and pale, fragile skin.

The patient states that she is so cold that she has all of her clothes on under her patient gown.

Based on her assessment, the nursing diagnosis for the patient is: a. risk for hyperthermia. b. risk for skin and tissue perfusion. c. risk for injury related to surgical positioning. d. risk for metabolic deterioration.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The perioperative nurse should consider a patient who is not at optimal weight at high risk for pressure ulcer development and plan on padding pressure areas to prevent skin and tissue damage. Intraoperatively, warm saline should be provided for irrigation and a forced-air warming device used. Patients with hypothyroidism are at increased risk of becoming hypothermic.

REF: p. 545 15. A total thyroidectomy may be done for a variety of malignant tumors. The most common form

of malignant thyroid nodule is a poorly encapsulated type known as: a. follicular carcinoma. b. anaplastic carcinoma. c. papillary carcinoma. d. medullary carcinoma.

ANS: C

Papillary carcinoma, which is poorly encapsulated, is the most common form (>70%) of malignant thyroid nodule. The second-most common form (10%), a well-differentiated form that is associated with iodine deficiency, is called follicular carcinoma. An undifferentiated form, medullary carcinoma accounts for 5% of malignancies. Anaplastic carcinoma is a highly aggressive and rapidly fatal malignancy that is more common in females and older adults.

REF: p. 550 16. Anatomic exposure is promoted and supported by proper body alignment in collaboration

with safe and secure surgical positioning. The optimal presentation of the thyroid and surrounding structures of the neck can be achieved with the patient in supine or beach-chair position. Select the positioning considerations that enhance visualization and access to important structures. a. 30-degree Trendelenburg tilt of the OR bed, shoulder roll, and arms tucked snuggly at sides b. Hyperflexion of the neck, shoulder roll, and arms tucked loosely at sides with palms facing up c. Hyperextension of the neck, shoulder roll, and 30-degree reverse Trendelenburg tilt of the OR bed d. Headrest, arms abducted at 90 degrees on armboards, and axillary roll ANS: C

Proper patient positioning on the OR bed is crucial for optimal exposure of the thyroid gland.

The patient is positioned supine. Some surgeons prefer a beach-chair position or a wedge under the back. Hyperextension of the neck is required for maximal exposure. A headrest provides proper support, keeps the head straight, and prevents aggravation of prior neck problems. Alternatively, a shoulder roll may be used. The arms are tucked at the side, the elbows are padded to protect the ulnar nerve, the palms faced inward, and the wrist is maintained in a neutral position. Reduction of venous congestion can be accomplished by a 30-degree reverse Trendelenburg tilt of the OR bed.

REF: p. 545

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 17. Total thyroidectomy is the removal of both lobes of the thyroid and all thyroid tissue present.

Total thyroidectomy is the desired surgical treatment for patients with: a. hyperthyroidism with more than two episodes of thyroid storm. b. thyroid cancer. c. autoimmune inflammatory thyroid dysfunction. d. hypothyroidism unresponsive to antithyroid medications.

ANS: B

For patients with cancer of the thyroid, total or near-total thyroidectomy is the desired treatment. Following surgery, the thyroid cancer patient may be treated with radioactive ablation therapy for residual or metastatic disease and thyroid hormone suppression therapy.

REF: p. 548 18. Substernal or intrathoracic thyroidectomy is indicated for goiters that are encroaching into the

substernal or intrathoracic regions, causing tracheal or esophageal obstruction. Access to the substernal compartment is typically facilitated by: a. splitting the sternum. b. using a right mini-thoracotomy approach. c. using long instruments through a regular thyroid incision. d. using a mediastinoscopy approach.

ANS: C

Extensions of goiters enlarging into the substernal and intrathoracic regions may occur. If they cause tracheal and esophageal obstruction, they are usually excised surgically. Longer instruments are sometimes required. Splitting the sternum is rarely necessary, because access to the substernal part of the gland is usually satisfactory through the standard thyroid incision.

REF: p. 552 19. Open parathyroidectomy is currently being replaced with less invasive and more targeted

techniques; however, the amount of parathyroid tissue that should be removed remains controversial and relates to whether single or multiple glands are involved. A portion of a gland must remain to: a. prevent hypocalcemia and its complications. b. serve as a marker for later surgery should the gland fail to produce PTH. c. regenerate into normal parathyroid tissue. d. maintain the patient in a state of hypercalcemia to compensate for the lost glands.

ANS: A

In the classic open approach, with the thyroid gland visible, bilateral neck exploration of the “normal” locations of the four parathyroid glands is conducted. A portion of a gland must remain to prevent hypocalcemia and its complications. The amount of remaining parathyroid tissue can then be adjusted to regulate PTH to the desired level.

REF: p. 555

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 20. A number of symptoms and signs are well-established manifestations of thyroid dysfunction.

The American Association of Clinical Endocrinologists (AACE) has established practice guidelines for the diagnostic evaluation and screening of hyperthyroidism and hypothyroidism. The AACE recommends the ___________ as the single best screening test. A history of ___________ are symptoms of concern, and patients with ___________ require MRI or CT imaging, because this may be indicative of metastasis. Select the clinical triad to complete this diagnostic screening guideline. a. serum TSH; calcifications; cough b. thyroxin profile; whole-body radiation; Hashimoto’s disease c. free thyroid hormone levels; thyroiditis; a pulsating neck mass d. TSH assay, neck or ear pain, dysphagia ANS: D

The AACE practice guidelines for the diagnostic evaluation of hyperthyroidism and hypothyroidism recommend TSH assay as the single best screening test. A thorough history and physical is indicated in screening for thyroid cancer. A history of being exposed to neck or whole-body radiation or being raised in iodine-poor areas should be assessed. A rapidly expanding neck mass, new onset of hoarseness, neck or ear pain, or cough are symptoms of concern. Patients with a fixed, immobile mass and/or hoarseness, dysphagia, or respiratory symptoms require CT or MRI imaging as part of the evaluation. These symptoms may be indicative of metastasis. Serum TSH measurement is the single most reliable test to diagnose all common forms of hypothyroidism and hyperthyroidism, with high sensitivity (98%) and specificity (92%).

REF: p. 542 21. An example of antithyroid drugs that would be administered during a thyroid storm crisis

would be: a. sodium iodide solution and Lugol’s solution. b. propylthiouracil and methimazole. c. guanethidine and ipodate sodium. d. propranolol and lithium.

ANS: B

Emergency care during thyroid storm requires the administration of antithyroid drugs such as propylthiouracil (PTU, Propyl-Thyracil), 300 to 900 mg/day; or methimazole (MMI) (Tapazole), up to 60 mg/day. It is also important to maintain a patent airway and adequate ventilation.

REF: p. 546 22. A 41-year-old woman with suspected primary adenocarcinoma of the thyroid is scheduled for

total thyroidectomy surgery. The scrub person, a new perioperative nurse, is determined to participate in employing risk reduction strategies in the scrub role. An example of risk reduction strategies for thyroid surgery, within the domain of the scrub role, would be: a. protecting the drapes from accidental blood and body fluid contact. b. providing efficient and expedient dressing materials as needed. c. maintaining sterility of the instruments until the patient leaves the room in the case of need for emergency tracheostomy. d. documenting nursing care assessment, practices, and timed events.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

The instrument table should be kept sterile until the patient is extubated and has left the OR. A tracheotomy tray with tubes should be readily available should an emergency tracheotomy be necessary.

REF: p. 542 23. Review the list below and select the answer that more accurately depicts the difference

between thyroid storm and thyrotoxicosis. a. Thyroid storm is fatal if not treated. b. Thyrotoxicosis causes systemic coagulopathy. c. Only thyroid storm is considered an emergency. d. Thyrotoxicosis represents a hypometabolic state.

ANS: A

Thyroid storm is a fulminating state that is fatal if untreated. It may be difficult to differentiate from signs of uncomplicated thyrotoxicosis. It is an accentuation of the same signs. Onset is heralded by high-grade fever, mental obtundation, and decompensation of one or more organ systems as a result of severe hypermetabolism. Signs and symptoms include heat intolerance, diaphoresis, hyperpyrexia, dehydration, sinus tachycardia, hypotension, atrial dysrhythmias, congestive heart failure, diarrhea, increased appetite with weight loss, nausea, and vomiting.

REF: p. 545 MULTIPLE RESPONSE 1. A minimally invasive video-assisted thyroidectomy (MIVAT) procedure relies on Miccoli

instruments added to the standard thyroid or neck dissection setup, a 30-degree endoscope, and an ultrasonic (harmonic) scalpel with scissors to ligate and divide the vessels. An important risk-reduction strategy for any minimally invasive procedure would be to (Select all that apply.): a. note the amount of CO2 volume in connected tank and tanks available. b. consider and plan for the possibility of conversion to open thyroidectomy. c. position and drape the patient as for thyroidectomy. d. use fire-resistant light cords, endoscopes, light sources, and cable connections ANS: B, C, D

The possibility of conversion to open thyroidectomy should be included on the operative consent form. Instruments and supplies for a possible open procedure are readied. A set of long Miccoli instruments is added to the standard thyroid or neck dissection setup. A 30degree endoscope and harmonic scalpel with scissors are used to ligate and divide vessels.

Fire safety precautions are implemented for illuminated light cords, endoscopes, light sources, and cable connection. The patient is positioned and draped as for thyroidectomy.

REF: p. 552

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 2. A 17-year-old girl with cancer of the thyroid secondary to leukemia went into remission 7

years earlier. She is in good health and eager to get back to school in time for the prom and final exams; however, she is very concerned about scarring from the surgery. The circulating nurse sat with the patient and encouraged her to discuss her fears and expectations. Together, they collaborated on a plan for the patient’s discharge and care of her incision. The nurse documented the patient’s nursing diagnosis as disturbed body image related to surgical scar in prominent location. The nurse discussed the patient’s concerns with the surgical team before the incision was made. The patient had a minimally invasive thyroidectomy approach, which left a small scar that was closed with a 4-0 nonabsorbable subcuticular suture. In the postoperative phase, the nurse provided the patient with her postoperative education relative to her incision. Select all the incision care instructions that would be relevant for the patient.

(Select all that apply) a. Instruct the patient to focus on positive feelings related to body image. b. Instruct the patient in postoperative turning measures that decrease strain on the suture line. c. Suggest accessories (e.g., jewelry, scarves, and certain necklines) that can be used to cover the scar until normal fading occurs. d. Instruct her to refrain from prolonged exposure to direct sunlight or tanning salons while the incision is healing. e. Use cosmetic creams with cocoa butter to decrease scarring and discoloration.

ANS: B, C, D

The nursing outcome for disturbed body image is that the patient will verbalize decreased disturbance in feelings related to body image. The nurse should take the following actions: Explain that the incision is made in the natural fold of the skin. Explain that techniques used for surgical closure minimize scarring. Instruct patient in postoperative turning measures that decrease strain on the suture line. Suggest that jewelry, scarves, and certain necklines can be used to cover the scar until normal fading occurs. Advise the patient to refrain from prolonged exposure to direct sunlight or tanning salons while the incision is healing.

REF: pp. 545-547

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 17: Breast Surgery Test Bank MULTIPLE CHOICE 1. Identify the marginal boundaries of the breasts. a. Second to fifth rib horizontally, lateral edge of sternum to midclavicular line b. Second to sixth rib horizontally, midsternum to midclavicular line c. Second to sixth rib horizontally, lateral edge of sternum to anterior axillary line d. Second to fifth rib horizontally, lateral edge of sternum to midaxillary line ANS: C

The breasts extend from the second to the sixth ribs and horizontally from the lateral edge of the sternum to the anterior axillary line.

REF: p. 558 2. The internal thoracic lymph nodes, which drain the inner half of the breast, can also be a

channel for the: a. secretion of estrogen. b. spread of metastasis. c. drainage of the outer half of the breast. d. spread of infections.

ANS: B

Lymph drainage generally follows the course of the vessels. Greater than 75% of lymph drainage, chiefly from the lateral quadrants, drains to the axillary lymph nodes. The remainder of lymph drains to either the parasternal nodes, the opposite breast (medial quadrants), or the inferior phrenic nodes’ lower quadrants. The internal thoracic nodes are few but are responsible for most lymph drainage from the inner half of the breast. Thus the lymph system can also be a channel for the spread of malignant disease from the breast to associated areas of the chest wall or to the axilla.

REF: p. 558 3. The mammary glands are affected by physiologic changes throughout a woman’s life span.

Select the option that best reflects the life cycle events that impact the anatomy and physiology of the breasts. a. Growth and development, menstruation, and menopause b. Menstruation, pregnancy, and lactation c. Hormone development, pregnancy, and menopause d. Growth and development, menstruation, and pregnancy and lactation ANS: D

The mammary glands are affected by three types of physiologic changes: (1) Those related to growth and development, (2) those related to the menstrual cycle, and (3) those related to pregnancy and lactation.

REF: p. 558

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. Fibrocystic change in the breast is an all-encompassing term used to describe many different

breast changes. These changes affect almost all women at some time in their lives. Nipple discharge is more commonly associated with benign lesions than with cancer; however, discharge is usually significant only if it is spontaneous, persistent, and: a. chronic. b. bilateral. c. painful. d. milky white.

ANS: A

Nipple discharge is more commonly associated with benign lesions than with cancer.

Discharge is usually significant only if it is spontaneous and persistent. The discharge may be clear or bloody. Chronic unilateral nipple discharge, especially if bloody, should prompt an investigation for occult carcinoma.

REF: pp. 558-559 5. In the past, radical procedures, which involved removal of the affected breast and all axillary

and thoracic lymph nodes, were used to treat breast cancer. These procedures did not significantly lower mortality. Which factor may have contributed to mortality after these procedures? a. Distant metastases may have already occurred without adjacent lymph node involvement at the time of its palpable detection. b. Early pathology techniques for frozen section and histology microexamination could not define margins. c. Breast cancer was believed to spread by direct extension from its initial site in the breast to adjacent lymph nodes. d. Tumor size was not usually correlated with involvement of lymph nodes and cancer spread.

ANS: A

Breast cancer may be a systemic condition at the time of diagnosis. Distant metastases may have already occurred without adjacent lymph node involvement at the time of palpable detection. This could explain why radical breast surgery of the past, which involved removal of the affected breast and all axillary and thoracic lymph nodes, did not greatly lower mortality.

REF: p. 561 6. Ductal ectasia is a benign breast disorder that is difficult to distinguish from cancer, primarily

because it presents with: a. bilateral tenderness, mottled skin patterns of the breast, and fullness. b. bilateral multicentric nodules and nipple discharge. c. mottled skin patterns of the breast and edema. d. a hard and irregular mass, nipple discharge, and enlarged axillary nodes.

ANS: D

Ductal ectasia, generally seen in women approaching menopause, is described by a hard, irregular mass or masses with nipple discharge, enlarged axillary nodes, redness, and edema.

It is difficult to distinguish from cancer.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 560 7. Women of high socioeconomic status and higher education also have a high incidence of

breast cancer, most likely due to: a. high-fat diet. b. lifestyle-related genetic mutations. c. later age at first birth. d. better compliance with regular screening.

ANS: C

Breast cancer incidence is greater in women of higher education and socioeconomic background. This relationship is possibly related to lifestyle differences, such as age at first birth.

REF: p. 561 8. Breast screening guidelines are developed and published by the American Cancer Society

(ACS) for asymptomatic women of various age and risk groups. Select the statement that best reflects the ACS guidelines for women at high risk for breast cancer. a. Biannual mammography with two views of each breast and clinical breast exam (CBE) b. An individualized screening plan c. Biannual clinical breast exam, mammography, and bimonthly breast self-exam (BSE) d. Annual mammography, ultrasonography, and magnetic resonance imaging (MRI) ANS: B

The ACS Breast Cancer Screening Guidelines for Asymptomatic Women recommends BSE monthly and CBE every 3 years for women ages 20 to 39. For women 40 and older, the guidelines recommend BSE monthly, CBE annually, and screening mammography (two views of each breast) annually. Asymptomatic women who are identified to be at higher risk need to have an individualized screening plan that may differ from these guidelines.

REF: p. 562 9. Review the list below and select the option that most accurately describes the action taken

after a fine-needle aspiration biopsy (FNAB) of a suspicious breast mass. a. The aspirate fluid is cytologically examined. b. The aspirate fluid is histologically examined by frozen section. c. The aspirate fluid is microscopically examined immediately by the procedural physician. d. The patient undergoes an immediate excisional biopsy if the aspirate fluid is positive for malignancy.

ANS: A

Once a mass is identified, the physician has multiple techniques to establish a diagnosis.

During an FNAB the physician or radiologist anesthetizes a small area of the breast with lidocaine. FNAB is mainly used for differentiation of solid from cystic masses but may also be performed when a new, dominant, unexplained mass is found in the breast. A 22- or 25gauge needle attached to a 20-mL syringe is inserted into the mass, and a small amount of the contents is aspirated, then prepared on a slide for cytologic examination.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: pp. 563-564 10. In 2012, pertuzumab was approved for use in combination with trastuzumab and with the

chemotherapy agent docetaxel. These agents are specifically indicated for which patients? a. Patients who are not responsive to adriamyacin and tamoxifin b. Patients treated with cancer antibodies made from their own stem cells. c. Patients with metastatic HER-2–positive breast cancer who have not had chemotherapy d. Patients who are not candidates for bilateral salpingo-oophorectomy.

ANS: C

These agents are indicated for use in patients with metastatic HER-2–positive breast cancer who have not received previous treatment with either chemotherapy or HER-2–targeted therapy.

REF: pp. 564, 566 11. Breast cancer is usually staged to measure the extent of the disease and to design a specific

treatment plan, using the TNM (T = tumor; N = node; M = metastasis) classification system.

Review the list below and select the option that most closely describes a stage 0 carcinoma in situ (CIS). a. Lobular carcinoma in situ (LCIS) has abnormal cells lining the lobule and often becomes invasive. b. Ductal carcinoma in situ (DCIS) is defined as abnormal cells lining the ductal system and is not invasive. c. LCIS has abnormal cells infiltrating the lobule and often does not become invasive. d. DCIS has abnormal cells lining the ductal system and is often invasive.

ANS: D

Stage 0 is CIS. DCIS is defined as abnormal cells that are in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not invaded the nearby breast tissue.

DCIS sometimes becomes invasive cancer if not treated. LCIS is defined as abnormal cells that are in the lining of a lobule. LCIS seldom becomes invasive cancer.

REF: p. 565 12. An 82-year-old woman was referred to the breast surgery service by her gerontologist because

of a large inflammatory mass in her left breast. The patient stated that the lump has existed for several years, and she believed it was just part of old age. The surgeon examined her and found tumor nodules growing into the skin of the breast, with breast swelling and redness.

Diagnostic imaging results described a tumor that had grown into the chest wall and may have spread to axillary lymph nodes and to other lymph nodes behind the breastbone and below the collarbone. Based on this description, what is the patient’s probable cancer stage? a. Stage IIa b. Stage IIIc c. Stage IIIb d. Stage IV ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Stage IIIc is a tumor of any size that has spread either to the lymph nodes behind the breastbone and axillary lymph nodes or to the lymph nodes above or below the collarbone.

REF: p. 565 13. Before surgery, the perioperative nurse should procure the necessary medical and surgical

supplies, instruments, and equipment for the planned operation. Mammograms, ultrasound, MRI, or other imaging studies should be available in the operating room (OR) for the surgeon’s review. The reason for the imaging studies’ availability in the OR is to: a. provide tools for teaching other surgery team members and students. b. confirm the correct surgical site and location of pathology. c. identify and confirm the correct patient. d. confirm the correct surgical site and location of pathology, and identify and confirm the correct patient.

ANS: D

Mammogram films or other imaging studies should be available in the OR for the surgeon’s review; their presence may be confirmed during the preoperative briefing and/or time-out. The facility protocol for identifying the correct surgical site should be followed. Often this consists of a checklist that is initiated during the time-out and includes verbal communication among surgical team members, review of the medical record and informed consent, confirmation of imaging studies, and direct observation of the marked surgical site.

REF: p. 568 14. A breast biopsy, performed after the patient has received a local anesthetic, will require

adjunct sedation and monitoring equipment. What is the highest-priority consideration for the nurse to note during the preoperative assessment? a. Skin assessment b. Allergies c. American Society of Anesthesiologists (ASA) physiologic status d. Risks for injury ANS: B

Patient allergies should be reviewed to avoid allergic or toxic reactions to local anesthetics, antibiotics, or pain medications.

REF: p. 568 15. A 35-year-old mother of twins was scheduled for a left breast lumpectomy. This is her third

lumpectomy in 6 years for benign fibrocystic disease. The patient shared her concerns with the perioperative nurse, worrying about her breast’s appearance after three similar surgeries in the same breast. The nurse noticed, on assessment, how much smaller the left breast was in comparison with the right. An appropriate action for the nurse to take in response to the patient’s concern would be to: a. recommend a plastic surgery practice associated with the ambulatory center. b. assure her that the size difference is not as significant as she believes. c. encourage her to discuss her feelings regarding body image and resulting changes. d. encourage her to have this discussion when the surgeon returns to do the site marking.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

Based on the nursing assessment, the perioperative nurse uses nursing diagnoses to develop a plan of care. A nursing diagnosis related to the patient’s care might include disturbed body image related to loss of body part. Outcomes identified for the patient could be stated as: the patient will discuss feelings regarding body image changes resulting from the surgical procedure. Appropriate interventions include allowing the patient to discuss concerns about her sexual attractiveness, loss of confidence, and perceived loss of femininity in an environment of support, respect, and comfort. In this patient’s case, the perioperative nurse may also encourage the patient to discuss her concerns regarding the appearance of her left breast with her surgeon on her postoperative visit.

REF: p. 568 16. A 39-year-old mother of 5 children was recently diagnosed with early-stage, noninvasive

DCIS. She has decided to have a bilateral preemptive modified radical mastectomy to minimize her risk of metastatic disease. She is calm and confident that she has made the right decision but she is concerned about the length of her recovery. The perioperative nurse recognizes the patient’s concern and assigns her a nursing diagnosis of: a. deficient knowledge related to unfamiliarity with the hospital environment. b. deficient knowledge related to ineffective preoperative preparation. c. deficient knowledge related to unfamiliarity with perioperative routines and anxiety about her future. d. deficient knowledge related to delayed discharge teaching.

ANS: C

The patient’s deficient knowledge is related to her unfamiliarity with perioperative routines, which include her postoperative course of recovery (i.e., her future).

REF: p. 568 17. An experienced nurse in the breast surgery service is preparing the OR for a radical

mastectomy procedure on a 72-year-old patient with invasive breast cancer. The nurse realizes that judicious use of electrosurgery will be important to maintain adequate hemostasis for this patient. She has assigned this patient a nursing diagnosis of risk for injury related to use of electrosurgery and is determined to achieve the desired relevant nursing outcome. What appropriate nursing interventions will provide a safe environment for both the patient and the intraoperative team? a. Position the dispersive pad far from the incision site to prevent contact with prep solution b. Activate the electrosurgical unit (ESU) before the dispersive pad and active electrode are connected c. Set power settings as low as possible to achieve the desired effect d. Use a trifolded green towel pocket for active electrode safety on the sterile field ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock An ESU or a surgical laser is used to provide both hemostasis and tissue dissection. Safe practices when using devices that generate surgical smoke require the use of a smoke evacuation system and accessories in both open and laparoscopic procedures. Set power setting as low as possible to achieve the desired effect. Position the dispersive pad as close to the operative site as possible. Select a site that is clean and dry, with good muscle mass; note and document the condition of the skin at the selected site. Use holster for active electrode on the sterile field.

REF: p. 568 18. A 27-year-old patient, who had a lumpectomy for early-onset breast cancer, arrived at the

ambulatory surgery center for infusion port insertion. She is scheduled to begin adjuvant chemotherapy next week. The patient is very nervous because during the previous lumpectomy, performed using a local anesthetic, she was not entirely sedated. The patient tells the perioperative nurse that she was uncomfortable and heard everything in the room but admitted that she did not feel pain. The nurse recognized the patient’s anxiety related to the surgical intervention and prepared to implement corrective actions in the OR. What nursing intervention best reflects one that would ensure support or contribute to the patient realizing her expected outcome? a. Ensure a quiet and calm environment of care b. Share the patient’s concerns with the anesthesia provider c. Have the patient wear a headset that plays classical, nonlyrical music during the procedure d. Ask each team member individually to be quiet during the procedure.

ANS: A

Maintain a quiet, calm environment. Encourage the patient’s questions and allow her time to verbalize fears, distress, and anxiety. Continue to assess the patient’s verbal and nonverbal signs of anxiety during the port insertion.

REF: p. 569 19. The catheter component of an infusion port system is inserted into which structure(s)? a. Left mammary or subclavian vein b. Right atrium by way of the jugular vein c. Subclavian or jugular vein d. Inferior vena cava ANS: C

A breast cancer patient who needs further medical treatment may opt to have an implanted venous access port placed under the skin in either the chest, the abdomen, or the upper arm.

The port has a soft, pliable plastic catheter that is threaded into the subclavian vein or right atrium by way of the subclavian or internal jugular vein under X-ray guidance.

REF: p. 566 20. A 46-year-old woman is in the phase II postanesthesia care unit (PACU) after an excisional

biopsy with sentinel lymph node (SLN) dissection. She is receiving her patient education as she prepares for discharge. The perioperative nurse has asked her to teach back the complications and side effects that could be observed after sentinel lymph node dissection.

What information does the nurse expect to hear?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. “The dye will make my urine blue for a few hours.” b. “I could have an allergic reaction to the dye, tingling, weakness, numbness, or pain

in my arm.” c. “I could set off the security door alarms at the mall from the radioactive dye left in

my veins.” d. “I will possibly be nauseous and could vomit from riding in the car on the way

home.”

ANS: B

Complications of SLN biopsy include risk of allergic reactions to the blue dye, isotope usage, rare instances of sensory or motor nerve damage, and pain.

REF: p. 575 21. A 65-year-old recently retired nurse was scheduled for a modified radical mastectomy. It has

been over 40 years since she worked as a perioperative nurse, and she vividly remembers the mutilating radical mastectomies of the past. She asks the perioperative nurse to describe the appearance of her incision at the end of the procedure. What description of the incision will the perioperative nurse explain to the patient? a. A crescent incision extends from the midaxillary line to the medial fourth rib attachment to the sternum. The incision will likely be closed with interrupted nylon sutures. b. A horizontal elliptic incision with lateral extension toward the axilla is made through the subcutaneous tissue. The incision will likely be closed with subcuticular uninterrupted polypropylene sutures. c. An oblique elliptic incision with lateral extension toward the axilla is made through the subcutaneous tissue. The incision may be closed with interrupted nonabsorbable sutures, staples, or a running subcuticular stitch. d. A vertical elliptic incision extends along the midclavicular line. The incision may be closed with interrupted nonabsorbable sutures, staples, or a running subcuticular stitch.

ANS: C

This surgery’s oblique elliptic incision encompasses the nipple-areola complex, a biopsy scar if an open biopsy has been performed, and excess skin of the breast. If skin is needed for reconstruction, it can be preserved and exposure obtained through incision rather than excision. The incision is closed with interrupted nonabsorbable sutures, staples, or a running subcuticular stitch for a better cosmetic result.

REF: p. 577 22. Many breast cancer patients subscribe to various complementary and alternative (CAM) and

integrative therapies to provide relief from anxiety, depression, pain, and the complications and side effects associated with chemotherapy and radiation therapy. Quality-of-life issues become important in providing comfort and life balance. Breast cancer patients who are interested in the benefits of CAM and integrative therapies would most likely seek assistance for their cancer care from which group of providers? a. Pharmacists b. Nutritionists and dietitians c. Wound ostomy care nurses d. Genetic counselors

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: B

Breast cancer patients are increasingly seeking and using CAM and integrative therapies to enhance their surgical and medical treatment. Besides using products such as green tea, botanicals, vitamins E and C, and flaxseed, breast cancer patients are incorporating massage therapy and meditation and enlisting the help of dietitians and nutritionists as they battle breast cancer.

REF: p. 566 23. Which breast surgery procedure is also called the nipple-sparing technique (NSM)? a. Subcutaneous mastectomy b. Breast conservation surgery c. Nipple reconstruction with alveolar tattooing d. Simple mastectomy ANS: A

Subcutaneous mastectomy is removal of all breast tissue with the overlying skin and nipple left intact. This is also called nipple-sparing mastectomy (NSM) surgery. This procedure is recommended for patients who have central tumors of noninvasive origin, chronic cystic mastitis, hyperplasic duct changes, multiple fibroadenomas or who have undergone several previous biopsies. This technique may also be used in women undergoing risk-reducing mastectomy and offered to patients with smaller tumors far from the nipple with favorable pathologic features.

REF: p. 576 MULTIPLE RESPONSE 1. A patient undergoing breast surgery will likely be extremely apprehensive about the

possibilities of having a malignancy, losing a body part, facing a negative reaction from her spouse and family, and experiencing a negative change in self-image. The preoperative interview of the breast surgery patient should consider: (Select all that apply.) a. the patient’s level of anxiety and possible causes. b. the patient’s understanding of her perioperative procedure. c. if the patient has ever lost a friend or family member to cancer. d. if the patient has misunderstandings about her disease or treatment plan.

ANS: A, B, C, D

During a preoperative interview, the perioperative nurse continues to assess the patient’s level of anxiety and possible causes, such as the possibility of a cancer diagnosis. Identification of fears and concerns helps in planning appropriate nursing interventions. The patient should identify the breast (and, if possible, the quadrant of the breast) where the mass is located and participate in surgical site marking. The perioperative nurse may reinforce the patient’s understanding of the proposed surgical procedure, verify that the patient can correctly state its name, and correct misunderstandings (as appropriate). Identifying the patient’s support systems and coping mechanisms helps manage anxiety and enhances the discharge planning process. If the patient has lost a relative or close friend to breast cancer, her coping mechanisms may be affected because of memories of that loss.

REF: pp. 566, 568

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 18: Ophthalmic Surgery Test Bank MULTIPLE CHOICE 1. The refractive apparatus of the eye directs (refracts) the light rays to strike the: a. retina. b. optic nerve. c. vitreous body. d. lateral geniculate body.

ANS: A

Light rays emanate from an object in the field of vision and transmit to the eye. These light rays pass through the clear cornea, travel through the clear vitreous fluid, and land directly on the macula, the central part of the retina and the area of highest sensitivity for details. The nerve endings of the retina pass the images as nerve impulses through the optic nerve to the brain, where the occipital area interprets the images.

REF: p. 580 2. The extraocular muscles work in yoked pairs, with ocular movements generated by an

increase in the tone of one set of muscles and a decrease in the tone of the antagonistic muscles. Of the two muscle types, how many are represented in each eye? a. Two recti muscles and four oblique muscles b. Two superior muscles and one lateral muscle c. Four recti muscles and two oblique muscles d. Two inferior muscles and two medial muscles ANS: C

Named according to their relative position on the eyeball, the extraocular muscles of the eyeball include the four recti (the superior rectus, inferior rectus, medial rectus, and lateral rectus) and two oblique muscles (the superior oblique and inferior oblique).

REF: p. 583 3. To accommodate near and distant focus, the lens changes shape and focus by relaxation and

tightening of the zonular fibers. What physiologic change of the normal aging process is typically corrected with bifocals? a. Cataracts b. Presbyopia c. Glaucoma d. Astigmatism ANS: B

Over time (particularly after age 40), the lens and lens zonules becomes progressively less elastic, resulting in presbyopia. This loss of accommodative power is typically corrected by reading glasses or bifocals.

REF: p. 582

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. How does the lacrimal gland differ from the lacrimal sac? a. The lacrimal gland produces hormones that stimulate the lacrimal sac to secrete

tears. b. The lacrimal sac stores and concentrates the tears secreted by the lacrimal gland. c. The lacrimal gland and lacrimal sac are the same structure. d. The lacrimal gland secretes tears that are drained by the lacrimal sac and duct

system.

ANS: D

The lacrimal gland produces aqueous tears and secretes them through a series of ducts onto the anterior ocular surface, thereby keeping the cornea moist and washing away any debris.

REF: p. 582 5. A wide range of equipment is used in ophthalmic surgery. The perioperative team’s

knowledge of proper operation should be confirmed through inservice education and training specific to new equipment, plus demonstrated competency. To ensure patient safety and appropriate function and application of surgical devices, which statement best reflects recommended practice when using complex biomedical equipment? a. Use the device according to the manufacturer’s directions and test for proper performance before the patient enters the operating room (OR) b. Follow the policy and procedure of the facility and/or unit, and request biomedical support c. Request assistance and technical support from the appropriate vendor representative; encourage the vendor to operate the device or equipment, or request biomedical support d. Follow the explanation and demonstration as originally provided by the preceptor during orientation ANS: A

For safety, all items must be used according to the manufacturer’s directions and tested for proper performance before the patient enters the OR. REF: p. 596 6. The nurse must ensure that the microscope used in ophthalmic surgery is specifically intended

for safe use in eye surgery. The perioperative nurse must also be familiar with adjusting the pupillary distance (distance between pupils of the user’s eyes) and diopter settings on the oculars (eyepieces) for operator vision correction to work without eyeglasses. How should the oculars be set for a user with astigmatism? a. Set the oculars to the same diopters as the user’s corrective lenses b. Set the oculars to the half setting of the diopters of the user’s corrective lenses c. Set the oculars at zero; users should wear their eyeglasses d. Set the oculars to 10 magnification prior to the surgeon adjusting to the user’s preference ANS: C

Users who have significant astigmatism should wear their eyeglasses and set the oculars at zero, because uncorrected astigmatisms cannot be entered into the microscope’s ocular setting.

REF: p. 596

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

7. Sutures used in ophthalmic surgery are very fine and range in size from 4-0 to 10-0. Handling

and arming these sutures can be a challenge for the scrub person with uncorrected presbyopia.

Eye sutures should be handled as little as possible to avoid: a. weakening and fraying. b. causing the formation of needle burrs. c. losing sutures among the drapes or on the floor. d. reaction and discomfort for the patient.

ANS: A

Fine eye sutures produce minimum reaction and discomfort for the patient. They should be handled as little as possible to avoid weakening and fraying. Ophthalmic needles also are very delicate and must be handled with extreme care and inspected for evidence of burrs before use.

REF: p. 597 8. Select the true statement about dacryocystorhinostomy (DCR). a. A DCR is performed for chronic or recurrent dacryocystitis, which is also called

epiphora. b. A dacrolithotripsy is attempted if the DCR is unsuccessful. c. DCR establishes a new passageway for tear drainage into the nasal cavity. d. The passageway is usually restored with the use of ultrasonic lacrimal probes.

ANS: C

Dacryocystorhinostomy (DCR) is the establishment of a new tear passageway for drainage directly into the nasal cavity. Dacryocystitis is an infection in the lacrimal sac, which may result in a localized cellulitis. Chronic or recurrent dacryocystitis in adults may necessitate probing or DCR because of resistant obstruction of the nasolacrimal duct related to infectionassociated scarring, dacryolith (calculus in the duct), or trauma. Another indication for DCR surgery may be intolerable epiphora (tearing) resulting from tear duct laceration following medial orbital wall fracture.

REF: p. 618 9. The perioperative nurse prepares a separate treatment set-up for the surgeon to use before the

DCR operative procedure is started. Select the statement that describes the justification for this separate treatment set-up. a. The surgeon will cut and mold the nasal splint to size before the nose becomes edematous. b. The silastic tubing needs to be cut to size and soaked during the procedure. c. The skin markings, with methylene blue, are done on clean skin before the skin prep. d. The nasal cavity is anesthetized with cocaine, and a local anesthetic is administered.

ANS: D

The nasal cavity is anesthetized topically with cocaine just before DCR. The surgery is performed after the patient has been administered a local or general anesthetic.

REF: p. 618

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

10. Select the appropriate procedure performed for a patient with Fuchs’ dystrophy, edema after

cataract surgery, or keratoconus (abnormal steepening) of the cornea. a. Endothelial keratoplasty b. Microscopic keratorefraction c. Laser epithelial keratomileusis d. Laser-assisted in-situ keratomileusis ANS: A

A corneal transplantation (keratoplasty) is performed when the patient’s cornea is thickened or opacified by disease and degeneration. A new technique used for posterior corneal pathology is Descemet stripping endothelial keratoplasty (DSEK). This is used for patients who have Fuchs’ dystrophy, corneal edema due to intraocular surgery, or failed corneal transplants. It consists of replacing the endothelium without transplanting the entire cornea.

REF: p. 616 11. A cataract is defined as any opacification of the lens. Cataracts may be congenital, post-

traumatic, or induced by medications but are most commonly the result of age-related changes. Which of the following statements about cataracts best describes its presentation or etiology (cause)? a. A cataract can be compared to a window that is foggy or yellowed. b. Cataracts can be classified as brittle or pliable, based on collagen matrix fibers in the capsule. c. Cataracts are an early sign of type 1 diabetes. d. The cloudiness is caused by clumping of lipoproteins in the lens capsule.

ANS: A

Normally, light passing through a clear lens projects a sharp image onto the retina. The lens is made up of mostly water and protein, and over time some of the protein may clump together, leading to clouding of the lens (cataract).

REF: p. 599 12. When preparing for pars plana vitrectomy in the posterior segment, the perioperative nurse

must be aware that a combined scleral buckling procedure may be necessary. Other important information the perioperative nurse should know before preparing the OR for the procedure includes the location of the ocular problem, the surgeon’s plan to address the problem, and the instrumentation and biomedical equipment and devices to be used. Technologic advances in ophthalmic surgery require that perioperative nurses be familiar with complex biomedical equipment. A best practice, stated below, relevant to the safe use of complex equipment would be to: a. determine the presence and appropriate date (not expired) of the biomedical monitoring label. b. confirm competence through inservice education and training specific to new equipment. c. schedule the manufacturer’s representative to be present to provide technical support. d. schedule the biomedical clinical engineer to check all equipment before each procedure.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

A wide range of equipment is used in ophthalmic surgery. The perioperative team’s knowledge of proper functioning and troubleshooting should be confirmed through inservice education and training specific to new equipment.

REF: p. 596 13. Miotics and mydriatics produce opposite effects on the pupil of the eye. Select the most

appropriate statement about miotic and mydriatic drugs. a. Miotic drugs are anticholinergic drugs useful in lowering intraocular pressure. b. Mydriatic drugs, such as phenylephrine, dilate the pupil. c. Miotic drugs dilate the pupil for posterior chamber access after lens removal. d. Mydriatic drugs are often referred to as cycloplegics.

ANS: B

Mydriatics: Phenylephrine 2.5%, and 10% (Neo-Synephrine, Mydfrin) promotes mydriasis (dilates pupil but permits focusing); cause vasoconstriction of conjunctiva and anterior vessels, used for objective examination of the retina, testing of refraction, easier removal of lens; and are used alone or with a cycloplegic. Miotics: (1) Carbachol 0.01% (Miostat) is a potent cholinergic (constricts pupil) used intracamerally during anterior segment surgery. (2) Acetylcholine chloride 1% (Miochol-E) is a cholinergic that rapidly constricts the pupil and is used intraocularly during anterior segment surgery to constrict a dilated pupil. (3) Pilocarpine hydrochloride 1% and 4% is a cholinergic (constricts pupil) used topically for lowering intraocular pressure in glaucoma.

REF: p. 590 14. Cycloplegic drugs produce a similar effect on the pupil as mydriatic drugs, with one

difference. From the options below, select the most appropriate statement about the effects of cycloplegics. a. Anticholinergics constrict the pupil and inhibit focusing. b. Epinephrine is added to balanced salt solution (BSS) to constrict sclera vessels and the pupil. c. Homatropine hydrobromide (Isopto Homatropine) sustains the longest and most potent duration of dilation. d. Cycloplegics and mydriatics have similar effects on dilating the pupil.

ANS: A

Cycloplegics are anticholinergics that dilate the pupil and inhibit focusing. Examples include tropicamide 0.25%, 0.5%, 1% (Mydriacyl) ; atropine 0.5%, 1%; cyclopentolate 0.5%, 1%, and 2% (Cyclogyl); and epinephrine preservative fee (PF) mixture.

REF: p. 589 15. Select the true statement about antimetabolite drugs and their indications for use. a. These cytotoxic/antineoplastic drugs are also useful as thrombolytic agents. b. Antimetabolites are regulated by tissue plasminogen activator (TPA) and facility

policies. c. 5-fluorouracil and mitomycin can both be administered topically to dissolve scars

and pterygia. d. Denuded corneal epithelium responds positively to topical applications of

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock mitomycin.

ANS: C

Fluorouracil (5-FU) and mitomycin (MMC) are antimetabolites used topically to inhibit scar formation in glaucoma filtering procedures and pterygium excision. Handle and discard these antimetabolites in compliance with the Occupational Safety and Health Administration (OSHA) and facility policies for safe use of antineoplastics.

REF: p. 594 16. A 59-year-old woman with a significant retinal tear close to the macula emerges from

anesthesia in the postanesthesia care unit (PACU) after a 4-hour pneumatic retinopexy with scleral buckling, posterior vitrectomy, and injection of a gas bubble to close and support the retinal tear. She will have to maintain a face-down head position for 7 to 10 days, followed by laser surgery or cryotherapy to seal the tear. As the patient prepares for discharge from the PACU, she informs the perioperative nurse that she has reserved a flight to Denver, Colorado in 3 weeks to visit friends and celebrate the end of her ophthalmic surgeries and survival of sustained face-down positioning during recovery. The nurse firmly informs her that she should cancel and delay her trip until the surgeon approves that type of travel. Which statement below justifies the nurse’s response to the patient’s vacation plans? a. Facial edema from sustained face-down position will not have resolved within the time frame before her vacation. b. Airplane cabin pressure and recirculated air are significant risk factors for infection after complex vitreous surgery. c. The dry air and high elevation of Denver will dehydrate the cornea and sclera, causing the sclera to buckle and the tear to loosen. d. Airplane cabin pressure and high elevations will cause severe enlargement of the gas bubble and increase intraocular pressure.

ANS: D

In pneumatic retinopexy, an intraocular injection of a bubble of air or therapeutic gases provides pressure against retinal breaks, allowing the detached retinal breaks to approximate the pigment epithelium. The intent of instilling a gas bubble is to sustain its size and hold the retina in place. Patient positioning after retinopexy is often face-down for several days to weeks but may include tilting the head to one side or the other as well. The head position is determined by the location of the retinal tear/hole. Adherence is often difficult because of physical and psychologic challenges. Patients are instructed to avoid air travel until the gas bubble is completely resolved or decreased to a level of 5% of the vitreous volume. Cabin pressurization in air travel will cause severe enlargement of the gas bubble with an increase in intraocular pressure and eye pain. Car or train travel to high elevations should also be avoided unless the change in altitude is done gradually.

REF: p. 610 17. Review the list below and select the correct definition for exenteration. a. Removal of the eye contents with sclera and muscles left intact b. Removal of the entire orbital contents, including the periosteum c. Removal of the entire globe, severing muscular attachments and optic nerve d. Removal of the vitreous, lens, and portion of the sclera ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Exenteration is removal of the entire orbital contents, including the periosteum, for certain malignancies of the globe or orbit. The procedure may also include removal of the external structures of the eyelids.

REF: p. 625 18. The procedure for cataract extraction with implantation of an intraocular lens (IOL) exposes

the patient to risks of infection of the anterior chamber and corruption of the implanted device. Appropriate measures for the circulating nurse and scrub person include managing patient safety needs. Efforts are directed at preventing foreign substances from being introduced intraocularly. Select the nursing actions that may ensure this outcome. a. Use instruments designed for single use only b. Cleanse debris from instruments with a cellulose sponge c. Use only latex-free gloves d. Soak instruments in sterile water when not being used by the surgeon ANS: B

The scrub person and the perioperative nurse must also manage additional patient safety needs. Foreign substances must not be introduced intraocularly. Lint-free drapes should be used to create the sterile field. Gloved hands should not touch the portion of an instrument used in an intraocular wound, and debris should be cleansed from instruments with cellulose sponges.

REF: p. 585 19. Review the list below, and select the option that describes an action that occurs during

vitrectomy. a. Excision of fibrotic membranes b. Resolution of vitrous opacities c. Replacement of the lens d. Placement of a CO2 bubble ANS: A

In the broader clinical sense of the term, vitrectomy surgery can also include the excision and removal of fibrotic membranes; the removal of epiretinal membranes; the electrocoagulation of bleeding vessels; the treatment of long-standing vitreous opacities, advanced diabetic eye disease, or severe intraocular trauma; the removal of retained foreign bodies; and the treatment of proliferative vitreoretinopathy, retinal detachment from giant tears, endophthalmitis, and diagnostic vitreous biopsy. Complications of vitrectomy include retinal detachment, retinal tears, cataract, and infection. Alternatively, the risk of no treatment can be total loss of vision.

REF: p. 606 20. Review the list below and select the statement that accurately describes toxic anterior segment

syndrome (TASS). a. TASS is characterized by the introduction of bacteria into the anterior chamber during surgery. b. Cultures of the vitreous typically show growth of gram-negative bacteria. c. TASS is characterized by the introduction of nontoxic materials into the anterior chamber during surgery.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. TASS typically presents within 24 hours after surgery.

ANS: C

TASS is a sterile postoperative inflammatory reaction caused by a noninfectious substance that enters the anterior segment, resulting in toxic damage to intraocular tissues. TASS is limited to the anterior segment of the eye, is always Gram stain and culture negative, and usually improves with steroid treatment. Possible causes of TASS include intraocular solutions with inappropriate chemical composition or concentration, pH, osmolarity, preservative, denatured ophthalmic viscosurgical devices, enzymatic detergents, bacterial endotoxin, oxidized metal deposits and residues, and factors related to intraocular lenses such as residues from polishing or sterilizing compounds. An outbreak of TASS is an environmental and toxic control issue that requires complete analysis of all medications and fluids used during surgery, as well as complete review of OR and sterilization protocols.

REF: p. 585 MULTIPLE RESPONSE 1. Patients presenting for ophthalmic surgery may have endured chronic progressive impairment

or recent decrease in visual acuity. Most patients are admitted through an ambulatory admission area adjacent to the surgical suite. Select the appropriate nursing actions when admitting the ophthalmic surgery patient.(Select all that apply) a. Fully orient the patient to the physical surroundings b. Use detailed descriptions and reinforce them c. Approach the patient from the unaffected side to avoid startling the patient d. Turn the lights down low to foster a calming environment ANS: A, B, C

On admission, a staff member should fully orient the patient to the physical surroundings.

Constant description and reinforcement are important to visually impaired patients.

Approaching the patient from the unaffected side increases the patient’s independence and decreases the possibility of startling the patient.

REF: p. 583 2. Anesthetic management impacts the success of ophthalmic surgery. Safe ambulatory surgery,

especially in certain populations, depends on patient selection, preoperative evaluation, preparation, monitoring, and local anesthesia techniques. Select the patients below that would be appropriate candidates for general anesthesia, instead of local anesthesia alone. (Select all that apply.) a. A 78-year-old patient with dementia and claustrophobia b. A 35-year-old patient who is uncomfortable being in enclosed spaces c. A 22-year-old healthy female for a tear duct probing d. A 48-year-old healthy male with mild head tremors ANS: A, B, C, D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Some patients with Alzheimer’s disease, head tremor in Parkinson’s disease, claustrophobia, chronic cough, or shortness of breath while lying flat may benefit from general anesthesia because of difficult management with regional anesthesia and light sedation. Youth, deafness, language barriers, dementia, severe anxiety, specific systemic diseases, known sensitivity to local anesthetics, potential of blood entering the airway (such as in tear duct procedures), and long duration of the operative procedure are among the conditions that may dictate use of general anesthesia.

REF: p. 584-585

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 19: Otorhinolaryngologic Surgery Test Bank MULTIPLE CHOICE 1. The external ear, which includes the auricle (or pinna) and external auditory canal, is

composed of cartilage covered with skin. The primary function of the auricle is to: a. gather and direct sound waves toward the inner ear. b. concentrate and conduct incoming sound waves into the external auditory canal. c. collect and amplify incoming sound waves by facilitating tympanic membrane vibration. d. facilitate air conduction of sound waves.

ANS: B

The auricles are fixed in position and lie close to the head; they concentrate incoming sound waves and conduct them into the external auditory canal.

REF: p. 626 2. Both ears provide stereophonic hearing that gives us very specific hearing capabilities.

Binaural hearing makes it possible for: a. determination of the source location of sounds. b. enhanced voice recognition. c. amplification and resolution of sound properties. d. recognition of more than one sound at a time.

ANS: A

Both ears provide stereophonic hearing that gives us very specific sound localization capabilities. Without binaural hearing, determining from where sounds emanate can be difficult. This is a common problem for patients with unilateral or asymmetric hearing loss.

REF: p. 626 3. The external ear canal lining is protected and lubricated with cerumen (earwax), which traps

foreign material and: a. liquefies foreign matter in the ear canal. b. lubricates the external ear. c. maintains the high acidic pH in the ear canal. d. reduces bacterial levels in the outer ear.

ANS: D

The canal lining is protected and lubricated with cerumen, a waxy substance secreted by sebaceous glands in the distal third of the canal. Cerumen helps to trap foreign material and has a mildly acidic pH that reduces bacterial levels in the outer ear.

REF: p. 626 4. A chain of three small articulated bones extends across the middle ear cavity and conducts

vibrations from the tympanic membrane across the middle ear into the oval window and the fluid-filled inner ear. What are the names of those three small articulating bones?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

Ossicles, incus, and crura Stapes, capitulum, and stirrup Malleus, incus, and stapes Anvil, head, and hammer

ANS: C

The malleus (hammer) consists of a head, neck, handle, and short process. The handle and short process are attached to the undersurface of the eardrum, and the head articulates with the body of the incus in the upper segment of the middle ear called the epitympanum or “attic.”

The incus (anvil) consists of a body and long and short processes. The distal end of the long process of the incus is called the lenticular process and articulates with the capitulum (head) of the stapes, which is the third, innermost bone. The stapes (stirrup) consists of a head, neck, anterior and posterior crura, and a mobile footplate that is secured to the oval window by an annular ligament. The movable joints between these ossicles contribute to a lever system that amplifies the received sound and transmits and converts vibrations from ambient air to the fluid of the inner ear.

REF: p. 626 5. The nasal sinuses serve as air spaces and communicate with the nasal cavity through the

__________. Anteriorly, on each side of the skull, the frontal sinus, the anterior ethmoidal sinus, and the maxillary sinus (antrum of Highmore) drain into the middle meatus; the posterior ethmoid and the sphenoid sinuses drain into the ______________ recess. a. septum; maxillary b. middle concha; ethmoidal c. crista galli; anteriomaxillary d. meatus; sphenoethmoidal ANS: D

The nasal sinuses serve as air spaces and communicate with the nasal cavity through the meatus. Anteriorly, on each side of the skull, the frontal sinus, the anterior ethmoidal sinus, and the maxillary sinus (antrum of Highmore) drain into the middle meatus; the posterior ethmoid and the sphenoid sinuses drain into the sphenoethmoidal recess.

REF: p. 628 6. The nasal septum is lined with blood vessels and mucus-secreting cells. The proper name of

this lining is the: a. Mucoperichondrium b. Septochondrium c. Nasoseptal mucosa d. Cartilaginous vascular bed ANS: A

The nasal septum is composed of three structures: the nasal cartilage, the perpendicular plate of the ethmoid bone, and the vomer bone. The septum is covered by mucoperichondrium on either side that contains blood vessels and mucus-secreting cells.

REF: p. 628

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 7. The nasal cavity is associated with the ear by way of the ____________, and communicates

with the conjunctiva through the __________________. Select the options that are appropriate to complete the sentence. a. torus tubarius; canaliculi b. eustachian tube; nasolacrimal duct c. nasopharynx; medial caruncle d. middle ear; lacrimal sac ANS: B

The nasal cavity communicates with the outside by its external openings, called the nares. The nares open into the nasopharynx through the choanae. The nasal cavity is also associated with each ear, sharing the torus tubarius (opening of the eustachian tube in the nasopharynx) with the paranasal sinuses (frontal, maxillary, ethmoidal, sphenoidal) through their respective orifices (meatus). The nasal cavity also communicates with the conjunctivae through the nasolacrimal duct.

REF: p. 628 8. The nasal turbinates increase the turbulence of the airflow through the nose to humidify the

air. The turbinates also serve another function to the accessory sinuses by: a. filtering inspired air and preventing sinusitis. b. warming and humidifying inspired air. c. giving resonance to the voice. d. trapping particle matter before it reaches the nasopharynx.

ANS: B

The turbinate bones of the nasal structure are arranged one above the other, separated by grooves that are composed of pseudostratified columnar ciliated respiratory epithelium. The turbinates act to increase the turbulence of airflow to humidify and regulate the temperature of air that is naturally inspired.

REF: p. 628 9. Which mouth structure is considered the boundary between the buccal cavity and the lingual

cavity? a. Hard palate b. Soft palate c. Teeth d. Floor of the mouth ANS: C

The portion of the mouth outside the teeth is the buccal cavity, and that on the inner side of the teeth is the lingual cavity. The portion of the mouth outside the teeth is the buccal cavity, and that on the inner side of the teeth is the lingual cavity. The hard palate forms the upper boundary of the oral cavity. The hard palate is formed by the maxilla and palatine bones. The mandible and floor of the mouth form the lower boundary of the oral cavity.

REF: p. 628 10. The salivary glands produce saliva, which serves to moisten the mouth and initiate: a. antibacterial activity in the mouth.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. carbohydrate digestion. c. protein breakdown. d. alimentary (gastrointestinal [GI]) tract peristalsis.

ANS: B

The salivary glands consist of three paired glands: the sublingual, the submandibular, and the parotid. They communicate with the mouth and produce saliva, which serves to moisten the mouth and initiate digestion of carbohydrates.

REF: p. 628 11. Of the three salivary glands, which one is the largest? a. Sublingual b. Submandibular c. Zygomatic d. Parotid ANS: D

The salivary glands consist of three paired glands: the sublingual, the submandibular, and the parotid. The parotid gland, the largest of the salivary glands, lies below the zygomatic arch in front of the mastoid process and behind the ramus of the mandible; it is divided into a superficial portion and a deep portion. The parotid duct (Stensen’s duct) pierces the buccal pad of fat and the buccinator muscle, finally opening into the oral cavity opposite the crown of the upper second molar tooth.

REF: p. 628 12. The supraglottis, glottis, and the subglottis represent three portions of which structure of the

throat? a. Epiglottis b. Tongue c. Larynx d. Pharynx ANS: C

The larynx can be divided into three portions: supraglottis (or upper portion above the true vocal cords), glottis (level of the true vocal cords), and subglottis (below the true vocal cords).

REF: p. 631 13. The palatine and lingual tonsils are situated in the oropharynx, while the adenoids are located

in the nasopharynx. Both adenoids and tonsils consist of: a. lymphoid tissue. b. glandular tissue. c. vascular tissue. d. mucosal tissue.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The adenoids, or pharyngeal tonsils, are suspended from the roof of the nasopharynx and consist of an accumulation of lymphoid tissue. The tonsils are situated on each side of the oropharynx, lodged in a tonsillar fossa that is attached to folds of membrane-containing muscle. The palatine tonsils (a pair of oval structures) are the only lymphatic organs covered with stratified squamous epithelium. The anterior and posterior tonsillar pillars join to form a triangular fossa, with the posterior lateral aspects of the tongue at its base. The lingual tonsils are lodged in each fossa.

REF: p. 629 14. The cricoid cartilage is a complete cartilaginous ring that resembles a signet ring; it rests

beneath the thyroid cartilage and supports the airway. What membrane, attached to the midline of the upper thyroid cartilage, protects the larynx during swallowing? a. False vocal cords b. True vocal cords c. Arytenoids d. Epiglottis ANS: D

The epiglottis is a slightly curled, leaf-shaped, elastic, fibrous membrane that is attached in the midline to the upper border of the thyroid cartilage. The epiglottis helps protect the larynx during swallowing.

REF: p. 631 15. Select the structure of the trachea that is a landmark during bronchoscopy. a. Cartilaginous ring b. Cricoid cartilage c. Carina d. Right main bronchus ANS: C

The carina is a ridge on the inside of the bifurcation of the trachea. It is a landmark during bronchoscopy and separates the upper end of the right main branches from the upper end of the left main branches of the bronchi.

REF: p. 632 16. Several types of diagnostic imaging studies visualize structures by producing serial sections

through different anatomic planes, highlighting specific structures or tissue densities.

Examples of these imaging diagnostics would be: a. complementary computed tomography (CT) scan with magnetic resonance imaging (MRI). b. auricular ultrasound. c. audiometry scan. d. tuning-fork conduction scan.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock CT scans are radiographic studies that visualize structures by producing serial sections, many times clinically referred to as cuts, through planes of the head and neck. CT imaging provides visualization of bone, soft tissue, and adjacent intracranial and extracranial pathologic conditions. MRI is an imaging modality using powerful magnetic and radiofrequency waves to reproduce cross-sectional images of the human body without exposing the patient to ionizing radiation. On an MRI scan, fat and fluid produce high-intensity signals, which appear as bright areas, whereas bone and air emit weak signals and appear as darkened areas. MRI is often used with CT imaging in a complementary fashion when evaluating lesions in and around bone for a variety of head and neck conditions, including tumors in the oral cavity, external auditory canal, middle ear, and mastoid.

REF: p. 636 17. Which of the diagnostic modalities listed below does not employ the use of ionizing

radiation? a. Audiogram b. MRI c. CT d. Both audiogram and MRI ANS: D

MRI is an imaging modality using powerful magnetic and radiofrequency waves to reproduce cross-sectional images of the human body without exposing the patient to ionizing radiation.

CT scans are radiographic studies that visualize structures by producing serial sections, many times clinically referred to as cuts, through planes of the head and neck. Two types of audiometric testing—pure tone and speech audiometry—are performed on patients with suspected hearing loss.

REF: p. 636 18. What is the purpose of using an intravenous (IV) injection of a radiopaque contrast dye during

select imaging diagnostic studies? a. There is enhanced uptake of radiation in areas of suspicion. b. It provides visual enhancement of anatomic structures. c. It minimizes ionizing radiation scatter to noninvolved anatomic structures. d. Contrast dye leaves a locator marker for impending surgery.

ANS: B

IV injection of iodine contrast agents produces visual enhancement of some anatomic structures and pathologic tissues, including highly vascularized tumors.

REF: p. 636 19. Audible facial nerve monitors (nerve integrity monitor systems) are used intraoperatively

during procedures in which the facial nerve is at risk for injury. The purpose of this monitoring technique is to assist in the early identification of the nerve, to increase the possibility of its preservation by minimizing trauma, and to assess its integrity after dissection.

Communication with the anesthesia provider is essential because: a. the electrodes are often in proximity to the anesthetic airway. b. manipulation of the anesthetic airway during the procedure can misplace the electrodes.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. muscle relaxants, paralyzing agents, and some local anesthetics must be avoided. d. the anesthesia provider is responsible for the facial nerve monitoring.

ANS: C

Electrodes are placed into the facial muscles before the patient is draped. Consultation and communication with the anesthesia provider are essential because the use of muscle relaxants, and long-term paralyzing agents must be avoided. In the setting of a tympanic membrane perforation, lidocaine should not be allowed to spill into the middle ear space when injecting the ear canal, because temporary facial paralysis can ensue from topical anesthesia of a dehiscent facial nerve in the tympanic segment.

REF: p. 644 20. The surgical microscope is often used to provide illumination and magnification for complex

procedures to the ear, laryngeal surgery, or reconstructive free flap procedures following neck surgery. A common eyepiece magnification for an otologic microscope is 12.5, and the usual objective (lens) is ______-mm focal length (f). A _______-mm lens is used for laryngeal surgery. a. 250 or 300; 400 b. 400; 150 c. 150; 400 d. 400; 250 or 300 ANS: A

A common eyepiece magnification for an otologic microscope is 12.5, and the usual objective (lens) is 250- or 300-mm f. A 400-mm lens is used for laryngeal surgery. The total magnification is determined by multiplying the magnification of the eyepiece by that of the microscope body times that of the objective. The type of head and objective selected is based on the surgeon’s preference. Microscopes equipped with a variable distance feature allow the surgeon to adjust the focal length from 200 to 400 mm without changing the lens objective.

REF: p. 645 21. Lasers assist in vaporization of scar tissue, granulomas, and cholesteatomas without damaging

surrounding tissue and may be used for select otolaryngologic procedures. Lasers can be secured to the operating microscope and laser energy delivered to the tissue by means of a: a. fiberoptic probe. b. beam separator. c. micromanipulator. d. flexible microlaser fiber.

ANS: C

Lasers can be secured to the operating microscope and laser energy delivered to the tissue by means of a micromanipulator. Lasers used in this specialty include the CO2, potassium titanyl phosphate (KTP), erbium:yttrium-aluminum-garnet (Er:YAG), and neodymium:yttriumaluminum-garnet (Nd:YAG) lasers. Laser energy is delivered directly to tissue by fiberoptic probes, which can be navigated around obstructing structures.

REF: p. 645

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 22. A power drill and assorted rotating burrs are essential for middle ear surgery and some sinus

procedures. A selection of burrs including assorted sizes of round cutting burrs and diamond polishing burrs should be available. During drill and power saw use, the scrub person keeps irrigation solution on the sterile field to: a. keep the drill bit or burr cool and prevent breaking. b. prevent clogging of the burr and contamination of the area with bone dust. c. prevent aerosolized bone dust particles, because they are an occupational hazard. d. avoid using a wire brush.

ANS: B

Bone dust must be prevented from settling in areas such as those in stapedectomy, tympanoplasty, endolymphatic sac, or fenestration surgery. A sterile field continuously flooded with irrigation solution helps to lessen clogging of the burr and washes bone dust from the field. A diamond burr cuts slowly and grinds the bone away rather than tearing into it; it is commonly used around vital structures. Cutting burrs assist in quickly removing bone from areas not close to vital structures. The grooves or teeth of burrs must be clean of bone dust.

Bone-cutting burrs tend to clog more easily than coarse-toothed burrs. A sterile wire brush may be used to keep burrs clean intraoperatively.

REF: p. 645 23. Myringotomy is often accompanied by the aspiration of fluid under pressure in the tympanum,

and the subsequent placement of small, hollow pressure equalization tubes. It is indicated for acute otitis media (AOM) in the presence of an exudate that has not responded to antibiotic therapy. If left untreated, what is the main concern for a child with chronic otitis media? a. Impaired language development b. Encephalitis c. Hearing loss d. Impaired language development and hearing loss ANS: D

The majority of children with AOM have spontaneous resolution. Hearing loss is the main concern when fluid is present in the middle ear. If left untreated, hearing loss can affect language development. If the fluid persists more than 8 to 12 weeks and is accompanied by hearing loss, removal of the fluid and placement of ventilating tubes in the eardrum are necessary.

REF: p. 648 24. Tympanoplasty is the surgical repair of the tympanic membrane and the tympanum and the

reconstruction of the ossicular chain. Conductive hearing loss is caused by an obstruction in the external canal or middle ear, which impedes the passage of sound waves to the inner ear. A common cause of conductive hearing loss would be: a. AOM. b. fluid invasion of the ear canal. c. perforation of the tympanic membrane. d. a healed myringotomy.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Tympanoplasty is indicated for conductive hearing losses caused by perforation of the tympanic membrane as a result of trauma or infection; for ossicular discontinuity; for chronic or recurrent otitis media; for progressive hearing loss; and for the inability to safely bathe or participate in water activities as a result of perforation of the tympanic membrane with or without hearing loss. Perforation of the tympanic membrane is the most common ear injury necessitating surgical intervention. It may be attributable to disease of the middle ear or tympanic membrane. Occasionally the tympanic membrane does not heal after myringotomy.

REF: p. 649 25. A stapedotomy is removal of the stapes superstructure and creation of a fenestra (opening) in

the fixed stapes footplate for treatment of abnormal bone growth around the footplate that results in its immobility. A prosthesis is placed to restore ossicular continuity and alleviate conductive hearing loss. The patient scheduled for a stapedotomy will probably have a surgical diagnosis of: a. otosclerosis. b. ossicular stenosis. c. indeterminate hearing loss. d. ossicular immotility.

ANS: A

Otosclerosis is the formation of abnormal bone around the stapes footplate, resulting in immobility of the footplate. Sound waves cannot be transmitted adequately through the oval window and round window to be changed into electrochemical impulses in the cochlea.

REF: p. 651 26. Acoustic neuromas arise from the Schwann cells of the vestibular portion of the eighth cranial

nerve and are benign tumors. What is the postauricular incisional approach that offers the best chance of saving the integrity of the facial nerve? a. Transaural b. Supra-aural c. Translabyrinthine d. Intravestibular ANS: C

The translabyrinthine approach for the removal of an acoustic tumor reduces mortality and morbidity and offers a good chance of saving the facial nerve if the tumor has not directly invaded it. The surgeon makes a postauricular incision slightly longer and more posterior than the incision for mastoidectomy and elevates the periosteum from the mastoid bone.

REF: p. 653 27. The Caldwell-Luc procedure is a radical antrostomy used to establish a large opening into the

wall of the inferior meatus leading to the sinuses. Where is this large incisional approach made? a. Proximal to the maxillary artery b. Antrum wall on the affected sinus side c. Canine fossa of the upper jaw d. Intranasally on the affected sinus side

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

The purpose of an antrostomy is to establish a large opening into the wall of the inferior meatus, which ensures adequate gravity drainage and aeration. This large opening allows removal of the diseased tissues in the sinuses under direct vision. The Caldwell-Luc approach is also used to access the maxillary artery in cases of extreme epistaxis. The procedure requires an incision into the canine fossa of the upper jaw and exposure of the antrum for removal of bony diseased portions of the antral wall and contents of the sinus.

REF: p. 660 28. A nasal polypectomy is the removal of polyps from the nasal cavity. Nasal polyps are benign,

grapelike clusters of mucous membrane and connective tissue. When the polyps become large, they obstruct the free passage of air, make breathing difficult, and cause a change in speech quality. Nasal polypectomies are typically performed endoscopically with the use of microdebriders, which remove the polyps by their mechanism of _______________. a. ultrasonic cavitation b. morcellation c. radiofrequency ablation d. laser vaporization ANS: B

Endoscopic nasal polypectomies are often performed with other sinus procedures that also require removal of diseased tissue. Because of the aggressive nature of polyps, microdebriders are particularly helpful in these cases. They can greatly shorten surgical time by their mechanism of morcellating the polyp and removing it by immediate suctioning while controlling bleeding, as opposed to each polyp being manually extracted with an instrument in small pieces.

REF: p. 659 29. Oral malignancies can be linked to specific carcinogens, the most important one being

tobacco. Benign or malignant lesions of the tongue, floor of the mouth, alveolar ridge, buccal mucosa, or tonsillar area are excised depending on the extensiveness of disease, involvement of surrounding vessels and nerves, and candidacy for surgery. Benign or small malignant tumors of the oral cavity may be excised without a neck dissection. Which indicator would prompt the surgeon to perform a neck dissection for benign or small malignant tumors? a. The patient is a smoker. b. Suspicious metastatic disease c. Presence of undiagnosed skin lesions of the head and neck d. Benign growth in the lower jugular region ANS: B

Benign or small malignant tumors of the oral cavity may be excised without a neck dissection, though in the presence of diagnosed or highly suspicious metastatic disease, a selective neck dissection may be performed in an effort to control a cancerous growth in the upper jugular lymphatic chain of the neck.

REF: p. 661 30. Uvulopalatopharyngoplasty (UPPP) is performed primarily to relieve obstructive sleep apnea

(OSA) and snoring. Select two common indications for UPPP surgery.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. b. c. d.

O2 saturation below 92%, and snoring Cardiac dysrhythmia during sleep and awake, and snoring O2 saturation below 80%, and apnea index worse than 20 O2 saturation below 85% on continuous positive airway pressure (CPAP), and apnea index below 20

ANS: C

UPPP is not a substitution for the use of CPAP, though the procedure may be considered when conventional use of CPAP fails. Two or more of the following indications are reason to perform the operation: an O2 saturation that drops below 80%; apnea index worse than 20; significant daytime sleepiness; heroic snoring; producing social or marital problems; or cardiac dysrhythmias, other than tachycardia or bradycardia, during sleep.

REF: p. 664 31. Microlaryngoscopy facilitates improved diagnosis and allows the laryngologist to view, with

relative ease, areas that previously were inaccessible or difficult to visualize. What are the two most common indications for microlaryngoscopy? a. Chronic hoarseness and cough b. Laryngeal polyps and nodules c. Epiglottitis and frequent choking d. Laryngeal injury and cancer ANS: B

Microlaryngoscopy facilitates improved diagnosis and allows the surgeon to view with relative ease areas that previously were inaccessible or difficult to visualize. It may also be used for minor surgery of the larynx, especially for the removal of polyps or nodules on the vocal cords.

REF: p. 658 32. During a stapedotomy or stapedectomy procedure, the perioperative nurse manages and

controls the environment of care by maintaining a quiet, warm, and comfortable operating room (OR). Energy modality devices and monitor alarms are turned down to the lowest audible setting for the team to hear without startling the patient. The English-speaking, nonanxious patient sedated using local or monitored anesthesia care (MAC) anesthetics is well-prepared by the perioperative nurse for sensory and procedural expectations. Which event occurs near the conclusion of the procedure that predicts patient outcome? a. The surgeon whispers softly in the patient’s operative ear to determine return of hearing. b. The surgeon irrigates the middle ear to promote and visualize movement of the ossicles. c. The surgeon asks the patient to repeat words as the external ear packing is placed. d. The surgeon whispers in the patient’s operative ear to determine delayed tympanoplasty.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Both of these procedures may be performed using MAC or local anesthetic for adults, enabling the surgeon to test hearing before the conclusion of the surgery. The surgeon may test the patient’s hearing by softly whispering to the patient (if the procedure is performed with the patient administered a local anesthetic) or by touching the malleus with a pick and observing for mobility of the malleus, incus, and stapes prosthesis (if performed with the patient administered a general anesthetic).

REF: p. 652 33. During endoscopic sinus surgery, patient eye protection includes: a. taping the eyelids closed. b. placing moist gauze over the eyelids. c. instilling eye lubricant into both eyes. d. fitting the patient with appropriate sized laser goggles.

ANS: C

A consideration that is crucial to a successful outcome in functional endoscopic sinus surgery (FESS) is to maintain the integrity of the patient’s periorbital cavities. The patient’s eyes must be visible to the surgeon at all times to avoid injury to the orbit or to immediately recognize injury if it occurs. The surgeon will monitor for movement of the eyeball or appearance of an intraorbital hematoma.

REF: p. 659 34. Benign or small malignant tumors of the oral cavity may be excised without a neck dissection,

though in the presence of diagnosed or highly suspicious metastatic disease, a selective neck dissection may be performed in an effort to control a cancerous growth in the upper jugular lymphatic chain of the neck. Typically, endotracheal anesthesia is used, and a pharyngeal pack of moist gauze may be inserted in the mouth. When head and neck surgery is performed, the perioperative nurse must be prepared for possible additional procedures. Of these possibilities, what is the highest-priority consideration for the perioperative nurse? a. Tracheostomy b. Microscopic free flap graft c. Laryngoscopy d. Difficult airway protocol ANS: A

For some tumors of the oral cavity, a tracheostomy is performed to ensure a patent airway after surgery. A percutaneous endoscopic gastric tube, neck dissection, and composite resection of both the mandible and the tongue with free flap reconstruction are considered for extensive disease.

REF: p. 663 35. Excision of the submandibular gland is performed to remove mixed tumors and calculi

associated with extensive chronic inflammation. The submandibular gland lies in close proximity to several important nerves and vessels. Of the following, what is the highestpriority perioperative nursing action related to submandibular surgery? a. Provide the scrub person with a bipolar electrosurgical unit (ESU) b. Provide the scrub person with a nerve stimulator c. Avoid local anesthetics on the sterile field if identification of major nerves will

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock take place d. Provide the anesthesia provider with an intraoperative nerve monitoring system ANS: C

The perioperative nurse must ensure that no local anesthetic is delivered to the sterile field if identification of major nerves is anticipated. A nerve stimulator and bipolar ESU may be requested.

REF: p. 663 36. Laryngoscopy is direct visual examination of the interior of the larynx by means of a rigid,

lighted speculum known as a laryngoscope to obtain a specimen of tissue or secretions for pathologic examination. What risk reduction strategy should the perioperative nurse employ in preparing for the conclusion of the procedure? a. Maintain instrument setup until the patient leaves the operating room (OR) b. Determine fire risk score c. Place O2 tank, nasal cannula, and bag/valve/mask on the transport vehicle d. Assist anesthesia provider with anesthesia emergence and transfer to the postanesthesia care unit (PACU) ANS: A

Laryngoscopy instrumentation should remain set up in the room until the patient is transferred, because the equipment may be needed if the patient experiences laryngospasm postoperatively and requires intubation.

REF: p. 668 37. When laryngoscopy, bronchoscopy, and esophagoscopy are performed in a single session on a

patient, the procedure is termed triple endoscopy or panendoscopy. The purpose of triple endoscopy is usually diagnostic. The most critical and appropriate role of the perioperative nurse during this complex diagnostic procedure is that of: a. documenting the procedure in the perioperative record. b. identifying, containing, and labeling all specimens accurately. c. carefully handling and reprocessing the endoscopes. d. assisting the anesthesia provider with maintaining the airway.

ANS: B

While inspecting for a malignancy, the surgeon views the structures, takes specimens for biopsy, and possibly makes smears or washings of the suspect areas. Specimens taken during endoscopic procedures should be labeled and removed from the back table as soon as possible. In some instances it may be helpful to indicate on the label that the specimens are microscopic.

REF: p. 669 38. Partial laryngectomy is removal of a portion of the larynx. It is done to remove superficial

neoplasms that are confined to one vocal cord or to remove a tumor extending into the ventricle or the anterior commissure or a short distance below the cord. The perioperative nurse, in preparing the patient for surgery and postprocedure expectations, can describe the postoperative voice as: a. enhanced voice with assistive tracheoesphageal puncture stoma.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. no voice, because the patient breathes through a tracheostoma. c. normal as the patient’s preoperative voice. d. a hoarse but serviceable voice.

ANS: D

The patient should be prepared for an altered voice quality postoperatively as well as for the possibility of total laryngectomy if the tumor proves too extensive for partial resection. A successful partial laryngectomy should leave the patient with the ability to phonate, though usually with a more hoarse voice.

REF: p. 671 39. Depending on the surgical defect, head and neck surgical procedures to remove malignant

tumors may also involve reconstructive procedures. The wound may be closed primarily, or local flaps and split-thickness skin grafts or full-thickness skin grafts may be used to restore function as well as cover defects. An important role of the perioperative nurse in the ongoing assessment of graft integrity includes which assessment tool? a. Skin-adhering adhesive temperature probe to detect subtle changes in graft perfusion b. Light-pressure skin blanch test for return perfusion and viability of graft c. Use of intraoperative and postoperative Doppler to detect presence of blood flow d. Interval flow cytometry readings of vascular perfusion to the graft ANS: C

For complex reconstructive procedures in the neck, a handheld Doppler unit (to determine the viability of blood vessels) or an electromyographic nerve monitor (to determine the location and quality of nerves) may be used.

REF: p. 645 40. When microlaryngoscopy is performed to remove polyps or nodules from the vocal cords,

which important postoperative instruction must the nurse give the patient during discharge teaching? a. Complete voice rest is essential. b. Coughing and deep-breathing exercises should be performed. c. Clearing the throat to remove secretions is advised. d. The patient should use a humidifier.

ANS: A

Voice rest may be used for minor surgery of the larynx, especially for the removal of polyps or nodules on the vocal cords. The patient is cautioned to observe complete voice rest or to whisper postoperatively. The patient should be provided with a pencil and paper or erasable slate to aid in communication. The patient’s restriction on speaking should be noted on the nursing plan of care and on the front of the chart.

REF: p. 668 41. During the preoperative assessment for a patient scheduled for nasal surgery using a local

anesthetic that includes epinephrine, what important consideration, relevant to epinephrine use, should be explored? a. Coagulopathy

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Renal status c. Cardiac status d. Anxiety ANS: C

Cardiac status should be noted, because many surgeons use epinephrine as an additive to the local anesthetic to achieve vasoconstriction and minimize blood loss. The epinephrine effect may contribute to cardiac dysrhythmias and an increased potential for cardiac arrest.

REF: p. 634 42. During otolaryngologic procedures using local anesthetic, the perioperative nurse plans the

environment of care as a quiet, warm, and functional domain of healing and comfort. An important consideration with most otolaryngologic patients identifies their specific _________ needs. a. communication b. anxiety c. airway d. pain ANS: A

Patients undergoing otolaryngologic procedures may have special communication needs that must be considered in planning effective care. The perioperative nurse should determine the best way to communicate with patients who have hearing deficits or impaired vocalization.

Information given to the patient should be reinforced as needed throughout the perioperative experience. The OR environment must be quiet and free of any loud noise. Intraoperative noises, such as those from suction, ESUs, and other equipment, should be explained to the locally anesthetized patient before they are generated. This will help avoid startling the patient and adversely affecting the success of the surgery.

REF: p. 636 43. During the preoperative assessment and teaching for a patient scheduled for otolaryngologic

surgery performed using local anesthetic, the perioperative nurse reviews with the patient normal coping mechanisms that are personally effective and supports and encourages the patient during the surgical intervention. The nurse is preparing the patient to anticipate: a. disturbed sensory perceptions. b. tachypnea. c. acute pain. d. claustrophobia.

ANS: C

The patient will communicate adequate pain control and display absence of physiologic indicators of pain (e.g., tachypnea, tachycardia, pallor, and hypertension). Review with the patient normal coping mechanisms that are personally effective; support and encourage these during surgical intervention. Describe the anticipated sequence of perioperative events.

Explain that some initial discomfort (e.g., pinprick followed by slight burning and then numbness) may be felt during the administration of local anesthetic. Inform the patient before the injection of local anesthetic; provide support and reassurance; evaluate patient response.

REF: p. 636

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

44. An experienced perioperative nurse is orienting a new perioperative nurse to otolaryngologic

surgery. The experienced nurse and the new nurse are the scrub persons and are preparing the sterile back table with instruments, accessory devices, and the medications used for the local anesthetics. They also set up a prep table with the initial local anesthetics to be given before the start of the procedure. The experienced nurse is determined to impart the critical nature of patient safety and prevention of medication errors during these procedures. The back table contains multiple medications that will be used for local anesthesia, vasoconstriction, and hemostasis. As a perioperative registered nurse (RN) scrub person, it is necessary that both the experienced and new nurse: a. label only the high-risk medications with their name, dose, percentage or strength, and amount. b. observe the four rights of medication administration. c. double-check only the high-alert medications such as concentrated epinephrine. d. be aware of the maximum recommended dosage of all local anesthetics and be alert for signs of reaction.

ANS: D

Be aware of the maximum recommended dosage of local anesthetics and be alert for signs of allergic reactions or toxic responses.

REF: p. 637 45. The perioperative nurse and his orientee have returned from an airway fire simulation exercise

with the otorhinolaryngologic surgeon, fellow, and anesthesia provider. They were amazed at the statistics for OR fires and the threat of serious injury to the patient and team. Patients undergoing otorhinolaryngologic procedures are at greater risk for fire injury because of the proximity of the surgical field to high concentrations of oxygen. The team discussed a plan to change their practices. An example of a valid fire prevention strategy that involves the entire surgical team during otorhinolaryngologic surgery would be: a. placing ESU active electrodes in a basin of sterile water. b. keeping cottonoid patties and strings completely dry when used around the laser. c. identifying the fire risk score during the postprocedure debriefing. d. collaborating with the anesthesia provider and surgeon to prevent fire risks.

ANS: D

Implementation of specific safety protocols for the use of the laser and the ESU in the airway includes the following: A laser-resistant endotracheal tube being used, and the tube should be chosen to be resistant to the laser used for the procedure (e.g., CO2, Nd:YAG, etc.). Before activating the laser, the surgeon should inform the anesthesia provider so that the oxygen concentration delivered to the patient can be safely reduced. Additionally, the surgeon should wait a few minutes before activating the laser to allow the oxygen concentration to diminish.

Before activating the ESU inside the airway, the surgeon should give the anesthesia provider adequate notice that the ignition source is about to be activated. The anesthesia provider should reduce the oxygen concentration to the minimum required to prevent hypoxia, and the surgeon should wait a few minutes before using the ESU to allow the oxygen concentration to diminish.

REF: p. 640

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 46. Surgical removal of hypertrophic adenoids to relieve upper airway obstruction is often

performed to create a patent nasal airway. The highly vascular adenoids are treated by which method(s) of hemostasis to control bleeding? a. Pharyngeal packing b. Cryotherapy c. Radiofrequency current d. Tannic acid and epinephrine paste ANS: C

Children with polysomnogram-proven sleep disorder breathing and hypertrophic adenoids should have their adenoids assessed as a complete workup. Adenoidectomy by curette, ablation, radiofrequency, and powered microdebriders has been described in the pediatric otolaryngology literature. Hemostasis is achieved depending on the method chosen, by electrocautery, radiofrequency, or direct pressure (using angled mirrors or endoscopic visualization).

REF: p. 667 MULTIPLE RESPONSE 1. FESS provides a more physiologic type of drainage by reducing trauma to normal tissues.

FESS involves the endoscopic resection of inflammatory and anatomic defects of the sinuses.

Select the appropriate indications for FESS. a. Inhibited mucociliary clearance b. Outflow obstruction c. Mucocele d. Sinus infections ANS: A, B, C, D

If there is obstruction of outflow (e.g., allergy, septal deflection, spurs) between the mucosa and the sinus, mucociliary clearance is inhibited, and secretions are retained in the sinus. This predisposes the patient to sinus infections and mucocele. The purpose of FESS is to ensure adequate drainage of the sinuses by resecting tissue and creating increased aeration of the sinuses.

REF: p. 658

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 20: Orthopedic Surgery Test Bank MULTIPLE CHOICE 1. Identify the layer of connective tissue that covers all bone. a. Periosteum b. Ligament c. Cartilage d. Fascia ANS: A

A layer of connective tissue called periosteum covers all bone. Ligaments are bands of dense connective tissue that hold bone to bone. Cartilage is a layer of elastic, resilient supporting tissue found at the ends of bones. Fascia is a band or sheath of connective tissue supporting or binding together internal organs or parts of the body.

REF: p. 679 2. A long bone fracture in a child can have devastating consequences in terms of the child’s

skeletal maturity and potential for limb shortening and malformation when the fracture line involves the: a. epiphysis. b. diaphysis. c. epiphyseal plate. d. cancellous bone.

ANS: C

Long bones consist of a shaft (diaphysis) and two ends (epiphyses). The shaft is composed of compact bone. The epiphyses flare out and consist of cancellous bone. They are covered by cartilage, which provides a cushion and offers protection during weight-bearing and movement. Until skeletal maturity, a line of cartilage called the epiphyseal plate separates the epiphysis from the diaphysis. Fractures in this region in children can be devastating, because they often lead to malformation and permanent limb shortening.

REF: pp. 679-680 3. The rotator cuff consists of which group of muscles? a. Deltoid, teres major, and teres minor b. Supraspinatus, infraspinatus, teres minor, and subscapularis c. Latissimus dorsi, deltoid, and teres major d. Supraspinatus, subscapularis, pectoralis major, and deltoid ANS: B

The muscles immediately surrounding the shoulder joint are the supraspinatus, infraspinatus, teres minor, and subscapularis; together they are referred to as the rotator cuff. These muscles stabilize the shoulder joint, whereas the powerful deltoid, pectoralis major, teres major, and latissimus dorsi muscles move the entire arm.

REF: p. 681

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

4. The scaphoid, also called the navicular, links the proximal row of carpal bones as it: a. articulates with each metacarpal head. b. attaches its rough surfaces to the ligaments. c. stabilizes and coordinates the movement of the proximal and distal rows. d. articulates proximally with its matching carpal row.

ANS: C

Functionally, the scaphoid links the rows as it stabilizes and coordinates the movement of the proximal and distal rows. Each carpal bone consists of several smooth articular surfaces for contact with the adjacent bones, as well as rough surfaces for the attachment of ligaments.

REF: p. 682 5. The vertebral bodies are connected by several cartilaginous joints. What purpose does this

connection enable? a. Communication between the spinous processes and vertebral bodies b. Vertebral flexion, rotation, and extension c. Vertebral flexion and torsion d. Sustains integrity and spinal support ANS: B

Vertebrae form the longitudinal axis of the skeleton. The vertebral bodies are connected by several cartilaginous joints, which enable the vertebrae to flex, extend, or rotate while being held together. Intervertebral disks and ligaments connect the bodies of adjacent vertebrae. The ligament flava bind the laminae of adjacent vertebrae.

REF: p. 680 6. Before surgery, the perioperative nurse reviews the patient record, noting relevant aspects of

the history and physical examination; the nature of the problem and its onset; and results of radiographic studies, laboratory data, and other findings. The nurse investigates the patient’s range of motion, neurovascular status, and general condition. The patient’s perception and understanding of the surgical procedure and postoperative rehabilitation is determined, and patient education is begun. Such activities reflect which important part of the nursing process? a. Assessment b. Nursing diagnosis c. Planning d. Implementation ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Assessment information helps the nurse to determine specific needs related to surgical positioning, skin preparation, equipment, instrumentation, and supplies. Results of the nursing assessment are stated as nursing diagnoses. Nursing diagnoses related to the care of patients undergoing orthopedic surgery might include the following: anxiety, risk for peripheral neurovascular dysfunction, risk for perioperative positioning injury, impaired gas exchange, risk for infection, and risk for imbalanced body temperature. Preoperative films or images are present in the operating room (OR) or procedure room. Planning is preparing in advance for what will or may happen and determining the priorities for care. Implementation is performing the nursing care activities and interventions that were planned and responding with critical thinking and orderly action as changes in the surgical procedure or patient’s condition or emergencies occur.

REF: pp. 687-688 7. An objective assessment of the patient’s condition, in terms of assigning an appropriate

preoperative surgical diagnosis and plan of care, would be obtained from: a. the physician consult with history, physical, and medical clearance. b. the patient’s own statements about symptoms, pain, onset, and disability. c. the signed surgical consent form. d. X-rays and imaging studies.

ANS: D

Radiographic films and imaging studies are objective measures of surgical pathology in terms of attaining a presurgical diagnosis. Assessment of the orthopedic patient is dynamic, beginning with initial patient consultation. The history and physical are done in the usual fashion. The signed operative consent provides information to confirm the scheduled procedure(s) and verify the operative site and side. The consent is usually obtained before admission to the surgery suite and should be reviewed for accuracy and completeness.

Additional measures that should be undertaken to verify the correct operative side and site include marking the surgical site and having the patient verify the site with the surgeon during the marking process and using a verification checklist, which includes documents such as the medical record, X-ray films, and imaging studies.

REF: p. 687 8. Select the true statement about application and operation of the pneumatic tourniquet. a. The tourniquet cuff should not overlap less than 3 inches or more than 6 inches. b. Limb exsanguination is optional, using a sterile sequential compression sleeve. c. In a healthy person, inflation time for an arm should not exceed 30 minutes. d. Pneumatic tourniquets are contraindicated in patients with bleeding tendencies.

ANS: A

Pneumatic tourniquets are frequently used for procedures involving the extremities.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Limb exsanguination is achieved by elevating the limb or by wrapping it, distally to proximally, with an Ace or Esmarch rubber bandage before tourniquet inflation. Preoperative assessment of the patient includes determining contraindications for use, including compartment syndrome, McArdle’s disease, hypertension, or other vascular problems.

Duration of tourniquet inflation should be kept to a minimum. It is recommended in the average, healthy 50-year-old person to apply continuous tourniquet pressure less than 1 hour on the upper extremity and less than 2 hours on the thigh. Tourniquet pressure should not exceed the recommended maximum cuff pressure limits of 300 to 350 mm Hg for the thigh and 250 to 300 mm Hg for the arm and the lower leg. The interval between inflation and deflation should be 5 minutes for every 30 minutes of tourniquet ischemia to minimize detrimental effects on muscles and nerves. Cuffs should overlap a minimum of 3 inches and a maximum of 6 inches; excess overlap can pinch skinfolds. A tourniquet cuff that is too short can loosen after inflation.

REF: pp. 692-693 9. Polymethyl methacrylate (PMMA, or bone cement) is an acrylic, cement-like substance

composed of a liquid methyl methacrylate monomer and a powder methyl methacrylatestyrene copolymer. What element is added to the powder component by the manufacturer to make the finished product radiopaque? a. Radiografinpaque b. Polycrylate sodium c. Barium d. Granular allograft bone ANS: C

The powder component is 10% barium sulfate, U.S. Pharmacopoeia (USP), which provides radiopacity to the finished product. The liquid monomer is highly flammable, and the OR should be properly ventilated. Caution should be exercised during mixing of the two components to prevent excessive exposure of OR personnel to the vapors of the monomer.

This exposure can cause irritation of the respiratory tract and eyes.

REF: p. 696 10. The surgeon may treat distal limb fractures with a closed reduction, rather than open or

external fixation, manipulating the fragments into position without incising the skin. When possible, this is the treatment of choice because it decreases the opportunity for infection, improves results (including bone union of the fracture), and minimizes the recovery period.

Closed reduction with local or light anesthesia may permit ambulatory surgery. Select a situation where closed reduction would be performed in addition to open reduction and fixation surgery to a distal limb. a. Significant bone comminution b. Where periosteal damage is evident c. Before an open procedure to reduce the fracture site d. When soft tissue entrapment is suspected ANS: D

Closed reduction may take place before an open procedure to reduce the fracture site, because soft tissue entrapped within the fracture site may result in complications after a closed reduction.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 701 11. Open reduction and internal fixation is a method of providing exposure of the fracture site and

using pins, wire, screws, a plate and screw combination, rods, or nails to correct the fracture.

Surgeons use open reduction and internal fixation when they are unable to reduce a fracture by closed methods, and skeletal traction is not indicated. What would be an advantage for an open rather than a closed fracture reduction technique? a. Direct observation and verification of fracture alignment b. Decreased opportunity for surgical site infection c. Improved bone union outcomes d. Ability to rule out comminuted or compound fractures without imaging ANS: A

The advantage is that anatomic alignment of the fracture can usually be obtained and verified through direct observation. Fractures that are comminuted or difficult to reduce can be more effectively treated using this technique.

REF: p. 703 12. Colles’ (wrist) fracture is a dorsally angulated fracture of the distal end of the radius. Most of

these fractures can be managed successfully with closed reduction and immobilization, but external fixation is especially useful in the case of a comminuted intra-articular fracture.

Internal fixation with Kirschner wires (K wires) is indicated when the distal end of the radius is severely comminuted and displaced. Select the nursing considerations for a patient with a Colles’ fracture fixation. a. Position in modified semi-Fowler with the hand table and tourniquet at the operative side. b. Provide soft tissue instruments in the OR and external fixation frame c. Place tourniquet cuff at mid-forearm level and set to systolic blood pressure level. d. Position affected wrist and take an anteroposterior and lateral film before surgeon’s arrival.

ANS: B

The patient is in the supine position with the arm extended on a hand table. Traction by means of finger traps may be required. A soft tissue set and a small bone set are required, along with a power drill, small elevator, and the external fixation device of choice. Fluoroscopy is necessary.

REF: p. 713 13. Vertebroplasty and kyphoplasty are used for the treatment of vertebral compression fractures

attributable to osteoporosis or pathologic conditions. Bone cement is injected into the vertebral body to decrease back pain and prevent further vertebral body height loss.

Equipment includes C-arm, radiolucent OR bed, and X-ray vests for staff as well as bone biopsy needles, vertebroplasty system, and cement injection system. An important nursing consideration relevant to this interventional radiology–assisted procedure would be to: a. shield the patient with a lead apron, covering from thyroid to reproductive organs. b. organize and have casting supplies available outside of the room. c. position patient in prone body alignment with padding to prevent skin and nerve injury. d. abduct both arms less than 90 degrees on attached armboards.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: C

Positioning of the patient requires careful vigilance to prevent skin breakdown and nerve damage. After the administration of anesthetic, the patient is positioned prone with hyperextension of the vertebral compression fracture on the radiolucent OR bed. Full body shielding would interfere with radiolucency of the operative site. These procedures do not require postprocedure casting. Armboards would interfere with movement of the C-arm image intensifier.

REF: p. 766 14. The term “hammer toe” is most often used to describe an abnormal flexion posture of the

proximal interphalangeal joint of one of the four lesser toes. A bunion (hallux valgus) is a soft tissue or bony mass at the medial side of the first metatarsal head. Both of these deformity conditions of the feet share similar surgical positions, instrumentation for fixation, and recovery plans. What nursing consideration is also shared by both procedures? a. Perform skin preparation on only the affected toes. b. Position patient supine and apply ankle tourniquet. c. Provide epinephrine for injection into the toes to decrease bleeding. d. Position the patient prone in normal body alignment with foot elevated on a gel roll.

ANS: B

The goals of surgery are correction of the deformity (cosmesis), resection of the abnormal bony components (reconstruction), and restoration of normal or near-normal range of motion (function). The anesthesia provider administers a general or regional anesthetic, and an ankle tourniquet is applied. The foot and leg are prepped and then draped using a sterile stockinette.

A soft tissue set, a small bone set, Kirschner wires, a power wire driver, and a microsagittal saw are required. The foot is prepped and draped. The toes are end organs, and epinephrine should be used with caution.

REF: p. 732 15. Bone grafting using allografts or autografts may be used to fill cavities after removal of large

amounts of bone that might result in instability, or to fill bony defects and to promote the union of fractures at the time of open reduction. Banked bone is available in many shapes of cortical and cancellous tissue. The American Association of Tissue Banks (AATB) accredits and periodically inspects bone-banking programs to ensure that specific standards are followed in the retrieval, processing, storage, and distribution of bone grafts. Bone graft that is sealed in a sterile labeled envelope from a tissue transplant company and stored in a vacuumsealed freezer, monitored with an alarm, would be considered a(n): a. reengineered human tissue product. b. allograft. c. xenograft. d. autograft.

ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Allografts are frozen until use. Vacuum-sealed freezers are monitored with an alarm. When requested for a procedure, the bone allograft is delivered to the field, slightly thawed, cultured, and washed with an antibiotic solution. Allografts are used when bone is not available from the patient because of the lack of sufficient quantity or because a secondary procedure is undesirable for the patient. Records are maintained on both donors and recipients. Like other implants, the recipient’s operative record should include the name of the bone bank from which the allograft was received, type of allograft, tissue number, and expiration date if applicable.

REF: p. 697 16. Osteoporosis is one of the most common and serious bone diseases and is responsible for

more than 2 million fractures a year. Osteoporosis-related fractures most commonly occur in the hip, spine, and wrist, but any bone can be affected. The excessive reduction of total bone mass in osteoporosis is due to: a. the loss of calcified matrix and collagenous fibers. b. the lack of exercise and weight-bearing physical activity. c. the loss of estrogen and testosterone. d. the loss of calcium or vitamin D. ANS: A

Osteoporosis is characterized by excessive loss of calcified matrix, bone mineral, and collagenous fibers, causing a reduction of total bone mass. Decreasing levels of estrogen and testosterone in the older adult result in reduced new bone growth and maintenance of existing bone. Inadequate intake of calcium or vitamin D; lack of weight-bearing activities, exercise, and physical activity; smoking; and caffeine intake are other contributing factors.

REF: p. 700 17. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone,

which leads to a reduced absorption of calcium and phosphorus. This malabsorptive condition is due to a deficiency of ______________ that can be treated by __________________. a. calcium; nutritional diet and mineral supplements b. vitamin D; dietary supplements and exposure to sunlight c. phosphorus; nutraceuticals and exposure to therapeutic radiation d. soy protein; weight-bearing exercise and sunlight ANS: B

Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone as a result of vitamin D deficiency, which leads to a reduced absorption of calcium and phosphorus. Risk factors for development of osteomalacia include malabsorption problems, vitamin D and calcium deficiencies, chronic renal failure, and inadequate exposure to sunlight. Medical treatment includes dietary supplements and exposure to sunlight.

REF: p. 700 18. Paget’s disease is a disorder affecting older adults. The bones are weak and poorly

constructed. This degenerative process results in: a. weak and nonsupported bone matrix. b. replacement of cancellous bone with cortical bone. c. rapid, disorganized bone remodeling.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. immature bone cells with air spaces.

ANS: C

Paget’s disease is characterized by proliferation of osteoclasts and compensatory increased osteoblastic activity, resulting in rapid, disorganized bone remodeling.

REF: p. 700 19. While not as prevalent as arthroplasty of the shoulder, knee, or hip, total elbow replacement is

indicated for patients with traumatic lesions or excessive bone loss from rheumatic or degenerative arthritis, resulting in elbow instability and pain or bilateral elbow ankylosis. The prosthesis may be used with or without PMMA, depending on the quality of the diseased bone and the design of the implant. If PMMA is not used, what replacement product, element, or substance is used? a. Synthetic bone putty b. Autologous local bone graft c. Hemostatic gel sponge with thrombin d. Side plates, screws, and circumferential wires ANS: B

If PMMA is not employed, bone grafting with local bone that has been resected may be used to help seat the ulnar component snugly and achieve adequate bony contact against the porous coating of the metal ulnar component. The design of implants and methods of fixation for postoperative stability have presented challenges that have been overcome in arthroplasty of other joints but remain a challenge in elbow arthroplasty. Postoperative stability of the elbow implant depends largely on the soft tissues surrounding the joint. Patients with degenerative arthritis generally have better results from elbow arthroplasty than those undergoing this procedure after injury to the elbow joint.

REF: p. 735 20. A 50-year-old woman with degenerative rheumatoid arthritis is having a two-joint

metacarpophalangeal implant of her left hand. The pneumatic tourniquet is applied to the patient’s upper left arm and has been inflated to 280 mm Hg for 38 minutes. The surgery is advancing as planned, and the surgeon is preparing to insert the second implant. The perioperative nurse circulator has set the time threshold for 60 minutes. During her preoperative assessment, the nurse noted no contraindications to pneumatic tourniquet use.

While the surgery is going well, and the nurse is confident that the second implant will be inserted and the wound closed before the tourniquet alarms, which risk reduction strategy would be appropriate for the nurse to employ? a. Be prepared to increase the time threshold to 90 minutes b. Suggest a let-down procedure to resanguinate the limb at 60 minutes if the second implant is not yet inserted c. Wait until the 60-minute alarm sounds d. Monitor duration and remind team before 1 hour is reached ANS: D

Duration of tourniquet inflation should be kept to a minimum. It is recommended in the average, healthy 50-year-old person to apply continuous tourniquet pressure less than 1 hour on the upper extremity and less than 2 hours on the thigh.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 693 21. A 68-year-old retired woman has chronic joint pain in both knees and hips. She does not have

osteoarthritis but is overweight and sedentary. While she believes she needs to convince her orthopedic surgeon that she should be considered a candidate for joint replacement surgery, her neighbor, a perioperative orthopedic nurse, is teaching her about the role of cartilage in the joints and how to prevent further injury. The neighbor has convinced the patient to join her in stretching exercises and a daily walk through the neighborhood. This program can help prevent degenerative conditions because: a. exercise makes the cartilage more vascular. b. exercise restores water to the cartilage intracellular compartment. c. weight-bearing activities and joint movement prevent cartilage from becoming thin or damaged. d. exercise and joint movement will increase joint lubrication and pain threshold.

ANS: C

Weight-bearing activities and joint movements keep cartilage from becoming thin or damaged and help prevent degenerative conditions. Cartilage is aneural (without nerves), alymphatic (without lymph tissue), avascular (without blood vessels), and high in water content. The lack of vascularity and loss of water from cartilage during a lifetime are causes of resulting degenerative disease, such as arthritis.

REF: p. 679 22. Ligaments are best defined as: a. bands of dense connective tissue that hold bone to bone. b. layers of elastic, resilient supporting tissue found at the end of bones. c. tough, long strands of fibers that form the ends of muscles. d. layers of connective tissue that nourish the bone.

ANS: A

Ligaments, tendons, and cartilage also form the skeletal structure. Ligaments are bands of dense connective tissue that hold bone to bone. They provide stability to a joint by encircling or holding ends of bone in place. Tendons are tough, long strands of fibers that form the ends of muscles. Cartilage is a layer of elastic, resilient supporting tissue found at the ends of the bones.

REF: p. 679 23. Bone healing follows a logical sequence beginning with the formation of a hematoma. Select

the action that typically occurs after formation of a hematoma. a. Remodeling b. Invasion of osteoblasts c. Fibrin network formation d. Callus formation ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock After the formation of a hematoma, a fibrin meshwork forms. Osteoblasts invade the fibrin meshwork, and blood vessels develop to build collagen. After several days, calcium deposits may form in the granulation tissue. These deposits eventually form new bone, known as callus. Within the callus, cartilage cells develop a temporary semirigid tissue that helps stabilize the bone fragments. The callus is immature bone that is remodeled by new connective tissue cells (osteoblasts) of the periosteum and the inner membrane of the bone cavity. Through this process, mature bone is formed, excess callus is resorbed, and trabecular bone is placed.

REF: p. 699 MULTIPLE RESPONSE 1. A cancellous bone graft consists of spongy bone usually taken from the anterior or posterior

crest of the ilium. A cortical bone graft, consisting of hard, dense bone, is removed from the crest of the ilium or the tibia. Why is the ilium a desirable site for graft harvest? (Select all that apply.) a. It is subcutaneous, making it easily exposed without difficulty. b. It is not a weight-bearing joint. c. It is an articulating joint. d. It has both cortical and cancellous bone. e. There are two, one anterior and one posterior. f. It has both allograft and autograft bone.

ANS: A, D

The location of the crest of the ilium is subcutaneous, allowing exposure without difficulty.

The surgeon makes an incision along the border of the iliac crest, and strips, elevates, and retracts the muscles on the outer table of the ilium. Strips of the iliac crest can be removed with an osteotome or oscillating saw. A cortical window may also be made in the outer table, and the surgeon may use curettes or gouges to remove cancellous bone chips. Autografts are often harvested from the iliac crest, where there is cortical and cancellous bone.

REF: p. 699 2. In an open anterior cruciate ligament (ACL) repair, an examination under anesthesia (EUA) is

performed immediately after induction of anesthesia, when the ligaments are completely lax, to evaluate the severity of the injury. The surgeon then makes a straight midline or slightly medial incision across the knee. Arthroscopic repair causes less patellar pain and decreased disturbance of extensor mechanisms. What preoperative indicators contribute to selecting the surgical approach (open or arthroscopic) of choice? (Select all that apply.) a. Classification and severity of the tear or capsular instability b. Surgeon experience and preference c. Patient history of a prior failed repair or gross knee joint disruption d. Surgeon’s choice of whether to use autograft or allograft to replace the torn ligament.

ANS: A, B, C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The selected treatment method depends on the classification and severity of the tear, the experience and preference of the surgeon, and a history of a previous failed repair.

Arthroscopic repair causes less patellar pain and decreased disturbance of extensor mechanisms and therefore is becoming the treatment of choice, if there is no other significant capsular instability or gross disruption of the knee joint.

REF: p. 756

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 21: Neurosurgery Test Bank MULTIPLE CHOICE 1. What is the term for the bloodless plane that contains loose areolar tissue and permits mobility

of the scalp? a. Pericranial plane b. Galea c. Subgaleal space d. Outer skull periosteum ANS: C

The subcutaneous tissue, which is exceptionally dense, tough, and vascular, is firmly attached to the galea. Most of the blood vessels lie superficial to the galea. The subgaleal space contains loose areolar tissue that permits mobility of the scalp. It is in this bloodless plane that the standard craniotomy scalp flap is created. The pericranium, or outer periosteum of the skull, separates the galea from the cranium.

REF: p. 768 2. Identify the large dura fold that separates the right and left cerebral hemispheres. a. Falx cerebri b. Tentorium cerebelli c. Falx cerebelli d. Tentorium cerebri ANS: A

The dura mater is a tough, shiny, fibrous membrane that is close to the inner surface of the skull and folds to separate the cranial cavity into compartments. The largest fold is the falx cerebri—an arch-shaped, vertically placed, midline structure separating the right and left cerebral hemispheres.

REF: p. 770 3. An important area of the brain that is critical for learning and memory is the ___________,

while emotion and social behavior are regulated by the ____________. a. parahippocampal gyri; limbic system b. amygdala; cingulate c. hypothalamus; septum d. hippocampus; amygdala ANS: D

The hippocampus is critical for learning and memory. The amygdala regulates the perceptive and expressive aspects of emotional and social behavior. The limbic system affects endocrine and autonomic functions of the body, recent memory, emotions, behaviors, and motivational and mood states. Restlessness and hyperactivity may result from lesions of this area.

REF: pp. 773-774

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. The brainstem is located in the posterior fossa and forms the floor of the fourth ventricle. It is

the site of many ascending and descending fiber tracts that allow for communication among the structures of the brain and between the brain and spinal cord. The brainstem consists of which three structures? a. Dura, epidura, and subdura b. Midbrain, pons, and medulla oblongata c. Mesencephalon, cephalon, and cerebrum d. Pons, medulla, and foramen magnum ANS: B

The brainstem consists of the midbrain, pons, and medulla oblongata. It is located in the posterior fossa and forms the floor of the fourth ventricle. It is the site of many ascending and descending fiber tracts that allow for communication among the structures of the brain and between the brain and spinal cord.

REF: p. 774 5. At each vertebral level is a pair of spinal nerves, each consisting of an anterior and a posterior

root. Select the statement that represents true information about motor or sensory distribution. a. The posterior root is the sensory root. b. Skin dermatomes represent motor innervations. c. The anterior root is the sensory root. d. Spinal ganglia exit the spinal cord through the cauda equina.

ANS: A

The posterior, or sensory, root contains cell bodies that lie in the spinal ganglia located in the intervertebral foramina, the opening through which the nerves exit from the spinal canal and emerge from the cord. In the lumbar region, the course of the nerves is nearly vertical, forming the cauda equina. The normal segmental sensory distribution is valuable in the anatomic localization of sensory disorders. Dermatomes are bands of skin innervated by a sensory root of a single spinal nerve.

REF: pp. 784-785 6. Twelve pairs of cranial nerves arise within the cranial cavity. Although they are part of the

peripheral nervous system, from a surgical standpoint they are considered part of the anatomy of the head. Which three pairs of nerves, conveniently considered together because of their motor influence on the eye, are subject to toxic, inflammatory, vascular, and neoplastic lesions? a. Ninth, tenth, and eleventh cranial nerves b. Second, third, and fourth cranial nerves c. Third, fourth, and sixth cranial nerves d. First, second, and third cranial nerves ANS: C

The third, fourth, and sixth cranial nerves are three pairs of nerves—the oculomotor, the trochlear, and the abducens, respectively. They are conveniently considered together because they are the motor nerves to the muscles of the eyes. They are affected by many toxic, inflammatory, vascular, and neoplastic lesions.

REF: p. 782

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

7. A familiarity with basic neurologic assessment tools gives the nurse the ability to perform a

standardized neurologic exam that can be used preoperatively to establish a baseline assessment and postoperatively to establish a return to baseline or assess postoperative neurologic stability. The Glasgow Coma Scale (GCS) is commonly used to assess patients with brain injury using three indicators of cerebral function: eye opening, verbal communication, and motor response to verbal and noxious stimuli. Within the scoring range for the GCS, the best possible score is _____, and the worst possible score is ______. a. 15; 3 b. 12; 0 c. 3; 15 d. 0; 12 ANS: A

Three indicators of cerebral function—eye opening, verbal communication, and motor response to verbal and noxious stimuli—are assessed, and the appropriate number of points for each is assigned and totaled. The best possible score is 15, and the worst possible score is 3.

REF: p. 791 8. Trigeminal neuralgia is an extremely painful and debilitating condition characterized by

unilateral intense pain in the ear, eye, lips, nose, scalp, forehead, teeth, or jaw. A variety of treatments, including microvascular surgical decompression, are available. Select a minimally invasive targeted therapy that has demonstrated significant success in ablation of the entry of the trigeminal nerve. a. Endovascular ablation b. Stereotactic alcohol injections c. Gamma Knife radiosurgery d. Cavitron ultrasonic surgical ablation ANS: C

Trigeminal neuralgia (tic douloureux, fifth cranial nerve pain) is a condition characterized by brief, repeated attacks of excruciating, lancinating pain in the face. When pharmacologic measures fail, surgery to decompress the nerve is undertaken. Frequently more than one treatment is necessary during the course of the disease. Newer options include Gamma Knife radiosurgery.

REF: p. 815 9. Interventional neuroradiology uses fluoroscopy to gain access to the intracranial circulation by

way of a percutaneous transfemoral catheter. The endovascular approach to the treatment of both ruptured and unruptured cerebral aneurysms is endosaccular occlusion. This is an excellent technique for aneurysms that are complex, have a neck that is too short for clipping, or are difficult to reach via traditional craniotomy. This approach is less invasive than the traditional open craniotomy with identification and clipping of the aneurysm followed by cranial closure and extended recovery. Select the true endovascular procedure that has been designed as an alternative to its open surgical option. a. Endovascular coil occlusion of an aneurysm b. Endovascular approach for ventriculoperitoneal (VP) shunt insertion c. Endovascular evacuation of intracranial hemorrhage

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Endovascular ultrasound ANS: A

Although surgical excision is still the standard treatment for intracranial arteriovenous malformation (AVM), surgical morbidity may be decreased by using endovascular embolization preoperatively in select cases. Endovascular embolization is also advantageous when employed as a preoperative treatment for select intracranial tumor resections.

Endovascular coil occlusion of the aneurysm is appropriate if the aneurysm is deemed treatable by either endovascular coiling or surgical clipping. There are several neurovascular disorders that are amenable to an endovascular procedure.

REF: pp. 805-806 10. Microsurgical techniques have been applied to cranial, spinal, and peripheral nerve operations.

Each time the surgeon must look away and then back to the surgical field, open wound time and anesthesia time are increased while the surgeon becomes reoriented to the field. A nursing action, in the scrub person role, directed toward assisting the surgeon in efficiency and expediting the microsurgical procedure would be to: a. have the patient prepped and draped before the time out. b. place the instruments and accessories within the surgeon’s peripheral vision. c. hand instruments proficiently, in direction of use, without delay. d. transfer microwiped instruments and accessories via the first assistant.

ANS: C

Use of the microscope restricts the surgeon’s field of vision and mobility; therefore, the scrub person and surgical assistant must be actively engaged in the procedure and must be proficient. The operative field, unless video monitoring is available, cannot be seen. Surgical personnel must understand the surgical procedure and the corresponding anatomy, know the names and uses of all microinstruments, and be proficient at passing the instruments to the surgeon without delay. Each time the surgeon must look away and then back to the surgical field, open wound time and anesthesia time are increased while the surgeon becomes reoriented to the field. Therefore, the assistance the scrub person gives the surgeon saves time and directly benefits the patient.

REF: p. 804 11. The perioperative nurse in the circulating role is planning for her three neurosurgical

procedures for the day. She is explaining the basic processes of the three procedures to the scrub person: (1) exploration of a severe head injury with increased intracranial pressure (ICP) to evacuate a hematoma and possible brain tissue, (2) a VP shunt insertion, and (3) a reconstructive craniosynostosis for an infant with severe deformity. To give the brain room to swell in the first procedure, the bone flap may need to be sterile-wrapped and stored for later replacement. What is the appropriate surgical approach to the brain for each of the procedures? a. Craniectomy, craniotomy, and cranioplasty b. Burr hole, craniectomy, and craniotomy c. Craniotomy, cranioplasty, and craniectomy d. Cranioplasty, craniectomy, and burr hole ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock A burr hole is the minimum exposure made to gain access to the brain. Burr holes are necessary for many neurosurgical procedures and can be used to access the intracerebral ventricles for the placement of a ventricular catheter (VP shunt) to drain obstructed cerebrospinal fluid (CSF). Craniectomy is the permanent removal of a section of the cranium using burrs and rongeurs to enlarge one or more burr holes. Craniectomy is indicated as treatment for craniosynostosis in infants and young children. A craniotomy may be performed to evacuate intracranial hematomas, tumors, or vascular lesions not accessible through a burr hole. The bone plate may be separated from the soft tissues, removed from the skull, and set aside for replacement at the end of the procedure. If intracranial swelling at the end of the procedure is a major concern, the bone plate may be frozen and stored in a sterile container according to hospital protocol to be used on the patient at a future date when the reduced ICP and swelling permits.

REF: pp. 807-808 12. Achieving hemostasis in delicate areas can be a challenge for the neurosurgeon. In addition to

using meticulous technique to prevent bleeding, topical agents are routinely used as an adjunct to hemostasis. Some hemostatic products form a composite clot that seals a bleeding site by using a thrombin component that converts fibrinogen in the patient’s blood to fibrin. Select the two hemostatic products that provide hemostasis by topical application, essentially acting as a patch rather than a clotting factor. a. Oxidized cellulose (Surgicel) and topical thrombin b. Bone wax and topical thrombin c. Bone wax and oxidized cellulose (Surgicel) d. Gelatin matrix (FloSeal) and collagen hemostat (Avitene) ANS: C

Bone wax is a hemostatic material that should be available for all cranial and spinal cord operations. Bone wax may be applied with the surgeon’s fingertip or with the tip of an instrument such as a Freer or Penfield elevator. The surgeon firmly rubs or packs the wax into the bleeding surfaces of bone. Bone wax is commonly used in burr holes, along the edges of a craniotomy, and on the cut edges of the spine. Oxidized regenerated cellulose is available in two forms: a rayon-like gauze (Surgicel) and a cotton-like form (Fibrillar). These are also absorbable hemostatic agents that are used to control bleeding from oozing surfaces, vessels, and sinuses in the brain. These hemostatic substances are presented in various sizes and shapes and are offered to the surgeon dry. The hemostatic material adheres to the bleeding area with gentle pressure.

REF: p. 802 13. The most frequently occurring tumors of the spine are metastatic, and the spine is the most

common site for skeletal metastasis. From which organs or disease processes do most secondary spinal tumors originate? a. Lung, breast, lymphoma, and myeloma b. Intestines, thyroid, soft tissue sarcoma, and breast c. Osteosarcoma, meningioma, lymphoma, and pancreas d. Myeloma, gastric, biliary, and lung ANS: A

Secondary spinal tumors most often originate from carcinomas of the lung, breast, prostate, and blood. Pain is the earliest and most prominent symptom, followed by weakness.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 787 14. Brain tumors are either malignant or benign, depending on the cell type. Both primary and

metastatic tumors of the brain and its membranes are included in the term intracranial tumors. Which two tumor types are the most frequently seen central nervous system (CNS) tumors in adults? a. Meningioma, oligodendroglioma b. Glioblastoma, metastatic tumors c. Medulloblastoma, metastatic tumors d. Astrocytoma, hemangioma ANS: B

An estimated 69,720 new primary brain tumors are expected to occur in 2013. Brain metastases outnumber primary neoplasms by at least 10 to 1 and are the most common brain tumor in adults. The exact incidence is unknown, but it has been estimated that 100,000 to 170,000 new cases are diagnosed in the United States each year. Glioblastoma multiforme (GBM), a grade IV astrocytoma, is an infiltrative, fast-growing, rapidly recurring cerebral tumor that occurs most frequently in the sixth and seventh decades of life. Glioblastomas represent 17% of all primary brain tumors, and account for about 54% of all gliomas. It is one of the few tumors that is capable of invading both cerebral hemispheres by crossing the midline.

REF: p. 774 15. Mediculous hemostasis is extremely important in neurosurgery. Numerous interventions and

types of materials are used to limit blood loss. Which of the following describes a best practice toward the goal of achieving hemostasis during neurosurgery? a. Gelatin sponge is commonly used to pack burr holes. b. Soft gauze sponges are routinely used to control bleeding around delicate neural tissue. c. Bone wax is commonly applied to oozing surfaces. d. Because gelatin sponge is absorbable, it can be left in the body.

ANS: D

Proper continuous hemostasis is crucial during any neurosurgical procedure. It is particularly important to be familiar with the various methods and types of materials utilized to achieve this goal. Bone wax, not gelatin sponge, is commonly applied to burr holes. Soft gauze is useful to control bleeding along skin edges at the initial incision, before the skull or spinal canal is entered. However, soft gauze sponges should not be used around the delicate neural tissue beneath the skull because they can injure fragile tissue; instead, compressed absorbent patties should be utilized around the spinal cord. For oozing surfaces, absorbable gelatin sponges are preferred. These sponges can be left in the body.

REF: p. 802 16. Brain tumors are either malignant or benign, depending on the cell type. Primary tumors

generally do not resemble the carcinomas and sarcomas found elsewhere in the body and rarely metastasize outside the CNS. Select the tumor that has been identified as an extremely rare and very malignant neoplasm. a. Germinoma

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Teratoma c. Meningioma d. Choriocarcinoma ANS: D

Choriocarcinoma is an extremely rare, very malignant neoplasm. Multiple factors are suspected of playing a role in the pathogenesis of intracranial neoplasms. Early diagnosis simplifies surgical treatment, because increased ICP and severe neurologic changes are not usually present. Meningiomas are usually benign, circumscribed, slow-growing tumors. A teratoma is a congenital tumor containing embryonic elements. It occurs most frequently in children and is likely to arise in or near the ventricular walls. The 5-year survival rate is 73%.

Germinoma is a neoplasm arising from germ cells. Survival with germinomas is much better than with nongerminomatous tumors (teratoma, embryonal cell carcinoma, choriocarcinoma).

REF: p. 775 17. The neurosurgical perioperative nurse is the circulating nurse on a cranial procedure. She is

helping a new surgical resident on his first day with the neurosurgical surgery service. She observes and coaches him carefully as he removes the patient’s hair from the intended incision site with the clippers and then combs the remaining hair away from the incision, holding it back with prepping solution. When the resident asks the scrub person for methylene blue and a sterile cotton-tipped applicator on a wood stick, the nurse intervenes and offers him an indigo carmine surgical skin marker. What was the nurse’s rationale for not using methylene blue as a skin marker? a. Methylene blue produces an inflammatory reaction in CNS tissue. b. Methylene blue markings tend to wash off during the prep. c. Methylene blue will not be able to be seen through the povidone-iodine. d. Methylene blue is not compatible with povidone-iodine.

ANS: A

Many neurosurgeons mark the incision line with a marking pen or a marking solution and wooden stick. If a marking solution is used, indigo carmine, gentian violet, or brilliant green is recommended. Methylene blue should never be present in a neurosurgical operating room (OR) because it produces an inflammatory reaction in CNS tissue.

REF: p. 800 18. A 69-year-old pipe smoker with a history of cardiac disease and atrial rhythm disturbance is

scheduled for a supratentorial craniotomy and is securely positioned in a semi-sitting position.

Intermittent pneumatic compression devices have been placed on both legs. Pulmonary lines have been placed and the nurse has prepared an area for preparation of transesophageal electrocardiography (TEE), if needed. During the procedure, the patient reacted with a decrease in arterial pressure and end-tidal CO2. Precordial “washing machine” sounds emanated from the Doppler. What could be the cause of his deteriorating physiologic status? a. Increased pressure from the intermittent pneumatic compression device. b. Ischemic cerebral vascular occlusion. c. Venous air embolism (VAE). d. Air bubbles in the arterial line.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Increased risk of an air embolism during surgery exists when the patient is in a sitting position and when a venous sinus may be breeched. A precordial Doppler ultrasound or a pulmonary artery catheter may be placed to monitor for an air embolus. A catheter in the right atrium can be used to remove an air embolus in the heart.

REF: p. 798 MULTIPLE RESPONSE 1. Select the statements that are accurate descriptions of the sensory and motor functions of the

brain. (Select all that apply.) a. Another name for the homunculus is the dermatome grid. b. Areas of fine motor and sensory control have more neurons. c. The right motor and sensory cortices control the right side of the body. d. The left motor and sensory cortices control the right side of the body.

ANS: B, D

The homunculus diagrams illustrate how the number of neurons corresponds to the degree of motor and sensory control required. For example, areas that need more fine motor control, such as the fingers and face, have a higher concentration of neurons than other areas. Keep in mind that the left motor and sensory cortices control the right side of the body and vice versa.

Destruction of an area of motor cortex results in loss of voluntary motor function on the corresponding area of the opposite side of the body.

REF: p. 772 2. Most patients will have undergone diagnostic procedures before arriving in the OR.

Radiologic and other diagnostic studies are of great significance to the surgical team for determining a surgical diagnosis and developing a plan for treatment. Magnetic resonance imaging (MRI) is the gold standard imaging scan for the diagnosis of tumors, abscesses, tissue/ligamentous injury, and disk herniation. Which three diagnostic tests of neurologic activity can be performed before surgery and also concurrently during the procedure? (Select all that apply.) a. Stereotactic computed tomography (CT) scan b. Electroencephalogram (EEG) c. Stereotactic MRI d. Ultrasound e. Evoked potentials (EPs) f. Myelogram ANS: B, D, E

EEG is a procedure that records the brain’s continuous electrical activity by means of electrodes placed on the scalp or intraoperatively on the brain. EPs are procedures that record the brain’s electrical response to visual, auditory, and sensory stimuli. Ultrasound is a noninvasive technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. It is often used to assess the blood flow in the carotid artery and the internal and external cranial arteries during surgery.

REF: p. 793

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 3. The perioperative circulating nurse has prepared the OR for a craniotomy for tumor and has

assembled the primary bed base attachments for the head fixation positioning system. She has verified with the surgeon and anesthesia provider that the bed attachment is properly secured before the start of patient positioning and is prepared for positioning and securing the patient’s head with the skull clamp. After the skull pins are secured, the nurse will step back to view the head placement and symmetry, ensuring that (Select all that apply.): a. the pins in the rocker arm are equidistant from the centerline of the patient’s head. b. the single pin in the extension arm is exactly at the centerline. c. the rocker arm is in the “CLOSED” position. d. the pins are at an angle of 90 degrees. e. the necessary pounds of clamping force are applied. f. the pins avoid the areas of the frontal sinus, temporal fossa, blood vessels, and nerves.

ANS: A, B, C, D, E, F

When properly placed, the pins in the rocker arm are equidistant from the centerline of the patient’s head and the single pin in the extension arm is exactly at the centerline. The pins are at an angle of 90 degrees, the necessary pounds of clamping force are applied, and the rocker arm is in the “CLOSED” position. Only properly trained OR staff should be permitted to operate these devices. The nurse must verify that the bed attachment is properly secured before the start of patient positioning. Once the anesthesia provider has determined that the patient is ready for positioning, the designated member of the OR team will pin the patient’s head with the skull clamp. Improper positioning of the skull pins may cause serious injury to the patient. Special attention should be paid to avoiding the areas of the frontal sinus, temporal fossa, blood vessels, and nerves.

REF: p. 799 4. A 29-year-old man is admitted through the ambulatory surgery center for a microdiscectomy,

one of several spinal surgeries performed to relieve pain caused by disk herniations. Select the appropriate criteria required for a patient to be considered a candidate for microdiscectomy as an ambulatory procedure. (Select all that apply.) a. Leg pain more than 2 weeks’ duration with foot numbness b. Ability to tolerate general and/or spinal anesthesia c. MRI confirmation of the nerve root compression level d. Leg pain longer than 6 weeks’ duration e. History and physical verifies candidacy for ambulatory surgery f. Ability to tolerate prone position g. Minimal relief received from prescribed pain medications h. Inability to ambulate without crutches or wheelchair ANS: B, C, D, E, F, G

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Microdiscectomies have the flexibility of being performed either in an ambulatory surgery center or in a hospital OR suite. Ambulatory surgeries are designed for patients who have a nominal health history and pose minimal risk for operative complications. Patients selected for microdiscectomies typically complain of leg pain longer than 6 weeks in duration, and receive minimal relief from prescribed pain medications. An MRI scan confirming the level of nerve root compression as well as a detailed history and physical will determine if the patient is a candidate for surgery. The procedure is typically performed using a general or spinal anesthetic, depending on the needs of the patient. After the anesthesia provider has control of the airway, the patient is positioned prone for maximum operative accessibility.

REF: p. 820 5. Parkinson’s disease is defined as a progressive neurodegenerative disorder of unknown origin

that is characterized by rigidity, tremors, postural instability, and bradykinesia. For those patients who remain responsive to levodopa, but experience a wearing off of the drug’s effects too quickly, or experience severe motor fluctuations, deep brain stimulation (DBS) may be a surgical option. DBS involves the surgical placement of an electrode into the patient’s basal ganglia for (Select all that apply.): a. a continuous drip infusion of levodopa. b. continuous high-frequency electrical stimulation. c. on-demand intermittent high-frequency ultrasound. d. at least an additional 4.6 hours per day of good motor function. e. pain management of uncontrolled tremors. f. permanent curative resolution of mild tremors.

ANS: B, D

DBS involves the surgical placement of an electrode into the patient’s basal ganglia for continuous high-frequency electrical stimulation. A major advantage of this type of procedure is that the stimulation parameters can be customized to each patient to optimize benefits. A study suggests that patients with DBS experience at least an additional 4.6 hours per day of good motor function.

REF: p. 807

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 22: Reconstructive and Aesthetic Plastic Surgery Test Bank MULTIPLE CHOICE 1. The science of plastic and reconstructive surgery, which means to mold or create form and

shape, improves appearance and body image through an understanding of: a. body geometry. b. the anatomy and biology of tissue. c. form and function. d. body image.

ANS: B

Plastic and reconstructive surgery is not limited to a single anatomic or biologic system. It is based on thorough understanding of the anatomy and biology of tissue.

REF: p. 823 2. A 46-year-old woman with an early-stage second primary cancer in her left breast has elected

to have a bilateral mastectomy with saline implants. She has requested that the surgeon also revise a small unsightly scar on her right knee and pierce her ears. While the patient’s breast tumor could be treated with an excisional biopsy, she has decided to have a mastectomy of both breasts, which is considered an appropriate preemptive (preventative) surgery for a woman of her age with two primary cancers of the breast. The saline implant insertion surgery is considered a _______________ procedure, the scar revision is considered a ___________ procedure, and the ear piercing is considered a _______________ procedure. a. reconstructive; reconstructive; reconstructive b. reconstructive; cosmetic; reconstructive c. cosmetic; reconstructive; cosmetic d. reconstructive; cosmetic; cosmetic ANS: D

There are two different subspecialties of plastic surgery. Cosmetic surgery restores or reshapes normal structures of the body, to modify or improve appearance. Reconstructive surgery treats abnormal structures of the body caused by birth defects, developmental problems, disease, tumors, infection, or injury to restore function and correct disfigurement or scarring. Scar revision involves the rearranging or reshaping of an existing scar so that the scar is less noticeable. The simplest form of scar revision is excision of an existing scar and simple resuturing of the wound.

REF: p. 823 3. The perioperative nurse circulating for a skin contracture release of the ear on a 5-year-old

boy transfers 0.25% bupivacaine via syringe to the scrub person’s sterile back table. The scrub person questions why she is not giving him bupivacaine with epinephrine, because there may be bleeding expected at the incision site. The nurse’s reply is based on the fact that: a. epinephrine is contraindicated in areas with limited vascularity, such as the ears. b. the nurse is complying with the surgeon’s standardized order on the preference list. c. epinephrine-induced vasoconstriction may interfere with normal tissue planes. d. pediatric heart rates are higher than adult heart rates, and epinephrine can cause

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock tachycardia.

ANS: A

Use of epinephrine is contraindicated in areas with limited vascularity, such as digits, the penis, nasal tip, and ears.

REF: p. 830 4. The perioperative nurse should verify with the patient that all of the preoperative prescribed

skin preparation regimens ordered by the surgeon have been performed. All body jewelry that pierces the skin should be removed before the skin prep. Select the statement that reflects a true special consideration for skin preparation before facial surgery. a. Use chlorhexidine gluconate (CHG) around the ears and eyes. b. Leave the eyebrows and eyelashes intact to preserve facial appearance and expression. c. Prep the skin graft and donor sites together with the same prep set and drape immediately. d. Isolate rashes, open sores, cuts, or lesions in the prep site with a sterile, clear adhesive patch.

ANS: B

The eyebrows and eyelashes, in particular, are left intact to preserve facial appearance and expression. The surgical site is marked before surgery by the surgeon to designate the correct site and to define landmark areas. Either a povidone-iodine solution, an iodine-alcohol mixture, chlorhexidine gluconate (CHG), or another broad-spectrum agent may be selected for the antimicrobial skin prep. The use of CHG should be avoided around the ears and eyes. It is important to place shields on the eyes and/or eye ointment if prepping the periorbital site or performing an extensive head and neck prep, to place plugs in the ear canals, and prevent pooling of the prep agent.

REF: p. 831 5. During the planning phase of a procedure for liposuction, the perioperative nurse will

assemble and organize supplies and devices, because the procedure may require: a. repositioning one or more times during surgery. b. meticulous accounting of fluid loss and blood replacement. c. the use of implant material. d. patient transfer to an alternating-pressure bed.

ANS: A

Whereas a majority of plastic surgical procedures are performed in the supine position, many also take place with the patient prone or lateral. Liposuction and postbariatric body contouring procedures may also require repositioning one or more times during surgery.

REF: p. 831 6. Skin grafting provides an effective way to cover a wound if vascularity is adequate, infection

is absent, and hemostasis is achieved. Skin from the donor site is detached from its blood supply and placed in the recipient site. The best description of a successful skin graft outcome is: a. the skin is a good color match.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. the recipient site develops a new blood supply from the base of the wound. c. capillary refill returns within 24 hours. d. a split-thickness graft is able to regenerate in an area of full-thickness loss.

ANS: B

Skin from the donor site is detached from its blood supply and placed on the recipient site, where it develops a new blood supply from the base of the wound. Color match, contour, and durability of the graft are all considerations in selection of an appropriate donor area.

REF: p. 838 7. Replantation is an attempt to reattach a completely amputated digit or other body part.

Revascularization is the procedure performed on incomplete amputations, when the part remains attached to the body by skin, artery, vein, or nerve. Good candidates for replantation are those with which of the following amputations? a. Almost any body part of a child b. Proximal portion of the hand at palm level c. Distal to middle foot d. Distal to middle thigh ANS: A

Good candidates for replantation are those with the following amputations: (1) thumb, (2) multiple digits, (3) distal portion of hand at palm level, (4) wrist or forearm, (5) elbow and above the elbow, and (6) almost any body part of a child.

REF: p. 845 8. Microsurgery, a fundamental tool in reconstructive plastic surgery, allows an almost unlimited

choice of reconstructive methods, replacement of lost tissue with similar components, and optimal selection of donor sites with minimal morbidity. Reconstructive microsurgical procedures include replantation of amputated body parts, repair of facial nerves, repair of lacerated nerves and blood vessels, treatment of extensive trauma to extremities and hands, reconstruction following removal of extensive cancers, and female to male transsexual reassignment. Today’s surgeons skilled in microsurgery can successfully anastomose the ends of a vessel or nerve measuring less than: a. 2 mm. b. 1.5 mm. c. 1 mm. d. 0.5 mm.

ANS: C

Today’s surgeons skilled in microsurgery can successfully anastomose the ends of a vessel measuring less than 1 mm in diameter.

REF: p. 845 9. Facial fractures are classified according to a system developed by Rene Le Fort in the early

1900s. A fracture that starts at the nasal bones; crosses the frontal process of the maxilla and lacrimal bones; and extends through the orbital floor, infraorbital rim, and lateral maxillary sinus wall is known as a: a. Le Fort I.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Le Fort II. c. Le Fort III. d. Le Fort IV. ANS: B

Le Fort I, or transverse maxillary, fracture is a horizontal fracture that includes the nasal floor, septum, and teeth. Le Fort II, or pyramidal maxillary, fracture (unilateral or bilateral) often involves the nasal cavity, hard palate, and the orbital rim. Le Fort III, or craniofacial dysjunction, fracture includes fractures of both zygomas and the nose. Like a mandibular fracture, a maxillary fracture also produces malocclusion. In addition, depending on the severity of the fracture, it may produce considerable deformity of the middle of the face, usually perceived as a flattening or smashed-in appearance. Closed reduction with intermaxillary fixation suffices for treatment of Le Fort I and some Le Fort II fractures.

REF: p. 849 10. A 46-year-old woman had a scar revision of her knee. The knee scar, before revision, was an

8-cm linear, thin scar that extended obliquely across the anterior portion of her knee. The tension of the scar tissue met resistance when she would bend her knee. The surgeon opted to remove the scar with a procedure to break up the linear scar and rearrange the tissue direction to form a natural line. The proper name of this tissue transfer scar revision is the: a. scar lysis. b. epidermolysis with remodeling. c. scarplasty. d. Z-plasty.

ANS: D

Z-plasty is the most widely used method of scar revision. It breaks up linear scars, rearranging them so that the central limb of the Z lies in the same direction as a natural skin line. Scars that are parallel to skin lines are less noticeable than scars that are perpendicular to skin lines.

A contracted scar line can also be lengthened with a Z-plasty.

REF: p. 851 11. A broad range of implant materials are used in plastic and reconstructive surgery. Select the

implant that represents a biologic composition of a surgical implant. a. Autologous human tissue b. Medical-grade sterile silicone c. Gold d. Polypropylene ANS: A

The range of materials available for implantation and augmentation in the specialty of plastic and reconstructive surgery has benefited from ongoing research. Biologic materials (autogenous grafts) are preferred when available. Autologous human tissue successfully used includes fat, solid dermis, and collagen. A cellular collagen (AlloDerm regenerative tissue matrix) is a material that allows for a strong intact repair in breast reconstruction postmastectomy procedures by providing soft tissue reinforcement or replacement. Human cadavers are used as a source for AlloDerm.

REF: p. 829

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

12. One of the most popular lasers used in plastic and reconstructive surgery is attracted to the

water in the skin cells and ablates the cells at a predetermined depth. Collagen material beneath the skin surface is also heated, resulting in smoother and slightly tighter skin. Several lasers are attracted to areas of darker pigmentation. This treatment has virtually replaced dermabrasion, because of its consistency in terms of depth of penetration and also because this technique is less dependent on user technique or skill. Select the laser modality that would be the best option for ablation or removal of a pigmented red tattoo. a. CO2 laser b. Erbium:yttrium-aluminum-garnet (Er:YAG) laser c. Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser d. Excimer laser ANS: C

The Nd:YAG laser is suited to ablate or remove benign pigmented lesions and red tattoos.

Common uses for lasers in plastic surgery include exfoliation, treatment of vascular malformations, removal of hair and tattoos, and tightening of collagen fibers in aging skin.

Candela dye, diode, and Q-Switch lasers are suited for pigmented benign lesions, tattoos, and hemangiomas.

REF: p. 856 13. Dermatomes are used for harvesting split-thickness skin grafts (STSGs) from donor sites. The

perioperative nurse, who is preparing for a procedure where STSGs will be taken to cover several large burn areas, will need to have available: a. sterile petroleum jelly and sterile impregnated gauze sheets. b. sterile mineral oil, tongue blades, and a mesher dermatome. c. sterile mineral oil and carriers. d. a nitrogen tank, sterile gauze fluffs, and antibiotic ointment.

ANS: B

A plastic local procedure instrument set is required, with the addition of a dermatome of choice, a skin mesher, sterile tongue blades, mineral oil, and a sterile marking pen.

REF: p. 839 14. A 6-year-old girl’s clothes caught fire during a camping trip when she fell into the campfire.

She is admitted with full-thickness burns involving both lower legs, circumferentially, excluding her feet, over less than 2% of her body surface area (BSA) and partial-thickness burns over less than 15% of her BSA. Based on the American Burn Association and the “Rule of Nines” classifications, the patient’s burns would be classified as ______________ with a burn surface area percentage of approximately ______________. a. minor; 17% b. moderate; 17% c. minor; 9% d. major; 18% ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The percentage of BSA system of the American Burn Association uses the following burn classification: minor burns: full-thickness burns over less than 2% of BSA; partial-thickness burns over less than 15% of BSA. Both of the patient’s lower legs were burned circumferentially, giving her a score of approximately 9% for the sum of both lower legs.

Moderate burns: full-thickness burns over 2% to 10% of BSA; partial-thickness burns over less than 15% to 25% of BSA. Major burns: full-thickness burns over 10% or more of BSA; partial-thickness burns over 25% or more of BSA, including any burns to the face, head, hands, feet, or perineum; inhalation and electrical burns; or burns complicated by trauma or other disease processes.

REF: p. 836 15. A burn patient is transferred to the operating room (OR) from the burn unit for debridement of

the partial-thickness burn areas and a dressing change under anesthesia. What is the most important preparation the perioperative nurse should perform before the patient arrives in the OR? a. Procure the allograft skin from the freezer and begin the thaw process b. Procure a basic plastic instrument set plus a knife dermatome and sterile mineral oil c. Prewarm the OR to above the normal ambient temperature and humidity d. Ensure that silver nitrate is available for dressing wounds.

ANS: C

Because patients who have sustained burns are vulnerable to hypothermia from the loss of BSA, the perioperative nurse should ensure the temperature and humidity in the OR are increased and exposure is limited only to the areas related to the planned surgical event.

Throughout the procedure, the temperature in the OR is constantly monitored to prevent hypothermia. The perioperative nurse will need to collaborate with the anesthesia provider in determining fluid replacement requirements.

REF: p. 836 16. A 28-year-old firefighter sustained significant full-thickness burns when he fell through the

roof of a burning building while fighting an explosive fire. Which of the following best describes the surgical treatments he will most likely need before he is discharged from the burn center to home? a. Debridement and monitoring of full-thickness skin regeneration b. Debridement, allograft placement during initial healing, and later split-thickness (ST) and full-thickness (FT) skin grafting c. Allograft and xenograft placement as temporary dressings until secondary granulation begins d. Tangential excision of the burn wound with antibiotic-soaked dressings ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Full-thickness burns may require debridement of necrotic tissue (eschar) before healing can occur by skin regeneration or grafting. An allograft may be used to cover the burned area during the initial healing process. A xenograft may also be used for covering the burned area.

An alternative method is tangential excision of the burn wound, which is performed with a knife dermatome. This type of excision usually extends only to the bleeding subcutaneous fat, rather than to fascia. Dressings saturated with the topical antimicrobial agent of choice are applied. Although skin grafting may be done at the time of wound debridement, it is usually performed several days later, particularly in burns that are extensive.

REF: p. 835 17. When coverage for a defect cannot be achieved through skin grafting, plastic surgeons rely on

other techniques to replace tissue. After mastectomy, reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap is one of several options for nonsynthetic prosthetic reconstruction. Another descriptive term for the TRAM flap is the: a. pedicle-based flap. b. free flap. c. composite flap. d. rotated tunneled flap.

ANS: A

Breast reconstruction options include alloplastic (artificial materials such as breast implants), autogenous (flaps), or a combination of both. Flaps may be pedicle-based or free flaps, requiring microsurgical techniques for their reconstruction. TRAM flaps are pedicle-based flaps used for breast reconstruction. The rectus muscle is the broad, wide abdominal muscle that reaches from under the ribs to the pubis, and either one or both sides of the muscle may be used for reconstruction. The blood supply (superior epigastric artery and vein) is carried within the muscle pedicle.

REF: p. 841 18. In addition to the individualized nursing diagnoses that apply to surgical patients, the patient

scheduled for plastic or reconstructive surgery can typically be expected to have which nursing diagnosis? a. Activity intolerance related to pain b. Disturbed body image related to congenital or acquired defect or developmental abnormality c. Risk for perioperative positioning injury related to improper body alignment d. Risk for impaired skin integrity related to length of surgical intervention ANS: B

Nursing diagnoses related to the care of the patient undergoing plastic and reconstructive surgery might include the following: risk for infection related to operative/invasive plastic/reconstructive procedure, disturbed body image related to congenital or acquired defect or developmental abnormality, risk for ineffective tissue perfusion related to surgical intervention, impaired comfort related to surgical/invasive procedure, deficient knowledge related to perioperative process, and anxiety related to surgical interventions or outcomes.

REF: p. 825

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 19. There are approximately 1 million reported cases of skin cancer per year with the majority

being the highly curable basal or squamous cell cancers. Not as common is the most serious skin cancer, malignant melanoma. Select the individual who is at the highest risk for skin cancer. a. An African American outdoor sportsman and airline pilot b. A fair-complexioned surfer and beach lifeguard who wears sunblock-protective clothing c. A fair-complexioned person testing positive for exposure to human papillomavirus d. A dark-complexioned person testing positive for human immunodeficiency virus ANS: C

A fair-complexioned person with exposure to human papillomavirus represents a person with two risk factors. Other risk factors include excessive exposure to ultraviolet radiation from the sun; occupational exposure to coal tar, pitch, creosote, arsenic compounds, and radium; and human immunodeficiency virus. Skin cancer is negligible in African Americans because of heavy skin pigmentation.

REF: p. 834 20. The three most common skin cancers are basal cell, squamous cell, and melanoma.

Treated early, skin cancers such as squamous cell and basal cell carcinomas may be cured by simple excision and closure (with pathologic diagnosis to ensure disease-free margins).

Melanoma is treated much more aggressively because of its high mortality. The A-B-C-Ds of the warning signs for skin cancer stand for: a. acute, borderline, color, dysplastic. b. asymmetry, blanching, cohesion, depth. c. aplastic, bilateral, chronic, dysplastic. d. asymmetry, border, color, diameter.

ANS: D

Any unusual skin conditions, especially a change in the size or color of a mole or other darkly pigmented growth or spot, should be suspicious of skin cancer. The mnemonic A-B-C-D stands for the following: A: Asymmetry: One-half of the lesion looks different from the other side.

B: Border irregularity: Instead of a smooth edge, the border is ragged or irregular.

C: Color: The color is usually irregular; may have a number of different hues and colors.

D: Diameter: Lesions larger than 6 mm have a greater chance of being a melanoma.

REF: p. 834 21. Mohs’ surgery is a specialized excision used to treat basal and squamous cell skin cancers.

Select the statement about Mohs’ surgery that best reflects the process, procedure, and outcome goal. a. Mohs’ surgery is diagnostic, an ambulatory procedure, and a definitive treatment. b. Lesions are mapped, excised, and examined by frozen section until clear margins are found. c. The procedure can be accomplished quickly while preserving the surrounding healthy tissue. d. The segments are excised and microscopically examined, and the defect is closed with a drain.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: B

The procedure involves excising the lesion layer by layer and examining each layer under the microscope until all the abnormal tissue is removed. Mohs’ surgery is usually completed on an ambulatory basis with the patient administered a local anesthetic. The procedure can be very time-consuming to accomplish, but it typically results in the preservation of the surrounding healthy tissue. Because the procedure is lengthy, patient preparation and comfort are essential to facilitate cooperation during the procedure. A horizontal layer of tissue is removed and divided into sections that are color-coded with dyes. A map of the surgical site is then drawn.

Frozen sections are immediately prepared and examined microscopically for any remaining tumor. If a tumor is found, the location(s) are noted on the map, and another layer of tissue is resected. The procedure is repeated as many times as necessary to completely remove the tumor.

REF: p. 832 22. A variety of implantable devices are used in aesthetic and reconstructive plastic surgery

procedures. Tracking of these devices is critical to patient safety. Institutions must report any incident of death or serious injury relating to the use of a medical device. What regulatory agency, commission, or act mandates this process when medical devices fail or cause injury? a. The Joint Commission (TJC), agency for sentinel events b. Original Equipment Manufacturer Device Tracking Commission c. Food and Drug Administration (FDA) Device Failure and Recall Act d. Safe Medical Device Act ANS: D

Under the Safe Medical Device Act, institutions must also report any incident of death or serious injury relating to the use of a medical device. The FDA has classified and identified more than 1700 different devices that must be reported if the device is suspected of causing serious injury or death to an individual. Nurses should work within their institutional policies to report these incidents.

REF: p. 830 23. A 52-year-old woman with a left mastectomy followed by a TRAM flap reconstruction was

beginning to emerge from anesthesia after her procedure. The perioperative nurse gently moved her arms from the abducted position on the armboards in preparation for her transfer to her postoperative bed and admission to the postanesthesia care unit (PACU). What risk reduction maneuver did the nurse employ to the patient’s bed before transferring her? a. Flattened the bed to a horizontal plane with slight reverse Trendelenburg to prevent headaches and support her airway b. Raised the head of the bead to low Fowler flex position to reduce the stretching on the abdominal donor graft wound site c. Raised the foot of the bed to minimize deep vein thrombosis formation d. Slid a wedge under the top of the mattress on the left side to prevent dependent edema in the graft site ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The OR bed and postoperative bed are flexed to minimize tension on the abdominal TRAM donor/graft wound site. The patient is positioned supine with arms extended on armboards during the surgery. Positioning the patient for this procedure is particularly difficult because of the need to promote closure of the abdominal wound, support circulation to the flap, and protect the patient from injury.

REF: p. 844 24. A 49-year-old post–bariatric surgery patient is scheduled for a VASER®-assisted

LipoSelection with tumescent infiltration. The tumescent is a solution of lactated Ringer’s, lidocaine, and epinephrine. The perioperative nurse is aware that using more than 70 mL/kg of wetting solution for infiltration can lead to fluid overload. Select the most appropriate nursing action related to minimizing the risk of tumescent solution overload or disproportion to lipoaspirate. a. The nurse will monitor the patient for syncope, cough, and bounding pulse. b. The nurse will keep the tumescent solution cool and monitor fluid volumes. c. The nurse will communicate and verify with the surgeon and/or anesthesia provider the total lipoaspirate and volume of wetting solution used. d. The nurse will titrate the flow rate of the tumescent solution in coordination with aspirate outflow.

ANS: C

For safety issues, the nurse needs to communicate and verify with the surgeon the total lipoaspirate and volume of wetting solution used. The surgeon typically injects a medicated solution into the fatty areas before removal because of concerns about large fluid volume shifts and blood loss after lipectomy. Fluid overload may present as increased blood pressure, jugular vein distention, bounding pulses, cough, dyspnea, lung crackles, and pulmonary edema.

REF: p. 859

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 23: Thoracic Surgery Test Bank MULTIPLE CHOICE 1. The thoracic outlet is a junction bound anteriorly by the manubrium, anterolaterally by the

first ribs, and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space. The great vessels of the head, neck, and arm pass through this space. Which syndrome is caused by the compression of these structures? a. Brachial plexus palsy b. Vertebral spondylolisthesis c. Thoracic outlet syndrome d. Thoracic plexus compression ANS: C

The thoracic outlet is a junction bound anteriorly by the manubrium, anterolaterally by the first ribs, and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space. The great vessels of the head, neck, and arm pass through this space. Compression of these structures may cause thoracic outlet syndrome.

REF: p. 869 2. The nerves of the lungs are a part of the autonomic nervous system. Which structures are

constricted and relaxed by their influence? a. The bronchi and the blood vessels b. The alveoli and the pulmonary vein c. The pulmonary artery and vein d. The bronchi and bronchioles ANS: A

The nerves of the lungs are a part of the autonomic nervous system. They regulate constriction and relaxation of the bronchi and of the blood vessels within the lungs.

REF: p. 870 3. Inspiration normally takes place when the intrathoracic pressure is slightly below atmospheric

pressure and when a partial vacuum exists between the parietal and visceral pleural (intrathoracic) surfaces. As the muscles of inspiration contract to enlarge the chest cage, which action by the lungs occurs to facilitate air intake? a. The lungs recoil and expand to draw air into them. b. The lungs are passive and follow the diaphragm and chest wall. c. The lungs produce a pressure gradient that suctions air. d. The alveolar sacs expand when triggered by neural triggers in all 10 lung segments.

ANS: B

As the muscles of inspiration contract to enlarge the chest cage, the lungs passively follow the diaphragm and chest wall because of decreased intrathoracic pressure. The acts of inspiration and expiration are the result of air moving in and out of the lung, causing pressure to equalize with that of the atmosphere at the end of expiration.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 871 4. As the perioperative nurse gathers information that is important to planning patient care, he or

she should inquire about a patient’s smoking history (including the use of cigars, pipes, tobacco, or controlled substances) and any exposure to secondhand smoke within the home and/or workplace and reinforce the need to abstain following surgery. Patients might be sensitive about smoking history because of the assumed relationship between smoking and lung disease. Select the best approach the nurse could use in assessing a patient’s smoking history. a. The nurse should begin preparing the patient for nicotine withdrawal. b. The nurse should avoid making assumptions about smoking and a cancer diagnosis. c. The nurse should note packs/day consumption to alert the surgeon to write postoperative orders for medication. d. The nurse should phrase questions so as not to suggest guilt about smoking behaviors.

ANS: D

The nurse should phrase questions in a way that will not result in guilt about smoking habits or assumptions that the diagnosed condition is associated with smoking. The nurse should also assess the patient’s pain tolerance to determine necessary teaching or tools that will assist in achieving positive postoperative outcomes.

REF: p. 872 5. After reviewing the laboratory results and assessing the patient, the perioperative nurse

determines that the patient’s nursing diagnosis is impaired gas exchange related to surgical intervention. Select the appropriate nursing intervention that is related to assisting the patient to experience adequate gas exchange during the surgical procedure. a. Decrease surgical time by anticipating needs of the patient and surgical team b. Collaborate in positioning the patient to provide access to the endotracheal tube, enable efficient ventilatory function, and prevent injury c. Obtain chest X-ray films for the intraoperative period d. Consult with the surgeon, requesting an order to repeat the laboratory test ANS: B

The nurse should collaborate in positioning the patient to provide access to the endotracheal tube, enable efficient ventilatory function, and prevent injury. The nurse should verify that a double-lumen endotracheal tube with a soft, inflatable cuff is available for the anesthesia provider. The nurse should collaborate in obtaining equipment and monitoring arterial blood gases (ABGs) and document ABG results. The nurse should assist with patient preparation for hemodynamic monitoring: electrocardiogram (ECG), CO2 analyzer, pulse oximeter, arterial pressure line, and central venous pressure line. The nurse should collaborate with the anesthesia provider in evaluating results provided by these monitoring devices during the procedure.

REF: p. 873

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 6. Patients having thoracic surgery share a common nursing diagnosis of risk for impaired skin

integrity related to surgical positioning, length of surgical intervention, or use of chemical antimicrobial agents on the skin. The type of position used in thoracic surgery is determined by the operative procedure planned. In addition to placing the patient in appropriate body alignment, what other interventions can ensure that the patient’s skin integrity is maintained? a. Ensure adequate padding and safe transfer b. Check pulses and skin condition immediately after positioning c. Adjust patient position during the procedure to ensure tissue perfusion d. Document skin integrity and conditions postoperatively ANS: A

Adequate padding and safe transfer should be implemented to prevent pressure injury.

The nurse should apply principles of positioning for efficient circulatory function for lateral or supine position during the procedure and pad and protect vulnerable neurovascular bundles and dependent pressure areas. The nurse should position the patient in the best possible body alignment to allow visualization of the operative field. The nurse should observe and document skin integrity and condition postoperatively and compare with preoperative status.

REF: p. 873 7. Of all the equipment, tools, and studies available during the patient’s preoperative diagnostic

phase, which exam is the most indispensable diagnostic tool to outline thoracic lesions and define space-occupying nature and shape? a. Virtual bronchoscopy b. Ultrasound c. Chest X-ray d. Computed tomography (CT) scan ANS: C

The chest X-ray film remains an indispensable diagnostic tool and is needed in the operating room (OR). This film outlines the lesion, if any is present, and defines its shape and spaceoccupying nature (e.g., tracheal shift). The presence of air in the hilar region, pleural effusion, or atelectasis may also be confirmed by radiologic evidence.

REF: p. 872 8. Direct visualization of the mucosa of the trachea, the main bronchi and their openings, and

most of the segmental bronchi may also include the removal of material for microscopic study and is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing, hemoptysis, obstruction, and abnormal roentgenographic changes. What diagnostic modality has been described? a. Standard bronchoscopy b. Flexible panendoscopy c. Rigid pulmonary investigation d. Video bronchogram ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Standard bronchoscopy is the direct visualization of the mucosa of the trachea, the main bronchi and their openings, and most of the segmental bronchi. It also includes removal of material for microscopic study if necessary. Bronchoscopy is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing, hemoptysis, obstruction, and abnormal roentgenographic changes.

REF: p. 880 9. Thoracotomy can be performed with the patient in one of three common positions: lateral,

semilateral, and supine. While the supine position is used for the median sternotomy approach, which of the lateral positions is used for an anterolateral approach? a. Semilateral b. Lateral c. Prone d. Lateral decubitus ANS: A

The type of position used in thoracic surgery is determined by the operative procedure planned. Thoracotomy can be performed with the patient in one of three common positions: (1) lateral for the posterolateral approach, (2) semilateral for the anterolateral approach, and (3) supine for the median sternotomy approach.

REF: p. 873 10. What is the ideal position for bronchoscopy? a. Supine b. Left semilateral c. Supine with a shoulder roll d. Semi-Fowler with neck extended ANS: C

Bronchoscopy is usually performed in the supine position, commonly with a shoulder roll.

REF: p. 873 11. A 46-year-old man with early-stage lung cancer was listening to his surgeon describe the

surgical plan in preparation for signing the informed consent. The surgeon described a procedure that would be done before the thoracoscopic lung surgery. The surgeon described an examination of the middle chest lymph nodes and the area below where the bronchi branch into the right and left lungs, and possibly taking biopsies of suspicious tissue. The procedure uses a hollow lighted tube with fiberoptic light-carrying fibers. Which diagnostic procedure will precede the patient’s thoracoscopic lung surgery? a. Laparoscopy b. Mediastinoscopy c. Bronchoscopy d. Panendoscopy ANS: B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Mediastinoscopy is the direct visualization and possible biopsy of lymph nodes or tumors at the tracheobronchial junction, under the carina of the trachea, or on the upper lobe bronchi or subdivisions. Mediastinoscopy may precede an exploratory thoracotomy in known cases of lung carcinoma or may be completed to assist in accurately staging the patient’s lymph node status. The mediastinoscope is a hollow tube with a fiberoptic light carrier. A fiberoptic light source with a light-intensity dial provides power and control of illumination.

REF: p. 882 12. Video-assisted thoracic surgery (VATS) is a minimally invasive operative technique that has

evolved over the past decade. It uses an endoscopic approach to visualize the thoracic cavity for diagnosis of pleural disease or treatment of pleural and lung conditions. In the adult, the surgeon creates a 2- to 3-cm incision between the ________ intercostal spaces for insertion of the 10- or 12-mm trocar. The trocar sites can also be used for insertion of a ____________. a. fourth and sixth; robotic EndoWrist grasper b. sixth and eighth; chest tube c. fifth and seventh; zero-degree scope d. sixth and eighth; video camera ANS: C

The surgeon creates a 2- to 3-cm incision between the fifth and seventh intercostal spaces for insertion of the 10- or 12-mm trocar. The zero-degree telescope is inserted to view the site so that the approach can be determined. After the selected procedure, the surgeon inserts a chest tube through one of the surgical puncture sites and secures it to the skin. Trocar sites are closed, and small dressings or adhesive skin tapes are applied.

REF: p. 883 13. Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved

spontaneous pneumothorax. The endpoint goal of a pleurodesis is to: a. prevent accumulation of pleuritic secretions. b. bond the parietal pleura to the lung. c. achieve permanent pneumothorax. d. cause adherence of the pleural layers.

ANS: D

Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved Ttype spontaneous pneumothorax. A variety of chemical agents are used to cause adherence of the pleural layers. Adherence of the pleural layers is thought to prevent the accumulation of pleural fluid in the case of pleural effusion and to prevent subsequent pneumothoraces.

REF: p. 883 14. During an endoscopic thoracic sympathectomy for hyperhidrosis, what action by the

anesthesia provider ensures exposure and minimizes damage to the lung? a. Positions the patient in the anterolateral position with an expandable axillary roll b. Decreases ventilatory pressure to decrease lung expansion during dissection c. Deflates the lung on recommendation of the surgeon during dissection and resection d. Decreases positive end-expiratory pressure (PEEP) until resection is complete

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

The anesthesia care provider deflates the patient’s lung as directed by the surgeon. Video monitors are placed on each side of the patient to allow the surgeon an unobstructed view from either side, because the procedure is performed bilaterally.

REF: p. 884 15. An example of a true statement about tumor, node, metastasis (TNM) and staging diagnostic

classification for lung cancer is: a. the staging system is based on the TNM findings. b. the TNM system is based on the staging classification. c. nodal involvement refers to a second primary lung cancer tumor. d. a patient with T1, N0, M0 has a benign tumor.

ANS: A

Staging is based on TNM findings. According to the TNM system, lung cancer has the following three stages: Stage I disease includes tumors classified as T1 with or without metastasis to the lymph node in the ipsilateral hilar region. Stage II disease includes those tumors classified as T2, with metastasis only to the ipsilateral hilar lymph nodes. Stage III includes all tumors more extensive than T2 or any tumor with metastasis to the lymph nodes in the mediastinum with distant metastasis.

REF: pp. 886-887 16. A patient’s mediastinal node biopsies were sent for immediate frozen section and revealed

metastasis of the primary tumor of the left upper lobe to the ipsilateral mediastinal nodes. The patient’s TNM and staging classification is: a. Stage II due to the TNM subset of T1, N1, M0. b. Stage I due to the TNM subset of T1, N0, M0. c. Stage IV due to the TNM subset of T4, N2, M1. d. Stage IA due to the TNM subset of T1, N1, M1.

ANS: C

T4: A tumor of any size that invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina; or presence of malignant pleural or pericardial effusion; or satellite tumor nodules within the ipsilateral primary tumor lobe of the lung. N2: Metastasis to ipsilateral mediastinal lymph nodes and subcarinal lymph nodes. M1: Distant metastasis is present. Stage IV: Any T, any N, and M1. Patients with lung cancer may have specific treatment based on their TNM characteristics.

REF: p. 887 17. Lung volume reduction surgery (LVRS) is an alternative surgical treatment for patients with

which pulmonary condition? a. Chronic pulmonary asthma with oxygen needed to keep saturation at 90% b. Acute unilateral pulmonary emphysema c. Severe bilateral heterogeneous or homogeneous emphysema d. Unsuccessful or failed laser surgery for giant lung bulla ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The National Emphysema Treatment Trial (NETT) suggests the following criteria as patient eligibility for LVRS: high-resolution CT evidence of moderate to severe bilateral heterogeneous emphysema or moderate to severe bilateral homogeneous emphysema; no previous laser surgery or LVRS; and no giant bulla. LVRS is an alternative surgical treatment for patients with chronic pulmonary emphysema.

REF: p. 892 18. A 59-year-old retired roofer with mesothelioma is scheduled for a left pleurodesis for

malignant pleural effusion and unresolved spontaneous pneumothorax. The perioperative nurse responsible for the thoracic surgery service has consulted with the surgeon to determine which agent will be used. She has an unsterile product that has been typically used in the past, but sterile processing informs her that they do not have the capacity to sterilize this agent. She also notes that the OR does not have a policy or guidelines for the administration of chemotherapeutic antineoplastic agents or safety training and a spill kit. Based on these conditions, which agent will the surgeon and nurse select for the patient procedure? a. Silver nitrate b. Bleomycin c. Talc powder d. Cyclines ANS: A

The perioperative nurse should consult with the surgeon before the procedure to determine the agent used. Silver nitrate coagulates cellular protein to form pleural eschar. Talc stimulates mesothelial cells to coordinate an inflammatory response. Facial talc is unsterile, contains asbestos, and requires stringent sterilization technique. Commercially available sterile talc is preferable. Bleomycin is an antineoplastic requiring special handling to reduce personal exposure. Cyclines indirectly stimulate pleural macrophages, activating pleural mesothelial cells.

REF: p. 883 19. The indications for single-lung transplantation (SLT) include restrictive lung disease,

emphysema, pulmonary hypertension, and other nonseptic end-stage pulmonary diseases, while the indications for double-lung transplantation (DLT) includes patients with: a. bilateral early-stage sarcoma without systemic disease. b. bilateral chronic infection causing end-stage renal failure. c. cystic fibrosis in end-stage pulmonary failure. d. bilateral disease, recent ex-smoker with a suitable living-related donor.

ANS: C

DLT is indicated for patients with cystic fibrosis or patients with a chronic infection in endstage pulmonary failure. Developments in SLT include donor contribution from living relatives for patients who have chronic disease and a high risk for death while waiting on the donor transplantation list. Contraindications for transplantation include history of carcinoma or sarcoma, significant renal dysfunction, or cigarette smoking within 3 or 4 months.

REF: p. 896

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 20. An experienced perioperative nurse was called to the surgical intensive care unit (ICU) to

assist the thoracic surgery fellow with a thoracostomy (chest tube reinsertion) on a postoperative thoracotomy patient who sustained a pneumothorax on removal of his chest tube. Recognizing this as a teaching opportunity with several new graduate nurses and a medical student, the nurse reviewed several risk reduction strategies related to chest tube insertion. She positioned the opened sterile insertion tray near the surgeon’s dominant hand.

Which of the chest tube insertion risk reduction strategies should be her next priority? a. Prevent contamination of the bed and fluid leakage b. Provide the patient verbal and physical comfort measures c. Employ standard precautions d. Avoid performing multiple procedures at the same time ANS: B

The thoracostomy may not take place in an OR setting. The procedure is usually done with monitored anesthesia care and local anesthesia. A local anesthesia set, including syringes, needles, and an anesthetic agent of choice for local injection, is needed. The minor instrument set is used, in addition to disposable chest catheters, water-seal drainage system, two aspirating needles, and culture tubes. The patient is placed in a lateral or sitting position.

Despite the administration of local anesthetic, thoracostomy can be uncomfortable for the patient. Administration of intravenous (IV) narcotic agents at the time of the procedure may help prevent pain during performance of the procedure. The perioperative nurse should provide explanations and emotional support to the patient during the procedure.

REF: pp. 895-896 21. After successful reinsertion of the patient’s chest tube, the nurse conducted a debriefing

session with the new graduate nurses and medical student and asked several reflective questions about the follow-up care of the patient and chest tube. What would be an appropriate question to ask the new nurses and student about follow-up care? a. How often should the chest tube be stripped? b. How high should the chest drainage system be hung above the patient’s waist? c. Why do we check alignment of the patient’s trachea? d. Who is authorized to remove the chest tube?

ANS: C

Additional management strategies include the following: checking alignment of the patient’s trachea; keeping the drainage system lower than the patient’s chest; keeping the chest tube as straight as possible, avoiding kinks and dependent loops; and not “stripping” the chest tube.

REF: p. 877 22. A 53-year-old male smoker with hemoptysis and dyspnea had an outpatient bronchoscopy. His

oxygen saturation remains below 90% on 2 L of oxygen. He is very concerned about the results of the biopsies and possible diagnosis. The pulmonologist has written an order for home oxygen to manage his dyspnea. The nurse is preparing the patient and his wife for discharge and reviewing specific instructions related to his bronchoscopy and home oxygen therapy. What does the nurse consider the most important aspect of education for him and his family? a. Stress the importance of not smoking or allowing others to smoke near the patient because of the possibility of combustion, fire, or explosion b. Demonstrate checking the gag reflex to determine when normal safe swallowing

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock returns, and food and fluids can be resumed c. Make the patient and family aware of the length of time until biopsy results will be available and the method used to obtain those results d. Remind the patient of the need to rest for 2 to 3 days after the procedure ANS: A

Never smoke while using oxygen, and warn visitors not to smoke near you. Oxygen does not burn or explode, but materials will burn faster in the presence of oxygen. Do not use flammable materials when using oxygen. Keep a fire extinguisher close by, and let your fire department know that you have oxygen in your home. Stay at least 5 feet away from gas stoves, candles, lighted fireplaces, or other heat sources.

REF: p. 879 23. A 38-year-old, healthy, nonsmoking woman with a suspicious lesion on the lateral margin of

her right middle lobe is having a thorascopic lung biopsy and has been selected and prepared for the ambulatory surgery center’s fast track recovery and discharge program. The plan is that she will be discharged on postoperative day 2 with a chest tube and portable drainage system.

The perioperative nurse has arrived to meet her, conduct the preoperative nursing assessment, and begin her discharge education. After asking if the patient has any questions or concerns, the nurse provides her with the important risk reduction strategies based on her procedure, condition, and postoperative expectations. What will be the primary focus of the nurse’s teaching? a. Diet, activity, pain management, and pulmonary hygiene b. Wound care, coughing and deep breathing, and importance of fluid intake c. Stripping the chest tube, dressing changes, and home medication administration d. Pain management, respiratory treatments, and indications for emergency care ANS: D

Essential teaching points to cover with the patient and caregiver include pain control, respiratory treatments (to include deep breathing and coughing as ordered by the surgeon), and activity. Because the chest wall has been entered, the nurse must emphasize the importance of seeking emergency care if the patient experiences difficulty breathing, sudden chest pain, palpitations, uncontrollable cough, or bloody sputum.

REF: p. 879

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 24: Vascular Surgery Test Bank MULTIPLE CHOICE 1. What properties enable arteries to compensate for changes in blood pressure and blood

volume? a. Regeneration and thick muscularis b. Dilatation and absence of valves c. Contraction and constriction d. Elasticity and distensibility ANS: D

The properties of elasticity and distensibility enable arteries to compensate for changes in blood pressure and volume. Because of the thicker muscle layer, severed arteries are capable of contracting and constricting enough to stop hemorrhage.

REF: p. 899 2. Identify the venous structure that prevents blood backflow. a. Semilunar intimal folds b. Coarctation segments c. Pressure receptors d. Venules ANS: A

Another difference is the presence of semilunar intimal folds, or valves, in veins that prevent backflow.

REF: p. 899 3. Patients with acute arterial insufficiency with occlusion usually present with the onset of the

six P’s: sudden severe pain, pulselessness, paresthesia, paralysis, pallor, and poikilothermia (coolness) of an extremity. This occlusion can be the result of which condition? a. Atrial tachycardia b. Rupture of an unstable atherosclerotic plaque c. Asystole d. Hypothermia ANS: B

Arterial insufficiency may result from an acute occlusion, as in embolic disease, or from the rupture of an unstable atherosclerotic plaque, causing acute thrombosis of the vessel. Emboli usually arise from the heart as a result of atrial fibrillation but may occasionally result from a myocardial infarction (MI), where a clot forms on the endocardium (the lining of the heart) in an area of muscle damage. Atherosclerotic plaque can also break loose from other areas and result in an acute arterial blockage.

REF: p. 903

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. Patients with chronic venous insufficiency (CVI) are not typically treated surgically as often

as patients with arterial disease because: a. CVI is not life-threatening or limb-threatening. b. venous surgery contributes to thromboembolism. c. surgical interventions for venous valves have not been refined. d. surgery is never successful.

ANS: A

Patients with CVI have not been treated surgically as often as patients with arterial disease for several reasons. CVI is generally not life-threatening or limb-threatening.

REF: pp. 904, 906 5. Which statement regarding risk factors for developing vascular disease is true? a. Cigarette smoking is more of a risk factor for lung disease than vascular disease. b. Advanced age, male gender, and family history are established risk factors for

atherosclerosis. c. A sedentary lifestyle can contribute to developing diabetes if one has

atherosclerosis. d. Arteriosclerosis is a natural part of the aging process.

ANS: D

Arteriosclerosis is a natural part of the aging process and occurs when the walls of the arterial vasculature undergo changes such as increased thickness and hardening, reducing the elasticity of the arteries. Risk factors for atherosclerosis are hypercholesterolemia, cigarette smoking, hypertension, and diabetes mellitus; relative risk factors include advanced age, male gender, hypertriglyceridemia, hyperhomocysteinemia, sedentary lifestyle, and family history.

REF: p. 903 6. While arteriosclerosis is a natural part of the aging process and occurs when the walls of the

arterial vasculature undergo changes such as increased thickness and hardening, reducing the elasticity of the arteries, certain risk factors for arteriosclerosis are modifiable by the individual. Select the modifiable risk factors that could minimize the potential for acute or chronic vascular insufficiency. a. Past surgical history and hypercholesterolemia b. Cigarette smoking and sedentary lifestyle c. Hypertension and diabetes d. Hyperhomocysteinemia and hypertriglyceridemia ANS: B

Cigarette smoking and sedentary lifestyle are modifiable risk factors, because the individual can improve his/her chances of avoiding acute and chronic vascular insufficiency by quitting cigarette smoking and becoming more physically active. Risk factors for atherosclerosis include hypercholesterolemia, cigarette smoking, hypertension, and diabetes mellitus; relative risk factors are advanced age, male gender, hypertriglyceridemia, hyperhomocysteinemia, sedentary lifestyle, and family history.

REF: p. 904

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 7. Why is the change in sound made by a passing train’s whistle similar to the reason the pitch

rises quickly in systole and drops quickly in early diastole when measuring arterial sounds? a. Both are explained by B-mode ultrasonography. b. Both involve the science of plethysmography. c. Both are explained by the Doppler effect. d. Both are explained by the science of atomic behavior in a strong magnetic field such as magnetic resonance imaging (MRI).

ANS: C

The Doppler effect is the change in the frequency of echo signals that occurs whenever there is a change in the distance between the sources of a sound and the receiving object. The probe, or transducer, is aimed toward the blood vessel at an angle of 45 to 60 degrees. This directs an ultrasound beam that is reflected back to the probe by moving red blood cells (RBCs). The velocity of the flow of cells is converted into an audible signal heard through a speaker. The signal is described as a swishing sound. The sound is called a signal, not a pulse.

REF: pp. 907-908 8. Vascular surgery patients are at risk for impaired skin integrity and ineffective tissue perfusion

related to surgical positioning, presence of vascular disease, and vascular clamping.

Positioning of the patient undergoing vascular surgery is of particular importance because of restricted circulation distal to the area of arterial obstruction and a generalized state of poor circulation. An appropriate protective intervention is reflected in which true statement about patient positioning for vascular surgery? a. The patient should be positioned on a radiopaque pressure-reducing mattress on the operating room (OR) bed. b. The nurse should protect the patient’s vulnerable neurovascular bundles from compression. c. The nurse should provide warmed sterile saline compresses to bony prominences to increase vascular perfusion. d. The scrub person should distribute the weight of instruments on top of the patient equally to prevent pressure injuries.

ANS: B

Protect vulnerable neurovascular bundles from compression. Position the patient on a pressure-reducing mattress on the OR bed that is radiolucent (X-ray compatible). Keep OR bed sheets dry and wrinkle-free. Pad all bony prominences. Maintain body alignment.

REF: p. 909 9. The Doppler transducer is the most widely used instrument for vascular study. What statement

regarding a Doppler is true? a. Doppler probes are expensive but can be steam sterilized. b. The Doppler probe can provide five different forms of information. c. Water-soluble gel is needed when the Doppler is used on intact skin. d. The Doppler is valuable in detecting accurate findings in the presence of stenosis.

ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The Doppler probe can provide information in three forms: the audible signal, a visible graph printout similar to an electrocardiogram (ECG) tracing, and a spectral analysis that appears on a screen and may be recorded on paper as well. It has the advantages of being readily available, inexpensive, and easy to use. The probes are heat-sensitive and must either be sterilized according to the manufacturer’s instructions or be inserted into a sterile sleeve or probe cover. The biggest drawback of the Doppler probe is a negative finding in the presence of a stenotic lesion.

REF: pp. 907-908 10. Assessing blood flow through diseased vessels by palpation is often difficult. Assessment of

the patient’s hemodynamic status during surgery can be further complicated by spasm of the vessel walls, the cool environment of the OR, and alterations in blood pressure. Vascular monitoring during carotid endarterectomy (CEA) is critical to determine the quality of cerebral perfusion. What vascular monitoring device is employed during CEA and which important surgical need is determined by its results? a. Doppler, need for embolectomy b. Laser flow cytometry, need for increased intravenous (IV) fluids c. Electromyogram (EMG), need for muscle relaxants d. Electroencephalogram (EEG), need for a shunt ANS: D

EEG monitoring is used for patients undergoing a carotid endarterectomy and allows for immediate observation of the slowing of brain waves caused by cerebral ischemia or reduced perfusion. The surgeon may elect to place a temporary shunt in the artery if this occurs during clamping, potentially reducing the chances of perioperative stroke.

REF: p. 910 11. Varicose veins are enlarged and distended veins that are visible and palpable beneath the skin.

Secondary varicose veins are believed to be a result of insufficiency of the deep venous system. The primary objective of varicose vein surgery, for the patient with secondary disease, is to prevent extremity: a. thromboemboli, claudication, and unsightly blue clusters of veins. b. ulceration, secondary edema, pain, and fatigue. c. venospasm, phlebitis, and vascular sacculations. d. vasculitis, pitting edema, and sclerosed vein clusters.

ANS: B

The objective of surgical intervention is to remove the diseased veins, thus preventing ulceration, secondary edema, pain, and fatigue in the extremity. Disease may prevent the normal functioning of these valves, resulting in distention; as the vein wall weakens and dilates, venous pressure increases, and the valves become incompetent. Dilation of the saphenous vein produces venous stasis, which may be followed by secondary complications, such as stasis ulcers.

REF: p. 928

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 12. A vena cava filter (Greenfield filter) maintains a patent vena cava but prevents pulmonary

emboli (PE) by trapping the emboli at the apex of the device. This procedure may be performed in the OR, radiology suite, or intensive care unit (ICU) for critical patients. Select the statement that best describes the appropriate preferred insertion approaches. a. Right jugular and right femoral b. Right jugular and left femoral c. Left jugular and left femoral d. Right and left femorals ANS: A

The head is turned to the left for jugular vein insertion, or the groin is exposed for femoral vein insertion. The right femoral vein is preferred over the left, because the anatomy of the left vein often makes threading the filter more difficult.

REF: p. 928 13. Surgically created arteriovenous fistulas are also referred to as a(n) _________ and are

indicated for enabling __________. a. axillo-femoral bypass; end-stage renal disease b. bridge shunt; peritoneal dialysis c. arteriovenous shunt; hemodialysis d. side-to-side anastomosis; cannulation ANS: C

Arteriovenous fistulas—direct connections between an artery and a vein—are the standard means of vascular access for long-term renal dialysis. The dilated vein can then be used for direct cannulation with large-bore needles for hemodialysis. This method is preferable to an external shunt, which carries a high risk of thrombosis and infection. The best access is achieved using the patient’s own vessels and creating a subcutaneous connection between the artery and vein, referred to as an arteriovenous shunt or bridge fistula. Arteriovenous shunts are indicated for long-term renal dialysis access.

REF: p. 925 14. During an open exploration of above-knee popliteal artery, an incision is made into the

femoral artery with a #11 knife blade and extended with Potts angulated scissors. What is the proper name of this surgical approach? a. Potts arterial punch cut b. Medial vasculotomy c. Femoral arteriotomy d. Popliteal arteriostomy ANS: C

An incision is made into the popliteal artery as explained in the text for femoral arteriotomy.

Femoropopliteal bypass is the restoration of blood flow to the leg with a graft bypassing the occluded section of the femoral artery. A saphenous vein or a straight synthetic graft can be used as bypass material.

REF: p. 920

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 15. Select the statement that best describes the comparative difference between open aortic

aneurysm repair and endovascular aneurysm repair (EVAR). a. The open aneurysm surgery approach has a small abdominal incision and similar patient morbidity. b. In EVAR, the prosthetic endograft or stent-graft is introduced into the aneurysm through a surgically exposed femoral artery. c. In EVAR, self-expanding or balloon-expandable catheters are used rather than staples. d. The EVAR prosthesis is a clone of the Greenfield thromboembolism filter.

ANS: B

EVAR differs from open surgical repair in that the surgeon introduces the prosthetic endograft or stent-graft into the aneurysm through a surgically exposed femoral artery and fixes it in place to the nonaneurysmal infrarenal neck and iliac arteries with self-expanding or balloonexpandable stents rather than sutures. A major abdominal incision is thus avoided, and patient morbidity related to the procedure is much reduced. The benefits of this procedure are a hospital stay of 1 to 2 days, a rapid return to normal physical activity, and a reduction in the mortality and complication rates compared with those of the conventional surgical procedure.

REF: p. 917 16. Substituting a cryo-preserved cadaveric vein or an in situ or reversed vein graft from the

patient for an arterial bypass graft is an option for patients who do not have healthy, easily accessible saphenous veins. How does an in situ vein graft differ from a reversed vein graft? a. With the in situ method, the vein segment is resected, reversed, and anastomosed into position. b. The in situ method leaves the saphenous vein in its position, and the valves are removed. c. Arteriovenous fistulas are a common complication with the reversed vein graft method. d. Valvulotomes are used to remove the valves in both methods.

ANS: B

Two methods of grafting veins are the in situ graft and the reversed vein graft. The in situ method leaves the vein in its place, side branches are ligated to prevent arteriovenous fistulas, and the valves that would impede arterial flow are disrupted with instruments specifically designed to cut valves, called valvulotomes. Autogenous vein grafting for infrainguinal bypass is considered the criterion standard. Reoperation is more frequent with the in situ method because of missed valves and residual arteriovenous fistulas. Reversal of a vein graft is performed per the surgeon’s preference or when it must be harvested from the contralateral limb.

REF: pp. 912-913 17. Heparin sodium is an anticoagulant. The basic mechanism of heparin’s action is best described

as: a. b. c. d.

it blocks the conversion of prothrombin to thrombin and fibrinogen to fibrin. it acts as an enzyme by lysing the fibrin-thrombin matrix. it extends the activated partial thromboplastin time (APTT). it dissolves and liquefies existing blood clots and thromboemboli.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: A

Heparin sodium is an anticoagulant that interferes with blood coagulation by inactivating thrombin and preventing the conversion of fibrinogen to fibrin.

REF: p. 911 18. Which drug is used to reverse, or neutralize, the effects of heparin? a. Prostigmine b. Promethazine c. Protamine sulfate d. Prothrombin ANS: C

The effects of heparin can be reversed by the administration of protamine sulfate. Since protamine sulfate is derived from fish sperm and testes, caution is advised when administering it to patients who are allergic to fish or who have received protamine-containing insulin. One milligram of protamine neutralizes 100 mg of heparin.

REF: pp. 911-912 19. The perioperative nurse with the vascular surgery service is preparing to discharge a 51-year-

old man who recently had endovascular surgery. The patient will be taking anticoagulation therapy for the next 12 weeks. Which statement regarding anticoagulation therapy is true and relevant to the patient? a. Eat foods high in vitamin K, such as tomatoes, dark leafy vegetables, bananas, and fish. b. Wear padding when engaging in contact sports. c. Use only hair removal cream; do not use an electric razor. d. Do not use tools such as saws or hammers, which could lead to an accident.

ANS: D

Important information about anticoagulation therapy that should be provided to the patient includes the following: Use only an electric razor or hair removal cream; do not use a straight razor. Take precautions to avoid injury. For example, do not use tools such as saws or hammers, which could lead to an accident. Avoid eating foods high in vitamin K, such as tomatoes, dark leafy vegetables, bananas, and fish. Avoid contact sports and other hazardous activities that can increase the risk of tissue injury. The patient and family or other caregiver should be provided with both verbal and written instructions.

REF: p. 914 20. A perioperative nurse circulator is preparing the OR for a vascular procedure where heparin

will be used. She has obtained the heparin from the medication dispensing system and is preparing to mix the heparin in IV saline according to the dosage on the surgeon’s preference/ pick list. The scrub person, also a perioperative nurse, is preparing the sterile back table.

Which expected and appropriate risk reduction strategies related to the use of heparin would the scrub person perform? a. Label syringe and medicine cup with the drug name, strength, and amount b. Verify the drug and labels with three qualified individuals including the surgeon c. Document medications used once the surgery is complete d. Comply with the seven rights of medication storage and documentation

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: A

In vascular surgery, several medications may be present on the sterile field at any given time.

These may include heparin, heparinized saline, protamine sulfate, and papaverine hydrochloride, as well as local anesthetic medications and contrast dye. During surgery various local anesthetic medications and irrigating solutions, such as thrombin, antibiotic, and heparin solutions, may be used. The scrub person ensures that each medication or solution container on the sterile field is labeled with the medication name, strength, and amount.

Labels should be verified by two qualified individuals if the person preparing the medication is not the person administering it. The perioperative nurse maintains an accurate record of the solutions used and the amounts administered.

REF: p. 914 MULTIPLE RESPONSE 1. Arterial procedures, especially those that involve the aorta, may place the patient at risk for

significant blood loss. A nursing diagnosis related to the care of patients undergoing vascular surgery is risk for deficient fluid volume related to loss of body fluids, with a nursing outcome stated as, “Fluid balance will be maintained as evidenced by postoperative pulses equivalent to preoperative level, hourly urine output of at least 30 mL, and good skin turgor.” Select all the nursing interventions that are appropriate to this outcome. a. Ensure availability of rapid infusion systems or blood salvage equipment b. Confirm the availability of ordered blood-replacement products c. Monitor and record ongoing estimation of blood loss d. Provide emotional support and comfort measures ANS: A, B, C

The perioperative nurse should confirm the availability of ordered blood-replacement products. The use of rapid infusion systems or blood salvage equipment should be determined and planned. Collaboration with the anesthesia provider and the surgeon should promote ongoing estimation and measurement of blood loss throughout the procedure; estimate blood loss on sponges and drapes; communicate to the anesthesia care provider and surgeon; initiate autotransfusion or use of an autologous blood salvage unit as required; record the amount of irrigation used; document the contents of the suction canisters; monitor and document hourly urine output (as applicable); communicate results of measurements; and collaborate with the collection and interpretation of intraoperative blood analyses.

REF: pp. 908-909 2. When selecting a vascular graft for a vascular bypass or replacement procedure, what are the

desirable characteristics that influence the surgeon’s choice of graft? (Select all that apply.) a. Thrombo-resistant, biocompatible, and easy to handle b. Fairly priced, variety of sizes, and ability to clot blood c. Sterilizable, nonantigenic, and last a lifetime d. Reasonably priced, permit blood passage without clotting, and hypoallergenic ANS: A, C, D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Desirable characteristics for vascular grafts are that they are reasonably priced, readily available in a variety of sizes, suitable for use anywhere in the body, biocompatible and hypoallergenic, and able to survive repeated sterilizations. Grafts should be easy to handle and last a lifetime while permitting blood passage without clotting or infection. Prosthetic grafts are nonantigenic; tissue incorporates well, which helps prevent infection, and such grafts generally resist thrombosis.

REF: p. 912 3. The perioperative nurse, with an understanding of the special surgical considerations for

vascular procedures, will plan for the possibility of angiography studies being performed during the intraoperative or interventional procedure. An appropriate consideration when preparing the OR or interventional procedure room would be to (Select all that apply.): a. assess the patient for allergies to contrast dyes. b. provide a radiolucent OR bed surface with X-ray capabilities. c. provide contrast media, catheters, impermeable sterile X-ray covers, and lead aprons. d. provide radiation-protection devices, such as lead aprons and shields ANS: A, B, C, D

Assess the patient for cardiac, vascular, and pulmonary disease; coagulation status; and allergies to ensure that the patient can tolerate a possible angiogram, because the contrast medium is toxic, and increased fluid volumes are needed if angioscopy is planned. Because the need for intraoperative arteriography or fluoroscopy for endovascular procedures is a possibility, the patient with a vascular disorder should be positioned on an appropriate OR bed with X-ray capabilities, and the availability of X-ray department personnel should be coordinated. Appropriate contrast media, catheters, and impermeable sterile X-ray covers must be available. Radiation-protection devices, such as lead aprons and shields, should be used for the patient, when possible, and for surgical team members.

REF: p. 906

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 25: Cardiac Surgery Test Bank MULTIPLE CHOICE 1. The internal mammary arteries (IMAs) are frequently used as grafts during coronary bypass

surgery. Where are they located? a. They diverge from the anterior interventricular branch of the right coronary artery. b. They diverge from the subclavian arteries behind the sternum. c. They diverge from the subclavian arteries anterior to the sternum. d. They diverge from the innominate artery.

ANS: B

The right and left IMAs (thoracic), used as grafts during coronary bypass surgery, branch off the subclavian arteries and course behind and parallel to the edges of the sternum.

REF: p. 931 2. In the pulmonary circulatory system, blood is pumped from the right ventricle (RV) through

the pulmonary valve into the main pulmonary artery (PA). The PA divides into the right and left pulmonary arteries, which further subdivide into the arterioles and capillaries of the lungs.

Where does the blood from the lungs flow next? a. Into the capillary beds b. Into the alveoli c. Through the pulmonary artery to the left atrium (LA) d. Through the pulmonary veins to the LA ANS: D

External respiration occurs in the capillary beds and the alveoli, where carbon dioxide is exchanged for oxygen. Freshly oxygenated blood from the lungs flows through the pulmonary veins into the LA. REF: p. 931 3. Identify the correct path of the cardiac conduction system. a. From the area where the superior vena cava (SVC) meets the right atrium to the

atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches b. From the sinoatrial (SA) node to the atrioventricular (AV) node to the bundle of His to the Purkinje system c. From the area where the SVC meets the right atrium to the AV junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches, and from the SA node to the AV node to the bundle of His to the Purkinje system d. Neither from the area where the SVC meets the right atrium to the AV junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches, and from the SA node to the AV node to the bundle of His to the Purkinje system

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock ANS: C

Within the myocardium itself, certain areas of tissue undergo natural modification to form a conduction system. The process of excitation and contraction originates in the SA node, located in the area where the SVC meets the right atrium (RA). The impulse spreads to the atria through internodal pathways and travels to the AV junction (which contains the AV node) located medial to the entrance of the coronary sinus in the RA, close to the tricuspid valve.

From the AV junction, the impulse spreads to the bundle of His, which extends down the right side of the interventricular septum. The bundle of His divides into the right and left bundle branches, which terminate in a network of fibers called the Purkinje system. Purkinje fibers are spread throughout the inner surface of both ventricles and the papillary muscles, which when stimulated produce contraction of the heart muscle.

REF: p. 933 4. The blood is oxygenated in the lungs and returns to the LA through the pulmonary veins.

Where does the blood flow after leaving the LA? a. Through the AV (mitral) valve into the left ventricle (LV) b. Through the tricuspid valve into the LV c. Through the aortic valve into the LV d. Through the aorta into the systemic circulation ANS: A

Each half of the heart contains an upper and a lower communicating chamber—the atrium and ventricle, respectively. The RA receives desaturated blood from the inferior and superior venae cavae and from coronary circulation via the coronary sinus. The LA receives oxygenated blood from the lungs by way of the pulmonary veins. From both atria, blood then flows through the AV valves into the ventricles. The LV pumps oxygenated blood into the major vessels of the systemic circulatory system by way of the aorta and its main branches to the head, upper extremities, abdominal organs, and lower extremities.

REF: p. 931 5. During the preoperative nursing assessment for a patient scheduled for cardiac surgery, the

perioperative nurse reviews the patient’s medication history with particular attention to medications that can affect the surgery or cause complications. Select the true statement about specific medications that can affect surgery or cause complications. a. Aspirin may increase platelet levels. b. Lipid-lowering drugs (statins) may promote new onset diabetes mellitus. c. Herbal products may promote the development of thromboemboli. d. Angiotensin converting enzyme inhibitors (ACEIs) may cause malignant hypertension.

ANS: B

The perioperative nurse reviews patient medication history with particular attention to vasoactive drugs, anticoagulants, and other medications that can affect surgery. Nurses should note that patients taking aspirin and other antiplatelet drugs (such as 2b/IIIa inhibitors) may require intraoperative replacement of platelets. Lipid-lowering drugs (statins) have shown cardiovascular benefits, but in high doses (i.e., 80 mg, compared to moderate doses of 40 mg) they have been associated with new onset diabetes mellitus. Patients taking herbal medicines may be at risk for increased bleeding, hypoglycemia, or other complications, depending on the specific side effects of some herbal drugs.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 938 6. Select the noninvasive diagnostic test that illustrates heart wall motion and blood flow through

the heart and quantifies cardiac function. a. Radionuclide imaging b. Cardiac catheterization c. Echocardiography d. Cardiac function studies ANS: A

Radionuclide imaging illustrates wall motion and blood flow through the heart and quantifies cardiac function. Patients generally tolerate these noninvasive techniques well, especially when they may be too unstable to withstand a cardiac catheterization. These techniques may also serve as a complement to catheterization.

REF: p. 941 7. Select the diagnostic test that represents an invasive cardiac study. a. Resting multiple-gated acquisition (MUGA) b. Exercise MUGA c. Cardiac function d. Electrophysiology studies ANS: D

The following are invasive diagnostic tests commonly performed for cardiovascular disorders: electrophysiology studies, aortography, arteriography, digital subtraction angiography, cardiac catheterization, ventriculography, endomyocardial biopsy.

REF: p. 939 8. In looking at the illustration below, which option most accurately defines its primary function?

a. b. c. d.

Exposes the internal mammary artery and facilitates dissection Exposes the aortic arch for cannulation Exposes the SVC and RA for cannulation Exposes the anterolateral coronary arteries for graft anastamosis.

ANS: A

The IMA retractors expose the retrosternal artery bed by elevating the sternal border.

REF: pp. 947-948

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 9. Complete heart block and bradydysrhythmias are the most common indications for pacemaker

implantation. A permanent pacemaker (pulse generator and electrodes) initiates atrial or ventricular contraction, or both. What therapy might be used for acute forms of heart block and dysrhythmias that occasionally occur during and after cardiac surgery? a. Transvenous endocardial stimulation b. A temporary pacemaker c. Epicardial cardioversion d. Resynchronization therapy ANS: B

A temporary pacemaker is also possible to remedy acute forms of heart block and dysrhythmias that occasionally occur during and after cardiac surgery. The transvenous or the epicardial approach may be used to place the electrodes.

REF: p. 1003 10. Among the treatment options for tricuspid valve disease are suture annuloplasty, ring

annuloplasty, and valve replacement with either a biologic or a mechanical prosthesis. Like the mitral valve, the tricuspid annulus is saddle-shaped, and techniques to repair the valve should consider this anatomic configuration for optimal repair. Patients with significant tricuspid stenosis, regurgitation, or failed tricuspid (suture or ring) annuloplasty may require insertion of a prosthetic biologic or mechanical valve. Because there are no specific tricuspid prosthetic valves available, what type of prosthetic graft would be created or implanted? a. An annuloplasty with a felt-pledgetted suture b. A tricuspid annular permanent dilator c. A mitral prosthesis d. An annuloplasty ring ANS: C

There are no specific tricuspid prosthetic valves; rather, a mitral prosthesis would be implanted.

REF: p. 987 11. An aneurysm of the LV can develop after a severe myocardial infarction. The affected area of

the myocardium is replaced by thin scar tissue that can rupture. The LV undergoes remodeling when the scar stretches as a result of the left ventricular pressure and forms an aneurysm. Left ventricular aneurysmectomy (LVA) is the excision of an aneurysmal portion of the LV. LVA is a form of left ventricular reconstruction undertaken to optimize cardiac function. Select the appropriate nursing action in preparation for LVA surgery. a. Place the patient in left lateral position b. Prepare for the procedure in the same manner as typical lung transplant surgery c. Have synthetic patch material and Teflon felt pledgets available d. Add 1, 2-0, and 4-0 cardiovascular sutures to setup ANS: C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Patient positioning is supine. Setup is the same as that described for open-heart surgery, with the addition of synthetic patch material, Teflon felt pledgets, and 0, 3-0, and 4-0 cardiovascular sutures. Occasionally additional Teflon felt strips bolster the suture lines. Patch closure of the ventriculotomy (endoaneurysmorrhaphy) is more common than traditional excision, plication, and oversewing of the ventricular tissue, because patch closure better preserves the geometry of the LV. REF: p. 982 12. Thoracic aortic aneurysmectomy is excision of an aneurysmal portion of the ascending aorta,

aortic arch, or descending thoracic aorta and replacement with a prosthetic graft, valve-graft conduit, or intra-aortic prosthesis. Aneurysms may be caused by atherosclerosis, trauma, infection, or cystic medial degeneration. Which presenting conditions will indicate that surgical intervention is necessary? a. Compromised circulation or danger of rupture b. Circumferential involvement c. Spindle-shaped morphology d. Combined saccular and fusiform morphology without dissection ANS: A

Surgical intervention becomes necessary when presenting symptoms indicate a compromised circulation or danger of rupture; generally, medical management with hypotensive agents to reduce stress on the vessel is the preferred initial treatment until surgical repair can be performed.

REF: p. 993 13. The temporary substitution of a pump oxygenator for the heart and lungs allows the surgeon

to stop the heart and perform cardiac procedures under direct vision in a relatively dry, motionless field. It also allows the surgeon to manipulate the heart without the risk of producing ventricular fibrillation and reduced cardiac output that jeopardizes perfusion to the myocardial, peripheral, and cerebral tissues. In traditional cardiopulmonary bypass (CPB), systemic venous return to the heart flows by gravity drainage through cannulae placed in the superior and inferior venae cavae or through a single two-stage cannula in the RA into tubing connected to the bypass machine. Blood is oxygenated, filtered, warmed or cooled, and pumped back into the systemic circulation through a cannula placed in the: a. femoral artery. b. axillary vein. c. descending aorta. d. femoral vein.

ANS: A

In traditional CPB circuits, systemic venous return to the heart flows by gravity drainage through cannulae placed in the superior and inferior venae cavae or through a single two-stage cannula in the RA into tubing connected to the bypass machine. Blood is oxygenated, filtered, warmed or cooled, and pumped back into the systemic circulation through a cannula placed in the ascending aorta or occasionally in the femoral artery or the axillary artery.

REF: p. 963

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 14. Formerly, ventricular assist devices (VADs) were reserved for those patients who could not be

weaned from CPB after open-heart operations, or who had end-stage cardiomyopathy. Current indications and choices have expanded, and a variety of active and passive devices are available to support circulation for short-, intermediate-, and long-term use. Select the statement that best reflects the implications for a patient with a VAD. a. The newer devices have eliminated bleeding complications. b. The VAD augments cardiac output from the right, left, or both ventricles. c. Patients with VADs benefit from enhanced catabolism and cellular nutrition. d. The artificial pump of the VAD increases the workload of the heart.

ANS: B

An expanding array of VADs are now available. Their position may be internal or external, they may be electrically or pneumatically powered, they may be pulsatile or nonpulsatile, and they may require warfarin anticoagulation. Most devices allow ambulation, and some enable the patient to be discharged from the hospital. As designed, VADs augment cardiac output from the left (LVAD), right (RVAD), or both (biventricular [BiVAD]) ventricles and decrease workload of the heart by diverting blood from the ventricle(s) to an artificial pump that maintains systemic perfusion. Patients with an LVAD benefit from the resulting enhanced anabolism, ambulation, and improved organ function. Complications (e.g., bleeding, thromboembolism, infection, device failure) persist, but they have lessened with the newer VADs. REF: p. 997 15. During a valve repair, the surgeon realized that the torn leaflet was too damaged to be repaired

and that the patient would be better served with a bioprosthetic replacement valve. The perioperative nurse selected the implant from its secure storage area and transferred it in its storage solution to the sterile back table. What is the appropriate risk reduction strategy to prepare the bioprosthetic valve for implantation? a. Rinse the biovalve in sterile albumin b. Rinse according to the biovalve manufacturer’s instructions c. Rinse the biovalve in 5 baths of sterile saline d. Rinse the biovalve in glutaraldehyde ANS: B

The amount of rinsing solution in each rinse basin, the number of basins, and the time for each rinse (and the total time of the rinsing baths) should be followed according to each manufacturer’s instructions. Safety considerations include storing prosthetic materials in a clean, protected environment and using them according to manufacturers’ instructions.

REF: p. 956 MULTIPLE RESPONSE 1. During the preoperative assessment of an adult with a previously corrected congenital heart

defect, the perioperative nurse should be aware of anatomic anomalies associated with the original defect, or its subsequent repair, that may alter the current surgical plan for a patient who had prior pediatric cardiac surgery. What is an appropriate nursing response when the assessment reveals the adult patient has undergone prior pediatric cardiac surgery? (Select all that apply.)

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. Prepare for endocardial injury if the heart is retracted or manipulated too forcefully b. Prepare to employ the current surgical plan, adding pediatric vascular clamps to

the set c. Consult with the surgeon for specific alterations to the typical plan for care d. Alert the staff to anticipate altered anatomy, special supplies, and potential

complications ANS: C, D

Consultation with the surgeon can alert the staff to anticipate different anatomy (and surgical landmarks), special supplies and prosthetic materials, and potential complications. In addition to age-specific changes, there are a growing number of adults with acquired heart disease who underwent surgery in childhood for repair of congenital cardiac lesions. For example, patients with a previous Blalock-Taussig shunt for tetralogy of Fallot may have altered pulmonary and subclavian artery anatomy; patients with a mechanical closure device inserted for an atrial septal defect may be at risk for endocardial injury if the heart is retracted or otherwise manipulated too forcefully. The nurse should be aware that anatomic anomalies associated with the original congenital defect, or its subsequent repair, may alter the current surgical plan.

REF: p. 938 2. Which statements regarding vascular clamps are true? (Select all that apply.) a. Vascular clamps are designed to partially occlude blood flow. b. Vascular clamps are designed to totally occlude blood flow. c. All vascular clamps are designed to hold vessels securely without trauma. d. All vascular clamps have similar angles, box locks, ring handles, and ratchets.

ANS: A, B, C

Vascular clamps, designed to occlude blood flow partially or completely, must be maintained in good condition if they are to prevent fracture of the delicate tunica intima of the blood vessels and still retain their specific holding qualities. There are many variations in construction of vascular instruments. Jaws may consist of single or double rows of fine, sharp, or blunt teeth or special crosshatching or longitudinal serrations. The working angles of the clamps also vary. All clamps are designed to hold vessels securely, without causing trauma.

REF: p. 947 3. Surgery for atrial fibrillation (AF) may also be performed through an open sternotomy or right

mini-thoracotomy incisions. By creating small areas of scar tissue in the cardiac muscle, electrical impulses are forced to follow an alternative conduction path or “maze.” Select all the statements regarding nursing considerations for the maze procedure that are true. (Select all that apply.) a. Monitor for heart rhythm problems b. Infuse cardioplegic solution through the aortic root and into the coronary arteries c. Monitor for bleeding, infection, and potential complications related to heart surgery d. Strip the chest tubes and test the pacing wires every 4 hours postoperatively ANS: A, C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Postoperatively, patients undergo monitoring for heart rhythm problems. In patients treated for AF, it may take up to 3 months for the heart to resume beating normally. Additional postoperative considerations include monitoring for bleeding, infection, and other potential complications related to heart surgery.

REF: p. 1003 4. An implantable cardioverter defibrillator (ICD) is an electronic device designed to monitor

cardiac electrical activity and deliver prompt defibrillation. Myocardial or thoracic subcutaneous patches may be added if the transvenous catheters alone do not adequately defibrillate the heart. Patients with previously implanted defibrillator patches may present for removal of a patch(es). Which nursing action would be appropriate during this procedure?

(Select all that apply.) a. Be prepared for emergency intervention if there is pacing as well as defibrillating b. Be prepared for emergency intervention if there is excessive bleeding c. Be prepared for emergency intervention if there is a lethal dysrhythmia d. Be prepared for emergency intervention if there is a hospital generator failure ANS: B, C

Perioperative nurses should prepare for emergency intervention if excessive bleeding or lethal dysrhythmia appears. EP studies performed before and after insertion enable diagnosis of the dysrhythmia and evaluation of device function, respectively.

REF: p. 1004 5. Open commissurotomy of the mitral valve, which is performed for mitral stenosis, is the

separation of fused, adherent leaflets of the mitral valve. The nurse assists in placing the patient in the supine position for a median sternotomy. The setup is the same as that described for open-heart procedures, with mitral valve instruments. Select two additional nursing actions that are relevant to the patient with open commissurotomy. (Select all that apply.) a. Have valve replacement instruments available b. Have tricuspid prosthetic implants available c. Have a transesophageal echocardiogram (TEE) probe and machine available d. Have anterolateral positioning devices available if valve replacement is needed ANS: A, C

Because there is a possibility that the valve may have to be replaced, instruments (and prostheses) for replacement as well as repairs must be available. TEE is used to establish a cardiac functional baseline and to confirm efficacy of the repair both after the cross-clamp is removed and the heart resumes beating and after the bypass is discontinued.

REF: p. 984 6. A percutaneous method of instituting femoral vein–femoral artery CPB can be used for

minimally invasive (or conventional open) procedures and in emergency situations where the environment is not conducive to traditional CPB methods. Select all the areas where percutaneous CPB would be indicated. (Select all that apply.) a. Renal dialysis unit b. Neonatal intensive care unit c. Cardiac catheterization unit d. Emergency department

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

ANS: B, C, D

A percutaneous method to institute femoral vein–femoral artery CPB is possible for minimally invasive (or conventional open) procedures and for emergencies in which the environment is not conducive to traditional CPB methods (e.g., in the cardiac catheterization laboratory, the intensive care unit, and the emergency department).

REF: p. 963 7. A 59-year-old woman with multiple prior cardiac procedures for congenital cardiac anomalies

at birth is scheduled for an open approach coronary artery bypass graft. During the preoperative interview and assessment, the perioperative nurse reviewed the patient’s hematologic tests, including a detailed coagulation profile to uncover possible hemorrhagic disorders. During the assessment the nurse learned of the patient’s many varied comorbid conditions, including prior vascular procedures, fibromyalgia, diabetes, and eczema. The nurse noted one of the patient’s many nursing diagnoses as risk for bleeding related to surgical incision(s), tissue dissection, altered coagulation function, and inadvertent hypothermia. As a result of this diagnosis, the nurse implemented measures to have blood available, measure and report blood loss, assist with the use of the autotransfusion system per protocol, and have topical hemostatic agents available. The patient will be free from excessive bleeding as evidenced by (Select all that apply.): a. chest tube drainage less than 100 mL/hr. b. dressings dry and intact. c. normal cardiac function studies. d. normal skin color, temperature, and turgor.

ANS: A, B

The patient will be free from excessive bleeding as evidenced by chest tube drainage less than 100 mL/hr, dressings dry and intact, normal coagulation function studies (or undergoing replacement treatment for deficient clotting factors), and normal body temperature.

REF: pp. 945-946 8. Disturbances of the conduction system affect the rate, rhythm, and effectiveness of the

contracting heart. Surgical techniques have been developed to treat a variety of supraventricular dysrhythmias and both ischemic and nonischemic ventricular tachydysrhythmias. Preprocedural electrophysiologic mapping of the patient’s conduction pathways identifies and locates aberrant pathways, or ectopic foci. A catheter is inserted percutaneously into the femoral vein or artery and threaded retrograde to the right or left atrium and ventricle. Various areas of the heart are tested in an attempt to reproduce the dysrhythmia; then the area of the heart where the rhythm disturbance originates is ablated.

Which treatment modality is employed to produce this selective ablation effect? (Select all that apply.) a. Cryotherapy b. Fiberoptic light energy c. Radiofrequency (RF) energy d. Ultrasonic energy ANS: A, C, D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Currently, the focus is on the selective ablation (with cryotherapy, ultrasonic energy, or RF energy sources) of tissues surrounding, for example, the pulmonary veins to reestablish normal conduction pathways.

REF: p. 1002 9. Cardiac surgery patients are at risk for decreased cardiac output related to emotional (fear),

sensory (pain), or physiologic (electrical, mechanical, or structural) factors. Which outcome indicators will provide evidence that the patient’s cardiac output will be consistent or improved? (Select all that apply.) a. Urine output is greater than 15 mL/hr. b. Skin is warm and dry. c. Cardiac output is improved from preoperative levels. d. The patient displays no signs of anxiety.

ANS: B, C

The patient’s cardiac function will be consistent with or improved from baseline levels established preoperatively as evidenced by hemodynamic indicators (blood pressure, oxygenation, ECG) within expected range; warm, dry skin; and urine output more than 30 mL/hr.

REF: pp. 944, 946

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 26: Pediatric Surgery Test Bank MULTIPLE CHOICE 1. Young children are predisposed to parasympathetic hypertonia (increased vagal tone), which

can be induced by: a. painful stimuli such as eye surgery or abdominal retraction. b. anxiety stimuli such as separation from a parent. c. environmental stimuli such as loud noise or flashes of light. d. thermal stimuli such as ambient excessive heat or cold.

ANS: A

Young children are predisposed to parasympathetic hypertonia (increased vagal tone), which can be induced by painful stimuli such as laryngoscopy, intubation, eye surgery, or abdominal retraction.

REF: p. 1008 2. The immature blood-brain barrier and decreased protein binding in infants increase their

sensitivity to which group of drugs? a. Anticholinergics, parasympatholytics b. Antidysrhythmic agents c. Opioids and hypnotics d. Adrenergics ANS: C

Medication distribution is different in neonates and infants compared with older children and adults because of an increased percentage of total body weight and extracellular body fluid.

Infants have an immature blood-brain barrier and decreased protein binding, which results in an increased sensitivity to sedatives, opioids, and hypnotics.

REF: p. 1009 3. The pediatric patient is at risk for imbalanced fluid volume related to invasive surgery and

accompanying blood loss. Select the outcome indicator that would best reflect that the goal of maintained fluid balance was attained. a. Blood pressure within acceptable range b. Bounding peripheral pulses c. Three wet diapers in 24 hours d. Intact mucous membranes ANS: A

The child will maintain fluid balance as evidenced by blood pressure within expected/acceptable range, palpable peripheral pulses, moist mucous membranes, and absence of peripheral edema.

REF: p. 1014

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 4. The perioperative nurse explained to the child at a developmentally appropriate level, what he

or she will experience in the preoperative, intraoperative, and postoperative phases of care.

The nurse briefly described the roles of various staff members who will be a part of the team responsible for the child’s care in the operating room (OR). She explained to the child and family the length of time that they will be separated from each other during the procedure and when they can be reunited in the postanesthesia care unit (PACU). She addressed the child within a developmental framework, taking into account the child’s cognitive and psychosocial abilities. She used medical play items, audiovisual aids, puppets, and photographs in the education process. While the nurse addressed the need for knowledge of the impending surgical procedure and provided education, she also employed interventions aimed at which nursing diagnosis? a. Risk for infection related to surgical intervention b. Fear related to unmet goals c. Anxiety related to separation from family and friends d. Risk for hypothermia related to loss of body surface heat ANS: C

Nursing diagnoses related to the care of pediatric patients undergoing surgery might include the following: anxiety related to separation from family and friends, fear related to developmental level (fear of the unknown, fear of painful procedures and surgery), risk for infection related to surgical intervention and other invasive procedures, risk for imbalanced fluid volume related to invasive surgery and accompanying blood loss, risk for hypothermia related to loss of body surface heat to environment and immature temperature-control mechanisms.

REF: pp. 1012-1013 5. A child’s comprehension of, and responses to, the environment are based on his or her

developmental age. Many theorists have provided excellent guidelines for assessing the pediatric patient’s developmental level in order to use appropriate interventions. The infant develops the belief that the world can be counted on to meet basic needs through the trust versus mistrust concept based on the stages of psychosocial and emotional needs. This theoretical framework of stages was described by ______________, while the stages based on changes in cognition and ability to think were described by _____________. a. Dr. Erik Erikson; Dr. Jean Piaget b. Dr. John Watson; Dr. Albert Bandura c. Dr. Jean Piaget; Dr. John Watson d. Dr. Karl Jung; Dr. Sigmund Freud ANS: A

The stages of growth have been described from a variety of different aspects. Dr. Jean Piaget described the stages by changes in cognition and the ability to think, and Dr. Erik Erikson based the stages on psychosocial and emotional needs. Their work provides an excellent guideline for assessing the pediatric patient’s developmental level in order to use appropriate interventions.

REF: p. 1009 6. The toddler uses symbols and engages in creative play. Toddlers are beginning to develop free

will and control over their bodies. Which of the interventions below is age-appropriate for toddlers?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. Sing songs from your own childhood that the child may be able to learn. b. Give only simple choices and involve them in actions when possible. c. Make up a story about their personal comfort item as you give it to their parent to

keep. d. Ask them about their concerns and offer information to decrease their fears.

ANS: B

Toddlers are very egocentric. They develop free will and increasing control of their body and feel regret and sorrow for inappropriate behavior. Give only simple choices; involve the child in actions when possible; use distractions; and sing songs the child may recognize. Allow personal item into OR for comfort/security.

REF: p. 1010 7. Personal comfort or security items should be permitted to accompany children to the OR who

are in which developmental age? a. Infancy to 1 year b. Toddler to early childhood c. School age to adolescence d. Infancy through adolescence ANS: D

Allow personal item into the OR for comfort/security in all developmental age groups.

REF: p. 1010 8. Improvements in instrumentation and the development of equipment in smaller sizes have

resulted in the evolution of minimally invasive surgery (MIS) from that of a rapidly growing field to one of routine practice in the pediatric surgical arena. The advantages of MIS for the pediatric population include which true statement? a. There is less risk for injury or complications with pneumoperitoneum insufflation. b. Pediatric patients having MIS procedures have less prevalence of adhesion formation. c. There is less possibility for abdominal injury from Foley catheter decompression. d. MIS procedures on children do not require the use of thromboembolic devices.

ANS: B

Advantages of MIS include diminished postoperative pain, improved cosmetic results, decreased prevalence of adhesion formation, and accelerated recovery periods and shorter hospital stays. Despite the technical congruence with adult MIS procedures, the pediatric populations undergoing these procedures have specific needs. Anesthesia providers must consider the size and age of the patient because of the risk of physiologic compromise related to insufflation. Likewise, steps are taken intraoperatively to decrease the likelihood of intraabdominal injury, such as insertion of an appropriate size Foley catheter to decompress the bladder or application of thromboembolic hose or sleeves to prevent deep vein thrombosis.

REF: p. 1019

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 9. Infants and children with severe gastroesophageal (GE) reflux can have life-threatening

complications, including obstructive apnea, aspiration pneumonia, esophagitis, and failure to thrive. What is the name of the procedure, performed open or laparoscopically, that is designed to create a competent antireflux barrier? a. Nissen fundoplication b. Roux-en-Y bypass c. Pyloromyotomy with pyloroplasty d. Sphincterotomy ANS: A

Nissen fundoplication is indicated for infants and children who experience severe gastroesophageal (GE) reflux. The cause of GE reflux in these patients is believed to be an inadequate antireflux barrier.

REF: p. 1020 10. An orchiopexy is the surgical placement and fixation of the testicle in a normal anatomic

position in the scrotal sac. If the testis fails to descend into the scrotum during gestation, it is considered undescended. Which statement regarding indications for orchiopexy is true? a. The normal path of the testis becomes obstructed. b. The testis is strangulated by contraction of the cremaster muscle. c. All testes that are undescended after 1 year require surgical placement in the scrotum. d. Retractile testes require surgical or hormonal treatment.

ANS: C

All testes undescended after 1 year require surgical placement in the scrotum for optimum maturation. Retractile testes require no surgical or hormonal treatment. Laparoscopic exploration may also be used to determine position, existence, or size of a “hidden” testis.

REF: p. 1047 11. Neuropathologic conditions requiring surgical intervention can be found in any age group.

What are the most common problems requiring neurosurgical procedures in infants and children? a. Skull fractures and epilepsy b. Craniosynostosis and hydrocephalus c. Occipital neuroma and trauma d. Aneurysms and craniostenosis ANS: B

Neuropathologic conditions requiring surgical intervention can be found in any age group.

The most common problems requiring neurosurgical procedures in infants and children include meningocele, myelomeningocele, encephalocele, craniosynostosis, hydrocephalus, brain tumors, and trauma.

REF: p. 1052

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 12. This orthopedic diagnosis is a complex deformity that is diagnosed prenatally through

ultrasound or at birth. It may occur unilaterally or bilaterally and may be idiopathic or one in a combination of other syndromes with associated anomalies. The general characteristic for all cases includes inversion of the foot such that the anterior foot is located in the typical position of the posterior foot; often there is a deep crease in the midfoot. Select the orthopedic diagnosis. a. Foot dystonia b. Clubfoot c. Orthopedia d. Subtalar orthopnea ANS: B

Clubfoot is a complex deformity that is diagnosed prenatally through ultrasound or at birth.

According to the American Academy of Orthopedic Surgeons (AAOS), clubfoot may occur unilaterally or bilaterally and may be idiopathic or one in a combination of other syndromes with associated anomalies.

REF: p. 1055 13. Cleft lip is usually associated with a notch or cleft of the underlying alveolus and a cleft of the

palate. Cleft lip repair is most often performed when the infant is about 3 months of age. Cleft lip is described as: a. two skin ridges situated near the midline of the central philtrum of the lip. b. absence of one or both philtral clefts with a notch in the alveolus. c. a deficiency of tissue (skin, muscle, and mucosa) along one or both sides of the upper lip. d. absence of the frenulum with resultant mandibular defect.

ANS: C

A deficiency in tissue (skin, muscle, and mucosa) along one or both sides of the upper lip or, rarely, in the midline results in a cleft at the site of this deficiency.

REF: p. 1056 14. Any misalignment of the eyes is called strabismus. The goal for treatment of strabismus is to

straighten the eyes so that binocular vision functions appropriately. Surgery may be recommended to change the alignment of the eyes relative to each other by: a. strengthening the lower eyelids. b. strengthening the upper eyelids. c. repositioning the eye muscles. d. performing bilateral rhytidectomy ANS: C

Surgery may be recommended to change the alignment of the eyes relative to each other by strengthening, weakening, or repositioning the eye muscles.

REF: p. 1061

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 15. A 12-year-old boy is scheduled for a laparoscopic hernia repair. During the preoperative

assessment and interview, the perioperative nurse notes that he has mild myotonia congenita.

The patient’s mother states that she is worried about the anesthesia because her husband’s brother died many years ago when he became very feverish during surgery and they could not cool him. The perioperative nurse’s appropriate risk reduction strategy in this situation would be to: a. perform a careful assessment of family history to identify risk for developing malignant hyperthermia (MH). b. advise the anesthesia provider to find an alternative to succinylcholine and sevoflurane. c. plan an inservice for the OR staff on MH crisis management. d. pursue a physician order for a laboratory test to rule out MH. ANS: A

Careful assessment of family history is essential to identify patients at risk for developing MH. MH, although very rare, may be more prevalent in the pediatric population as a result of the administration of inhalational anesthetics and succinylcholine. In addition, physiologic conditions present in some pediatric patients are associated with a higher risk of MH. These conditions include congenital myopathies such as central core disease and King-Denborough syndrome.

REF: p. 1017 16. Baby Boy Doe is a newborn found outside of the emergency department (ED). He is

hypothermic and has several deep lacerations across his back, abdomen, and legs that will require surgical repair. He is transferred to the surgical bay of the ED and prepared for anesthesia induction. Which risk reduction strategies are appropriate during the preanesthetic phase to achieve and maintain normothermia? a. Adjust room temperature to 23° to 24° C (73.4° to 75.2° F). b. Provide a radiant heat lamp during placement of monitoring lines and induction. c. Wrap lower extremities in elastic bandages and encase in a plastic bag for newborns. d. Keep child exposed as much as possible to benefit from the heat lamp.

ANS: B

Adjust room temperature approximately 1 hour before arrival of the child: 26° to 27° C (78.8° to 80.6° F) for infants and newborns; 23° to 24° C (73.4° to 75.2° F) for older children.

Provide radiant heat lamp for use during placement of monitoring lines, induction of anesthesia, positioning, skin prep, and draping. Keep child covered as much as possible.

Consider wrapping lower extremities in soft gauze or stockinette and encasing in plastic bag for newborns and infants.

REF: pp. 1014-1015 17. A 14-year-old boy is scheduled for spinal fusion with implantation of rods from T10 to L2.

During the preoperative interview and assessment, he asks the perioperative nurse how bad his pain will be when he wakes up and if he will have enough pain medicine available. He also wonders how the nurse will know when his pain is severe enough to give him pain medicine.

The perioperative nurse assures the patient that he will have many options available to him to manage his pain after the surgery. An appropriate risk reduction strategy that the nurse can implement during the preoperative assessment is to:

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. explain and demonstrate the adolescent pediatric pain tool. b. explain that he will have patient-controlled analgesia (PCA) and his parents can

manage his pain for him. c. tell him to teach his parents what he knows about the pain scale. d. request a consult with the pain service to explain the pain management plan to him.

ANS: A

In the past, many common fallacies existed about pain in the pediatric population. The evaluation of a pediatric patient’s level of pain is performed using a variety of assessment tools (pain scales) that are based on the age and developmental level of the child. The adolescent pediatric pain tool (APPT) is a line drawing of a body; the child marks the drawing where he or she has pain. Other tools include Likert-type scales rating pain on a score of 0 (no pain) to 10 (worst pain) or incorporate several components of pain assessment (subjective and objective data).

REF: p. 1017 18. Children are more prone to foreign-body ingestion than adults. What is the most significant

risk? a. Aspiration with airway obstruction b. Esophageal impaction c. Mucosal tear d. Poisoning ANS: A

The most significant risk of foreign-body ingestion is aspiration. Children are more prone to aspiration than adults because their laryngeal sphincters are immature, they do not have molars to chew all foods adequately, and they often run, shout, and play with objects in their mouths. Commonly aspirated food items include candy/gum, peanuts and other nuts, seeds, popcorn, hot dogs, vegetable matter, meat matter, and fish bones. Commonly aspirated nonfood items include coins, toy parts, crayons, pen tops, tacks, nails, needles, pins, beads, and screws. Aspiration may produce a complete or partial airway obstruction.

REF: p. 1050 MULTIPLE RESPONSE 1. Much like the adult population, many traditional “open” pediatric surgical procedures are

being replaced by MIS procedures. Because the field of pediatric MIS is relatively new, surgeons are at an advantage because they are able to combine virtual reality techniques and robotics with the most current technology and instrumentation. Select all of the MIS procedures commonly performed in pediatric patients. a. Living-related donor kidney transplant b. Gastric fundoplication c. Correction of pectus excavatum d. Closure of patent ductus arteriosus ANS: B, C, D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Common pediatric MIS procedures for general surgery include diagnostic laparoscopy, pyloromyotomy, splenectomy, gastric fundoplication, and cholecystectomy. Thoracoscopic approaches may be used for correction of pectus excavatum, lung biopsy, sympathectomy, and closure of a patent ductus arteriosus (PDA).

REF: p. 1019 2. Select all the injuries or conditions that reflect probable child abuse or neglect. a. Abrasions of both knees b. Multiple bug bites c. Severe injuries inconsistent with the history d. Severe diaper rash with the presence of ammonia burns ANS: C, D

If a child is reported to have experienced a routine fall but appears to have severe injuries, the inconsistency of the history with the trauma sustained indicates suspected child abuse. The symptoms of neglect reflect a lack of both physical and medical care. Manifestations include failure to thrive without a medical explanation, multiple cat or dog bites and scratches, feces and dirt in the skinfolds, severe diaper rash with the presence of ammonia burns, feeding disorders, and developmental delays.

REF: p. 1012 3. Vascular access in pediatric patients may be established intraoperatively for short-term

(weeks) or long-term (months, years) use. Select all the examples of a long-term (months, weeks) use vascular access catheter. a. Central venous line b. Implanted port c. Peripherally inserted central venous catheter (PICC) d. Power injection port ANS: A, B

Central venous lines or implanted ports are placed for long-term access to provide parenteral nutrition, chemotherapy, bone marrow transplantation, or multiple intravenous (IV) access lines for the critically ill patient. An example of short-term use includes PICC lines for antibiotic therapy.

REF: p. 1018 4. During the planning process, the perioperative nurse determines nursing interventions that

will assist in meeting the appropriate goal statement of the desired nursing outcome. What nursing intervention is appropriate, when implemented, in protecting the pediatric patient from fluid volume imbalance? a. Measure and record the urinary output and output from other drainage tubes b. Weigh sponges on a gram scale and report estimated loss c. Provide appropriate amounts of IV fluid replacement d. Calculate the estimated total blood volume for the patient according to the patient’s age ANS: A, B, C

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The following are nursing interventions directed toward protecting the patient’s fluid volume balance: maintain and protect patency of intravenous lines; review laboratory analyses for results of total blood volume; calculate estimated total blood volume using a formula of 85 to 90 mL/kg of body weight if total blood volume has not been determined by laboratory tests; provide gram scales for weighing sponges discarded from the operative field, weigh sponges, and report estimated loss; provide suction units with reservoirs that measure in 5- to 10-mL increments; measure and record quantity of irrigating fluid used; provide appropriate amounts of IV fluid replacement (e.g., 250-mL containers); measure and record urinary output and output from other drainage tubes; send laboratory specimens for analysis as indicated; and review results indicating fluid status.

REF: p. 1014 5. Children classified in the early childhood phase or who are preschool age begin to imagine

and explore. Their thinking is dominated by perceptions and, often, distorted reasoning. They are magical thinkers. What would be an appropriate intervention for preschool age children? a. Allow them to play with a saline-filled syringe to decrease their fear of injections b. Allow them to play with their own mask and place on their stuffed bunny’s face c. Tell them a story during anesthesia induction d. Draw faces on inflated latex gloves and give each glove a name of a surgical team member ANS: B, C

For the preschool or early childhood patient, use stories during induction. They like colorful Band-Aids. Allow the child to handle unfamiliar objects to decrease stress (e.g., mask, pulse oximeter probe). Allow personal item into OR for comfort/security.

REF: p. 1010

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 27: Geriatric Surgery Test Bank MULTIPLE CHOICE 1. A number of screening tools have been developed to accurately establish biologic age. One

tool, the Comprehensive Geriatric Assessment (CGA), is a multidimensional evaluation that scrutinizes medications, functional ability, comorbid conditions, cognitive ability, mental function, nutritional status, and socioenvironmental factors. In geriatric medical studies, the CGA has been valuable in providing a metric for describing healthy aging and: a. predicting the incidence of hospitalization. b. identifying at-risk individuals. c. measuring performance of activities of daily living. d. determining success of interventions.

ANS: B

The CGA is a multidimensional evaluation that scrutinizes medications, functional ability, comorbid conditions, cognitive ability, mental function, nutritional status, and socioenvironmental factors. The CGA may be used both to identify at-risk individuals and to guide interventions.

REF: p. 1085 2. As a person ages, digestive secretions decrease, mucus becomes thicker (causing dysphagia),

and saliva becomes more alkaline. Decreased peristalsis and gastric motility, resulting in muscle tone loss, will cause delayed stomach emptying. What common digestive condition may result from delayed stomach emptying? a. Odynophagia b. Dysphagia c. Esophagitis d. Mucositis ANS: C

Esophagitis can result from delayed stomach emptying. Esophageal mobility is reduced as a person gets older, and a more relaxed cardiac sphincter slows emptying in the esophagus, increasing the prevalence of esophageal reflux.

REF: p. 1092 3. Age-related changes cause decreased blood flow to the kidneys with a resultant decrease in

nephron function. Which condition is created from the cumulative effect of the multiple drugs that the elderly patient will receive during the perioperative phase? a. Adverse drug reaction b. Polypharmacy psychosis c. Weakened bladder muscle tone with urinary incontinence d. Liver toxicity ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock During the perioperative phase of the patient’s hospital stay, the greatest number and variety of drugs are given; the cumulative effect increases the chances for adverse and consequential results.

REF: p. 1089 4. Impaired nutritional status is highly prevalent among the elderly; as many as 12% of men and

8% of women in the healthy geriatric population are considered undernourished. During the preoperative assessment and interview, what information will the perioperative nurse review, in addition to a thorough assessment including body mass index and Mini Nutritional Assessment? a. The nothing by mouth (NPO) status b. The serum albumin level c. The medication record for use of vitamins d. The use of nutritional supplements ANS: B

Higher rates of surgical complications and increased postoperative mortality have been observed in patients with poor nutritional status, as determined by a low body mass index, weight loss, a low preoperative serum albumin level, or a low Mini Nutritional Assessment score.

REF: p. 1086 5. Which action is considered a best practice when communicating with geriatric patients with

cognitive impairments? a. Treat the person as if he/she is special and address him/her in a soft, quiet manner. b. Speak moderately loud, facing the patient and holding his/her hand. c. Approach the patient from the front and identify yourself. d. Take measures to minimize emotional inflections in your message.

ANS: C

When communicating with elderly adults who have cognitive impairments, perioperative nurses and surgical technologists should consider the following strategies: try not to startle the person when starting a communication; approach them from the front, knock, or announce your presence by calling the person’s name; approach patients who have a left-sided hemiparesis from the right side and vice versa; identify yourself.

REF: p. 1091 6. The occurrence of perioperative mortality in geriatric surgical patients is influenced by several

evidence-based factors. Select the patient most at risk for perioperative mortality. a. A 70-year-old woman, scheduled for an emergency bowel resection with an American Society of Anesthesiologists (ASA) class IV b. A 70-year-old man scheduled for a bunionectomy of the right foot, ASA class II c. A 70-year-old man with type 2 diabetes, scheduled for a robotic-assisted prostatectomy, ASA class III d. A 70-year-old woman with a hearing aid and bilateral cataracts, scheduled for a dilatation and curettage (D&C), ASA class IV ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock According to Kim and Zenilman (2007), the occurrence of perioperative mortality in geriatric surgical patients is influenced by the presence of coexisting disease, emergency surgery, and site of surgery. Presence of coexisting disease is quantified according to the ASA Physical Status Classification. Patients with an ASA status of IV or V are consistently found to have greater mortality than those with a physical status of I or II. Surgical risk in elders increases dramatically when the surgery is of an emergent nature. Major vascular, intrathoracic, and intra-abdominal procedures are reported to have a higher surgical risk than other surgical procedures in elders.

REF: p. 1084 7. Hyperthyroidism is the great masquerader in the elderly population and can easily be missed

in patients older than 60 years. It can be severe and even life-threatening. An important assessment point during the preoperative interview that could influence the positioning for the surgical procedure is based on which true statement? a. The patient may have osteoporosis caused by hyperthyroidism. b. Euthyroid syndrome is prevalent in hyperthyroidism and impairs neck flexion. c. Positional injury can trigger thyroid storm. d. Patients who have been exposed to radioactive iodine are at risk for pressure injuries.

ANS: A

Hyperthyroidism may also cause osteoporosis. Almost any condition that can make a person ill can cause euthyroid syndrome; therefore elders are more susceptible because of their comorbid conditions. Medication to suppress hormone secretion by the gland, surgery to remove the hyperfunctioning tissue, and use of radioactive iodine (RAI) to destroy the gland are the three treatment options. Following surgery, the perioperative nurse must be aware of the possibility of a hyperthyroid storm that can be precipitated by the stress of the procedure, systemic infections, and anesthesia induction.

REF: p. 1100 8. The perioperative nurse assigns the patient scheduled for cataract surgery the following

nursing diagnosis: ineffective breathing patterns attributable to the patient’s chronic lung disease. The nurse also documents a secondary nursing diagnosis: high risk for injury related to increased intraocular pressure. Which potential event can result in this secondary nursing diagnosis? a. The patient may cough while lying in the supine position. b. The patient may be anxious and try to raise his or her head during the procedure. c. Patients with cataracts have glaucoma and may move their head to relieve the pressure. d. Hypoxia from chronic lung disease can increase intraocular pressure.

ANS: A

Patients with chronic lung disease who are lying in the supine position may experience coughing, which can increase intraocular pressure and jeopardize the outcome of the surgery.

Because elderly patients may have concurrent systemic disease, even a low-stress procedure should not be treated lightly. Age-related changes, such as hearing loss and musculoskeletal disease, may pose a challenge during ophthalmic surgery because the patient must lie still for long periods and be able to follow verbal instructions.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock REF: p. 1101 9. Perioperative nurses caring for older adults must consider factors that affect the choice of

medications and the effects of those medications on this population. Physiologic changes may affect the absorption, distribution, metabolism, and excretion of medications. Which statement about medication metabolism is true? a. Older adults have faster excretion times as a result of increased renal blood flow. b. Older adults have slower excretion times as a result of increased liver size and increased blood flow. c. The increased liver size and increased blood flow in older adults decrease liver enzyme activity. d. Older adults have slower excretion times attributable to a reduced glomerular filtration rate.

ANS: D

Changes in metabolism include decreased liver size, decreased hepatic blood flow, decreased liver enzyme activity, decreased renal blood flow, and reduced glomerular filtration rate, leading to slower excretion times for medications and allowing serum drug levels to rise.

REF: p. 1087 10. An 87-year-old woman has been scheduled for a right cataract extraction with intraocular lens

implant of her right eye. She also has a cataract in her left eye and is hearing-impaired in both ears. The perioperative nurse conducted a preliminary nursing assessment 1 day earlier by telephone and has documented her preliminary nursing interventions for the intraoperative nurse. Which nursing action by the perioperative nurse will assist the patient to maintain accurate perception and interpretation of environmental and sensory stimuli throughout the perioperative period? a. Leave the operating room (OR) lights on high illumination during the procedure b. Leave hearing aids and eyeglasses in place as long as possible c. Speak moderately louder than normal voice tone d. Ask if she is able to read lips and request that the team not wear masks ANS: B

Changes in vision, hearing, taste, smell, and touch may influence the patient’s response to care. If preadmission communication is done, the perioperative nurse may ask about vision and hearing and remind patients to bring their glasses and hearing aids to the facility. Of particular importance in the OR is an awareness of the older person’s difficulty in adapting to changes in light. Moving patients from a dimly lit holding area to the bright lights of the OR can cause momentary “blindness.”

REF: p. 1090 11. An 83-year-old woman, admitted for an abdominal perineal resection for early sigmoid

cancer, has a recent history of a 4% weight loss. On admission to the OR, she is tachypneic, her tongue and mucous membranes of her mouth are dry, her speech is slurred, and she is confused. Her surgical unit nurse states that the patient’s bowel prep the night before was successful. The patient states that she has to vomit. The anesthesia provider tries to find a good vein for an intravenous (IV) access and asks the perioperative nurse to look for a possible vein on the patient’s other arm as the left arm veins are flat. Based on these conditions, what nursing diagnosis is the patient presenting?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. Risk for deficient fluid volume related to intraoperative blood loss b. Deficient fluid volume related to age-associated total body water and plasma

volume loss c. High risk for deficient fluid volume related to NPO status and bowel prep d. Deficient fluid volume related to NPO status and bowel prep ANS: D

The patient’s fluid volume deficit is due to her NPO status and bowel prep in addition to other age-related factors and possibly her primary surgical diagnosis. Since her surgery has not yet begun, her deficit is not related to intraoperative causes.

REF: pp. 1094-1095 12. A retired perioperative nurse celebrated her 100th birthday with family and friends. Which age

group is she now a member of? a. Elite-old b. Centennial-old c. Old-old d. Frail-old ANS: A

The retired perioperative nurse is now considered “the elite-old”. The aging population is categorized accordingly: 65 to 74 years of age: the young-old 75 to 84 years of age: the middle-old 85 to 99 years of age: the old-old 100 years of age or more: the elite-old REF: p. 1081 13. Minimally invasive surgeries continue to increase in popularity. It seems logical that older

patients would benefit from smaller incisions that produce less postoperative pain, atelectasis, and ileus. However, regardless of age, every surgical procedure possesses a certain amount of risk. Which minimally invasive surgical component can present hemodynamic and pulmonary consequences in patients with severe cardiac or pulmonary disease? a. Robotic-assisted pelvic approach b. CO2 pneumoperitoneum c. Ultrasonic dissection d. Radiofrequency ablation ANS: B

Any procedure, even those considered low risk, can have poor outcomes, depending on the patient’s overall condition. The extent of hemodynamic and pulmonary consequences of CO2 pneumoperitoneum is still unclear. In patients with severe cardiac or pulmonary disease, recommendations include invasive monitoring to maintain adequate volume loading and use of alternate gas sources or gasless techniques.

REF: p. 1102

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 14. An ethical consideration with older surgical patients centers on the dilemma of do not

resuscitate (DNR) orders. When considering the decision to maintain or suspend DNR orders prior to surgery, the guiding principle should be to: a. seek legal consultation through the facility ethics department. b. facilitate the family to collaborate on consensus. c. respect the patient’s autonomy. d. develop a facility-wide policy for either suspension or maintaining of DNR orders.

ANS: C

The organization’s policy must give the patient a voice in the intraoperative area. Even though the patient may have made end-of-life decisions, the fact that the patient has signed the surgical informed consent implies that he or she seeks to improve quality of life, which is incompatible with withholding cardiopulmonary resuscitation (CPR). It is difficult to differentiate between a cardiac arrest precipitated by anesthesia and one that is spontaneous.

The anesthetic agent itself promotes cardiovascular instability. Consideration should be given to the medical indications for the procedure with the goal of treatment to alleviate pain and morbidity and provide for the patient’s comfort. The guiding principle in the decision to maintain or suspend DNR orders should be respect for the patient’s autonomy. Elderly patients have the right to participate in the process for making end-of-life decisions.

REF: p. 1102 MULTIPLE RESPONSE 1. When considering surgery for an elderly patient, the risk of surgery should be measured

against the risk of not operating, and the expected postoperative quality of life. Which important factors should be evaluated in the decision-making? (Select all that apply.) a. Personal motivation b. Patient’s financial health and insurance c. Patient’s state of independence d. Disease course versus life expectancy e. Patient’s support system f. Surgical risk versus nonoperative management ANS: A, C, D, F

Surgical intervention and management should be tailored to the patient’s symptoms, overall functional and health status, and the predicted advantage of palliative intervention. Important factors that need to be evaluated are disease course versus life expectancy, state of independence, personal motivation, and surgical risk versus nonoperative management.

REF: p. 1084 2. There are many important considerations related to the extent of surgical treatment. Therefore,

the decision for surgery relies heavily on the patient’s physical status at the time of surgery and on the extent of disease progression. When treating patients who are nearing the end of life, attention should promote (Select all that apply.) a. maximizing the quantity of life. b. solely shifting to maximizing survival. c. maximizing the quality of life and dignity. d. minimizing suffering.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock e. prescribing aggressive, preventive surgical treatment. f. minimizing institutional cost and resources.

ANS: C, D

When treating patients who are nearing the end of life, attention should shift from solely maximizing survival to maximizing the quality of life and dignity while minimizing suffering.

Early identification of problems with aggressive, preventive surgical treatment is considered more appropriate than waiting for problems to develop.

REF: p. 1085 3. Age-related skin changes include a thinning epidermis and decreased subcutaneous fat and

elasticity. Which skin-related actions should the perioperative nurse take with regards to the older patient? (Select all that apply.) a. Smooth bed linens under the patient or positioning devices b. Assess potential pressure areas before anesthesia induction and positioning c. Wash skin often with soap and water d. Gently lift, not slide, the patient to and from the OR bed ANS: A, B, D

The skin loses elasticity and subcutaneous fat and becomes more prone to shear force and pressure injury. Because of the thinness of the skin and small-vessel fragility, bruising and hemorrhaging are common. Therefore, review risk factors for intraoperative pressure ulcer development; assess potential pressure areas before anesthesia induction and positioning, noting bruises, sores, skin tears, rashes, lesions, and pressure ulcers; avoid friction and shearing forces by using a four-person lift, a lift sheet, or lifting device when transferring the patient to or from the OR bed and turning the patient to the desired surgical position; prevent wrinkling of linen under the patient or positioning devices; place electrosurgical dispersive pad in the most appropriate area while avoiding bony prominences; avoid pooling of solutions under the patient; apply tape sparingly to prevent skin injury; consider paper tape or a nonadherent dressing on fragile skin; position the patient; and evaluate for signs and symptoms of physical injury to skin and tissue.

REF: pp. 1087, 1089 4. Changes to the elderly person’s skeleton, such as the loss of bone mass, contribute to skeletal

instability and make fractures of the hip, rib, distal radius, and vertebrae very common. Which interventions will the perioperative nurse provide in positioning older patients in the OR? (Select all that apply.) a. Assess the patient’s pain rating before anesthesia induction and positioning b. Position the patient using appropriate padding and joint protection devices c. Apply pressure to the popliteal space and heels d. Abduct the armboards to above a 90-degree angle through anatomic range of motion ANS: A, B

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock The nurse takes extra care in positioning elderly patients in the OR, ensuring appropriate padding and joint protection. Actions include assessing pain and skeletal/range-of-motion limitations before anesthesia induction and positioning; assessing potential pressure areas before anesthesia induction and positioning; placing safety strap above the knees and preventing undue pressure on the popliteal space and heels; ensuring that armboards are maintained at less than a 90-degree angle; providing adequate padding to protect potential pressure areas; maintaining body alignment within restrictions imposed by chronic pain and musculoskeletal age-related changes; using gentleness during positioning and turning; and keeping the head and neck in a comfortable position that limits hyperextension.

REF: pp. 1090, 1094 5. Common abdominal procedures in people older than 65 years include cholecystectomy, lysis

of adhesions, appendectomy, and partial excision of the small bowel. Many important clinical signs of abdominal disease may be less obvious in the elderly patient. Which of the following would be appropriate questions for the perioperative nurse to ask during the preoperative interview and assessment? (Select all that apply.) a. “Do you take nonsteroidal antiinflammatory medications like ibuprofen?” b. “Do you smoke cigarettes?” c. “Have you ever had, or have, peptic ulcer disease?” d. “Do you often stand for long periods of time?”

ANS: A, B, C

The common use of nonsteroidal antiinflammatory drugs (NSAIDs) may mask symptoms or even predispose elderly patients to acute abdominal disease. The age group older than 65 years has seen an increase of ulcer disease. Many believe that the higher incidence of Helicobacter pylori infection, prevalent use of NSAIDs, and the prevalence of cigarette smoking in elders account for the age-related differences. Up to 80% of peptic ulcer–related deaths occur in patients older than 65 years.

REF: p. 1100 6. The predominant reason for urologic surgery in elderly men is benign prostatic hypertrophy

(BPH). Which appropriate assessment questions would the perioperative nurse ask the patient scheduled for a transurethral resection of the prostate (TURP) during the preoperative interview? (Select all that apply.) a. If he has symptoms that describe evidence of constipation b. If he has symptoms that describe evidence of painful urination c. If he has symptoms that describe evidence of blood in the urine d. If he has symptoms that describe evidence of straining at urination ANS: B, C, D

As part of history taking, the nurse should determine if symptoms such as dysuria (painful urination), micturition (straining at urination), and hematuria (blood in the urine) exist.

REF: p. 1101

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 7. A 92-year-old man is scheduled for emergency surgery for a strangulated scrotal hernia. He is

thin and frail with a preoperative body temperature of 97.2° F. His skin is pink, and he is not shivering even though he states that he is cold. The perioperative nurse and the anesthesia provider have planned for the patient’s hypothermia before he was transferred to the OR. What are the appropriate actions the nurse can take to raise the patient’s core temperature?

(Select all that apply.) a. Use active warming intraoperatively by applying a forced air–warming system b. Use warm blankets during transport to the OR c. Adjust ambient room temperature to a level of comfort d. Use warmed sterile irrigation, IV solutions, and skin preparation solutions ANS: A, B, C, D

Use active warming intraoperatively by applying a forced air–warming system. Use warm blankets during transport to the OR, and replenish as needed throughout the perioperative period (include the patient’s feet within blanket covering). Adjust and maintain ambient room temperature at comfortable levels. Use warmed irrigation and preparation solutions (as recommended by the manufacturer). Administer warmed blood and blood products and intravenous fluids at room temperature. Identify risk factors for unplanned hypothermia. Place a warmed sheet on the OR bed before patient transfer. Monitor the patient’s temperature.

Provide additional head covering (cloth, plastic, or reflective) during surgical procedures.

Minimize exposure of the patient. Remove wet linens before transport to the postanesthesia care unit (PACU).

REF: p. 1094 8. Perioperative nurses have a unique opportunity to assess and screen for signs of emotional and

physical abuse in elderly patients during their preoperative assessment and while assisting with surgical positioning. Select the signs that may indicate abuse. (Select all that apply.) a. The older person has malnutrition or dehydration. b. The older person is crying. c. The older person has burns or pressure sores. d. The older person verbalizes fear of the caregiver. e. The older person complies with the treatment plan. f. The older person shows signs of poor hygiene.

ANS: A, C, D, F

Signs that may indicate elder abuse include the following: The older person demonstrates excessive agreement or compliance with the caregiver.

The older person shows signs of poor hygiene, such as body odor, uncleanliness, or soiled clothing or underpants.

The older person has malnutrition or dehydration.

The older person has burns or pressure sores.

The older person has bruises in various stages of healing that may indicate repeated injury.

The older person lacks adequate clothing or footwear.

The older person has not received adequate medical attention.

The older person verbalizes lack of food, medication, or care.

The older person verbalizes being left alone or isolated in some way.

The older person verbalizes fear of the caregiver.

The older person verbalizes his or her lack of control in personal activities or finances.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock If such signs are present, the perioperative nurse should report the suspected abuse to the appropriate authority.

REF: p. 1085

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 28: Trauma Surgery Test Bank MULTIPLE CHOICE 1. Traumatic deaths may occur in three phases or time frames. Which phase occurs within the

first 1 to 2 hours after the injury, where definitive trauma care has the most significant effect? a. Phase I b. Phase II c. Phase III d. Phase IV ANS: B

The second phase occurs within the first 1 to 2 hours after the injury. These patients have injuries to the spleen, liver, lung, or other organs that result in significant blood loss. This is the group in which definitive trauma care (i.e., appropriate and aggressive resuscitation with adequate volume replacement) may have the most significant effect (the golden hour).

REF: p. 1104 2. Which statement regarding level I and level II trauma centers (TCs) best describes the

difference between the two types of centers? a. A level I TC is staffed 24 hours/7 days, while a level II has many support services that are open and staffed 8 hours/5 days. b. A level I TC has a transplant program, while a level II is only able to complete organ procurements. c. A level I TC provides care for every type of injury, while a level II lacks some specialized resources. d. A level I TC requires trauma certification and 8 hours of annual trauma education for all staff, while a level II does not.

ANS: C

TCs are classified based on the scope of available services and resources. A level I TC is capable of providing total care for every type of injury. Accepting this designation commits the TC to providing qualified personnel and equipment necessary for rapid diagnosis and treatment on a 24-hour basis. A level II TC provides comprehensive care for all injuries but lacks some of the specialized clinicians and resources required for the level I designation. A level II facility may provide surgical intervention if the critical nature of the injury dictates immediate intervention before transfer to a level I facility.

REF: p. 1104 3. Which statement regarding level III and level IV TCs best describes the difference between

the two types of centers? a. A level III TC provides advanced cardiac life support (ACLS), surgery, stabilization, and transfer, while a level IV only provides ACLS services before immediate transfer to a higher level center. b. A level III TC immediately transfers to a higher level center, while a level IV does not accept trauma patients. c. A level III TC determines severity of injury and provides ACLS support before

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock transfer to a level IV center, while a level IV provides all comprehensive services. d. A level III TC provides all types of trauma services but is located in a rural setting, while a level IV provides post-hospital convalescent care for trauma patients.

ANS: A

A level III facility provides prompt evaluation, resuscitation, emergency surgery, and stabilization, as needed, before transfer to a higher-level facility. The American College of Surgeons (ACS) recommends that in level II and III centers, an operating room (OR) team be readily available at all times. Depending on the population served and the volume of urgent cases, this requirement may be met with on-call staff. A level IV TC has the ability to provide advanced trauma life support before patient transfer.

REF: p. 1104 4. Mechanism of injury (MOI), or kinematics, involves the action of forces on the human body

and their effects. Motor vehicle collisions (MVCs) account for a high degree of blunt trauma.

In the case of an adult trauma victim who is the driver in a head-on MVC at high speed, where the head hits the windshield and the chest impacts the steering wheel, what is the MOI and description of the possible injuries? a. Acceleration; contusion of the occipital lobe of the brain and posterior chest wall b. Deceleration; contusion of the frontal lobe of the brain and anterior chest wall c. Acceleration/deceleration; injury to the anterior and posterior brain and internal thoracic organs and vessels d. Blast force trauma; impact force causes subdural and epidural hemorrhage and transaction of the thoracic aorta and great vessels ANS: C

During an MVC, actually three collisions occur. The first collision is that of a car into another object. The second collision is the impact of the occupant’s body on the vehicle’s interior. The third collision occurs when an internal body structure hits a rigid bony surface. A coupcontrecoup injury of the brain, for example, is the result of an acceleration force to one area of the brain and a deceleration force to an opposite area. The blunt trauma injury results from a combination of forces, such as acceleration and deceleration, and may not result in a break of the skin.

REF: pp. 1106-1107 5. An adult man was the victim of a low-velocity, low-caliber gunshot wound to the anterior left

quadrant of the lower abdomen. The gun was shot at far range. What is the trajectory of the gunshot? a. Small entrance wound with blast injury to the left sigmoid colon and large exit wound b. Large entrance wound with complete transection of the left colon and no exit wound c. Large entrance wound with possible injury to left quadrant vessels and contusion of anterior sigmoid colon d. Small entrance wound with no exit wound; energy is dissipated to the tissues ANS: D

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Penetrating trauma is a result of the passage of a foreign object through tissue. The degree or extent of tissue injury is a function of the energy that is dissipated to the tissue and the surrounding areas. The anatomic structures most often injured include the liver, intestines, and vascular system. The extent of the injury relates to the nature of the foreign object (e.g., bullet caliber, knife size), distance from the weapon, structures penetrated, and amount of energy dissipated to the structures. Commonly the entrance wound is smaller than the exit wound because of the dissipation of energy, but an exit wound may not always be present.

REF: p. 1106 6. When the patient arrives in the emergency department (ED), the trauma team initiates a

primary assessment. This is a logical, orderly process of patient assessment for potential life threats. These assessment activities are based on established protocols for advanced trauma life support (ATLS). The mnemonic “ABCDE” is used, representing assessment of the following: airway, breathing, circulation, disability, and exposure. The D and E represent what degree of investigation? a. D = musculoskeletal impairments; E = environmental issues b. D = a brief reflex examination; E = extraneous sensory impairments c. D = history of prior impairments; E = events that contributed to the injury d. D = a brief neurologic examination; E = exposure to reveal all life-threatening injuries ANS: D

The mnemonic “ABCDE” is used, representing assessment of the following: airway (with cervical spine precautions), breathing, circulation, disability (brief neurologic examination), exposure (to reveal all life-threatening injuries, including environmental control [thermoregulation]).

REF: p. 1107 7. Trauma patients often arrive with cervical collars in place, or collars are placed by the ED

team if cervical spine is suspected. What event needs to take place before the team removes the cervical collar and continues care? a. A halo traction apparatus is applied. b. A cervical radiograph is obtained to rule out injury to the neck. c. A computed tomography (CT) scan with contrast of the upper body is obtained to rule out vascular involvement. d. A myelogram of the cervical spinal canal is obtained to rule out injury to the spinal cord.

ANS: B

A trauma team member can stabilize the head and neck, if necessary, until a cervical collar is placed. Once placed, the team does not remove it until an examination and cervical radiograph confirms there is no neck injury.

REF: p. 1108 8. The extent of injury after blunt trauma may be difficult to determine. What noninvasive

diagnostic test is critical to diagnosis in potential traumatic brain injury? a. Pupil reflex and response to light b. Skull radiograph

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. CT scan of the head d. Neurovascular arteriography ANS: C

If the resources are available, the TC protocol may also include a CT scan as a diagnostic or screening tool. Depending on the MOI, such as a fall, CT scans of the head and abdomen may be performed. Because injuries in blunt trauma are very difficult to diagnose, the CT scan is frequently done before patient transfer to the OR. A high index of suspicion is maintained for other injuries until proven otherwise. Bowel injuries may be missed during initial scanning. A CT scan of the brain revealing an injury incompatible with life may alter the course of definitive treatment for a patient.

REF: p. 1110 9. Focused assessment with sonography in trauma (FAST) may assist with diagnosis in difficult

situations. Which group of scans is performed, and what do they identify? a. Chest, pelvic, and four abdominal scans; collections of fluid and free air b. Chest, abdominal, and cervical spine scans; hemorrhage c. A full body scan; midline shifts d. Upper and lower extremity scans; compartment syndrome ANS: A

FAST is a portable, noninvasive scan that can be used to determine the presence of free fluid in the chest or abdomen. The typical FAST scan consists of chest, pelvic, and four abdominal scans. The chest scan examines right and left chest views and can determine the presence of pericardial fluid. The upper right abdominal scan evaluates the hepatorenal area, the first area that shows the presence of air. The left upper scan examines the splenorenal area. The left and right paracolic gutters are also scanned. The pelvic scan assesses for free fluid near the bladder.

REF: p. 1110 10. The perioperative nurse may not be able to assess the trauma patient until the patient arrives in

the OR for surgical intervention. If the patient’s condition permits, the perioperative nurse should obtain a brief, precise report from the ED nurse. One component of this report is the AMPLE history. What are the components of the AMPLE mnemonic? a. Assessment, MOI, pulse, level of consciousness, electrolytes b. Available family, medical history, problem, language, environmental conditions of event c. Allergies, medications, past medical history, last meal, event leading to injury d. Additional diseases, mean arterial pressure, prior surgeries, labs, extraneous injuries ANS: C

This history is referred to as the AMPLE history and includes the following: allergies, medications, past medical history, last meal (and last menstrual period when appropriate), events or environment leading to the accident or injury.

REF: p. 1108 11. What is the description of damage control surgery, and what conditions may be present?

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock a. Trauma surgery performed by a nontrauma surgeon; lack of specialty training b. Surgery performed during ambulance or helicopter transfer; patient movement c. Surgery that puts emphasis on trauma impact instead of complete anatomy repair;

intentional retained sponges d. Surgery performed in the ED; inadequate sterile technique ANS: C

Damage control surgery is a well-recognized surgical strategy that sacrifices complete, immediate repair to adequately address the physiologic impact of trauma and surgery. Damage control surgery is a series of operations performed to accomplish definitive repair of abdominal injuries with consideration of the patient’s physiologic tolerance. The focus is on control of hemorrhage and contamination to stop bleeding and control any intestinal, biliary, or urinary leak into the abdominal cavity. If counted soft goods are intentionally left in the patient (e.g., in a damage control procedure at a level II, III, or IV center before transfer to a level I facility), the number and type of soft goods left in the wound should be documented on the perioperative nursing record and communicated when there is a transfer in patient care.

The operative dictation by the surgeon should also verify the presence of retained soft goods, their type, and their number. This allows for accurate counts in subsequent procedures and prevents the potential for inadvertently retained soft goods.

REF: p. 1121 12. Blunt force to the larynx can result in a fracture and impose immediate airway obstruction.

These patients are at risk for a lost airway and may require immediate tracheotomy followed by repair of the fracture when the fracture is unstable or displaced. It is also important to consider that a trauma patient is assumed to have a full stomach; thus these patients are at high risk for aspiration and resultant pneumonia. What is an appropriate nursing action in the event of a lost airway after anesthesia induction and before intubation? a. Assist the anesthesia provider with securing the airway while applying cricoid pressure b. Assist the anesthesia provider by inserting a nasogastric tube and connecting to suction c. Leave the room to get the emergency tracheostomy tray and trach tubes d. Increase the oxygen delivery and perform a head tilt–chin lift ANS: A

Under the direction of the anesthesia provider, the perioperative nurse applies cricoid pressure. This pressure is maintained over the cricoid area until the cuff on the endotracheal (ET) tube is inflated and tube placement verified by the anesthesia provider.

REF: p. 1116 13. Mandibular fractures are highly associated with assault as the MOI. The goals of operative

intervention are to reduce and immobilize the fracture, prevent infection, and restore facial cosmesis and function. What might be an appropriate nursing action and a nursing outcome statement for a patient with a mandibular fracture caused by assault? a. Give 100% oxygen; the patient will have the ability to verbalize concerns and ask questions b. Provide support and explain interventions; the patient will have fear-related behaviors c. Provide caring behaviors and offer comfort to allay fear and anxiety; the patient

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock will not experience aspiration d. Provide orientation to surroundings; the patient and family will experience decreasing anxiety and fear ANS: D

The patient and family will experience decreasing anxiety and fear, as evidenced by orientation to surroundings, ability to verbalize concerns and ask questions of the healthcare team, decreased fear-related behaviors (e.g., crying, agitation), and use of effective coping skills.

REF: p. 1112 14. Trauma to the chest area is the primary cause of death in approximately 25% of trauma

victims. Involvement of the heart, great vessels, lungs, and diaphragm, attributable to penetrating or blunt injury, can provide multiple unexpected findings when the chest is opened. Because of the nature of the potential findings and expected surgical intervention, what would be an appropriate preparatory nursing action? a. Set up the autotransfusion system and resuscitation equipment b. Prepare the rapid response team and chaplain to be on alert c. Call for the small fragment set for rib fracture fixation at closure d. Prep the patient from the xiphoid to mid-thigh ANS: A

Autologous blood salvage units should also be considered during patient care preparation because blood salvage will be done if not contraindicated by the nature of the injury. Because of the unexpected nature of trauma, planning perioperative care is of the utmost importance.

Equipment, instruments, and supplies that have a high probability of use must be immediately available. When the trauma patient is transferred to the OR, the extent of injury is not always known.

REF: p. 1112 15. A trauma patient is rushed to the OR after a primary survey is completed in the ED. He is a

36-year-old man with multiple penetrating gunshot wounds to the abdomen. He is bleeding profusely. What appropriate nursing actions are critical in the rapid preparation for this procedure? a. Set up the autotransfusion system. b. Prep the patient from the suprasternal notch to the mid-thigh c. Place the aortic cross-clamp on the Mayo stand d. Open a silo-bag closure system on the sterile field ANS: B

The perioperative nurse should prep the patient from the suprasternal notch to the mid-thigh.

This allows for rapid access to the chest to clamp the aorta should massive hemorrhage control be indicated; it also allows for exposure of the femoral arteries for potential cannulation and access to the thigh for harvesting a saphenous vein. If the abdomen is difficult to close, alternative wound closure techniques may be used to prevent the occurrence of abdominal compartment syndrome. One such method is to use a silo-bag closure, in which heavy plastic is trimmed to fit and sutured to skin edges.

REF: p. 1115

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

16. A 26-year-old woman is rushed to the OR after a primary and secondary survey in the ED.

She was hit by a small truck as she was riding her bicycle through a busy intersection. She has sustained rib fractures and several fractured transverse vertebral processes. Renal injury is suspected. As the perioperative nurse prepares to insert a urinary catheter, she notices blood at the urinary meatus. What should the nurse’s next action be? a. Place a gauze dressing over the perineum after inserting the urinary catheter b. Insert the catheter and notify the surgeon c. Discontinue the catheter insertion d. Insert a latex-free straight catheter to empty the bladder and then remove it ANS: C

In these instances an indwelling urethral catheter should not be inserted. Laceration of the kidney is closely associated with fracture of the ribs and transverse vertebral processes. This injury is detected by the presence of blood at the urinary meatus. Blood at the urinary meatus may indicate a tear in the anterior urethra.

REF: pp. 1127-1128 17. If an injury to a patient is a result of a violent crime, the team must give special attention to

preservation of evidence during the course of patient care. When clothing is removed from the patient, why must it be placed and secured in a paper bag rather than a plastic bag? a. Plastic bags may trap moisture and allow mold growth, destroying evidence. b. It is easier to write identifying information on paper rather than plastic. c. Plastic bags trap air, which could kill anaerobic microorganisms needed as evidence. d. Paper bags are more secure as they cannot be untied and retied.

ANS: A

Clothing is placed in paper bags, labeled appropriately, and given to law enforcement personnel. Plastic bags trap moisture and may facilitate growth of mold, which could destroy evidence. The transport vehicle sheet should also be handled in a similar manner, since evidence may be present.

REF: p. 1115 18. A 7-year-old girl fell off of a swing at school and landed on her head. She is not conscious. On

the baseline neurologic exam, her Glascow Coma Scale (GCS) is 5. What is the recommended immediate treatment of choice? a. Reassess with the modified GCS for children b. Phenytoin 15-20 mg/kg IV c. Monitor for hypotension and drug interactions d. Intubate with controlled ventilation ANS: D

For patients with a score of 8 or less, intubation with controlled ventilation is the immediate treatment of choice. In the highly combative patient, intubation may also be performed to allow adequate assessment of the extent of injury.

REF: p. 1122

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 19. A 19-year-old woman is admitted to the OR for elevation of a depressed skull fracture without

evidence of a hematoma. She has a history of seizure disorder and is at risk for increased cerebral pressure (ICP). The anesthesia provider administers a loading dose of medication to use for induction and another medication to decrease ICP under anesthesia. Select the appropriate induction and ICP-lowering medications. a. Phenobarbital; midazolam (Versed) b. Fentanyl (Sublimaze); decadron c. Etomidate (Amidate); mannitol (Osmitrol) d. Propofol (Diprivan); furosemide (Lasix) ANS: C

Etomidate (Amidate) is the most commonly used induction agent. It acts in about 1 minute and lasts about 5 minutes and is often used in trauma patients, because it does not cause an increase in ICP or worsening of hypotension. An osmotic diuretic such as mannitol has proven to be beneficial in lowering ICP without reducing cerebral blood flow.

REF: p. 1116 20. With injury to the brain, swelling may occur quickly, requiring aggressive decisions to

manage increasing ICP. What is an appropriate diuretic medication to give, and what nursing actions would be indicated for an older adult patient with traumatic brain injury, increased ICP, and a history of congestive heart failure (CHF)? a. Mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status b. Furosemide (Lasix) 20-40 mg IV; monitor for hypotension and note extent of diuresis c. Mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status; and furosemide (Lasix) 20-80 mg IV; monitor for hypotension and note extent of diuresis d. Neither mannitol (Osmitrol) 1.5/kg IV; monitor cardiovascular status; nor furosemide (Lasix) 20-80 mg IV; monitor for hypotension and note extent of diuresis ANS: B

Furosemide (Lasix): Adult dose 20-40 mg IV is the appropriate diuretic medication for managing ICP, because furosemide lowers ICP and blood pressure (BP). Adverse reactions of mannitol (Osmitrol) include pulmonary edema and CHF. REF: p. 1114 21. What special consideration should be made when assessing geriatric trauma patients before

surgery? a. They may have preexisting diseases and conditions. b. They commonly have diminished mental capacity and will have difficulty understanding the information provided. c. They have increased physiologic reserves. d. The Glascow Coma Scale cannot be applied if the patient has dementia.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Preexisting medical conditions, medication use, decreased physiologic reserves, and the physical and psychologic stress experienced during surgical interventions place elderly trauma victims at increased risk for perioperative complications. The physiologic effects of aging combined with the preinjury health status of many elderly patients significantly affect their ability to respond to initial treatment for traumatic injuries and subsequent surgical intervention.

REF: p. 1118 22. Autotransfusion can present a vital asset in trauma care when considering the high blood loss

associated with many traumatic injuries. This process provides immediate volume replacement, decreases the amount of bank blood used, and reduces the possibility of transfusion reactions or risk of transfusion with bloodborne pathogens. What are the contraindications to using autotransfusion as a blood replacement source? a. Clean, hemodiluted blood b. Blood contaminated with food, bowel contents, or antibiotic irrigation c. Blood and fluids squeezed out of sterile bloody sponges d. Pooled blood from a torn aorta ANS: B

The blood collected in the salvage unit must be free from contamination. If the abdomen is contaminated with free food particles or colonic perforation is present, the blood cannot be used. Similarly, once antibiotic irrigation is initiated, the blood salvage unit is not used.

During autologous blood salvage the surgical technologist squeezes out additional blood and fluid from saturated sponges before discarding them from the surgical field.

REF: p. 1115 MULTIPLE RESPONSE 1. The emergency medical services system consists of trained prehospital personnel who arrive

at the scene and perform definitive interventions designed to reduce morbidity and mortality.

What is the primary role of the prehospital personnel? (Select all that apply.) a. Scoop and run to the nearest hospital ED while performing ABCs b. Deliver the victim to the hospital before the end of the golden hour c. Determine the severity of injury and initiate medical treatment d. Identify the most appropriate facility to which to transport the victim ANS: C, D

The golden hour starts at the scene, where prehospital personnel determine the severity of injury, initiate medical treatment, and identify the most appropriate facility to which to transport the patient.

REF: p. 1104

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 29: Interventional and Image-Guided Procedures Test Bank MULTIPLE CHOICE 1. Select the diagnostic and interventional radiology (IR) procedure that is not classified as a

vascular procedure. a. Percutaneous nephrolithotomy b. Peripherally inserted central catheter (PICC) insertion c. Portal hypertension management (TIPS) d. Uterine artery embolization ANS: A

IR categorizes procedures into vascular or nonvascular categories. Depending on the institution, interventional radiologists, vascular surgeons, and interventional cardiologists perform peripheral vascular work, endovascular aortic stenting, inferior vena cava (IVC) filter placement, arteriovenous (AV) fistulas, and other similar procedures. For nonvascular IR procedures (e.g., biopsies, ablations, embolizations) the patient is positioned, prepped, and draped per the specific site and procedure.

REF: p. 1132 2. Diagnostic and therapeutic procedures performed in a comprehensive cancer center IR

department might include the injection of targeted antimetabolic drugs into the blood supply that feeds a tumor to block further blood flow and kill cancer cells. Select the appropriate procedure. a. Transarterial placement of microspheres (90Y) b. Chemoembolization of the liver c. Brachytherapy delivery d. Tumor ablation with radiofrequency (RFA) ANS: B

The appropriate procedure is chemoembolization. Additional IR procedures include embolization such as uterine fibroid, solid organ, radioembolization, and vessel (pulmonary, uterine, varicocele, portal vein).

REF: p. 1133 3. The IR procedure that is used to correct a blocked or narrowed blood vessel and restore flow

is called: a. angioplasty. b. venoplasty. c. intimaplasty. d. adventiaplasty.

ANS: A

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock Microcatheters (coaxial catheters) provide access to very small vessels. Balloon catheters have angioplasty balloons. Angioplasty is a nonsurgical means to open atherosclerotic vessels using fluoroscopy guidance to inflate a balloon-tipped catheter compressing atherosclerotic plaque.

Peripheral angioplasty refers to vessels outside the coronary and cerebral vasculature, most notably the aortoiliac, infrapopliteal, superior femoral artery (SFA), and other lower-extremity vessels. Indications for peripheral angioplasty include lifestyle-limiting claudication, chronic leg ischemia, restenosis of a previous graft anastomoses, treatment pre- or post-bypass surgery, tissue ulceration, and necrosis. After establishing vessel access, the patient receives heparin to achieve the desired anticoagulation status. The surgeon advances the appropriate guidewire across the stenosis or occlusion and positions the balloon catheter in the affected area using radiopaque markers and fluoroscopy. The balloon is inflated with a mixture of sterile saline and contrast medium to a specific atmosphere of pressure.

REF: p. 1146 4. Select the statement that correctly describes the mechanism of action of contrast media. a. Contrast media are used to enhance visualization of anatomic structures by

influencing tissue radiopacity with different concentrations of iodine. b. A contrast agent works by having either a higher or lower density than the body

tissue being investigated. c. Contrast media radiopacity is related to its iodine concentration. d. A contrast agent works by the speed of delivery affecting blood flow and

hemodilution.

ANS: B

Contrast media are substances used to enhance the visibility of blood vessels, fluid, and other structures. Contrast agent classification is by effect, either positive or negative. A negative contrast agent is a substance with a lower density than the body tissues being investigated (e.g., carbon dioxide, air). A positive contrast agent has a higher density than the body tissue being investigated (e.g., iodine-based contrast media, barium sulfate, and gadolinium).

REF: p. 1148 5. Contrast media–induced nephrotoxicity (CIN) can occur as a result of a physiologic change.

After the administration of contrast media, a transient increase in blood flow is then followed by a longer period of decreased blood flow to the kidneys. Which statement best describes a true risk factor for CIN? a. Biphasic renal flow has been shown to induce CIN. b. Underlying renal insufficiency is believed to be a predictor of CIN. c. Occasional nephrotoxic drug use and dehydration among diabetic patients comprise the majority of patients with CIN. d. Vasodilatation, toxic stress, and tubular necrosis are known contributing factors as cited by a recent study.

ANS: B

The incidence of CIN is negligible with normal renal function but increases 4% to 11% with mild to moderate insufficiency alone, defined as a plasma creatinine 1.5 to 4 mg/L. The incidence rises to 9% to 38% with diabetes, and more than 40% in patients with advanced renal dysfunction, marked volume depletion, advanced heart failure, or multiple contrast studies within a 72-hour period; and more than 50% if baseline plasma creatinine exceeds 4 mg/dL, particularly in patients with diabetic neuropathy.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

REF: p. 1149 6. Reactions to contrast media can occur, and the risk varies according to several patient and

contrast-related factors. What is the single best predictor of a contrast-related reaction? a. Allergy to shellfish b. Allergy to iodine c. Prior reaction to contrast media d. A history of local anesthetic reactions ANS: C

The frequency of acute adverse reactions is about eight times higher in patients with a previous reaction, with the severity of the reaction increasing with each exposure. Severe, lifethreatening anaphylactoid or nonallergic anaphylactic reactions are rare.

REF: p. 1150 7. The majority of serious reactions to contrast media occur immediately or within 20 minutes

after the injection. Increased capillary permeability and constriction of bronchial smooth muscle cells are present. Which statement by the patient would alert you to the possibility that the patient was having a mild reaction to the contrast agent? a. “I am having trouble breathing, and my heart is racing!” b. “I feel dizzy, hot, kind of nauseated, and my nose is stuffy.” c. “I am having pain and tightness in my chest and shoulders.” d. “I am itchy all over and there are shooting pains in my IV arm!”

ANS: B

The majority of contrast reactions are mild and include coldness at the injection site, nausea with or without vomiting, headache, warmth or pain at the injection site, paresthesias, dizziness, and itching. Reactions resembling an “allergic” response are atypical with a frequency from 0.004% to 0.7%. Reactions of this type manifest as a rash or urticaria, and very rarely bronchospasm.

REF: p. 1150 8. The principle of ALARA, as low as reasonably achievable, is a protective measure designed

to protect both patients and staff. What are the three principles of ALARA? a. Time, distance, and shielding b. Dose, rad, and rem c. Time, dose, and depth d. Scatter, leakage, and tissue density ANS: A

The ALARA principle should be used. Personnel should be familiar with the three principles of radiation protection: time, distance, and shielding.

REF: p. 1140 9. Fluoroscopy time should be limited as much as possible. Which measures aid perioperative

staff to limit the time of live fluoroscopy? a. Sounding an audible warning alarm on fluoroscopy equipment after 5 minutes of fluoroscopy

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock b. Requiring nonessential team members to retreat to the control room during live

imaging c. Programming image-hold and loop-replay technique prior to imaging d. Shutting off fluoroscopy equipment automatically after 5 minutes of continuous

imaging ANS: A

The U.S. Food and Drug Administration (FDA) requires that fluoroscopy equipment produce an audible warning sound after 5 minutes of fluoroscopy. Other radiation reduction techniques and applications include beam collimation, pulsed versus continuous fluoroscopy, digital fluoroscopy imaging techniques, and specific dose-reduction protocols for computed tomography (CT) and fluoroscopy.

REF: p. 1140 10. Distance is key to providing protection during fluoroscopy, because radiation exposure

follows the inverse square law. (For example, the exposure at 2 meters from the source will be only one-fourth as much as the exposure at 1 meter’s distance.) When positioning the patient relative to the fluoroscopy image intensifier/C-arm, the patient should be placed as far away from the _______________ and as close to the __________as possible for optimal image quality and minimum radiation dose to the patient’s body. a. fluoroscope; lead shield b. image intensifier; X-ray tube c. X-ray tube; image intensifier d. beam; radiologist ANS: C

The team ensures the patient is positioned as far from the X-ray tube and as close to the image intensifier as possible for optimal image quality and minimal radiation dose (Mauro. 2009).

REF: p. 1140 11. Some of the new complex interventional procedures may require prolonged fluoroscopic

guidance in order to perform and complete the procedure. Which patient safety strategy will reduce exposure risk to the patient? a. Total body shielding of the patient above and below the body b. Changing the beam’s entry point to reduce repeated exposure to the same area c. Placing a dosimeter on the patient, both under and outside the lead patient shield d. Increasing the pause between pulses when using pulse-mode fluoroscopy ANS: B

Strategies that will reduce exposure risk to the patient include changing the beam’s entry point to reduce repeated exposure to the same area, ensuring proper dosing protocols are in place, keeping extremities out of the beam, maximizing the distance between the X-ray tube and patient; minimizing the distance between the patient and image receptor, minimizing fluoroscopy time, using last-image-hold and stored fluoroscopic image settings to review findings, using collimation to the fullest extent, and considering the use of other diagnostic technologies.

REF: p. 1140

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock 12. Personnel radiation monitoring is an important part of radiation exposure safety. Select the

statement that best describes the proper placement of the personal radiation dosimeter. a. On the trunk under the apron and at the collar level outside the apron b. Attached to the facility identification badge and worn at all times c. On the waist under the apron and the collar over the apron d. On the trunk outside the apron and the neckline of the scrub shirt under the apron ANS: A

Personnel radiation monitoring is an important part of radiation safety. Personal radiation dosimeters are worn on the trunk (under the apron) and at the collar level (outside the apron) to measure exposure. These dosimeters should not be left on aprons, because this would cause inaccurate readings when an apron is worn by another user.

REF: p. 1140 13. A diagnostic or therapeutic radiology procedure may necessitate the administration of heparin

or other anticoagulant or antiplatelet medications, because vascular injury can lead to thrombus development. Heparin is often used to prevent acute thrombosis and ischemic episodes. Which condition is a contraindication for the use of heparin? a. A patient who is administered protamine sulfate b. Hypersensitivity to heparin or excessive bleeding c. Thrombolysis or angioplasty procedures d. Sensitivity to the thrombin inhibitor bivalirudin ANS: B

Heparin is contraindicated in the patient with heparin hypersensitivity, hemorrhage, and acute thrombocytopenia.

REF: p. 1146 14. Thrombus formation often depends on the size of a catheter’s outer diameter, with respect to

the vessel’s inner diameter and indwelling time. Select the best practice to prevent thrombus formation. a. Instill heparinized saline through a high-speed injector b. Use heparinized normal saline in pressure bags and a flush line c. Instill thrombolytic drugs at first signs of a fresh clot d. Flush the catheter frequently through a high-volume pump ANS: B

The physician flushes the catheters frequently, usually after removing the wire and every few minutes when in the vessel and again on removal, to reduce the incidence of thrombus.

Interventional procedures require pressure bags with heparinized normal saline, high-pressure tubing, connectors, and three-way stopcocks and manifolds within the flush line for the drawing up and discard of flush, contrast medium, or blood.

REF: p. 1146 15. The new neuroangiography interventional room has a biplane configuration. What is the

correct description of a biplane configuration? a. It has an elevated platform for conversion to cardiac angiography. b. It has two C-arms—one on the ceiling and one on the floor.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock c. It has three-dimensional fluoroscopy imaging. d. It can acquire images from more than three reference points at the same time.

ANS: B

A biplane configuration has two C-arms—one on the ceiling and one on the floor. Biplane, as the name suggests, acquires images from two reference points at the same time. Clinical settings for biplane imaging include neuroangiography, congenital and/or structural cardiac abnormalities, and complex electrophysiology (EP) mapping procedures.

REF: p. 1144 16. What are the indications for using a power injector during an IR vascular procedure? a. To propel contrast agents and also emergency drugs into the arterial system b. To bolus contrast media at a rapid preset flow rate c. To provide torque to guide the catheter through stenosed vessels d. To decrease the procedure and radiation exposure time for the patient ANS: B

Radiographic contrast is administered by a handheld syringe or a power injector. A power injector allows the operator to bolus contrast media at a rapid preset flow rate, triggered by a hand or foot switch. The physician selects the quantity, type of contrast media, dilution, and injection rate. Location of the power injectors is either free standing or table mounted.

REF: p. 1144 17. Needles, guidewires, sheaths, catheters, and vascular closure devices are a number of specialty

items used for IR procedures. A sheath is commonly inserted at the arterial or venous puncture site. What is the function of the sheath? a. To protect the puncture site and vessel from damage b. To dilate the vessel and prevent backflow c. To prevent thromboembolism development d. To hold the guidewire and catheter in place ANS: A

Sheaths protect the puncture site and vessel from damage and increase patient comfort during multiple sheath and dilator exchanges. Sheaths have a valved end to prevent backflow of arterial blood and a side arm to infuse heparinized saline solution.

REF: p. 1146 18. Catheters are available in a variety of lengths and shapes, each with a specific advantage.

Select the true statement about a pigtail catheter that describes its indications for use. a. It is a microcatheter with one hole used in neuroendovascular procedures. b. It can be used for balloon angioplasty in biliary procedures. c. It has an in-line air trap for pulmonary artery procedures. d. It can deliver a large amount of contrast medium through its side holes.

ANS: D

A pigtail catheter delivers a larger amount of contrast medium because of additional side holes, compared to a catheter with one end hole.

REF: p. 1146

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

19. Most IR procedures are initiated with the Seldinger technique. The first step of the technique

is placement of the needle in the vessel. Select the step below that is performed after the needle is placed in the lumen of the vessel. a. Catheter is threaded over a guidewire. b. Guidewire is inserted. c. Needle is removed. d. Dilator is inserted.

ANS: B

The Seldinger technique uses a hollow needle and guidewire to obtain vessel access for percutaneous procedures. The steps include inserting a needle; placing the needle in the lumen of the vessel (the inner cannula is removed); inserting the guidewire; removing the needle (the guidewire remains in place); threading the catheter over the guidewire; and removing the guidewire.

REF: p. 1153 MULTIPLE RESPONSE 1. Extravasation occurs when contrast medium is injected into or leaks into soft tissue. It can

cause tissue damage as a result of the toxicity of the agent or through pressure (e.g., compartment syndrome). Select all the appropriate corrective treatment actions. (Select all that apply.) a. Apply warm or cold compresses b. Apply anesthetic ointment or cream to affected area c. Alert the pharmacy immediately for a reversal neutralizing agent d. Consult a surgeon for fasciotomy if pulses are lost e. Attempt to withdraw the contrast agent back through the catheter f. Elevate the affected limb ANS: A, D, F

Before the procedure, the patient should be instructed to report any burning, stinging, swelling, or tight feeling that occurs with the injection of the contrast agent. There should be a close follow-up for any extravasation, because the initial evaluation may not reveal the extent of the problem. Treatment includes limb elevation and warm or cold compresses as per the physician. It may take up to 2 weeks for tissue damage, discoloration, blistering, and sloughing to occur following extravasation. Compartment syndrome is often identifiable within 24 hours. Symptoms include coolness in the extremity and continuing swelling after the initial extravasation. Loss of pulses is a medical emergency, requiring a fasciotomy.

REF: p. 1151 2. In the IR suite, the concomitant use of various imaging modalities creates a different

environment and new dimension of patient care. Because IR is procedure based, it requires a higher standard of patient care than general radiology. The scope of IR nursing practice is diverse and includes which roles? (Select all that apply.) a. Patient education b. Preprocedure planning c. Calculating radiation dosimetry

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock d. Sheath placement e. Administering conscious sedation f. Circulating ANS: A, B, E, F

Depending on the institution, physician expertise, and case load, nurses may rotate or float from diagnostic radiology to IR. In other institutions, diagnostic and IR registered nurses (RNs) are separate departments, with different reporting structure, physician oversight, and dedicated staff. Nurses working within radiology may also work in the holding area. The scope of IR nursing practice is diverse and includes patient education, preprocedure planning, circulating, scrubbing, administering conscious sedation, patient recovery, and postprocedure discharge planning. The procedures performed encompass many different organ systems, various pathologies, and disease processes and are performed in different environments using a variety of imaging technology. As with traditional surgery, patient safety, procedural setup, instrumentation, medications, conscious sedation–monitoring, patient assessment, and complication management are IR nursing responsibilities.

REF: p. 1135

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Chapter 30: Integrative Health Practices Test Bank MULTIPLE CHOICE 1. Progressive relaxation techniques, biofeedback, meditation, and cognitive-behav-

ioral approaches have a well-documented theoretical basis with supporting scientific evidence. What is the theoretical clinical justification for this relationship categorized as mind-body medicine? a.

Targeted therapies can balance the equality of the mind with the body.

b.

The mind has the ability to affect the body.

c.

The body has the ability to positively and negatively affect the mind.

d.

Many mind-body theories have been supported by high-level research.

ANS: B

Mind-body intervention is a growing scientific movement that has explored the mind’s ability to affect the body. Some mind-body interventions (e.g., behavioralcognitive therapy), formerly categorized as complementary and alternative medicine (CAM) therapies, have been assimilated into conventional mainstream medicine. Other mind-body interventions still considered CAM include hypnosis, music, dance, art therapy, prayer, and mental healing.

REF: p. 1163 2. Herbal, orthomolecular, individual biologic therapies and special dietary treat-

ments are encompassed in biologically based therapies. Which of the biologically based therapies listed below are classified as therapeutic nutrition? a.

Veganism, vegetarianism, raw food diets

b.

Cartilage products from cattle, sheep, or sharks

c.

Bee pollen

d.

Orthomolecular megavitamins

ANS: A

Herbs are plants or parts of plants that contain and produce chemical substances that act on the body. Some diet therapies are believed to promote health and prevent or control health. Proponents of diet therapies include religious factions such as Seventh-day Adventist or Jewish Kosher. Veganism, vegetarianism, raw food diets, and diets promoted by Drs. Atkins, Pritikin, and Weil are other examples of

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therapeutic nutrition. Orthomolecular therapies use differing concentrations of chemicals or megadoses of vitamins aimed at treating disease. Many biologic therapies are available but not currently accepted by mainstream medicine, such as the use of cartilage products from cattle, sheep, or sharks for treatment of cancer and arthritis or the use of bee pollen to treat autoimmune and inflammatory diseases.

REF: p. 1163 3. Massage therapy is one of the oldest methods known in the practice of health-

care. One experimental pilot showed that using massage with which other therapy during the perioperative period reduced postoperative prolactin levels and anxiety? a.

Therapeutic touch manipulation

b.

Music therapy

c.

Aroma therapy

d.

Prayer therapy

ANS: B

Massage therapy is one of the oldest methods known in the practice of healthcare. One experimental pilot showed that using massage with music therapy during the perioperative period reduced postoperative prolactin levels and anxiety.

Many different massage techniques are aimed at helping the body heal itself through the use of manipulation of the soft body tissues.

REF: p. 1164 4. Select the true statement that best differentiates biofields from electromagnetic

fields. a.

Electromagnetic fields are generated from sources of earth energy, while biofields originate from animal or plant life.

b.

The body produces biofields from body hormone secretions, while electromagnetic fields are produced from body electrolytes.

c.

Biofields originate from within the body, while electromagnetic fields are from outside of the body.

d.

Electromagnetic fields are produced within the body by nerve/muscle interactions (e.g., sinoatrial [SA] and atrioventricular [AV] node), while biofields

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are micronerve plexuses that distribute sensory perceptions.

ANS: C

Energy therapies have been categorized into two groups: biofield therapies (those that focus on fields believed to originate within the body) and electromagnetic fields (those that originate from other sources). The existence of energy fields that originate within and around the body has not yet been definitively proven.

REF: p. 1164 5. Naturopathic medicine emphasizes health restoration as well as disease treat-

ment based on the belief that disease is a manifestation of alterations in the body’s natural healing processes. Which modality is considered within the scope of naturopathic medicine? a.

Herbal saunas

b.

Buddhism

c.

Therapeutic fasting

d.

Homeopathy

ANS: D

Naturopathic physicians use multiple modalities, including clinical nutrition and diet; acupuncture; herbal medicine; homeopathy; spinal and soft tissue manipulation; physical therapies involving ultrasound, light, and electric currents; therapeutic counseling; and pharmacology.

REF: p. 1163 6. Which therapy is guided by the principle that dysfunction of one part of the body

often affects secondarily the function of other discrete, possibly indirectly connected body parts? a.

Ayurvedic medicine

b.

Mind-body medicine

c.

Reiki therapy

d.

Manual healing methods

ANS: D

Manual healing methods are based on the principle that dysfunction of a part of the body often affects secondarily the function of other discrete, possibly indirectly connected body parts. Theories have been developed for correction of these secondary dysfunctions by realigning body parts or manipulating soft tissues.

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REF: p. 1164 7. Select the alternative or complementary therapy that would be appropriate to in-

tegrate into the plan of care in the perioperative setting. a.

Chiropractic manipulation under anesthesia

b.

Homeopathic medications integrated into the anesthesia plan

c.

Guided imagery before and during anesthesia induction and during recovery

d.

Ayurveda cleansing practices integrated into the skin preparation

ANS: C

Guided imagery, or thinking in pictures, is the natural language of the unconscious mind and is used by the autonomic nervous system as a primary mode of communication. Guided imagery for surgical patients may be in the form of prescripted tapes that lead the patient through relaxation exercises and provide healing suggestions. In other instances the perioperative nurse may assist the patient with guided imagery through the use of a calming, monotone voice; a smooth speaking delivery; and the use of relaxing images, such as a place in nature.

REF: p. 1166 8. A certified clinical aromatherapy practitioner (CCAP) asks the pediatric patient for

a favorite flavor from a short list of banana, strawberry, bubble gum, mint, or tuttifruiti, and then proceeds to place a drop of the chosen flavor into the inhalation mask before anesthesia induction. The child inhales the favorite flavor while drifting off to sleep. This complementary therapy falls within the category of: a.

clinical aromatherapy.

b.

herbal sedation.

c.

aroma anxiolysis.

d.

postoperative nausea and vomiting (PONV) prevention.

ANS: A

Aromatherapy in perioperative services involves the therapeutic use of fragrance (e.g., aromatic plant extracts and essential oils) applied to the patient’s body through inhalation or topical methods, or rarely ingestion. Long before Western medicine use of aromatherapy and herbs was part of physicians’ practice and prescriptive use, it was taught in all of the original Nightingale schools. Clinical aromatherapy is gaining acceptance with consent and participation of patients. It

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is practiced by CCAPs, knowledgeable about the specific properties of essential oils and how they interact with patients and the therapeutic environment. CCAPs use clinical-grade essential oils in a controlled way for specific, measurable outcomes. These may affect the patient on a psychologic, physiologic, or cellular level.

REF: p. 1166 9. Which therapeutic and healing therapy can the patient use throughout the periop-

erative experience (e.g., preoperative, intraoperative, and postoperative phases)? a.

Biofield therapy with transcutaneous electrodes

b.

Music therapy with headphones

c.

Aromatherapy with saturated cotton balls in a net bag

d.

Warmed herbal packs placed on the neck and chest

ANS: B

The therapeutic and healing properties of music have been recognized throughout history. Music has been shown to reduce stress and can block out unwanted noises around the patient during all perioperative phases, which makes the environment more enjoyable for the patient.

REF: p. 1166 10. Therapeutic touch (TT) is a contemporary interpretation of several ancient heal-

ing modalities now used in perioperative practice. Why does the title therapeutic touch sound like a misnomer? a.

There is no scientific evidence to support this modality as therapeutic.

b.

The practitioner does not have to touch, or make skin contact with, the patient.

c.

TT does not fit with the fast-paced surgical environment.

d.

The practitioner absorbs the negative energy of the patient, which is not therapeutic for the practitioner.

ANS: B

Therapeutic touch was developed in 1972 by Dolores Krieger and Dora Kunz.

The manipulation is primarily 2 to 4 inches off the body. The centered practitioner

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assesses, directs, and modulates biofield energy to achieve the relaxation response for healing of the whole person. With TT, the practitioner manipulates the energy field by directing or modulating using the sense of touch much like the other four major senses of the body. All these senses are able to act from a distance without direct connection. The human energy field extends a few inches away from the body surface, and the practitioner senses fine energetic cues such as changes in pattern.

REF: p. 1164 11. A dietary supplement, as defined by the Dietary Supplement Health and Educa-

tion Act (DSHEA), is a product that contains a number of ingredients that are intended to supplement the individual’s diet. Which ingredient is considered an appropriate additive to classify a product as a dietary supplement? a.

Water

b.

Amino acid

c.

Food and Drug Administration (FDA)– approved coloring

d.

Nonorganic fiber

ANS: B

Since 1994, when DSHEA was passed, the definition of dietary supplements has broadened. A product that contains a vitamin, mineral, herb, amino acid, or other botanic or dietary substance used to supplement the diet is considered a dietary supplement; this includes concentrates, metabolites, constituents, extracts, and combinations of listed ingredients. These supplements are no longer subject to premarket safety evaluations by the FDA. REF: p. 1169 12. Anesthesia providers are concerned about the potential increased risk of instabil-

ity intraoperatively resulting from inhibition of coagulation. Which herbal supplement, from the list below, would be implicated in a coagulation interaction? a.

Feverfew

b.

Lavender

c.

Rosemary

d.

Licorice

ANS: A

Many plants contain anticoagulant components, including ginger, ginseng, feverfew, and others. However, it is unknown if the danger posed is clinically significant.

REF: p. 1169

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

13. Select the herbal supplement that may cause potential adverse cardiac effects

such as palpitations and hypertension. a.

Lavender

b.

Garlic

c.

Ephedra

d.

Ginger

ANS: C

Ephedra has been associated with adverse cardiovascular effects, including hypertension, palpitations, tachycardia, stroke, and seizures. Hypertension and cardiac dysrhythmias are potential adverse events that may result from the sympathetic stimulation that occurs during intubation and surgery.

REF: pp. 1170-1171 14. The National Center for Complementary and Alternative Medicine (NCCAM) has

categorized the many integrative health practice modalities into five major domains. Biofield therapies are therapies that focus on fields believed to originate within the body. To which domain category does biofield therapy belong? a.

Mind-body interventions

b.

Energy therapies

c.

Manipulative and body-based methods

d.

Biologically based therapies

ANS: B

Energy therapies have been categorized into two groups: biofield therapies (those that focus on fields believed to originate within the body) and electromagnetic fields (those that originate from other sources). The existence of energy fields that originate within and around the body have not yet been definitively proven. However, many studies have examined the experiences of recipient or practitioner and the outcomes of this type of energy therapy. Examples of therapies with a biofield basis include acupuncture, reiki, qi gong, TT, and healing touch. Therapies that involve electromagnetic fields use unconventional pulsed fields, magnetic fields, alternating current fields, or direct current fields. These therapies have been clinically applied with patients who have arthritis, cancer, and pain.

REF: p. 1164 15. In many cultures a naturalistic or holistic approach often assumes that there are

external factors (some good, some bad) that must be kept in balance if we are to remain well. Select the balance system that is common across several cultural belief systems.

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Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

a.

“open” and “closed”

b.

“hot” and “cold”

c.

“dawn” and dusk”

d.

“fire” and “water”

ANS: B

The balance of “hot” and “cold” is a part of the belief system in many cultural groups, such as the Arab, Chinese, Filipino, and Hispanic cultures. To restore a disturbed balance (i.e., to treat) requires the use of opposites (e.g., a hot remedy for a cold problem). Different cultures may define hot and cold differently. It is not a matter of temperature, and the words used might vary; for example, the Chinese have named the forces yin (cold) and yang (hot). Western medicine cannot ignore the naturalistic view if many of its patients are to have appropriate treatment for illness as well as disease.

REF: p. 1163 16. Anesthesiologists recommend that patients stop taking any herbal supplements

before surgery to prevent adverse herb-drug interactions. How long before surgery should the patient stop taking herbal supplements? a.

5 days

b.

10 days

c.

2 weeks

d.

3 weeks

ANS: C

Because the use of botanic supplements may increase the risk of adverse herbdrug interactions, patients should be counseled to discontinue herbs preoperatively. Generally anesthesiologists recommend that patients stop taking any herbal supplement at least 2 weeks preoperatively.

REF: p. 1173 17. What ancient Egyptian treatment promotes balance and wellness through nerve

stimulation by pressure applications? a.

Tai chi

b.

Reflexology

c.

Trephining

d.

Ayurveda

ANS: B

Reflexology is the ancient Egyptian method of applying pressure to sites (such as the foot, hands, ears) that correspond with organs and nerves to cause a reflex

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arc of stimulation to the area in need.

REF: p. 1165 MULTIPLE RESPONSE 1. Many alternative medical therapies are culturally, ethnically, spiritually, or reli-

giously derived and have a wide range of applications from health promotion to the treatment of illness. Key foundations of several therapies are a focus on universal connectedness (e.g., that all living and nonliving things are joined together; health will be good if one’s mind and body are in harmony and balance; disease arises when a person is out of harmony with the universe). Which of the therapies listed below prescribe to this belief system? (Select all that apply.) a.

Asian medicine

b.

Ayurvedic medicine

c.

Homeopathic medicine

d.

Chiropractic medicine

e.

Allopathic medicine

ANS: A, B

A significant aspect of Asian medicine is an emphasis on diagnosing and treating disturbances of qi (pronounced chee), or vital energy, and restoring its proper balance. Ayurveda is a traditional system from India that strives to restore the innate harmony of the individual while placing equal emphasis on body, mind, and spirit. Ayurvedic practitioners use many products and techniques to cleanse the body and restore balance.

REF: pp. 1161-1162 2. Patients may be reluctant to communicate information about their use of herbal

products, botanicals, or dietary supplements, because they may be unsure of the reaction of healthcare professionals to their use of alternative substances. Many herbal products have actions that could be dangerous during surgery. Select all the true statements about herbal supplements and perioperative drugs. (Select all that apply.) a.

Some herbal supplements may accentuate the toxicity of anesthetics.

b.

Some herbal supplements may interfere with drug metabolism or clearance.

c.

Some herbal supplements may have significant sedative actions.

d.

Some herbal supplements may cause

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central nervous system (CNS) depression. e.

Some herbal supplements inhibit the binding of naloxone.

ANS: A, B, C, D, E

Some herbal supplements may accentuate the toxicity of anesthetics or interfere with drug metabolism or clearance. Some botanicals have significant sedative actions. Anesthesia providers are concerned about the potential for valerian and St. John’s wort to prolong or potentiate the sedative effect of anesthetic agents.

Valerian has been associated with CNS depression. St. John’s wort has been found to inhibit the binding of naloxone.

REF: p. 1169 3. Palpation during the nursing assessment is considered a “laying on of hands,”

and may be interpreted as therapeutic by the patient. Select the statement that best reflects the nurse-patient relationship during nursing assessment. (Select all that apply.) a.

This can be interpreted as a physical invasion of the patient’s body.

b.

The nurse’s hands should be warm and the touch gentle to promote calmness and trust.

c.

Warm, gentle palpation symbolizes respect for the patient and for the privilege the patient gives the nurse.

d.

Palpation is best performed without emotional communication or evidence of caring behaviors.

ANS: A, B, C

Palpation involves the use of your hands and fingers to gather information through the sense of touch. Certain parts of your hands and fingers are better than others for specific types of palpation. Touch is in many ways therapeutic, and palpation is the actuality of the “laying on of hands.” It is the moment at which health practitioners begin their physical invasion of the patient’s body. The oft-repeated advice that the approach to palpation be gentle and the practitioner’s hands be warm is not only practical but also symbolic of respect for the patient and for the privilege the patient gives.

REF: p. 1164 4. As a result of DSHEA, the FDA can restrict a marketed supplement only if its use

has shown the product is unsafe. Because herbal products are so readily avail-

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able and have such widespread media attention, many people think that they can safely self-medicate. Why should the public be aware and educated about dietary supplements and potential harmful effects? (Select all that apply.) a.

There are no regulations establishing criteria for purity or manufacturing procedures.

b.

Impurities and unknown substances may be present in these products.

c.

The potential exists for variability in the potency of different batches of the same botanical product.

d.

There are no regulations establishing criteria for identification of ingredients.

ANS: A, B, C, D

There are no regulations establishing criteria for purity, manufacturing procedures, or identification of ingredients for these supplements. Therefore the potential exists for high variability in the potency of different batches of the same botanical product. In addition, impurities and unknown substances may also be present in these products.

REF: p. 1169

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