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Alexanders Care Of the Patient in Surgery 14th Edition Rothrock – Test Bank
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 02: Patient Safety and Risk Management
- Governmental and professional agencies and organizations, whether voluntary (governmental) 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 based and supported authority on health throughout most of the world|
WHO was created by and functions within the United Nations (UN) as the directing and coordinating authority for health throughout UN member nations.
REF: Page 21
- 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 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.|
The Association of Operating Room Nurses (now called the Association of periOperative Registered Nurses [AORN]) began organizing in the early 1950s. AORN’s conferences and publications were replete with patient safety information. Its first conference in 1954 included programs on methods’ improvement, explosion prevention, bacteria destruction, the surgeon-nurse relationship, and positioning.
REF: Page 18
- The perioperative environment is a dangerous place for both patients and staff. The surgical patient is at risk for harm, regardless of age, surgical diagnosis, or planned procedure. Select the physical risks.
|a.||Chemical, thermal, and radiation burns|
|b.||Anxiety and knowledge deficit|
|c.||Lost or mislabeled specimen|
|d.||Breaches of confidentiality, privacy, and dignity|
A physical risk is some damaging or noxious element that comes into contact with the patient to cause harm, such as electrosurgical/laser beam, pooled prep solution, glutaraldehyde retained in an endoscope, or a retained foreign object.
REF: Pages 34, 37-38
- Sara Martin, 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. In addition to comfort and caring behaviors and reassurance from the perioperative nurse to mitigate Sara’s nervousness and fears, the admission 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.||allergies, history and physical report, level of anxiety.|
|b.||lab and imaging results, blood transfusion orders.|
|c.||signed consent, advance directives, and personal belongings.|
|d.||All of the options must be verified.|
Key features of the Universal Protocol for perioperative patient care are performing a preoperative verification process, marking the operative site, and conducting a “time out” immediately before starting the procedure. A properly performed “time out” includes information about the patient and the procedure.
REF: Page 19
- Sara was positioned, prepped, and draped following general endotracheal anesthesia induction. The team assembled around Sara and the sterile field 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 attention together.|
|c.||perioperative services has a physician champion and surgeon buy-in.|
|d.||someone simultaneously checks the patient ID band.|
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: Pages 21, 24
- 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.|
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: Page 19
- 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: ____________________________________________________________________.
Select the quote that best relates perioperative nursing care to the NPSG.
|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 surgery.”|
|d.||“Primum non nocere” (first do no harm).”|
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: Pages 18-20
- After Sara Martin emerged from anesthesia and was extubated, she was transferred to the PACU by the anesthesia provider and perioperative nurse. She had an excision of a benign subglossal cyst. A hand-off report was given to the accepting PACU nurse. The anesthesia provider and perioperative nurse described the procedure, allergies, weight in kilograms, intake and fluid loss, anesthetics and medications, pain, and several other critical parameters of physiologic status. Choose the answer below that completes the blanks in this sentence: _________________________ is the first element of information that should be shared in the hand-off report; the ______________________ has the responsibility for the ultimate transfer of information.
|a.||PACU bed space number; anesthesia provider|
|b.||The names and roles of the perioperative nurse and anesthesia provider; receiving PACU nurse|
|c.||Patient identification; receiving PACU nurse|
|d.||Patient identification; anesthesia provider|
All patient encounters should begin with patient identification verification. The receiving healthcare provider bears the responsibility of obtaining all of the information needed to safely care for the patient before the transferring staff leave 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 hand-off communication must include an opportunity to ask and respond to questions.
REF: Page 26
- 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|
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: Page 31
- 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 RFID chips|
At a minimum, all facilities should have a “count” policy that reflects AORN’s Recommended Practices for Sponge, Sharp, and Instrument Counts. While standard counting prevented 82% of retained sponges, bar-coded and RFID-tagged sponges prevented about 97.5% of retained sponges. The bar-coded sponges were the most cost-effective. 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.
REF: Page 34
- Norma Miller, 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.|
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 or uptake of surgery-infused diagnostic fluids. 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 monitor and collaborate in controlling the fluid and electrolyte status of the patient intraoperatively.
REF: Pages 42-44
- Spencer Robertson is a 4-week-old frail neonate who had a rectal exam and dilatation under anesthesia following prior surgery for imperforate anus. When the drapes were removed from Spencer, the perioperative nurse noted an area of redness, swelling, and abrasions on the buttocks of the patient. Spencer had been positioned prone 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?
|a.||Neonates have extremely delicate skin prone to injury.|
|b.||Preoperative skin condition was not assessed and documented.|
|c.||The relieving nurse did not receive a hand-off report from the circulating nurse.|
|d.||All of these options are contributing factors.|
All of the above factors could have collectively contributed to the skin injury. The skin condition could also have been present on admission to the OR and not seen or noted. Findings from sentinel event reports over the last 2 decades demonstrate that the individual efforts of the best nurses, surgeons, and anesthesia providers, combined with a recognized need for teamwork, may not be sufficient in the perioperative setting.
REF: Page 19
- 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 grams = 1.2 milliliters = 1.5 cc.|
|c.||Consider saline-soaked sponges equal to blood-soaked sponges when urine is involved in the operative field.|
|d.||Combine sponge weight values with irrigation measurement values to calculate estimated blood loss.|
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: Pages 39-40
- 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.|
Measure blood in the suction canister(s) at regular intervals, subtracting the amount of any irrigating solution used.
REF: Page 39
- 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. Point-of-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|
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: Pages 42-44
- 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.|
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: Page 45
- Which of the following situations requires informed consent from the patient/family?
|a.||Elective cosmetic surgical procedure|
|c.||Permission to photograph medically-related images during the procedure|
|d.||All of the options require consent.|
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: Page 45
- Select the appropriate order for administering blood and blood products.
|a.||Verify informed consent for blood, separate blood bag from identification slips, sign slips, verify identification 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|
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 identification 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: Page 41
- 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 lab efficiency.|
|b.||Send all specimens to the lab 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.|
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 lab. Formalin, a combination of methanol, water, and formaldehyde, is frequently used to preserve specimens if they are not taken to the laboratory immediately.
REF: Page 37
- Loss or mishandling of a surgical specimen could be considered negligence and could result in:
|a.||another surgical procedure.|
|b.||improper specimen analysis.|
|c.||improper specimen preparation.|
|d.||All of the above|
Communication errors pose significant risks to patients in the misidentification of a surgical specimen before its arrival in the pathology lab. These errors include the following: specimen not labeled, empty specimen container, incorrect laterality, incorrect tissue site, incorrect patient, no patient name, no tissue site.
REF: Page 37
- Ann Ames, RN, CNOR, and Joy Toll, CST, participated in a simulation on intraoperative counts, performing in their usual roles with Ann as the circulating nurse and Joy as the scrub person. They were determined to demonstrate best practice in performing surgical counts. They reviewed the unit practice standard and current AORN evidence-based guidelines. Select the appropriate order of counts that Ann and Joy demonstrated to their peers.
|a.||Joy counted the back table, Mayo stand, and sterile field while Ann counted the sponge bags and 3 in the kick bucket.|
|b.||Joy and Ann counted aloud together as Ann pointed to the sponges in the sponge bag and then as Joy touched each sponge, moving from back table to Mayo stand to sterile field.|
|c.||Ann and Joy each counted aloud as Joy pointed to items on the floor and kick bucket, and back table. To expedite the count Ann counted aloud as she pointed out the sponges in the sponge bag while Joy completed the back table.|
|d.||The surgeon searched the wound as Ann and Joy counted the floor, sponge bag, dip basin, kick bucket, back table, Mayo stand, sterile field, and the sponge wrapped around the new ostomy.|
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: Page 36
- As the placenta was delivered and the uterus prepared for closure, the scrub person gathered up all of her 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 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; however, it probably is an error in transcription.|
|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.|
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, and a search is made for the missing item, including the surgical wound, field, floor, linen, and trash (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: Page 36
- 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 addresses 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 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.”|
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, and a search is made for the missing item, including the surgical wound, field, floor, linen, and trash (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: Page 36
- Sandra Williams 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. Sandy was exercising her:
|a.||understanding and rights under the Patient Self-Determination Act.|
|b.||right to informed consent.|
|c.||autonomy to protect herself from negligence and malpractice.|
|d.||hope that everyone would honor HIPAA.|
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: Page 45
- Monica Sorensen, a 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 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. Monica insisted that her Do Not Resuscitate (DNR) status NOT be rescinded. She was conscious and competent and knew what was best for herself. Monica was taking full advantage of what provision for her care?
|a.||Patient Self-Determination Act|
|d.||Patient Self-Determination Act and advance directives|
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 Patient Self-Determination Act (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: Page 45
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 14: Genitourinary Surgery
- The renal artery and vein enter and exit the kidney on the medial side of the organ through a concave area known as the:
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. The renal pelvis, a funnel-shaped structure that lies within the kidney and posterior to the renal vascular pedicle, divides into several branches called calyces (Figure 14-3). The renal artery and vein with their accompanying nerves and lymphatics are referred to as the pedicle of the kidney.
REF: Page 478
- Select the statement about the prostate that best reflects its location, size, and weight.
|a.||The prostate sits adjacent to the urethra, is 2 to 4 cm in depth, and weighs about 25 g.|
|b.||The prostate sits below the urethra, is 2 to 3 cm in depth, and weighs 25 to 30 g.|
|c.||The prostate sits below the bladder, is 2 cm in depth, and weighs about 25 to 40 g.|
|d.||The prostate sits below the base of the bladder, is 4 cm at the base, and weighs 20 to 30 g.|
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. The gland is about 4 cm at the base, is about 2 cm in depth, and normally weighs 20 to 30 g (see Figures 14-5 and 14-7).
REF: Page 481
- The kidneys are highly vascular organs. Approximately how much of the entire circulating blood volume do the kidneys process at any one time?
|b.||1 ml per kg body weight|
|d.||30 ml per hour|
The kidneys are highly vascular organs that process approximately one fifth of the entire volume of blood at any one time.
REF: Page 481
- 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|
|d.||pituitary hormones; cortisol and norepinephrine|
Each adrenal gland has a medulla, which secretes epinephrine (adrenaline), and a cortex, which secretes steroids and hormones. Secretions from the adrenal cortex are influenced by the activity of the pituitary gland.
REF: Page 478
- 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.|
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: Pages 478-479
- 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.||All of the options are desired outcomes.|
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: Page 484
- 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. What 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.||This plan addresses all three outcomes.|
The outcome statement, “The patient will discuss fears and concerns regarding sexual function” is sensitive to the following nursing interventions: clarify the patient’s understanding of risks and benefits of the surgical procedure; provide an open, accepting environment for the patient to discuss potentially embarrassing issues; maintain patient privacy and dignity; consider making a referral for the patient to discuss options available to achieve sexual function.
REF: Page 485
- During urologic surgery large quantities of irrigating fluids are infused intraoperatively. An appropriate nursing intervention would include:
|a.||monitoring and recording the volume of 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.|
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 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: Pages 485, 488
- Shawna Bolten, 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 hand-off 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. Shawna’s immediate response should be:
|a.||no response; 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.|
When medications are used intraoperatively the containers should always be labeled with the medication name, strength, and concentration (when needed). During hand-offs, the medication verification process should take place. Local anesthetics that contain epinephrine should be used with caution in urology. Many urologic interventions involve “end-organs” (the scrotum, testicles, and penis). The use of epinephrine in these areas can result in an ischemic situation and should be avoided. Shawna immediately notifies the team that an inaccuracy has been detected.
REF: Page 486
- Justin Reynolds, a 26-year-old male with a ureteral stone, is transferred to the cystoscopy bed for a cystoscopy, ureteroscopy, and laser lithotripsy under fluoroscopy of a left ureteral stone. The circulating nurse assists Justin 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 Justin’s assistance, she 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 Justin 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.|
In some procedures involving stones of the kidneys or ureters, intraoperative fluoroscopy is used. When fluoroscopy (C-arm) is to be employed, 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: Page 487
- James Romano, 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 James’ room to complete his discharge instructions, which she began 3 days ago on his admission to the preoperative unit. Although James 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 James that he will soon demonstrate or regain a normal pattern of urinary elimination, what statement would best ensure that James will be able to accomplish his outcome?
|a.||James should learn catheter care and measures to facilitate voiding after catheter removal.|
|b.||The nurse should teach James about catheter care and how to void when it is removed.|
|c.||James should be able to “teach back” proper catheter care to the nurse.|
|d.||The nurse should demonstrate proper catheter care techniques.|
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 James teach back proper catheter care and provide time for questions and clarification about home care.
REF: Pages 485, 493
- Prostate cancer is the most frequently diagnosed cancer in men and is the 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 and Jamaican descent, low-fat diet, no family history|
|d.||45 years old, African descent, low-fat diet|
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 old, 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 first-degree relatives with prostate cancer.
REF: Page 512
- 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 what 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.||All of the options define the AUA score system.|
The American Urological Association (AUA) recommends that starting at age 40 the prostate-specific antigen (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 = clinically unsuspected disease; stage B = tumor confined to the prostate gland; stage C = tumor localized to the periprostatic area; stage D = metastatic prostate cancer.
REF: Page 514 (Box 14-2)
- 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, the more aggressive the cancer.|
|d.||The Gleason score is determined by doubling the AUA score.|
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. Men with a Gleason score of 2 to 4 are generally cured by surgery; scores from 5 to 6 indicate mildly aggressive cancer cells; a score of 7 indicates the cancer is moderately aggressive. Scores between 8 and 10 indicate highly aggressive tumors and are associated with a poor prognosis after surgery (Epstein, 2007).
REF: Pages 513-514
- Wilber Johnson, an 84-year-old retired musician of Jamaican descent, was seen by his family practice physician for urinary problems. His physician performed a digital rectal exam (DRE), which was abnormal, ordered a PSA, and referred him to a urologist. Wilber’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 surgical treatment plan for Wilber?
|a.||Transurethral resection of the prostate (TURP)|
|b.||Simple perineal prostatectomy|
|c.||Radical open prostatectomy with lymph node dissection|
|d.||No surgery. Wilber is not a candidate for surgery.|
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 (Epstein, 2007). 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: Pages 484, 513
- 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,” what 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|
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: Page 549
- In transurethral resection of the prostate gland (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|
TURP is one surgical method of treating benign obstructive enlargement of the prostate gland. If the prostate gland is cancerous, a radical retropubic or radical perineal prostatectomy, in conjunction with open or laparoscopic pelvic lymph node dissection, is usually performed. TURP may also be used in men who cannot have a radical prostatectomy, or to relieve symptoms caused by prostate cancer before other treatments are initiated.
REF: Page 513
- High-intensity focused ultrasound (HIFU) is a noninvasive technique used in the treatment of prostate cancer. HIFU is a targeted therapy that is highly focused into a small area without causing collateral tissue damage. Aside from primary therapy, HIFU can be used as salvage therapy, primarily after radiation. HIFU can be performed as an outpatient procedure, often with an epidural anesthetic. The HIFU-directed energy modality is best described as:
|a.||high-temperature nonionizing thermal energy.|
|b.||cavitation of the prostate cell cytoplasm by the implosion of microscopic bubbles.|
|c.||mechanical shearing force of ultrasonic waves.|
|d.||radiofrequency coagulation of prostatic cell nuclei.|
HIFU is highly focused into a small area, creating intense heat of 80° to 100° C, which is lethal to prostate cancer tissue. HIFU destroys tissue by heat, rather than by cavitation or mechanical shearing. Since ultrasound is nonionizing, there is no collateral tissue damage.
For the majority of patients, HIFU is indicated as a curative therapy. The best candidates are clinical/pathologic stages T1c to T3. Because of the limited focal length of HIFU, gland volume cannot be 40 ml or larger. Aside from primary therapy, HIFU can be used as salvage therapy, primarily after radiation. HIFU can also be repeated without any increase in risk or complications.
REF: Page 513 (Research Highlight)
- A wide variety of ureteral and urethral 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?
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: Page 491
- 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 or sibling or parent, ABO and HLA compatibility, good health|
The kidney donor must be in good health. ABO (blood typing) and histocompatibility (human leukocyte antigen [HLA] tissue typing) along with a negative white cell (lymphocyte) crossmatch determine donor-recipient 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 (UNOS, 2009). 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: Pages 559-560
- Although each potential kidney transplant recipient is judged individually as a candidate, which condition from the list below would most likely eliminate a patient as a candidate for kidney transplant?
|c.||Post-treatment cancer in remission|
Each potential recipient is judged individually in regard to kidney transplantation. Most persons younger than 55 years are acceptable; older patients are less tolerant of postoperative complications. The following are contraindications for renal transplantation: systemic disease that precludes major surgery, oxalosis (a metabolic disorder), a positive HLA cytotoxic antibody screen, untreatable cardiovascular disease, active cancer, and noncompliance.
REF: Page 562
- 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.
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: Page 488
- 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.|
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: Page 488
- 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.
|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
The flexible cystoscope (Figure 14-16) is used for patients with obstructive symptoms resulting from prostatic hyperplasia and a 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: Page 487
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 30: Workplace Issues and Staff Safety
- What one factor describes the high incidence of musculoskeletal disorders 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|
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: Page 1258
- 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. Essentially, what is the recommended maximum weight limit for one person in a patient handling task? 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.||37 lb; wear a support belt|
|d.||35 lb; use assistive lift devices|
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: Page 1261
- 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.|
Anticipatory 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: Pages 1261-1262
- A 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?
|c.||Uneven floor surface|
Hospitals should ensure that there are no uneven floor surfaces, including thresholds, on floors. While 36% of same-level incidents occurred because of floor contaminants such as wet floors, the remainder (64%) of the falls on the same level occurred at transition areas, such as from dry to wet, on uneven floor surfaces, or from one type of floor surface to another. Hospitals should ensure that there are no uneven surfaces, including thresholds, on floors.
REF: Page 1262
- 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:
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: Page 1265
- 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.|
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: Page 1265
- Select the true statement that best explains the OSHA exposure control plan.
|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 exposure control plan is similar to 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 exposure control plan is designed to provide guidelines to control risks and protect workers from sharps injury and bloodborne pathogens.|
|d.||The OSHA exposure control plan is a materials management strategy to explore replacements for sharps and other healthcare devices that can cause sharps injury and blood exposure.|
OSHA regulations require healthcare organizations to protect their workers and to have a sharps injury and bloodborne pathogen exposure control plan (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 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: Pages 1265-1266
- 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 exposure control plan was designed to provide the framework for the culture of safety.|
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 (CDC, 2008b).
REF: Page 1267
- Select the guideline that complements the design of the culture of safety model.
|a.||Take advantage of a personal injury event to educate yourself 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.|
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 exposure control plan. Finally, follow the exposure control policy if injured, including immediate reporting of the incident and commencement of exposure response procedures.
REF: Page 1267
- What is the purpose of a Material Safety Data Sheet (MSDS)?
|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 survey|
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 Material Safety Data Sheets (MSDSs) for all chemicals and mixtures of chemicals (OSHA, 2009).
REF: Pages 1273-1274
- Where are the sources of radiation exposure in an operating room setting?
|a.||Ionizing sources (e.g., ultrasound machines) and nonionizing sources (e.g., 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)|
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: Page 1277
- Which of the following may be a consequence of high-dose or full-body radiation?
|a.||Radiation poisoning, heart disease, stroke, and death|
|b.||Nausea, vomiting, diarrhea, and weakness|
|c.||Cancer and mental retardation in children of mothers exposed during pregnancy|
|d.||All of the options are possible consequences of high-dose or full-body radiation|
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. Ionizing radiation at high doses may also lead to cancer and mental retardation in children of mothers exposed during pregnancy, and it has been linked to other health effects such as heart disease and stroke.
REF: Page 1277
- 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. What types of 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|
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: Page 1278
- Charlene Majors is an anesthesia provider with 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 Charlene have?
|a.||Allergic contact dermatitis|
|b.||Irritant contact dermatitis|
|c.||Type I IgE-mediated hypersensitivity reaction|
|d.||Combined-effect latex allergy|
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. A true latex allergic response is immediate, IgE-mediated, 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: Page 1278
- Healthcare professionals should employ strategies to reduce their risk of allergic reaction to latex in the perioperative environment. Select a best practice for minimizing the risk of latex allergy development in nonallergic patients, and the risk of 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.||Use nonlatex gloves for activities not likely to involve contact with infectious materials.|
|d.||Wear an OR hat without an elastic band and do not wear rubber tennis shoes.|
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. Do not use oil-based hand creams or lotions when wearing latex gloves, which can cause glove deterioration.
REF: Page 1278
- Linda Gardner is highly allergic to latex and the anesthesia provider plans to give Linda prophylactic medications before anesthesia. What medications might be administered to Linda in the preoperative holding area?
|a.||Epinephrine and an H2-blocker|
|b.||Vasopressin and atropine|
|c.||Prednisone and a beta-agonist inhaler|
Prednisone can be given as a prophylactic medication before surgery. 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: Page 1280
- 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.|
|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.|
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. The CDC developed a single set of precautions incorporating the major features of Universal Precautions and Body Substance Isolation (BSI) (CDC, 1996). Universal Precautions, for the first time, applied Blood and Body Fluid Precautions to all individuals, regardless of infection status (CDC, 1996).
REF: Pages 1274-1275
- Contact with infected patients or infectious material places healthcare workers at risk for occupational-acquired infection. Many diseases and infections can be prevented through immunizations and vaccines. What group of communicable diseases are healthcare workers at risk for acquiring or transmitting?
|a.||Tuberculosis, hepatitis A, meningococcal disease, and typhoid fever|
|b.||Tetanus and diphtheria|
|c.||Hepatitis B, influenza, measles, mumps, rubella, varicella, and pertussis|
Healthcare workers are found to be at risk for acquiring or transmitting HBV, influenza, measles, mumps, rubella, varicella (CDC, 1997), and pertussis (CDC, 2006b). By receiving the seasonal influenza vaccination, healthcare workers protect themselves, their patients, and their families. Routine immunization of healthcare workers against tuberculosis, HAV, meningococcal disease, typhoid fever, or vaccinia is not currently recommended by the Advisory Committee on Immunization Practices (CDC, 1997). There is currently no vaccination for HCV.
REF: Pages 1276-1277
- What vaccine should healthcare workers receive if they are caring for immunocompromised patients?
|a.||Live attenuated influenza vaccine (LAIV)|
|b.||Inactivated influenza vaccine|
Healthcare workers caring for severely immunocompromised patients should receive inactivated influenza vaccine. Live attenuated influenza vaccine (LAIV) is currently available for workers in healthcare professions. LAIV is approved only for nonpregnant healthy persons ages 5 to 49 years (CDC, 2006a). Instead, the inactivated influenza vaccine is the preferred vaccine when workers have direct contact with this group of patients (CDC, 2006a). Bordetella is a gram-negative coccobacilli of the phylum Proteobacteria and the most common cause of tracheobronchitis (kennel cough) in dogs.
REF: Pages 1276-1277
- Teamwork is a major component of OR efficiency, quality of care, and patient safety. The Joint Commission has reported breakdowns in communication as a leading cause of adverse events and errors. A study on teamwork in the operating room, in 2008, measured such domains as difficulty speaking up, conflict resolution, nurse-physician collaboration, feeling supported by others, asking questions, and heeding nurse input. On analysis, the researchers found:
|a.||teamwork climate variability was greater within hospital OR levels than between hospitals|
|b.||surgeons and anesthesiologists were more satisfied with physician-nurse collaboration than were nurses|
|c.||OR nurses and CRNAs gave high ratings of the teamwork climate given by physicians|
|d.||there were discrepant attitudes about collaboration between the nurses and nurse anesthetists (CRNAs)|
Surgeons and anesthesiologists were more satisfied with physician-nurse collaboration than were nurses. OR teamwork climate variability was greater between than within hospital OR levels. OR nurses and CRNAs did not reciprocate the high ratings of teamwork climate given by physicians. The findings of this study add a research tool for assessing teamwork in the OR and include greater detail to more general reports of discrepant attitudes about collaboration between physicians and nurses.
REF: Page 1281
- 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 risk reduction strategies reflect appropriate nursing actions?
|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
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: Pages 1263-1265
- AORN has developed a list of risk reduction strategies that the perioperative nurse and surgical technologist can use to protect themselves from exposure injuries during surgery. Which safe sharp handling practices reflect true statements that are appropriate intraoperative nursing actions for the scrub person?
|a.||Wearing a double layer of gloves|
|b.||Keeping track of, and accounting for, all sharp items throughout the procedure|
|c.||Using blunt suture needles|
|d.||Counting sharps only twice during the procedure to restrict handling and contact|
|e.||Giving verbal notification when passing a sharp device|
|f.||Passing sharp items using neutral/hands-free techniques instead of passing hand to hand|
ANS: A, B, C, E, F
During the procedure use the following practices to reduce sharps injuries: Use neutral or hands-free techniques for passing sharp items, instead of passing hand to hand. Give verbal notification when passing a sharp device. Be aware of other sterile team members in and near the area when handling a sharp device. Keep track of, and account for, all sharp items throughout the procedure. Keep hands away from the surgical site when sharp items are in use (i.e., suturing, cutting). AORN advises double-gloving during invasive procedures, noting that 18 clinical trials have demonstrated that double-gloving minimizes the risk of exposure to blood and that double-gloving reduces by as much as 87% the risk of exposure to blood and body fluids if the outer glove is punctured. All published studies to date have demonstrated that the use of blunt suture needles can substantially reduce or eliminate needlestick injuries from surgical needles.
REF: Page 1263
- 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. Select the appropriate risk reduction strategy that protects the environment and perioperative worker from exposure to ambient waste anesthetic gas.
|a.||Check the anesthetic delivery system for irregularities or breaks.|
|b.||Turn off the room or local ventilation system.|
|c.||Ensure that the scavenging system is properly connected to the gas outlet.|
|d.||Ensure proper facemask fit before delivering anesthesia gas.|
|e.||Turn the breathing system off before turning off the gas.|
|f.||Use high-flow gas delivery for more rapid induction.|
ANS: A, C, D
OR workers must know the risks, potential health effects, and precautions that should be taken. The following steps can be initiated before anesthesia induction to reduce exposure to waste anesthetic gases (WAGs): Inspect the anesthetic delivery system before each use, looking for irregularities or breaks in the system. Activate the room or local ventilation system. Ensure scavenging equipment is properly connected. Connect the gas outlet to the central scavenging system. Ensure proper facemask fit before delivering anesthesia gas. Turn the gas off first before turning off the breathing system. Use the lowest anesthetic gas flow rates possible for proper functioning of the anesthesia delivery system and for patient safety. Avoid very high anesthetic gas flow rates to prevent leaks because high-flow rates generate more waste anesthetic gases than low-flow rates.
REF: Pages 1267, 1273
- Number the corrective actions in the appropriate order in which they should occur in the event of a staff person receiving a needlestick injury.
____ a. Identify the source patient.
____ b. Undergo immediate testing; ensure confidentiality for HIV, HBV, and HCV infections.
____ c. Alert the supervisor of the injury.
____ d. Document the exposure in detail, for the staff member’s records as well as for the employer.
____ e. Wash wound with soap and water; flush mucous membranes.
_____f. Immediately report to employee health, the emergency department (ED), or the designated facility.
1 = E
2 = C
3 = A
4 = F
5 = B
6 = D
When 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 begin the following procedures immediately: (1) Wash with soap and water all wounds and skin sites that have been contacted by blood or body fluids. Flush mucous membranes with water. (2) Alert your supervisor and initiate the injury reporting system used in your workplace. (3) Identify the source patient; this patient should be tested for HIV, HBV, and HCV infections. (4) Immediately report to employee health, the emergency department (ED), or the designated facility. (5) Get tested immediately and confidentially for HIV, HBV, and HCV infections. (6) Document the exposure in detail for your own records, as well as for the employer and for workers’ compensation purposes.
REF: Pages 1266-1267