Alexander’s Care of the Patient in Surgery 16 Th Edition By Jane Rothrock – Test Bank
Chapter 04: Infection Prevention and Control Test Bank
- Surgical site infections (SSIs) are most often caused by gram-positive cocci and may arise from the patient’s own endogenous The most typical causative microorganism cultured from SSIs is:
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
- 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 The surgeon expects that the result will show a gram-positive coccus. This Gram stain designation is based on the:
- ability to cause plasma to coagulate and form a microscopic
- physical and chemical properties of the cell
- formation of aerobic clustered
- appearance of a thicker and brownish-colored cell
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
- The hospital epidemiologist was alerted when several cultures had recently revealed suspicious 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?
- The female patient because she is immunocompromised and elderly and has
- The male patient because he has pilonidal sinus tracts from sacral pressure caused by racing
- The female patient because she has a mixed microorganism culture that is coagulase-negative
- The male because he has a high microbial load that is coagulase-positive
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
- 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 given intravenously within 1 hour of the incision for every procedure with an incision or entered body system
- Vancomycin paste applied to cut edges of the sternum in cardiac surgery
- Tobramycin and methylmethacrylate bead implants into deep orthopedic incisions at risk for osteomyelitis
- Bacitracin ointment on a clean subcuticular sutured incision as part of the dressing
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
- The Centers for Disease Control and Prevention (CDC) have identified pathogens that could pose a threat to national and world security and safety through Select the four most probable agents that could be used to cause mass transmission, mortality, panic, and social disruption.
- Anthrax, tuberculosis, difficile, tularemia
- Smallpox, plague, botulism, tularemia
- Smallpox, monkeypox, avian influenza, anthrax
- Anthrax, H1N1 influenza, botulism, smallpox
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
- An 86-year-old male was admitted to the intensive care unit (ICU) 3 weeks ago for heart failure and intractable atrial 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?
- Contact precautions with eye protection
- Both standard precautions and contact precautions
- Body substance isolation
- Droplet precautions with standard isolation technique
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
- 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 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?
- Plague and tuberculosis
- Smallpox and tuberculosis
- Ebola virus and monkeypox
- Anthrax and smallpox
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
- Positive-pressure air handling systems with unidirectional flow of non-recirculated air from the ceiling to the floor are designed to:
- create mild air turbulence to prevent dust from settling on
- augment the oxygen-enriched environment with dust-free ai
- flow clean air over the patient and prevent corridor air
- redirect and absorb ambient anesthetic
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
- The design of the physical space within an OR attempts to minimize horizontal surfaces by placing cabinets flush with the 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:
- mobilize resting dust from these
- contaminate unsterile
- disrupt the multidirectional
- mobilize material from the sterile back
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
- All surgical patients present with the risk for hypothermia from a variety of factors inherent in the surgical 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.
- Surround the patient with a forced air–warming blanket and foil head
- Set the ambient room temperature between 68° and 73° F and limit
- Line the OR bed with a circulating fluid mat and insert a rectal temperature probe
in the patient.
- Cover and surround the patient with several warm bath blankets and change them at frequent
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
- The mechanism of lethality (microbial death) with steam sterilization is achieved with this
- Time, temperature, and steam pressure
- Reduced and limited mitosis within the bioburden
- Saturated vaporization of the microbial cytoplasm
- Denaturation and coagulation of enzyme proteins
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
- Within a steam sterilizer, at a temperature of 100° C (212° F), the water condensation and the steam are the same This scientific phenomenon is called
and will .
- steam saturation; not kill microorganisms
- steam distribution; promote microbial kill
- sterilization; kill all microorganisms to 106
- saturated steam; kill microbes at 106
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 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
- With the production of more steam in the sterilizer chamber, the pressure increases as 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:
- 70% or
- 55% or greater
- <3% of the mixture is liquid
- <1% of the mixture is liquid
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
- Sterilization prepares instruments to be used within, and on, sterile It kills vegetative microorganisms and endospores within a probability of 106. The process of decontamination prepares instruments to be:
- handled without
- free of
- clean at a high level of
- Used on nonsterile ear, nose, and throat (ENT)
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 high- pressure 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
- Qualities of an effective packaging material must include several key Select the three most important qualities.
- Cost, good microbial barrier, lint-free writable surface
- Good steam penetration and removal, good microbial barrier, aseptic presentation
- Aseptic presentation, event-related sterility indicators, writable surface
- Stackable in sterilizer/storage shelf, comparable cost, low toxicity
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
- The final step, after decontamination and before sterilization, is the prep, pack, and wrap 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.
- Air-dry, inventory, inspect, lubricate, assemble and string instruments, wrap and tape
- Inspect, unlock locked clamps, count and string instruments, place indicators, wrap and tape
- Inspect, unlock locked clamps, string instruments, inventory, replace missing items, wrap
- Inspect, inventory against list, assemble, place integrators, wrap and tape
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
- Both sterilization and disinfection describe the elimination of microbial contamination and the achievement of a state suitable for patient care in select However, disinfection differs from sterilization in that the process for disinfection uses:
- contact precautions as well as universal
- hospital-grade disinfectant/sterilants.
- semicritical medical devices used for ambulatory
- agents to disinfect and eliminate most, if not all, pathogenic
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
- An integrator is a multiparameter indicator designed to measure:
- time and
- pressure, steam, and
- temperature, time, and presence of
- sterility and
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
- The evening before the procedure was scheduled, the central sterile processing department received two complete sets of an orthopedic spine fusion system that contained titanium- implantable instrumentation, four flexible coated retractor blades, and an unsterilized internal paper inventory 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:
- hydrogen peroxide gas plasma sterilization for
- steam sterilization for the implant sets and paper inventory form, hydrogen peroxide gas plasma for the retractors, wrapped
- steam sterilization for the implant sets, hydrogen peroxide gas plasma for the retractors and paper inventory form, wrapped
- steam sterilization for everything with a shortened dry
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
- The scrub person is preparing to self-don a wraparound sterile gown before Select the best practice to follow for the self-gowning procedure?
- Hold the gown away from the body and allow it to unfold with the outside toward the wearer
- Keep hands on the outside of the gown as it completely unfolds
- Slip one hand into an open armhole at a time, while using the other hand to hold the shoulder of the gown in place
- Push the hands and forearms into the sleeves, advancing the hands just to the proximal edge of the
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
- The skin preparation for a vaginal-assisted laparoscopic hysterectomy begins
before and after the procedure.
- at the vagina and perineum; the nurse should check with the anesthesia provider before touching the patient
- 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
- at the cleanest area first and proceeds to less clean areas (abdomen then vagina/perineum); a skin assessment should be performed
- at the vagina and perineum first with urinary catheter insertion and then proceeds to the pelvic abdomen; a skin assessment should be performed
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
- Closed gloving is the technique of choice for the initial donning of sterile gloves by the scrubbed team member; however:
- it can only be used for the initial
- it requires two people to execute without
- there is a risk of contamination if the thumbs are not
- it is only used by scrubbed registered nurses (RNs) and surgical
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
- Which glove lubricant, used to facilitate easy donning, is considered a best practice?
- Sterile talcum powder
- Sterile corn starch powder
- Sterile silicone powder
- Glove lubricant is not
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
- Which of the following lists the correct order of the proper steps in the removal of soiled sterile attire when breaking scrub?
- Mask, gown, gloves, shoe covers
- Gown, lead apron, shoe covers, mask, gloves
- Mask, gown, hat, gloves
- Gown, gloves, mask
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
- 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 Which choice lists the appropriate first three steps in the removal of the sterile gown?
- Wipe gloves clean, untie side gown closure, grasp gown at one shoulder seam
- Wipe gloves clean, grasp gown at both shoulder seams, pull over and off arms
- Unfasten gown back closures, grasp gown at one shoulder seam, pull down over both arms and gloves while everting glove cuffs
- Grasp both gown shoulders, slide gown down over arms, grasp gloves inside gown sleeves and pull gown and gloves off
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
- Describe the best practice for aseptic removal of sterile gloves after removal of the sterile gown at the end of the Select the best practice to protect the wearer from cross- contamination.
- Remove both gloves together using the gloved fingers of one hand to secure the everted cuffs of the other hand, turning both gloves inside Discard gloves in regular trash since they are inside out. Remove mask by the ties and wash hands.
- Using the gloved fingers of one hand to secure the everted cuff, remove the glove, turning it inside 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.
- Remove both gown and gloves in the decontamination area and wash hands
- Remove the gown in the OR before transferring the case cart to the decontamination area, where the gloves are removed and
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
- The surgical hand scrub is designed to:
- render the hands, nails, and arms surgically
- target a narrow range of
- work slowly and depend on cumulative
- fully sterilize the skin on the hands and
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
- Decontamination of the hands can be done by a variety of 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.
- Use an alcohol-based hand
- Use an anatomic scrub, with a prescribed number of strokes plus
- If using a brush, its bristles should be as stiff as can be tolerated by the
- Sponges are no longer recommended for surgical hand hygiene because they have been linked to skin cell
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
- Which of the following choices reflects the appropriate order of four of the steps in preparing for the surgical hand scrub procedure?
- Wash hands and wrists, remove jewelry, replace mask and eye protection, contain
- Contain hair and earrings in hat, wash hands and clean under nails, place mask and eye protection, remove jewelry
- Remove jewelry, contain hair, don fresh mask and eye protection, wash hands and forearms
- Don fresh mask, contain hair, place eye protection, clean under nails
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
- If a sterile glove becomes contaminated during the procedure, the best practice for corrective action is:
- regloving with open-glove or assistive glove
- regloving with closed-glove
- removing gown and gloves and regowning and
- placing a new sterile glove over the contaminated
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
- 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 Select the correct statement that refers to double gloving in terms of a best practice.
- The CDC endorses double gloving only when nonlatex gloves are
- Wearing two glove layers permits regloving using the closed-glove technique for a contaminated
- Wearing a glove liner between both layers of gloves may eliminate the risk of perforation to the inner glove, protecting the wearer from sharps
- Double gloving is the best practice that can protect both the healthcare provider and the
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
- Sterile surgical drapes are used to create the sterile field, protecting the patient from endogenous and exogenous sources of Which action is essential to maintaining the sterile field?
- Providing barrier protection from microorganisms, fluid, and particulate matter
- Limiting environmental impact and flammability
- Ensuring a fiscally responsible cost/benefit ratio and reducing glare
- Selecting drapes that do not exhibit “memory” folds
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
- When applying sterile drapes to create the sterile field on the patient, which of the following principles is most important?
- The circulating nurse should monitor the scrub person’s gowned arms when reaching over the sterile parts of the
- Gently shake and fan out the drapes to open up the folds before approaching the
- Drape the patient starting with the incision area and proceeding to the
- Drape the far side
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
- The transplant team received the liver from the procurement team moments after it arrived by medical air 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?
- 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
- The patient should have been held in preoperative holding until the liver was split and the second segment placed back into the
- The back table should have been covered with sterile drapes and moved to a second available
- 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
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
- Effective instrument decontamination is dependent on a particular sequence designed to lower bioburden to the lowest What is the first step in processing a basic set of laparotomy instruments through decontamination?
- Rinse with cold water in deep
- Remove and discard all disposable
- Wipe instruments with sterile water during surgical
- Transport in closed container to decontamination
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
Chapter 06: Positioning the Patient for Surgery Test Bank
- A 325-pound male is scheduled for a 6-hour abdominal 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?
- The scrub person leaning with his or her forearm on the Mayo stand
- A self-retaining retractor post clamped to the OR bed rail and tightened against the patient’s side
- A Deaver retractor and two right angle clamps placed on the patient’s thighs when draped
- Full-leg sequential compression wraps on both legs throughout the entire surgery
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
- A 325-pound male is undergoing a 6-hour abdominal 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 shearing force injury to the tissue from having been slid into position
- Skin creases from wrinkled sheets
- Incontinence from an inadequate bowel prep
- Side-to-side striations across his back and buttocks from the lifting sheet
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
- 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 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?
- Heat and moisture from prolonged bed rest
- Pressure of his elbows resting on the bed for 2 days
- Friction from his elbows rubbing over the sheets when slid up in bed
- Negativity from the bath blankets the nurses stacked to make arm rests for the patient
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
- Select the nursing activity that would reduce the impact of an extrinsic factor that could cause a pressure injury to the
- Assisting the anesthesia provider with checking and hanging albumin before anesthesia induction
- Washing the patient’s back, heels, scapulae, and elbows with chlorhexidine gluconate (CHG) wipes before transfer to the OR bed
- Fluffing the surface of the OR bed with warm bath blankets and eggcrate foam before patient transfer to the OR bed
- Removing all but one layer of linen from the dry polymer elastomer gel mattress surface of the OR bed before patient transfer
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
- A 92-year-old frail female nursing home patient was admitted for dehydration, anemia, and respiratory 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?
- Shearing force factors
- Intrinsic factors
- Bed rest precaution factors
- Extrinsic factors
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
- Recent studies on the relevance of the Braden pressure ulcer risk scale in the perioperative and critical care setting are In which perioperative setting would the Braden scale be most predictive as a baseline metric?
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
- A patient undergoing a laparoscopic Nissen fundoplication procedure will be positioned in both high and low lithotomy during the After the patient is repositioned into low lithotomy, the perioperative nurse should:
- position the patient back in supine before repositioning in low
- reposition as quickly as possible to avoid pressure
- reprep and redrape after
- reassess the patient for body alignment, tissue integrity, and pressure
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
- A 14-year-old patient with marked scoliosis is in prone position with gel bolster rolls, gel pads, and pillows for a spinal Before the skin prep is begun, the perioperative nurse should check the positioning for pressure areas on the:
- genitals, knees, toes, and
- breasts, forehead, and
- genitals, breasts, toes, eyes, and all areas in contact with the OR bed or
- forehead, toes, and
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
- The circulating nurse instructed the new anesthesia resident in the proper positioning of the arm and hands on the OR bed She cautioned him to avoid pressure on the elbow to prevent:
- ulnar nerve
- radial artery
- radial nerve
- pressure sore of the
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
- Prolonged lithotomy positioning can result in neuropathies of the The most frequently
injured nerves are the obturator, sciatic, femoral, and
nerve, which can result
in injury from .
- tibial; hyperextension
- common peroneal; full leg pneumatic compression sleeves
- iliopsoas; hyperabduction and contact with candy cane stirrup pole
- patellar; deep tissue injury from contact pressure with underside of Mayo stand
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
- The lateral kidney position allows approach to the retroperitoneal area of the 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.
- head; vena cava
- foot; dependent ureter
- kidney bridge; vena cava
- kidney bridge; renal artery
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
- While Fowler’s position offers the best respiratory excursion for the patient, the patient is at
higher risk for
- venous thromboembolism (VTE)
- sacral ischemia
- restless leg syndrome
- compartment syndrome
because of dependent pooling in the hips and legs.
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
- 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 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?
- Diminished lung capacity of nondependent lung
- Celiac plexus injury
- Decreased blood return to the right side of the heart
- Scalene node rupture
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
- 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
arm and under the .
- around; body
- under; mattress
- over; mattress
- around; OR bed rail
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
- A 52-year-old 425-pound male patient is scheduled for surgery at the bariatric surgery center in 3 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.
- 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
- 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
- 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
- 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
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
- A frail and thin 91-pound, 83-year-old woman is scheduled for a right pneumonectomy for non–small cell lung 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.
- 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
- 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
- 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
- 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
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
- Positioning devices should be used according to the original equipment manufacturer’s instructions to reduce the capillary interface pressure to below:
- 40 mm
- 32 mm
- 50 mm
- 100 mm
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
- Select three basic criteria requirements that an OR bed mattress must
- Nonallergenic, pressure-reduction capabilities, radiolucent
- Electrically conductive, latex-free, black
- Nonflammable, compatible with warming/cooling devices, black
- Fluid resistant, bactericidal, pressure-reduction capabilities
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
- Select the positioning device and accessory commonly used for neurosurgical
- Cavitron ultrasonic surgical aspirator (CUSA) head positioner
- Crutchfield cranial tongs
- Mayfield head positioner
- Cushing head stabilizer
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
- Select the positioning devices and accessories commonly used for bariatric
- Air-filled, roller, or slider transfer device
- Lower body ramp
- Elevated padded heel supports with foot board
- Abduction pillow
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
- 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 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)
- Respiratory compromise and ventilation resistance
- Pelvic pressure from abdominal organs
- Shearing injury to soft tissues
- 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
- 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 These measures included (Select all that apply.):
- Locking the remote control for the OR bed and placing it in a secured
- Place patient directly on gel overlay without a sheet
- Use a vacuum-packed positioning device (beanbag)
- 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
Chapter 11: Gastrointestinal Surgery Test Bank
- Select the statement that best describes the functional components of the gastrointestinal (GI)
- The GI tract is a continuous pathway from mouth to
- Peristaltic waveforms produce agitation, which digests large food
- The alimentary canal extends from the mouth to the
- The microscopic ecosystem of the GI tract is an unbalanced colony of
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
- A patient whose neck has been slashed and has a severed lower trachea may also have injury to the:
The esophagus begins at C6 and passes through the neck posterior to the trachea.
REF: p. 295
- Exposure of intra-abdominal anatomy is crucial to safe surgery and employs varied instruments, applications of highly technical energy sources, patient manipulations, light, and Review the list below and select the technique that is initiated to promote exposure.
- Insertion of self-retaining retractors
- Employing the Hasson technique
- Establishing pneumoperitoneum
- Insertion of fan retractor
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
- When compared with open and laparoscopic techniques, the potential benefits of NOTES include no visible scars, possibly less pain, and potentially shorter hospital Select a complication that is the most typical risk associated with NOTES.
- Paralytic ileus
- Intestinal obstruction
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
- 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 Review the list below and select the nursing diagnosis that is most closely related to bowel isolation technique.
- Risk for infection
- Risk for metastasis
- Risk for tissue injury
- Risk for positional injury
Bowel technique, also referred to as contamination or isolation technique, prevents cross- contamination 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
- 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 This practice is designed to meet the expectation for the following nursing outcome: The patient will be free from injury due to:
- fluid and electrolyte
- thermal burns and
- impaired tissue
- thermal burns and adhesions and impaired tissue
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
- A 72-year-old male is scheduled for a total colectomy with ileostomy in the 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:
- deficient knowledge related to surgical energy
- disturbed body image related to intestinal
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
- Which statement about the McBurney incision is most correct?
- It is an oblique inguinal incision in the left lower
- It is the incision of choice to repair a direct inguinal
- It is an oblique inguinal incision in the right lower
- The direction is more transverse than
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 one- third of the distance between the anterior iliac spine and the umbilicus.
REF: p. 308
- Triangular orientation is a term used to describe the method used to provide instrument access to the anatomy during abdominal It is uniquely associated with which surgical incision?
- Mid-epigastric transverse incision
- Left paramedian incision
- Thoracoabdominal incision
- Laparoscopic port incisions
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
- 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:
- epiploic branches of the peritoneal
- gastric branches of the gastroepiploic vessels
- gastric branch of the peritoneal
- Treitz arterial
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
- Two patients are scheduled to have a gastrojejunostomy for How will perioperative planning differ for a patient weighing 280 lb as compared to that for a 120 lb patient?
- The ligament of Treitz will not need to be identified in a lighter
- Forced air–warming devices are more important for a lighter
- The anastomosis will require sutures rather than staples for the heavier
- Deaver retractors will replace Richardson retractors with the heavier
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
- A 42-year-old woman has been diagnosed with severe gastroesophageal reflux disease (GERD) without the dysplastic changes of Barrett’s 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?
- Thoracoabdominal partial esophagectomy
- Endoscopic mucosal resection
- Intraluminal plication of the lower esophageal segment
- Heller’s myotomy
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
- Pure NOTES procedures are transluminal procedures performed using flexible endoscopes and instruments passed through the scopes’ working Many surgeons use a hybrid NOTES technique. What is the difference between the pure NOTES and hybrid technique?
- Pure NOTES does not use the rectal
- Hybrid NOTES is laparoscopic
- Pure NOTES does not use the vaginal
- Hybrid NOTES considers the umbilicus a natural
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 3- or 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
- Select the diagnosis/procedure option that pairs the correct surgical diagnosis with the surgical/endoscopic procedure for diseases of the
- Barrett’s dysplasia of the distal esophagus/endoscopic mucosal resection (EMR)
- GERD/photodynamic therapy (PDT)
- Zenker’s diverticulum/Ivor Lewis esophagectomy
- Esophageal varices/Heller myotomy
EMR is the excision of dysplastic lesions related to Barrett’s esophagus (BE).
REF: p. 317
- Review the list below and select the answer that reflects the correct match between the procedure and the
- Duodenoscopy for gastric reflux disease and hiatal hernia
- Roux-en-Y for gastritis
- Esophagogastroduodenoscopy (EGD) for gastric ulcer disease
- Small bowel enteroscopy for ulcerative colitis
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
- A 12-year-old girl with a history of weight loss and stomach upset and pain after eating is also small for her 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?
- GI manometry
- Small bowel enteroscopy
- Capsule endoscopy
- Stretta procedure
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
- Select the option that pairs the correct surgical diagnosis with the surgical/endoscopic procedure for diseases of the
- Colon cancer/laparoscopic Roux-en-Y (RNY)
- Ascites/hyperthermic intraperitoneal antibiotic therapy (HIAT)
- Obesity/laparoscopic adjustable gastric banding (LAGB)
- Esophageal varicies/photo dynamic therapy (PDT)
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
- A 38-year-old female has been admitted through the emergency department (ED) for severe abdominal pain, distended abdomen, and 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.
- Keloidal mass of the mesentery
- Endometriosis plaques on the small bowel
- Small bowel obstruction with torsion
- Ruptured appendix
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
- A 55-year-old woman has arrived for an outpatient Stretta 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 :
- she is typed and screened; type and crossmatch
- her ride home arrives; a responsible adult
- she is NPO for 2 more hours; a bowel prep
- her esophagus is cleansed; return of gag reflex
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
- A patient consulted a noted colorectal surgeon after experiencing episodes of rectal bleeding over the last 2 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?
- Endoscopic retrograde cholangiopancreatoscopy (ERCP) with biopsies
- Rectal manometry with dilatation
- Flexible sigmoidoscopy with chromotherapy
- Colonoscopy with endoscopic ultrasound (EUS)
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
- A 19-year-old male has suffered from subsacral pain and swelling for 2 weeks and finally was referred to a colorectal surgeon for 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?
- Internal hemorrhoidectomy
- External hemorrhoidectomy
- Removal of rectal foreign body
- Pilonidal cystectomy
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.
REF: p. 346