Test Bank For Alexanders Care of the Patient in Surgery 14th Edition Rothrock

Test Bank For Alexanders Care of the Patient in
Surgery 14th Edition Rothrock
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Chapter 01: Concepts Basic to Perioperative Nursing
Test Bank
1. The Perioperative Patient Focused Model presents key components of nursing
influence that guide patient care. Select the statement that best describes the
dynamic relationship within the model.
The patient experience and the nursing presence are in continuous
b. Structure, process, and outcome are the foundation domains of the model.
c. The perioperative nurse is the central dynamic core of the model.
d. The interrelated nursing process rings bind the patient to the model.
The Perioperative Patient Focused Model consists of domains or areas of nursing
concern: nursing diagnoses, nursing interventions, and patient outcomes. These
domains are in continuous interaction with the health system that encircles the focus of
perioperative nursing practice—the patient.
REF: Pages 2-3
2. AORN’s Standards of Perioperative Nursing Practice that describe nursing
interactions, interventions, and activities with patients fall under which standards
Process standards relate to nursing activities, interventions, and interactions. They are
used to explicate clinical, professional, and quality objectives in perioperative nursing.
REF: Page 4
3. Which order best describes the process used to implement evidence-based
professional nursing?
a. Literature search, theory review, data analysis, policy development
b. Regional survey, literature search, meta-analysis, practice change
c. Identify problem, scientific evidence, develop policy, evaluate outcome
Identify issue, analyze scientific evidence, implement change, evaluate
Evidence-based practice is a systematic, thorough process by which to identify an
issue, to collect and evaluate the best evidence to design and implement a practice
change, and to evaluate the process.
REF: Page 12
4. The ambulatory surgery unit is planning to develop a standardized skin
preparation practice for their unit. The best process to gather scientific
information is to:
conduct a survey of skin prep policies at the next AORN chapter meeting.
review their surgical site infection data from the last 6 months.
conduct a literature search on antimicrobial agents and infection prevention.
review the scientific literature from the leading manufacturers of prep
Perioperative nurses have an ethical responsibility to review practices and to modify
them, based upon the best available scientific evidence, using research and other forms
of high-quality evidence to guide practice.
REF: Page 12
5. The cardiac team is developing a standardized sterile back table setup and is
unable to find sufficient research evidence for their project. Where might they
look for information on best practices?
Survey regional facilities that perform cardiac surgery for their back table
Review case studies and expert opinions on sterile back table setups.
Review AORN’s recommended practice on creating the sterile field.
All of the options are correct.
When there is not enough evidence to guide practice, perioperative nurses should
consider gathering information from varied trusted sources that reflect best practices.
REF: Pages 13-14
6. How do institutional standards of care, such as policies and procedures, differ
from national standards, such as AORN’s Standards of Perioperative Nursing
They are written by nurses.
They are written specifically to address responsibilities and circumstances.
They are collaborative and collective agreement statements.
They are rarely based on research.
Institutional standards apply to the system or facility that develops them and can be
directive about specific actions in specific circumstances; national standards provide
generalized authoritative statements that can be implemented in all settings.
REF: Pages 3, 12
7. Which of the following actions best describes an element of the perioperative
nursing assessment?
Scanning the surgical schedule for the day before morning report
Reading the pick/preference list attached to the case cart
Reviewing the patient medical record
Studying an on-line tutorial about the intended surgical procedure
Assessment is the collection of relevant health data about the patient. Sources of data
may be a preoperative interview with the patient and the patient’s family; review of the
planned surgical or invasive procedure; review of the patient’s medical record;
examination of the results of diagnostic tests; and consultation with the surgeon and
anesthesia provider, unit nurses, or other personnel.
REF: Page 5
8. Lonna Weber is a frail 76-year-old diabetic woman who is scheduled for major
surgery. She is vulnerable and at high risk for harm because of several factors
related to her preexisting conditions and overall health status. As part of
developing a plan to guide Lonna’s care, the nurse uses standardized descriptive
terms to guide care. This step of the nursing process is called:
nursing diagnosis.
nursing assessment.
nursing outcome.
nursing intervention.
Nursing diagnosis is the process of identifying and classifying data collected in the
assessment in a way that provides a focus to plan nursing care.
REF: Page 7
9. During the admission interview, the nurse initiated the discharge teaching and
demonstrated crutch-walking activities. The teaching activities are what stage of
the nursing process?
Nursing assessment
Nursing implementation
Nursing outcome preparation
Nursing evaluation
Implementation is performing the nursing care activities and interventions that were
planned and responding with critical thinking and orderly action. Implementation is the
“work” of nursing.
REF: Page 9
10. While conducting the preoperative interview with Clair Conners, a patient
scheduled for a septoplasty, the perioperative nurse learned that Clair was latex
sensitive. Based on this knowledge, the nurse reviewed the pick/preference list
and reassembled the surgical case cart setup to reflect this new information and
change in care delivery. Which two phases of the nursing process are
represented in the nurse’s actions?
Assessment and planning
Assessment and implementation
Planning and implementation
Nursing diagnosis and intervention
Planning is preparing in advance for what will or may happen and determining the
priorities for care. Planning is based on patient assessment results in knowing the
patient and the patient’s unique needs. Implementation is performing the nursing care
activities and interventions that were planned and responding with critical thinking and
orderly action. Implementation is the “work” of nursing.
REF: Pages 8-9
11. The perioperative nurse implements protective measures to prevent skin or
tissue injury caused by thermal sources. Successful accomplishment of this
intervention would meet which of the following desired nursing outcomes?
The patient is free from signs and symptoms of chemical injury.
The patient is free from signs and symptoms of electrical injury.
The patient is free from signs and symptoms of radiation injury.
All of the options are correct.
Chemical and thermal sources used in surgery can cause skin and tissue burns (e.g.,
electrosurgery, povidine-iodine, radiation, lasers). The patient is free from signs and
symptoms of chemical injury, radiation injury, and electrical injury are approved
NANDA-International nursing diagnoses.
REF: Pages 8, 10
12. The nursing diagnosis is derived from:
a. patient data retrieved from the nursing assessment.
b. synthesized clues from the admitting diagnosis and surgery schedule.
the approved NANDA-International list attached to the patient medical
d. the admission form on the front of the chart.
Nursing diagnosis is the process of identifying and classifying data collected in the
assessment in a way that provides a focus to plan nursing care.
REF: Page 7
13. Doreen Jasper, a preoperative admission for laparoscopic cholecystectomy with
operative cholangiogram, was interviewed by her perioperative nurse in the
preoperative intake lounge. Doreen’s weight on admission was 245 lb. After the
assessment, the nurse returned to the OR and modified the standard plan of care
by instituting risk reduction strategies that were derived from information from the
preoperative assessment. A good example of this action would best be described
replacing the regular OR bed with a bariatric-specific OR bed.
providing protective lead aprons for all staff during the procedure.
writing the patient’s name, allergies, and body weight on the white board.
administering antibiotics to the patient 1 hour before the incision.
Planning is preparing in advance for what will or may happen and determining the
priorities for care. Planning based on patient assessment results in knowing the patient
and the patient’s unique needs so that alterations in events, such as positioning the
patient on a bariatric-specific OR bed as opposed to a regular OR bed, can be readily
accommodated. Replacing the OR bed with a larger OR bed is a nurse-sensitive
preventive intervention that provides equipment based on patient need.
REF: Page 8
14. Accurate documentation is an integral part of all phases of the nursing process.
For this reason, perioperative nursing care documentation:
a. should not include technical care.
must include a description of patient care delivered and patient response to
that care.
c. must be aligned with appropriate PNDS elements.
d. will have PNDS integrated into all mandatory fields.
Documentation of the nursing care given should include more than the technical
aspects of care, such as the sponge count or the application of the electrosurgical
dispersive pad. Nursing care documentation should be associated with the assessment
and nursing diagnoses, with preestablished outcomes against which the
appropriateness and effectiveness of care may be judged.
REF: Page 10
15. When delegating a task, such as a preoperative skin prep, to an unlicensed
individual, the perioperative nurse:
a. still retains responsibility and authority for the outcome of the task.
b. must comply with the seven “rights” of delegation.
c. transfers the authority to perform the task to a competent person.
transfers the supervision of the competent person to another competent
Delegation transfers to a competent person the authority to perform a selected nursing
task in a selected situation according to the five “rights” of delegation. When the
perioperative nurse delegates a task, he or she retains accountability for that
REF: Page 10
16. The nursing excellence center for education at Sunny Shores Hospital developed
standards for nursing advancement that would reflect high-level achievement of
professional performance. They developed a clinical advancement ladder based
on the leading skill and knowledge acquisition model and established worthy
criteria for each level. Select the response that might best describe the highest
level of achievement for a perioperative staff nurse.
CNOR credential, BSN, and chair of the nursing research committee
Published article in the Sunny Shores newsletter and 15 years’ service pin
BCLS instructor and weekend EMT transport
All of the options are correct.
Achieving certification (certified nurse, operating room [CNOR]), pursuing lifelong
learning, and maintaining competency and current knowledge in perioperative nursing
are the hallmarks of the professional.
REF: Page 4
17. Performance improvement activities in the perioperative practice setting are
designed to promote:
cost savings by eliminating fines for near-misses and never events.
customer satisfaction and loyalty.
performance measurement activities.
efficient, effective quality care.
Performance improvement efforts encompass improvements in quality and
effectiveness, based on ethical and economic perspectives. A performance
measurement and improvement approach facilitates the delivery of safe, high-quality
perioperative patient care.
REF: Page 14
18. Perioperative nursing diagnoses and interventions are directed toward, and
guided by, the tremendous risks for harm to the patient inherent in surgery and
interventional procedures; therefore nursing actions can generally be categorized
Perioperative nurses possess a unique understanding of desired outcomes that apply to
all patients. In contrast to some nursing specialties in which nursing diagnoses are
derived from signs and symptoms of a condition, much of perioperative nursing care is
preventive in nature, based upon knowledge of inherent risks to patients undergoing
surgical and invasive procedures. Perioperative nurses identify these risks and potential
problems in advance and direct nursing interventions toward prevention of undesirable
outcomes, such as injury and infection.
REF: Page 3
19. A registered nurse first assistant (RNFA) is considered an advanced practice
nurse when he/she has achieved:
RNFA certification.
clinical performance ladder level 4 or above.
graduate degree in nursing (MSN).
facility practice privileges.
APNs must have graduate nursing education (at least a master’s degree).
REF: Page 16
20. Emerging perioperative nursing roles are defined by the tremendous growth in
science and technology combined with the increasing complexity of surgery and
the interventional disciplines. An example of an emerging nursing role is:
sterile processing clinical specialist.
general surgery service liaison.
weekend resource nurse.
Informatics nurse specialist.
Informatics is another specialty in which some perioperative nurses are focusing.
Pressures for more efficient management of fiscal, material, and human resources have
stimulated the development of electronic information systems for diverse functions in
perioperative patient care settings.
REF: Page 16
21. The relationship between the Perioperative Patient Focused Model and the
Perioperative Nursing Data Set (PNDS) is evidenced by their unique language
and use of the nursing process to guide care. The most notable feature of their
similarity is that the PNDS:
promotes standardized perioperative documentation.
fosters research on best practices.
begins with outcome statements.
promotes standardized perioperative documentation and begins with
outcome statements.
Similar to the Perioperative Patient Focused Model, the PNDS begins with patient
outcomes. Each outcome is defined and interpreted, and presents criteria by which to
measure outcome achievement.
REF: Page 11
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 03: Infection Prevention and Control in the Perioperative Setting
Test Bank
1. Surgical site infections (SSIs) are most often caused by gram-positive cocci and
may arise from the patient’s own endogenous sources. The most typical
causative microorganism cultured from SSIs is:
Staphylococcus epidermidis.
Streptococcus pyogenes.
Staphylococcus aureus.
The organisms most commonly found in postoperative SSIs include staphylococcal,
enterococcal, pseudomonal, and streptococcal species. S. aureus is the most frequently
identified organism.
REF: Page 48
2. A swab of a fluid collection from an edematous, red, and separating
postoperative wound is sent to the microbiology lab for culture, sensitivity, and
Gram stain. The surgeon expects that the result will show a gram-positive
coccus. This Gram stain designation is based on the:
ability to cause plasma to coagulate and form a microscopic clot.
physical and chemical properties of the cell wall.
formation of aerobic clustered spheres.
appearance of a thicker and brownish colored cell wall.
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: Pages 48-49
3. The hospital epidemiologist was alerted when several cultures had recently
revealed suspicious similarities. He was concerned about two unrelated patients
with similar abscesses in similar body regions. Susan Grant, a 72-year-old
diabetic patient taking immunosuppressive medications for chronic Crohn’s
disease, had an incision and drainage of a perianal fistula. Shawn Ames, a
healthy 22-year-old 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. Susan’s specimen results showed a significant colony
growth of S. aureus plus differential growth of coagulase-negative S.
epidermidis, while Shawn’s specimen was a high colony growth coagulasepositive, similar subtype of S. aureus. The epidemiologist charged his
department to be alert for this S. aureus subtype and cross-check for trends. He
was 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?
Susan because she is immunocompromised and elderly and has Crohn’s
Shawn because he has pilonidal sinus tracts from sacral pressure caused
by racing
Susan because she has a mixed microorganism culture that is coagulase
Shawn because he has a high microbial load that is coagulase positive
Coagulase-positive staphylococci are more virulent or pathogenic than coagulasenegative staphylococci. S. aureus is hemolytic, parasitic, pathogenic, and coagulase
positive. S. epidermidis is parasitic, less pathogenic, and coagulase negative. Virulence
is the potency of a pathogen measured in the numbers required to kill the host.
REF: Pages 48-49
4. While antibiotics have been credited with saving lives, misuse of antibiotics has
contributed to the evolution of multidrug-resistant organisms (MDROs). Antibiotic
use is prolific in the perioperative setting. Select the antibiotic application has
evidence to support it as a best practice and not, potentially, a misuse of
Antibiotics given IV 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
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: Pages 55, 58
5. The Centers for Disease Control and Prevention (CDC) has identified pathogens
that could pose a threat to national and world security and safety through
bioterrorism. Select the four most probable agents that could be used to cause
mass transmission, mortality, panic, and social disruption.
Anthrax, tuberculosis, C. difficile, tularemia
Smallpox, plague, botulism, tularemia
Smallpox, monkeypox, avian influenza, anthrax
Anthrax, H1N1 influenza, botulism, smallpox
The potential for bioterrorism is a reality in today’s world. The CDC has identified agents
that may pose a risk to 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: Pages 64-66
6. Willard Braun was admitted to the ICU 3 weeks ago for heart failure and
intractable atrial fibrillation. He has had diarrhea for 4 days that has cultured C.
difficile. The transmission-based precautions sign on the door to his room alerts
the staff to employ:
Contact Precautions with eye protection.
both Standard Precautions and Contact Precautions.
body substance isolation.
droplet Precautions with standard isolation technique.
In addition to Standard Precautions, Contact Precautions should be used for patients
known or suspected to be infected or colonized with epidemiologically important
organisms that can be transmitted by (1) direct contact, as occurs when the caregiver
touches the patient’s skin, or (2) indirect contact, as occurs when the caregiver touches
patient care equipment or environmental surfaces in the patient’s room.
REF: Page 64
7. Ernesto Horn was admitted to the emergency department (ED) with respiratory
symptoms, facial and upper body abrasions, burns, and moist lesions after a
small package, delivered to his office, exploded and sprayed him with dried
powder and glass shards. In response to the reported mechanism of injury, the
ED team sequestered him in a secluded area away from the rest of the patients.
The team believed that this was highly suspicious of a bioterrorism event. The
epidemiologist was called and the patient was transferred to a negative-pressure
isolation room and placed on Standard, Contact, Airborne, and Droplet
Precautions. Based on these actions, what microorganism agents might be
suspected to be involved?
Plague and tuberculosis
Smallpox and tuberculosis
Ebola virus and anthrax
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: Page 65
8. 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 surfaces.
augment the oxygen-enriched environment with dust-free air.
flow clean air over the patient and prevent corridor air intake.
All of the options are correct.
To control bioparticulate matter in the OR environment, ventilating air should be
delivered to the room at the ceiling and exhausted near the floor and on walls opposite
to those containing inlet vents. Airflow should be in a downward directional flow, moving
down and through the location with a minimum of draft, to the floor and exhaust portals.
Air pressure in the 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: Page 67
9. The design of the physical space within an OR attempts to minimize horizontal
surfaces by placing cabinets flush with the wall. This prevents dust settling on
multiple surfaces and decreases the areas that have to be monitored and
cleaned. Another concern with horizontal surfaces is that air turbulence from staff
movement and activity plus door movement, when it opens and closes, can:
mobilize resting dust from these surfaces.
contaminate sterile areas.
disrupt the unidirectional airflow.
All of the options are correct.
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: Page 67
10. All surgical patients present with the risk for hypothermia from a variety of factors
inherent in the surgical experience. Hypothermia has been shown to be a factor
that may place the surgical patient at risk for infection and delayed healing.
Select the intervention that is an engineered control factor to protect the patient
from hypothermia.
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
Cover and surround the patient with several warm bath blankets and
change them at frequent intervals.
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° F (20° C) to 73° F (23° C).
REF: Page 67
11. The mechanism of lethality (microbial death) with steam sterilization is achieved
with this event.
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: Pages 67-68
12. Within a steam sterilizer, at a temperature of 100° C (212° F), the water
condensation and the steam are the same temperature. This scientific
phenomenon is called ___________________ and will __________________.
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 100° C (212° F) when this occurs. At this point, the steam is said to
be saturated. This 100° C (212° F) temperature is insufficient to kill microorganisms,
however. To kill microorganisms, a saturation temperature of 250° F (121° C) is
REF: Page 68
13. With the production of more steam in the sterilizer chamber, the pressure
increases as well. The steam should contain little or no entrapped liquid water.
Steam quality is the term that describes the amount of water mixed with the
steam. The constitution of high-quality steam would be measured by:
97% or greater.
<3% of the mixture is liquid water.
All of the values are correct.
The higher the steam pressure, the higher the temperature. The steam is the sterilizing
agent. Any compressed air remaining in the chamber mixes with the steam and lowers
the steam temperature. This reduced-temperature steam is incapable of sterilization.
Steam entering the sterilizer chamber should contain little or no entrapped 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: Page 68
14. Sterilization prepares instruments to be used within, and on, sterile tissues. It kills
vegetative microorganisms and endospores within a probability of 106. The
process of decontamination prepares instruments to be:
handled without gloves and prepared for sterilization.
free of bioburden and safely handled with gloves.
clean at a high level of disinfection.
None of the options are correct.
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: Pages 68-69
15. Qualities of an effective packaging material must include these key
characteristics. Select the three most important qualities.
Cost, good barrier, lint-free writable surface
Good steam penetration and removal, good 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 costeffective by cost and value analysis.
REF: Page 71
16. The final step, after decontamination and before sterilization, is the prep, pack,
and wrap process. The sterile processing technologist has taken the laparotomy
set from the washer/decontaminator to prepare for sterilization. Select the most
appropriate order that the instrument set must travel before reaching the steam
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: Page 71
17. Both sterilization and disinfection describe the elimination of microbial
contamination and the achievement of a state suitable for patient care in select
situations. However, disinfection differs from sterilization in that the process for
disinfection uses:
contact Precautions as well as Universal Precautions.
hospital-grade disinfectant/sterilants.
semicritical medical devices used for ambulatory procedures.
agents to disinfect and eliminate most, if not all, pathogenic microbes.
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: Page 81
18. An integrator is a multiparameter indicator designed to measure:
time and pressure.
pressure, steam, and temperature.
temperature, time, and presence of steam.
sterility and pressure.
Integrators are so named for their ability to integrate time, temperature, and the
presence of steam. They reduce the risk of using an unsterile pack and may be used
with numerous types of sterilization processes.
REF: Page 74
19. The evening before the procedure was scheduled, the central sterile processing
department received two complete sets of an orthopedic spine fusion system that
contained titanium-implantable instrumentation, four flexible coated retractor
blades, and a sterilized internal paper inventory form. The sterilization
instructions provided by the vendor representative recommended steam
sterilization for the implants, but stated that the flexible coated blade retractors
could not be exposed to temperatures higher than 220° F. The appropriate
sterilization option for these instruments and devices would be:
hydrogen peroxide gas plasma sterilization for everything.
steam sterilization for the implant sets and paper inventory form, hydrogen
peroxide gas plasma for the retractors, wrapped separately.
steam sterilization for the implant sets, hydrogen peroxide gas plasma for
the retractors and paper inventory form, wrapped separately.
steam sterilization for everything with a shortened dry time.
Low-temperature hydrogen peroxide gas plasma sterilization should be used for
moisture-sensitive 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: Page 80
20. The circulating nurse prepped the face, neck, and upper chest for a radical neck
dissection. After removing the protective towels around the prep site, the surgical
fellow applied the head drape and the rest of the patient was draped. During the
preincision surgical time-out, the fire risk score was determined to be high. When
the surgeon reentered the room, after leaving the room to scrub, and donned her
gown and gloves, she noticed an area on the neck that did not look prepped. She
asked for prep solution on a sponge and sponge forceps to complete the prep
area, taking care not to moisten the head drape. After handing off the used
sponge forceps she asked for the scalpel. What step was omitted in this
The new prep area was not given time to dry.
The time-out should have been repeated with the surgeon scrubbed.
The patient should have been reprepped and redraped with all new drapes.
The scrub person should have given the surgeon a sterile towel to cover the
unprepped area.
Avoid pooling of preparation solution. If linens on the OR bed or the patient become
soaked with solution, remove them from the area. Allow preparation solution to dry
completely (3 to 5 minutes) before surgical drapes are applied. This may be
incorporated as a time-out or “all-clear” announcement before proceeding with the
draping process.
REF: Page 104
21. The skin preparation for a vaginal-assisted laparoscopic hysterectomy begins
______________ and _____________ 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: Pages 101, 103
22. 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 gloving.
it requires two people to execute without contamination.
there is a risk of contamination if the thumbs are not extended.
All of the options are correct.
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: Page 99
23. Which glove lubricant, used to facilitate easy donning, is considered a best
Sterile talcum or corn starch powder
Sterile petroleum-based oils
Sterile silicone film
None of the options is a best practice.
The use of 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
REF: Page 98
24. 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: Page 99
25. To protect the forearms, hands, and clothing from contacting bacteria on the
outside of the used gown and gloves, members of the scrubbed surgical team
should use the following procedure to remove soiled gowns and gloves. Which
choice lists the appropriate first 3 steps in the removal of the sterile gown?
Wipe gloves clean, untie side gown closure, grasp gown at one shoulder
Wipe gloves clean, grasp gown at both shoulder seams, pull over and off
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 together.
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 body while turning the gown inside out and
discarding carefully in the designated receptacle.
REF: Pages 100-101
26. Describe the best practice for aseptic removal of sterile gloves after removal of
the sterile gown at the end of the procedure. Select the best practice to protect
the wearer from 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 out.
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 out. Discard appropriately. Using the ungloved hand,
grasp the fold of the everted cuff of the other glove and remove the glove,
inverting the glove as it is removed. Discard in biohazard trash. Remove
mask by the ties and discard. Wash hands.
Both practices are appropriate.
Neither practice is appropriate.
Using the gloved fingers of one hand to secure the everted cuff, remove the glove,
turning it inside out. Discard appropriately. Using the ungloved hand, grasp the fold of
the everted cuff of the other glove and remove the glove, inverting the glove as it is
removed. Discard appropriately. After leaving the restricted area, remove the mask by
touching the ties or elastic only. Discard in the designated receptacle. Wash hands and
REF: Pages 100-101
27. The surgical hand scrub is designed to render the hands, nails, and arms:
surgically clean.
free of transient microorganisms, dirt, and skin oils.
coated with residual antimicrobial residue to prevent microbial regrowth.
All of the options are correct.
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. The skin can never be rendered
sterile, but it can be made surgically clean by reducing the number of microorganisms
REF: Page 93
28. Decontamination of the hands can be done by a variety of methods. The Joint
Commission (TJC) states that a thorough handwash with an antimicrobial agent
may be as effective as the traditional surgical scrub using a brush or sponge.
Facility infection control procedures govern the selection of materials and the
methods used for surgical hand hygiene. Select the best practice for surgical
hand hygiene.
a. Alcohol-based hand rub
b. Anatomic counted strokes with 4% chlorhexidine gluconate brush
c. Anatomic timed strokes with povidine iodine sponge
d. Any of the options with an antimicrobial hand wash
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 where
long and repeated scrubbing may be traumatic to the skin. A thorough handwash with
an antimicrobial agent may be as effective as the traditional surgical scrub using a
brush or sponge. An anatomic scrub, using a prescribed amount of time or number of
strokes plus friction, is employed for effective cleansing of the skin. The prescribed
number of strokes with a brush is usually 30 strokes to the nails and 20 strokes to each
area of the skin. When using the timed approach, the institution’s policies and
procedures should be followed. A standardized procedure for handwashing should be
established and followed within the healthcare setting. This may be accomplished by a
surgical scrub or with the use of an approved hand rub agent.
REF: Page 93
29. 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 hair.
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.
A standardized procedure for handwashing should be established and followed within
the healthcare setting. 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. If visibly
soiled, wash hands and forearms with soap and running water immediately before
beginning the scrub procedure.
REF: Pages 93-94
30. If a sterile glove becomes contaminated during the procedure, the best practice
for corrective action is:
reglove with open-glove or assistive glove technique.
reglove with closed-glove technique.
remove gown and gloves and regown and reglove.
place a new sterile glove over the contaminated glove.
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: Page 99
31. In several studies, it was determined that the risk of contamination and
subsequent infection to the wearer can be reduced by wearing two pairs of sterile
surgical gloves, as opposed to wearing one pair. Select the correct statement
that refers to double gloving in terms of a best practice.
The Centers for Disease Control and Prevention (CDC) endorses double
gloving for all surgery and invasive procedures.
Wearing two glove layers permits regloving using the closed-glove
technique for a contaminated glove.
Wearing a glove liner between both layers of gloves may eliminate the risk
of perforation to the inner glove, protecting the wearer from sharps injury.
The AORN publication titled Recommended Practices for Prevention of
d. Transmissible Infections in the Perioperative Practice Settingrecommends
the double-glove procedure during invasive procedures.
The AORN publication titled Recommended Practices for Prevention of Transmissible
Infections in the Perioperative Practice Setting recommends the double-glove procedure
during invasive procedures because of several issues based on a systematic review of
the literature.
REF: Page 99
32. Sterile surgical drapes are used to create the sterile field, protecting the patient
from endogenous and exogenous sources of contamination. Of the
characteristics listed, which are essential to maintaining the sterile field?
Provide barrier protection from microorganisms, fluid, and particulate matter
Limit environmental impact and flammability
Ensure a fiscally responsible cost/benefit ratio and reduce glare
All of the options are important.
Sterile drapes provide a barrier to microorganisms, particulate matter, and fluid while
protecting the patient from both exogenous and endogenous sources of contamination.
REF: Page 104
33. 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 unsterile parts of the patient.
Gently shake and fan out the drapes to open up the folds before
approaching the patient.
Drape the patient starting with the incision area and proceeding to the
d. All of the options reflect violations of sterile technique.
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: Page 107
34. The transplant team received the liver from the procurement team moments after
it arrived by medical air lift. The OR was ready with a scrubbed team of a
circulating nurse, scrub person, transplant surgeon, and surgical resident and
with a sterile back table set up 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 patients.
The patient should have been held in preoperative holding until the liver was
split and the second segment placed back into the cooler.
The back table should have been covered with sterile drapes and moved to
a second available room.
The surgeon should proceed with splitting the liver, replacing the segment
for the second patient back into the cooler, and storing the cooler in the
back of the OR for the second transplant patient, whose procedure will
follow in the same OR.
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 are 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.
REF: Page 107
1. Effective instrument decontamination is dependent on a particular sequence
designed to lower bioburden to the lowest level. Number the steps below to
reflect the correct order of processing a basic set of laparotomy instruments
through decontamination.
_____ a. During surgical procedure, wipe instruments with sterile water.
_____ b. Transport in closed container to decontamination area.
_____ c. Employ ultrasonic washer.
_____ d. Preclean with neutral enzyme agent in leakproof container in procedure room.
_____ e. Disassemble and unlock all instruments; place heavy instruments on bottom.
_____ f. Rinse with cold water in deep sink.
_____ g. Remove and discard all disposable sharps.
_____ h. Place in automated instrument washer/decontaminator.
Items to be sterilized should be precleaned to lower the bioburden to the lowest
possible level. 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. Initial
decontamination should begin immediately on completion of the surgical procedure. 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. An enzyme solution, foam, or spray can
be added to the instruments to begin the process of breaking down any proteinaceous
materials that may remain on the instruments. Soiled instruments should be within
leakproof containers or trays inside plastic bags when they are transported from the OR
for cleaning and decontamination. In the decontamination area, pretreatment involves
an initial cold water rinse with tap water or a soak in cool water with a protein-dissolving
and blood-dissolving enzyme. After completion of this pretreatment, the instruments
should be processed in an automated device, and washed by hand if an automated
device is not available Automated processing is completed with the use of
washer/sanitizers or washer/decontaminators. The ultrasonic cleaning process is
designed to remove fine soil from crevices and box-lock areas of instrumentation. It
should be used only after gross debris has been removed from instruments.
REF: Pages 68-69
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 11: Surgery of the Liver, Biliary Tract, Pancreas, and Spleen
Test Bank
1. The liver, pancreas, and spleen share many similarities. Select the statement
about these organs that is true.
All three are solid organs and very vascular.
All three are metabolic organs.
All three organs have terminal attachments to the duodenum.
All of the options are false.
All three organs are solid (not hollow or collapsible) organs. A pathologic condition in
the liver, biliary tract, pancreas, or spleen often requires surgical intervention. These
organs are highly vascular and control many metabolic and immune functions of the
REF: Pages 357-361
2. The functional units of the liver are the lobules. The functional cells of the liver
are the ______________ and they manufacture _______________.
a. Kupffer cells; phagocytes
b. sinusoid cells; lymphocytes
c. hepatocytes; bile
d. portal triad cells; ductal epithelium
Lobules are the functional units of the liver. Each lobule contains a portal triad that
consists of a hepatic duct, a hepatic portal vein branch, and a branch of the hepatic
artery, nerves, and lymphatics. The hepatic cords consist of numerous columns of
hepatocytes—the functional cells of the liver. The hepatic sinusoids are the blood
channels that communicate among the columns of hepatocytes. The sinusoids have a
thin epithelial lining composed primarily of Kupffer cells—phagocytic cells that engulf
bacteria and toxins. Bile is manufactured by the hepatocytes.
REF: Page 357
3. The liver is essential in the metabolism of carbohydrates, proteins, and fats,
generating nutrient stores of which substance that supplies energy sources to the
brain and body?
Carbohydrate glucose substrate
Serum glucosamine
Bile salts
The liver is essential in the metabolism of carbohydrates, proteins, and fats. It
metabolizes nutrients into stores of glycogen, used for regulation of blood glucose levels
and as energy sources for the brain and body functions.
REF: Pages 357-358
4. The biliary system (also called the biliary tree) drains bile from the gallbladder to
the ampulla of Vater. The primary function of the gallbladder is to:
manufacture bile.
convert bile salts into bile enzymes.
store and concentrate bile.
contract to secrete bile into the hepatic duct.
The gallbladder, which lies in a sulcus on the undersurface of the right lobe of the liver,
terminates in the cystic duct (Figure 11-3). This ductal system provides a channel for
the flow of bile to the gallbladder, where it becomes highly concentrated during storage.
The liver produces about 600 to 1000 ml of bile each day. The gallbladder’s average
storage capacity is 40 to 70 ml. As the musculature of the gallbladder contracts, bile is
forced into the cystic duct and through the common duct. As the sphincter of Oddi in the
ampulla of Vater relaxes, bile is released, flowing into the duodenum to aid in digestion
by emulsification of fats.
REF: Page 359
5. The head of the pancreas is fixed to the:
biliary tree
The pancreas (see Figure 11-3) is a fixed structure lying transversely behind the
stomach in the upper abdomen. The head of the pancreas is fixed to the curve of the
REF: Pages 359-360
6. While the pancreas’ function is carbohydrate metabolism with the production of
insulin and digestive enzymes, the spleen’s function is primarily ___________
with the production of _______________.
immunologic; leukocytes
metabolic; granulocytes
anabolic; plasma cells
as a blood reservoir; phagocytes
The spleen has many functions. Among them are defense of the body by phagocytosis
of microorganisms, formation of nongranular leukocytes and plasma cells, and
phagocytosis of damaged red blood cells. It also acts as a blood reservoir. The
pancreas contains groups of cells, called islets, or islands, of Langerhans, that secrete
hormones into the blood capillaries instead of into the duct. These hormones are insulin
and glucagon, and both are involved in carbohydrate metabolism.
REF: Pages 360-361
7. An example of an indication for liver transplantation would be:
end-stage liver disease resulting from advanced hepatic cancer with
b. acute fulminant biliary disease of unknown origin.
c. infection caused by untreated cystic anomalies.
d. primary hepatic cancer.
Liver transplantation is indicated for patients with primary hepatic cancer, chronic
hepatocellular disease, chronic cholestatic disease, metabolic liver disease, acute
fulminant liver disease, and inborn errors of metabolism. When malignancies are the
cause of end-stage liver disease, the right upper quadrant may be radiated
intraoperatively—after hepatectomy and before transplantation.
REF: Page 390
8. Matthew Ryan, a 9-year-old boy, is admitted to the emergency department for a
sledding accident, when he lost control of his sled and crashed into a tree. He is
pale and in pain; his abdomen is tender and firm to palpation. The CT scan
suggests rupture of the spleen with internal bleeding. Matthew’s scheduled
surgery will most probably be a(n):
laparoscopic splenic resection with sutured mesh overlay.
open splenic lobectomy with vascular ligation.
open total splenectomy.
open splenic repair with sutured anastomosis and argon plasma coagulation
vessel sealing.
Splenectomy is removal of the spleen. It is performed for multiple reasons, including
trauma to the spleen. Contraindications to laparoscopic splenectomy include severe
portal hypertension, uncorrectable coagulopathy, severe ascites, extreme
splenomegaly, extensive adhesions, and most traumatic injuries to the spleen. For
these patients, an open approach is indicated.
REF: Page 393
9. The Whipple procedure is the removal of the head of the pancreas, the entire
duodenum, a portion of the jejunum, the distal third of the stomach, and the
____________ as a surgical treatment for____________.
left lobe of the liver; metastatic hepatocytoma
distal segment of the spleen; pancreatic metastasis
inferior margin of the ligament of Treitz; pancreatic cancer
lower half of the common bile duct; pancreatic cancer
Pancreaticoduodenectomy (Whipple procedure) is the removal of the head of the
pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach,
and the lower half of the common bile duct, with reestablishment of continuity of the
biliary, pancreatic, and GI tract systems.
REF: Page 384
10. Open common bile duct (CBD) exploration may be indicated in some cases
a. the patient has undergone prior biliary surgery.
a positive cholangiogram shows a CBD obstruction during an open
c. laparoscopy technology is not available.
d. All of the options are correct.
With the advent of endoscopic, percutaneous, and laparoscopic techniques (Figure 1113), open exploration of the common bile duct is rarely performed. When these newer
methods are not available, when they are not possible because of prior surgery, or
when an open procedure is otherwise necessary, open common bile duct exploration is
REF: Page 378
11. An example of a potential risk associated with pneumoperitoneum would be:
a. tachycardia caused by peritoneal irritation from the CO2.
CO2 absorption into the peritoneal capillaries, causing decreased oxygen
c. bradycardia from CO2 pressure lower than 15 mm Hg.
d. gas embolus into an exposed blood vessel during the procedure.
CO2 is the gas of choice for pneumoperitoneum. The perioperative nurse should set the
insufflation unit to a maximum pressure of 15 mm Hg. Pressure higher than 15 mm Hg
may result in bradycardia or a change in blood pressure, or may force a gas embolus
into an exposed blood vessel during the operative procedure.
REF: Page 375
12. Steven Morganstein, a 51-year-old male with hepatobiliary disease, is scheduled
for surgery. The perioperative nurse, during the preoperative assessment,
questions and examines the patient for signs and symptoms of jaundice,
petechiae, and lethargy and:
reviews his chart for bleeding and coagulation times and the platelet count.
asks Steven his blood type and when he last donated blood.
palpates Steven’s abdomen for left upper quadrant tenderness and liver
reviews the findings of his endoscopic retrograde cholangiopancreatoscopy
The patient with hepatobiliary disease may have extreme jaundice, urticaria, petechiae,
lethargy, and irritability. Depending on the extent of the disease, bleeding and
coagulation times may be increased and the platelet count decreased, contributing to
intraoperative concerns with achieving hemostasis.
REF: Pages 361, 390
13. Luanne Williamson, a 39-year-old, 248-lb mother of 4 children, is assisted with
transfer from a transport vehicle to the OR bed for laparoscopic cholecystectomy,
operative cholangiogram, and possible common bile duct exploration. The
perioperative nurse determined that Luanne is at risk for positional injury related
to her size and the positional requirements and OR bed manipulations required
for this procedure. An appropriate nursing implementation for positioning this
patient would be to:
place two safety belts over the thighs and lower legs to prevent the patient
from sliding out of position when the surgeon tilts the table for better
exposure and access.
place a positioning lift under the lower right side of the chest to elevate the
lower rib cage for exposure and access to the viscera in the right upper
quadrant of the abdomen.
abduct the patient’s right arm on an armboard at less than 90 degrees to
allow an assistant to stand near the patient’s right upper quadrant and
retract the liver with a wide Deaver retractor.
place two safety belts over the thighs and lower legs to prevent the patient
from sliding out of position when the surgeon tilts the table for better
exposure and access, and place a positioning lift under the lower right side
of the chest to elevate the lower rib cage for exposure and access to the
viscera in the right upper quadrant of the abdomen.
For biliary surgery, the patient is placed in supine position. The patient’s arms are
usually placed on padded armboards with the palms up and fingers extended.
Armboards are maintained at less than a 90-degree angle to prevent brachial plexus
stretch. A small positioning aid may be placed under the lower right side of the thorax to
elevate the lower rib cage, providing better exposure and access to the viscera in the
right upper quadrant of the abdomen. A lateral tilt of the OR bed may be used in
combination with reverse Trendelenburg’s position for procedures such as laparoscopic
REF: Pages 362, 365-366
14. The circulating nurse approaches the preoperative holding lounge to see her next
patient, Alfred Neumann, a 57-year-old nurse newly diagnosed with pancreatic
cancer. He had an ERCP 1 week ago and, based on the findings, was scheduled
for surgery at the comprehensive cancer center, where he works in the
interventional endoscopy unit. He is aware of the poor prognosis for this disease
and his nurse has recorded his nursing diagnosis as: Anxiety related to
impending surgical procedure, perioperative events, and surgical outcome. An
appropriate nursing action for Alfred would be to:
encourage verbalization of his fears and reinforce the standardized ageappropriate coping mechanisms.
describe for him the steps of the operative procedure.
offer emotional reassurance by using touch, assisting him to a position of
comfort on the OR bed, and offering warm blankets (thermal comfort).
share with Alfred his nursing diagnosis and reinforce the desired nursing
outcome related to anxiety.
When patients are anxious, the perioperative nurse should speak slowly and clearly,
using terminology the patient can understand. Offer emotional reassurance by using
touch, assisting the patient to a position of comfort on the OR bed, and offering warm
blankets (thermal comfort).
REF: Pages 365-366
15. Jan Stuyvesant, a perioperative nurse, was the scrub person during a robotic-
assisted laparoscopic cholecystectomy. She locked the robotic endoscissor into
the adaptor on the robotic arm and positioned the tip end into the trocar port in
order for the surgeon to dissect the cystic duct and artery, while the surgical
assistant placed the clips on the cystic duct and artery. As she reached across
the sterile field to insert the cholangiocatheter through the port, the anesthesia
provider accidentally made contact with the distal end of the catheter as he stood
up to reach the monitor controls. The contaminated end of the catheter touched
the endoscopic clip applier, the endoscissor connector that the surgeon was
using, the glove of the assistant, and Jan’s gown sleeve. The surgeon ordered
everyone to change their gown and gloves and covered the port area with a
sterile towel. What was the rationale for the surgeon to continue to dissect and
not change his attire?
The tip of the dissector that was in the patient’s abdomen was not
The surgeon planned to remove the dissector after he finished dissecting
and then dispose it.
The surgeon’s gown was not touched, just the dissector connection to the
robotic arm.
The surgeon was not in contact with the sterile field because he worked
from the robotic console.
The surgeon manages the robotic system from a console away from the operative field.
With current robotic systems, the surgeon sits at an operative console with threedimensional imaging and handheld controls. Movement of the controls follows the
movement of the instrument’s tip. Robotic arms function just like a surgeon’s hands.
REF: Pages 377-378
16. Joanne Grizwald, a 24-year-old woman with type 1 diabetes who is in end-stage
kidney failure, is scheduled for a combined kidney-pancreas transplant. She is
relatively healthy and at normal weight for her height in spite of her disease
process. Her bleeding time and coagulation parameters are within normal limits.
The circulating nurse has set up the autotransfusion system, verified Joanne’s
blood type, and crossmatched blood availability. The scrub person, while
organizing the sterile back table, identified several instruments that she will not
need. She organizes those instruments on the most distant part of the back table.
What instruments is the scrub person unlikely to need during this procedure?
Based on Joanne’s coagulation status, excess bleeding is not expected to
be an issue.
Hemostasis will be achieved by the use of microfibrillar collagen agents that
do not leave electrosurgical eschar (burned tissue) on the bleeding
surfaces, thereby reducing the chance of infection.
Any excess bleeding will be removed and returned to the patient through the
autotransfusion system.
The transplant procedure is an open approach and laparoscopic
instruments (the insulated electrosurgical-adapted scissors, graspers, and
the endoscopic suction tips) are not needed.
Pancreatic transplantation is the implantation of a pancreas from a donor into a recipient
for patients with type 1 (formerly known as juvenile-onset) diabetes. Options for
pancreatic transplant include a pancreas transplant alone (PTA), an option chosen for
patients with functioning kidneys, or a simultaneous pancreas-kidney transplant (SPK).
The whole-organ pancreatic transplantation procedure is performed through an oblique
incision opposite the side of the renal transplant in the lower abdominal quadrant.
REF: Page 385
17. During an emergent total open splenectomy on a patient with blunt force trauma
to the abdomen, the circulating nurse and anesthesia provider noticed rustcolored urine in the urinary collection container. They had just hung the third unit
of whole blood. What nursing action is the first priority?
Send a sterile urine sample for stat cytologic studies.
Notify the scrubbed team of the urine color change and check the bladder
for trauma.
Stop the blood transfusion.
Check the blood unit for patient-specific identification and expiration date.
The first response is to stop the transfusion; the surgical team had just started
transfusing another unit of blood and the probability of a transfusion reaction is likely.
There would be no immediate harm to the patient from stopping the blood transfusion.
Instead, the surgical team should increase the IV flow rate of saline or lactated Ringer’s.
When additional blood or blood products are required, the perioperative nurse
communicates with blood bank personnel so that products are readily available, and
then in conjunction with the anesthesia provider completes the required steps to verify
blood/blood products before transfusion. Autologous blood or donor-directed blood
products may be used in elective procedures involving the liver, pancreas, spleen, and
biliary tract. Cell saver devices may be used.
REF: Page 369
18. What technologic characteristic of robotic surgery provides a superior indication
for robotic-assisted laparoscopic cholecystectomy?
The surgeon controls two instruments plus a camera while an assistant
suctions and retracts.
Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage.
The magnified three-dimensional picture may reduce bile duct injuries
during dissection.
Robotic stapler and suture devices promote intracorporeal anastomotic
Robotic surgery enables surgeons to perform more advanced and complex procedures.
The view of the ductal anatomy is subjectively superior with robotic surgery because of
the magnified three-dimensional picture, which may reduce bile duct injuries.
REF: Pages 376-377
19. Marvin Townsend is a 29-year-old man with paraplegia caused by spinal cord
injury from a diving accident 4 years ago. He is transported into the trauma ED
after being hit by a car as he was crossing the street in his wheelchair. He has a
possible rupture of his liver and is scheduled for surgery. The perioperative
nurse, on response to the trauma call, meets him in the ED to conduct a
preoperative assessment and prepare for his procedure. Marvin tells the nurse
that he is latex-sensitive because he was told that as a spinal cord injured person
he should always be considered latex-allergic. An appropriate risk reduction
strategy for Marvin’s latex sensitivity/allergy would be to:
advise the anesthesia provider to premedicate with an H2 blocker,
diphenhydramine, and prednisolone.
alert the OR and postoperative recovery areas of his latex allergy, check the
b. setup for latex-containing items, and replace those items with non-latex
transfer his care to the pediatric OR in the adjoining hospital where
everything in the OR is latex-free.
position code and latex carts outside of the OR and watch for signs of latex
d. reaction; tape an epinephrine-filled syringe to the head of his transport
Notify healthcare providers in other perioperative areas of the patient’s latex sensitivity
status. Plan for a latex-safe environment of care: remove all latex products from the
room unless no alternative exists.
REF: Page 369
20. Jarvin Patel, a 42-year-old woman from Mumbai, India, is visiting her daughter
and new grandson. She is a devout follower of Hindu religious practices and has
been diagnosed with splenomegaly, possibly from idiopathic thrombocytopenia.
Jarvin is scheduled for a total splenectomy. During the preoperative assessment,
the perioperative nurse, an observant Hindu herself, is concerned about the
possibility of significant bleeding because of Jarvin’s coagulopathy and the need
for hemostatic agents that are typically used to stop bleeding. Many of these
products are manufactured from bovine source products and it would be in
conflict with Jarvin’s religion to use products from a cow. An appropriate risk
reduction strategy for selection of hemostatic agents that would not be in conflict
with Jarvin’s belief system would be:
substitute absorbable gelatin and oxidized collagen products; soak in
substitute absorbable gelatin and oxidized collagen products; use high ESU
substitute absorbable gelatin and oxidized collagen products; use regular
ESU settings.
substitute microfibrillar collagen soaked in thrombin; add epinephrine
These hemostatic products do not contain bovine products: absorbable gelatin, powder,
or compressed forms (Gelfoam); purified porcine gelatin, beaten, dried, and heatsterilized;and oxidized cellulose (Surgicel, Surgicel Nu-Knit); absorbable oxidation
product of cellulose. These products are manufactured from bovine products:
absorbable collagen (Collastat, Superstat, Helistat); bovine collagen origin. Collagen
activates the coagulation mechanism, aggregation of platelets; microfibrillar collagen
(Avitene, Instat), hydrochloric acid salt of purified bovine corium collagen; thrombin
enzyme extracted from bovine blood.
REF: Page 368
21. The donor liver OR is prepared for an open laparotomy procedure with basic
laparotomy and vascular instruments and accessories. A second sterile
instrument table is set up to receive and prepare the procured liver. Select the
additional instruments and accessories needed on the donor organ preparation
vascular instruments, silk sutures and ties, sterile ice, flushing solution, and
slush machine.
flushing solution, ice chest, sterile ice, powered sternal saw, and long
Kocher clamps.
culture tubes, Wisconsin University forceps, Deaver retractors, and slush
toothed forceps, vessel loops, two sterile plastic draw-string bags, and
flushing solution.
The donor OR is prepared for a major laparotomy procedure. Basic instrumentation and
equipment includes a basic laparotomy set, cardiovascular instruments, power sternal
saw, and nephrectomy instruments. A sterile, draped, medium-size instrument table is
needed for preparation of the liver away from the main sterile field and instrument
tables. The procurement team provides special Collins solution for flushing the organs,
sterile plastic containers and ice chests for organs, and in situ flush tubing. The liver is
generally placed in two plastic Lahey bags immediately after procurement.
REF: Page 391
22. The recipient liver OR is arranged for a major laparotomy and vascular procedure
with customized instruments, supplies, and sutures according to the transplant
surgeon’s preference. In addition to the general patient care accessories,
equipment, and supplies needed for any large surgery, also included are
intraoperative laboratory testing and an autotransfusion system. Describe the
boundaries of the surgical skin prep for the patient about to receive a liver
From neck to midthigh; midaxillary line to midaxillary line
From nipple line to pubis; bedline to bedline
From the neck to midthigh; bedline to bedline
From nipple line to midthigh; midaxillary line on the patient’s left side, and
bedline on the right
Each transplant surgeon has preferred instruments, supplies, and sutures. The patient
is placed supine with knees slightly flexed and padded. An indwelling urinary catheter is
inserted after induction of anesthesia. The patient is prepped from the neck to midthigh,
bedline to bedline. Prep solution should not pool at the bedline or wet the sheets on the
OR bed. Fire safety precautions for prep solutions must be followed.
REF: Page 391
1. Both Maryanne and Charles Rigler had surgery 6 days ago. Charles had a living-
related donor liver transplant and Maryanne, the matched donor, provided a
segment of her healthy liver for her husband. They have both recovered as
expected and are preparing for discharge. They are concerned about who will be
the primary caregiver, since they are both recovering at the same time and rate.
They also realize that they will need clear and realistic instructions and support
because of their unique situation. They are most concerned about incision care,
side effects that could mean complications, nutrition, and activity restrictions and
escalation. An appropriate risk reduction strategy for Maryanne and Charles
would give first priority to (select all that apply):
secure an order for social services consult.
secure an order for a physical rehabilitation plan.
provide Maryanne and Charles with the standard discharge education with
emphasis on their concerns.
elicit their abilities to provide for themselves and their resources of support.
The patients should be included in the decision-making about their post discharge care
and have the opportunity to discuss, with the nurse or other healthcare services, their
resources for support in order for them to mutually make a decision about professional
assistance and needs that are in the best interest of their recovery. After receiving their
discharge expectations, they can better compare the expectations and events with their
capabilities and resources. The general discharge instructions for liver surgery patients
include the following: keep the incision area clean and dry; solid foods should be added
gradually; chew solid foods well, and avoid gulping, eating fast, or swallowing large and
bulky portions; avoid carbonated beverages for 3 to 4 weeks to help prevent gas
bloating; eat small, frequent meals; follow medication instructions and conduct
medication verification; increase exercise gradually to return to normal activities of daily
living; exercise regularly; and make an appointment for follow-up care with the surgeon.
REF: Pages 370-371
1. Number the sequence of critical steps for receiving, checking, and verifying the
transplant organ.
____ A. The organ arrives at the OR.
____ B. The circulating nurse and a second RN verify the organ tag with the preliminary
crossmatch report to ensure the following match: the recorded ABO type of the recipient
is the same or is compatible with the recorded ABO type of the donor, the UNOS
(United Network for Organ Sharing) number on the organ is the same as the UNOS
number on the Preliminary Crossmatch Report. The two RNs then identify the patient
according to hospital policy and sign the Transplant Verification form.
____ C. The transplant surgeon verifies that the UNOS number on the Preliminary
Crossmatch Report is the same as the UNOS number on either the organ container or
the paperwork provided and verifies the compatibility of the organ and the patient by
ABO blood type. The transplant surgeon signs the Transplant Verification form.
____ D. The Transplant Verification form and Preliminary Crossmatch Report are
placed on the permanent part of the patient’s medical record.
____ E. Crossmatch and ABO reports from the human leukocyte lab and blood bank
are received.
____ F. The Transplant Verification form (deceased donor) is attached to the record.
____ G. Once the patient is taken into the OR, a time-out is taken with the OR team
according to OR policy and procedure.
____ H. The OR charge nurse verifies the recipient’s preliminary crossmatch and ABO
____ I. The circulating nurse identifies the box with a recipient patient label.
Before the transplant surgical procedure, a process of nine checkpoints is implemented
to ensure identity and matching between the organs/tissues of the donor and the
recipient. Before the patient enters the OR, the following must occur: (1) Once a
transplant has been posted, Preliminary Transplant Crossmatch Reports are faxed from
the human leukocyte antigen (HLA) lab to the transplant OR. The blood bank will fax
ABO reports. (2) The OR charge nurse verifies the posted recipient’s Preliminary
Crossmatch Report and the ABO report. (3) The organ arrives at the OR. (4) The
circulating nurse applies an addressograph label to the box with the organ. (5) The
circulating nurse and another registered nurse together do the following: (a) verify the
tag on the organ with the Preliminary Transplant Crossmatch Report to ensure the
following match: (i) the recorded ABO type of the recipient is the same or is compatible
with the recorded ABO type of the donor, (ii) The UNOS (United Network for Organ
Sharing) number on the organ is the same as the UNOS number on the Preliminary
Transplant Crossmatch Report; (b) identify the patient according to usual hospital
policy; (c) sign the Transplant Verification form. In the OR the following must occur: (6)
Preliminary anatomic checks are done by the surgeon. The transplant surgeon verifies
that the UNOS number on the Preliminary Transplant Crossmatch Report is the same
as the UNOS number on either the organ container or the paperwork provided and
verifies the compatibility of the organ and the patient by ABO blood type. The transplant
surgeon signs the Transplant Verification form. (7) Once the patient is taken into the
OR, a time-out is taken with the OR team according to OR policy and procedure. (8)
The Transplant Verification form and Preliminary Transplant Crossmatch Report are a
permanent part of the patient’s medical record. (9) The Transplant Verification form
(deceased donor) is attached to the record.
REF: Page 386
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 21: Plastic and Reconstructive Surgery
Test Bank
1. The science of plastic and reconstructive surgery, which means to mold or create
form and shape, improves appearance and body image through an
understanding of:
body geometry.
the anatomy and biology of tissue.
form and function.
body image.
Plastic and reconstructive surgery is based on a thorough understanding of the anatomy
and biology of tissue. Derived from the Greek word plastikos, which means to mold or
give form, plastic surgery is a medical specialty that restores or gives shape to the body.
REF: Page 885
2. Denise Michaelson, a 46-year-old woman with an early-stage second primary
cancer in her left breast, has elected to have a bilateral mastectomy with saline
implants. She has requested that the surgeon also revise a small unsightly scar
on her right knee and pierce her ears. While Denise’s breast tumor could be
treated with an excisional biopsy, she has decided to have a mastectomy of both
breasts, which is considered an appropriate preemptive (preventative) surgery for
a woman of her age with two primary cancers of the breast. The saline implant
insertion surgery is considered a _______________ procedure, the scar revision
is considered a ___________ procedure, and the ear piercing is considered a
_______________ procedure.
reconstructive; reconstructive; reconstructive
reconstructive; cosmetic; reconstructive
cosmetic; reconstructive; cosmetic
reconstructive, cosmetic and cosmetic
There are two different subspecialties of plastic surgery. Cosmetic (aesthetic)
surgery restores or reshapes normal structures of the body, to improve appearance and
self-esteem. Reconstructive surgery treats abnormal structures of the body caused by
birth defects, developmental problems, disease, tumors, infection, or injury, to restore
function and correct disfigurement or scarring. Scar revision involves the rearranging or
reshaping of an existing scar so that the scar is less noticeable; scar revision is
considered an aesthetic procedure.
REF: Pages 885, 916
3. Marla, the perioperative nurse circulating for a skin contracture release of the ear
on a 5-year-old boy, transfers 0.25% bupivacaine via syringe to the scrub
person’s sterile back table. The scrub person, Jake, questions why she is not
giving him bupivacaine with epinephrine, since there may be bleeding expected
at the incision site. Marla’s reply to Jake is based on the fact that:
epinephrine is contraindicated in areas with limited vascularity, such as the
Marla is complying with the surgeon’s standardized order on the preference
epinephrine-induced vasoconstriction may interfere with normal tissue
pediatric heart rates are higher than adult heart rates and epinephrine can
cause tachycardia.
Use of epinephrine is contraindicated in areas with limited vascularity, such as digits,
the penis, nasal tip, and ears.
REF: Page 894
4. The perioperative nurse should verify with the patient that all of the preoperative
prescribed skin preparation regimens ordered by the surgeon have been
performed. All body jewelry that pierces the skin should be removed before the
skin prep. Select the statement that reflects a true special consideration for skin
preparation before facial surgery.
Use chlorhexidine gluconate (CHG) around the ears and eyes.
Leave the eyebrows and eyelashes intact to preserve facial appearance and
Prep the skin graft and donor sites together with the same prep set and
drape immediately.
Isolate rashes, open sores, cuts, or lesions in the prep site with a sterile,
clear adhesive patch.
The eyebrows and eyelashes, in particular, are left intact to preserve facial appearance
and expression. The use of CHG should be avoided around the ears and eyes. When
prepping for a skin graft procedure, separate skin prep setups are needed for the graft
and donor sites.
Inspect for any rashes, bruises, open sores, cuts, or other skin conditions.
REF: Page 894
5. During the planning phase of a procedure for liposuction or post–bariatric
contouring procedures, the perioperative nurse will assemble and organize
supplies and devices because the procedure may require:
repositioning one or more times during surgery.
meticulous accounting of fluid loss and blood replacement.
pressure dressings.
patient transfer to an alternating-pressure bed.
Whereas a majority of plastic surgical procedures are performed in the supine position,
many also take place with the patient prone or lateral. Liposuction and post–bariatric
body contouring procedures may also require repositioning one or more times during
REF: Page 895
6. Skin grafting provides an effective way to cover a wound if vascularity is
adequate, infection is absent, and hemostasis is achieved. Skin from the donor
site is detached from its blood supply and placed in the recipient site. The best
description of a successful skin graft outcome is:
the skin is a good color match.
the recipient site develops a new blood supply from the base of the wound.
capillary refill returns within 24 hours.
a split-thickness graft is able to regenerate in an area of full-thickness loss.
Skin from the donor site is detached from its blood supply and placed in the recipient
site, where it develops a new blood supply from the base of the wound. Color match,
contour, and durability of the graft are all considerations in selection of an appropriate
donor area. Color, temperature, signs of infection, blanching of the skin, excessive pain
and discomfort, edema, vasoconstriction, and venous congestion should be noted and
any change reported to the surgeon.
REF: Pages 904-905
7. Replantation is an attempt to reattach a completely amputated digit or other body
part. Revascularization is the procedure performed on incomplete amputations,
when the part remains attached to the body by skin, artery, vein, or nerve. Good
candidates for replantation are those with the following amputations:
almost any body part of a child.
proximal portion of the hand at palm level.
distal to middle foot.
distal to middle thigh.
Good candidates for replantation are those with the following amputations: (1) thumb,
(2) multiple digits, (3) distal portion of the hand at palm level, (4) wrist or forearm, (5)
elbow and above the elbow, and (6) almost any body part of a child. The success of
digital replantation depends primarily on the microsurgical repair of one digital artery
and two digital veins.
Replantation of an amputated part is ideally performed within 4 to 6 hours after injury,
but success has been reported up to 24 hours after injury if the amputated part has
been cooled.
REF: Pages 911-912
8. Microsurgery, a fundamental tool in reconstructive plastic surgery, allows an
almost unlimited choice of reconstructive methods, replacement of lost tissue
with similar components, and optimal selection of donor sites with minimal
morbidity. Reconstructive microsurgical procedures include replantation of
amputated body parts, repair of facial nerves, repair of lacerated nerves and
blood vessels, treatment of extensive trauma to extremities and hands,
reconstruction following removal of extensive cancers, and female to male
transsexual reassignment. Today’s surgeons skilled in microsurgery can
successfully anastomose the ends of a vessel or nerve measuring less than:
2 mm.
1.5 mm.
1 mm.
0.5 mm.
Today’s surgeons who are skilled in microsurgery can successfully anastomose the
ends of a vessel or nerve measuring less than 1 mm in diameter. The surgeon’s use of
an operating microscope or loupes for microsurgical procedures depends on the
procedure to be performed, condition of the tissue, and personal preference.
REF: Page 911
9. Facial fractures are classified according to a system developed by Rene Le Fort
in the early 1900s. A fracture that starts at the nasal bones, crosses the frontal
process of the maxilla and lacrimal bones, and extends through the orbital floor,
infraorbital rim, and lateral maxillary sinus wall is known as a:
Le Fort I.
Le Fort II.
Le Fort III.
Le Fort IV.
Le Fort I, or transverse maxillary, fracture—this horizontal fracture includes the nasal
floor, septum, and teeth. Le Fort II, or pyramidal maxillary, fracture (unilateral or
bilateral)—often involves the nasal cavity, hard palate, and the orbital rim. Le Fort III, or
craniofacial dysjunction, fracture—includes fractures of both zygomas and the nose.
Like a mandibular fracture, a maxillary fracture also produces malocclusion. In addition,
depending on the severity of the fracture, it may produce considerable deformity of the
middle of the face, usually perceived as a flattening or smashed-in appearance. Closed
reduction with intermaxillary fixation suffices for treatment of Le Fort I and some Le Fort
II fractures.
REF: Page 916
10. Denise Michaelson had a scar revision of her knee performed along with her
bilateral mastectomy with saline implants and ear piercing procedures. The knee
scar, before revision, was an 8-cm linear, thin scar that extended obliquely
across the anterior portion of her knee. The tension of the scar tissue met
resistance when she would bend her knee. The surgeon opted to remove the
scar with a procedure to break up the linear scar and rearrange the tissue
direction to form a natural line. The proper name of this tissue transfer scar
revision is the:
a. scar lysis.
b. epidermolysis with remodeling.
c. scarplasty.
d. Z-plasty.
Z-plasty is the most widely used method of scar revision. It breaks up linear scars,
rearranging them so that the central limb of the Z lies in the same direction as a natural
skin line. Scar revision involves the rearranging or reshaping of an existing scar so that
the scar is less noticeable. The simplest form of scar revision is excision of an existing
scar and simple resuturing of the wound.
REF: Page 916
11. A broad range of implant materials are used in plastic and reconstructive surgery.
Select the implant that represents a biologic composition of a surgical implant.
Autologous human tissue
Medical-grade sterile silicone
The range of materials available for implantation and augmentation in the specialty of
plastic and reconstructive surgery has benefited from ongoing research. Biologic
materials (autogenous grafts) are preferred when available. Autologous human tissue
successfully utilized includes fat, solid dermis, and collagen. Human cadavers are used
as a source for acellular collagen (AlloDerm).
REF: Page 893
12. One of the most popular lasers used in plastic and reconstructive surgery is
attracted to the water in the skin cells and ablates the cells at a predetermined
depth. Collagen material beneath the skin surface is also heated, resulting in
smoother and slightly tighter skin. Several lasers are attracted to areas of darker
pigmentation. This treatment has virtually replaced dermabrasion, because of its
consistency in terms of depth of penetration and also because this technique is
less dependent on user technique or skill. Select the laser modality that would be
the best option for ablation or removal of a pigmented red tattoo.
CO2 laser
Erbium:YAG laser
Nd:YAG laser
Excimer laser
The Nd:YAG laser is suited to ablate or remove benign pigmented lesions and red
Common uses for lasers in plastic surgery include exfoliation, treatment of vascular
malformations, removal of hair and tattoos, and tightening of collagen fibers in aging
Candela dye, diode, and Q-Switch lasers are suited for pigmented benign lesions,
tattoos, and hemangiomas.
REF: Pages 891-892, 922-923
13. Dermatomes are used for removing split-thickness skin grafts (STSGs) from
donor sites. The perioperative nurse preparing for a procedure where STSGs will
be taken to cover several large burn areas will need to have available:
sterile petroleum jelly and sterile impregnated gauze sheets.
sterile mineral oil, tongue blades, and a mesher dermatome.
sterile mineral oil and carriers.
a nitrogen tank, sterile gauze fluffs, and antibiotic ointment.
Sterile mineral oil and tongue blades should be available when STSGs are being
obtained. Several types of skin meshers are available. Each is designed to produce
multiple uniform slits in a skin graft, approximately 0.05 inch apart. These multiple
apertures in the graft can then expand, permitting the skin graft to stretch and cover a
larger area. Meshing also facilitates drainage through the graft, preventing fluid
accumulation under a graft. The graft is placed on the carrier and passed through the
REF: Page 890
14. Marissa Walton is a 6-year-old girl with full-thickness burns involving both lower
legs, circumferentially, excluding her feet, over less than 2% of her body surface
area (BSA) and partial-thickness burns over less than 15% of her BSA, after her
clothes caught fire during a camping trip when she stepped into the campfire.
Based on the American Burn Association and the “Rule of Nines” classifications,
Marissa’s burns would be classified as ______________ with a burn surface
area percentage of approximately ______________.
minor; 17%
moderate; 17%
minor; 9%
major; 18%
The percentage of body surface area (BSA) system of the American Burn Association
uses the following burn classification: Minor burns: Full-thickness burns over less than
2% of BSA; partial-thickness burns over less than 15% of BSA. Both of Marissa’s lower
legs were burned circumferentially, giving her a score of approximately 9% for the sum
of both lower legs. Moderate burns: Full-thickness burns over 2% to 10% of BSA;
partial-thickness burns over less than 15% to 25% of BSA. Major burns: Full-thickness
burns over 10% or more of BSA; partial-thickness burns over 25% or more of BSA,
including any burns to face, head, hands, feet, or perineum; inhalation and electrical
burns; or burns complicated by trauma or other disease processes.
REF: Pages 898, 901-902
15. Marissa Walton is transferred to the OR from the burn unit for debridement of the
partial-thickness burn areas and a dressing change under anesthesia. What
important preparation for the procedure will the perioperative nurse perform
before Marissa arrives in the OR?
Procure the allograft skin from the freezer and begin the thaw process.
Procure a basic plastic instrument set plus a knife dermatome and sterile
mineral oil.
Prewarm the OR to above the ambient high temperature for an adult.
Collaborate with the anesthesia provider to determine fluid replacement
Because patients who have sustained burns are vulnerable to hypothermia from the
loss of BSA, the perioperative nurse should ensure the temperature and humidity in the
OR are increased and exposure is limited only to the areas related to the planned
surgical event. Throughout the procedure, the temperature in the OR is constantly
monitored to prevent hypothermia. The perioperative nurse will need to collaborate with
the anesthesia provider in determining fluid replacement requirements.
REF: Pages 899-900
16. Josh Tremain, a 28-year-old firefighter, sustained significant full-thickness burns
when he fell through the roof of a burning building while fighting an explosive fire.
What surgical treatments may Josh need before he is discharged from the burn
center to home?
Debridement and monitoring of full-thickness skin regeneration
Debridement, allograft placement during initial healing, and later splitthickness (ST) and full-thickness (FT) skin grafting
Allograft and xenograft placement as temporary dressings until secondary
granulation begins
Tangential excision of the burn wound with antibiotic-soaked dressings
Full-thickness burns may require debridement of necrotic tissue (eschar) before healing
can occur by skin regeneration or grafting. An allograft may be used to cover the burned
area during the initial healing process. A xenograft may also be used for covering the
burned area. An alternative method is tangential excision of the burn wound, which is
performed with a knife dermatome. This type of excision usually extends only to the
bleeding subcutaneous fat, rather than to fascia. Dressings saturated with the topical
antimicrobial agent of choice are applied. Although skin grafting may be done at the
time of wound debridement, it is usually performed several days later, particularly in
burns that are extensive.
REF: Page 900
17. When coverage for a defect cannot be achieved through skin grafting, plastic
surgeons rely on other techniques to replace tissue. After mastectomy,
reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap is
one of several options for nonsynthetic prosthetic reconstruction. Another
descriptive term for the TRAM flap is the:
pedicle-based flap.
free flap.
rotated tunneled flap.
The transverse rectus abdominis myocutaneous (TRAM) flap for postmastectomy
breast reconstruction is the most common pedicle-based flap used for breast
reconstruction. The rectus muscle is the broad, wide abdominal muscle that extends
from under the ribs to the pubis, and either one or both sides of the muscle may be
used for reconstruction. The blood supply (superior epigastric artery and vein) is carried
within the muscle pedicle. The muscle along with its pedicle is severed at its most distal
origins and pulled through a subcutaneous tunnel to the chest to form a breast.
Although this procedure has the added benefit of an abdominoplasty, if there is
inadequate abdominal tissue the patient may require a small mammary prosthesis.
REF: Page 909
18. In addition to the individualized nursing diagnoses that apply to surgical patients,
the patient scheduled for plastic or reconstructive surgery can typically be
expected to have the following nursing diagnosis:
Risk for Infection related to operative/invasive plastic/reconstructive
Disturbed Body Image related to congenital or acquired defect or
developmental abnormality.
Risk for Ineffective Tissue Perfusion related to surgical intervention.
All of the nursing diagnoses are relevant to most plastic and reconstructive
surgery patients.
Nursing diagnoses related to the care of the patient undergoing plastic and
reconstructive surgery might include the following: Risk for Infection related to
operative/invasive plastic/reconstructive procedure, Disturbed Body Image related to
congenital or acquired defect or developmental abnormality, Risk for Ineffective Tissue
Perfusion related to surgical intervention, Impaired Comfort related to surgical/invasive
procedure, Deficient Knowledge related to perioperative process, and Anxiety related to
surgical interventions or outcomes.
REF: Page 888
19. There are approximately 1 million reported cases of skin cancer per year with the
majority being the highly curable basal or squamous cell cancers, accounting for
more than 50% of all cancers. Not as common is the most serious skin cancer,
malignant melanoma, with an estimated 68,720 cases per year. Select the
individual who is at the highest risk for skin cancer.
a. An African-American outdoor sportsman and airline pilot
A fair-complected surfer and beach lifeguard who wears sunblock-protective
A fair-complected person testing positive for exposure to human
A dark-complected person testing positive for human immunodeficiency
A fair-complected person with exposure to human papillomavirus represents a person
with two risk factors. Other risk factors include: excessive exposure to ultraviolet
radiation from the sun; fair complexion; occupational exposure to coal tar, pitch,
creosote, arsenic compounds, and radium; and human immunodeficiency virus. Skin
cancer is negligible in African Americans because of heavy skin pigmentation.
REF: Pages 898, 901
20. The three most common skin cancers are basal cell, squamous cell, and
Treated early, skin cancers such as squamous cell and basal cell carcinomas may be
cured by simple excision and closure (with pathologic diagnosis to ensure disease-free
Melanoma is treated much more aggressively because of its high mortality. The A-B-CDs of the warning signs for skin cancer stand for:
acute, borderline, color, dysplastic.
asymmetry, blanching, cohesion, depth.
aplastic, bilateral, chronic, dysplastic.
asymmetry, border, color, diameter.
Any unusual skin conditions, especially a change in the size or color of a mole or other
darkly pigmented growth or spot, should be suspicious of skin cancer. The mnemonic AB-C-D stands for the following:
A: Asymmetry: One half of the lesion looks different from the other side.
B: Border irregularity: Instead of a smooth edge, the border is ragged or irregular.
C: Color: The color is usually irregular; may have a number of different hues and colors.
D: Diameter: Lesions larger than 6 mm have a greater chance of being a melanoma.
REF: Pages 898, 901
21. Mohs’ surgery is a specialized excision used to treat basal and squamous cell
skin cancers. Select the statement about Mohs’ surgery that best reflects the
process, procedure, and outcome goal.
Mohs’ surgery is diagnostic, an ambulatory procedure, and a definitive
Lesions are mapped, excised, and examined by frozen section until clear
margins are found.
The procedure can be very time-consuming to accomplish, but typically
results in the preservation of the surrounding healthy tissue.
The segments are excised and microscopically examined and the defect is
closed with a drain.
The procedure involves excising the lesion layer by layer and examining each layer
under the microscope until all the abnormal tissue is removed. Mohs’ surgery is usually
completed on an ambulatory basis with the patient administered a local anesthetic.
Because the procedure is lengthy, patient preparation and comfort are essential to
facilitate cooperation during the procedure. A horizontal layer of tissue is removed and
divided into sections that are color-coded with dyes. A map of the surgical site is then
drawn. Frozen sections are immediately prepared and examined microscopically for any
remaining tumor. If tumor is found, the location or locations are noted on the map and
another layer of tissue is resected. The procedure is repeated as many times as
necessary to completely remove the tumor.
REF: Pages 897-898
22. A variety of implantable devices are used in aesthetic and reconstructive plastic
surgery procedures. Tracking of these devices is critical to patient safety.
Institutions must report any incident of death or serious injury relating to the use
of a medical device. What regulatory agency, commission, or act mandates this
process when medical devices fail or cause injury?
The Joint Commission agency for sentinel events
Original Equipment Manufacturer Device Tracking Commission
Food and Drug Administration Device Failure and Recall Act
Safe Medical Device Act
Under the Safe Medical Device Act, institutions must report any incident of death or
serious injury relating to the use of a medical device. The manufacturer of the device
must have a mechanism to locate implantables after they have been distributed.
Devices may be recalled for sterility issues, malfunction, or any event that is found to
pose a serious health risk. The U.S. Food and Drug Administration (FDA) regulates the
process of tracking medical devices and directs the tracking of devices whose failure
would result in serious, adverse health consequences; devices that are intended to be
implanted in the human body for more than 1 year; and devices that are life-sustaining
and life-supporting and are used outside of a facility such as a hospital, nursing home,
or ambulatory surgery center.
REF: Page 892
23. Margaret Slayton, a 52-year-old woman with a left mastectomy followed by a
TRAM flap reconstruction, was beginning to emerge from anesthesia after her
procedure. The perioperative nurse gently moved Margaret’s arms from the
abducted position on the armboards in preparation for her transfer to her
postoperative bed and admission to the PACU. What risk reduction maneuver did
the nurse employ to Margaret’s bed before transferring her?
Flattened the bed to a horizontal plane with slight reverse Trendelenburg to
prevent headaches and support her airway
Raised the head of the bead to low Fowler’s flex position to reduce the
stretching on the abdominal donor graft wound site
c. Raised the foot of the bed to minimize deep vein thrombosis formation
Slid a wedge under the top of the mattress on the left side to prevent
dependent edema in the graft site
The OR bed and postoperative bed are flexed to minimize tension on the abdominal
TRAM donor/graft wound site. The patient is positioned supine with arms extended on
armboards during the surgery. Positioning the patient for this procedure is particularly
difficult because of the need to promote closure of the abdominal wound, support
circulation to the flap, and protect the patient from injury.
REF: Page 910
24. Sherrel Farmer, a 49-year-old post–bariatric surgery patient, is scheduled for a
Vaser-Assisted LipoSelection with tumescent infiltration. The tumescent is a
solution of lactated Ringer’s, lidocaine, and epinephrine. The perioperative nurse
is aware that using more than 70 mL/kg of wetting solution for infiltration can lead
to fluid overload. Select an appropriate nursing action related to minimizing the
risk of tumescent solution overload or disproportion to lipoaspirate.
The nurse will monitor the patient for syncope, cough, and bounding pulse.
The nurse will warm the tumescent solution and monitor fluid volumes.
The nurse will communicate and verify with the surgeon and/or anesthesia
provider the total lipoaspirate and volume of wetting solution used.
The nurse will titrate the flow rate of the tumescent solution in coordination
with aspirate outflow.
For safety issues, the nurse needs to communicate and verify with the surgeon the total
lipoaspirate and volume of wetting solution used. The surgeon typically injects a
medicated solution into the fatty areas before removal because of concerns about large
fluid volume shifts and blood loss after lipectomy. Fluid overload may present as
increased blood pressure, jugular vein distention, bounding pulses, cough, dyspnea,
lung crackles, and pulmonary edema.
REF: Pages 924-925
25. Franklin Hardy, a 46-year-old man with multiple moles and skin lesions, was
undergoing skin lesion excision surgery performed using a local anesthetic. After
90 minutes of surgery and multiple field block injections of 1% lidocaine with
epinephrine 1:100,000 and 0.5% bupivacaine, Franklin told the perioperative
nurse that he felt dizzy with ringing sensations in both ears, a metallic taste in his
mouth, and numbness of the tongue and lips. He became confused and restless
and showed an increased heart rate and blood pressure. The perioperative nurse
recognized his signs and symptoms of _____________________ and began
immediate treatment with _______________.
bupivicaine and lidocaine toxicity; airway support
local/subcutaneous infiltration; aspiration of gastric contents
lidocaine overdose; lipid emulsion infusion
a potential life-threatening complication; anticonvulsants and ACLS
Central nervous system (CNS) symptoms such as loss of responsiveness,
disorientation, tremors, or seizures must be treated conventionally by ensuring
oxygenation and ventilation, securing the airway to protect aspiration of gastric contents
in patients at risk, administering anticonvulsants, and instituting Advanced Cardiac Life
Support protocols in the case of cardiac arrest. While widely used, local anesthetics are
not free from hazards. A recent FDA warning notes that the potential life-threatening
complications, “such as irregular heartbeat, seizures, breathing difficulties, coma and
even death,” can occur when applied to a large area of skin or when the area of
application is covered. An example of a newer treatment for local anesthetic toxicity is
lipid emulsion rescue therapy, which has been used in isolated situations for
bupivacaine toxicity.
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