Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 01: Concepts Basic to Perioperative Nursing
a.The patient experience and the nursing presence are in continuous interaction.b.Structure, process, and outcome are the foundation domains of the model.c.The perioperative nurse is the central dynamic core of the model.d.The interrelated nursing process rings bind the patient to the model.
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
Process standards relate to nursing activities, interventions, and interactions. They are used to explicate clinical, professional, and quality objectives in perioperative nursing.
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a.Literature search, theory review, data analysis, policy developmentb.Regional survey, literature search, meta-analysis, practice changec.Identify problem, scientific evidence, develop policy, evaluate outcomed.Identify issue, analyze scientific evidence, implement change, evaluate process
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.
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a.conduct a survey of skin prep policies at the next AORN chapter meeting.b.review their surgical site infection data from the last 6 months.c.conduct a literature search on antimicrobial agents and infection prevention.d.review the scientific literature from the leading manufacturers of prep solutions.
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.
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a.Survey regional facilities that perform cardiac surgery for their back table models.b.Review case studies and expert opinions on sterile back table setups.c.Review AORN’s recommended practice on creating the sterile field.d.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.
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a.They are written by nurses.b.They are written specifically to address responsibilities and circumstances.c.They are collaborative and collective agreement statements.d.They are rarely based on research.
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.
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a.Scanning the surgical schedule for the day before morning reportb.Reading the pick/preference list attached to the case cartc.Reviewing the patient medical recordd.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.
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a.nursing diagnosis.b.nursing assessment.c.nursing outcome.d.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.
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a.Nursing assessmentb.Nursing implementationc.Nursing outcome preparationd.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.
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a.Assessment and planningb.Assessment and implementationc.Planning and implementationd.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
a.The patient is free from signs and symptoms of chemical injury.b.The patient is free from signs and symptoms of electrical injury.c.The patient is free from signs and symptoms of radiation injury.d.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
a.patient data retrieved from the nursing assessment.b.synthesized clues from the admitting diagnosis and surgery schedule.c.the approved NANDA-International list attached to the patient medical record.d.the admission form on the front of the chart.
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.
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a.replacing the regular OR bed with a bariatric-specific OR bed.b.providing protective lead aprons for all staff during the procedure.c.writing the patient’s name, allergies, and body weight on the white board.d.administering antibiotics to the patient 1 hour before the incision.
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.
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a.should not include technical care.b.must include a description of patient care delivered and patient response to that care.c.must be aligned with appropriate 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.
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a.still retains responsibility and authority for the outcome of the task.b.must comply with the seven “rights” of delegation.c.transfers the authority to perform the task to a competent person.d.transfers the supervision of the competent person to another competent person.
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 delegation.
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a.CNOR credential, BSN, and chair of the nursing research committeeb.Published article in the Sunny Shores newsletter and 15 years’ service pinc.BCLS instructor and weekend EMT transportd.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.
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a.cost savings by eliminating fines for near-misses and never events.b.customer satisfaction and loyalty.c.performance measurement activities.d.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.
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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.
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a.RNFA certification.b.clinical performance ladder level 4 or above.c.graduate degree in nursing (MSN).d.facility practice privileges.
APNs must have graduate nursing education (at least a master’s degree).
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a.sterile processing clinical specialist.b.general surgery service liaison.c.weekend resource nurse.d.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.
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a.promotes standardized perioperative documentation.b.fosters research on best practices.c.begins with outcome statements.d.promotes standardized perioperative documentation and begins with outcome statements.
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.
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Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 03: Infection Prevention and Control in the Perioperative Setting
a.Staphylococcus epidermidis.b.Streptococcus pyogenes.c.Staphylococcus aureus.d.Enterococcus.
The organisms most commonly found in postoperative SSIs include staphylococcal, enterococcal, pseudomonal, and streptococcal species. S. aureus is the most frequently identified organism.
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a.ability to cause plasma to coagulate and form a microscopic clot.b.physical and chemical properties of the cell wall.c.formation of aerobic clustered spheres.d.appearance of a thicker and brownish colored cell wall.
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
a.Susan because she is immunocompromised and elderly and has Crohn’s diseaseb.Shawn because he has pilonidal sinus tracts from sacral pressure caused by racingc.Susan because she has a mixed microorganism culture that is coagulase negatived.Shawn because he has a high microbial load that is coagulase positive
Coagulase-positive staphylococci are more virulent or pathogenic than coagulase-negative 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
a.Antibiotics given IV within 1 hour of the incision for every procedure with an incision or entered body systemb.Vancomycin paste applied to cut edges of the sternum in cardiac surgeryc.Tobramycin and methylmethacrylate bead implants into deep orthopedic incisions at risk for osteomyelitisd.Bacitracin ointment on a clean subcuticular sutured incision as part of the dressing
Drug resistance from treatment-related causes is often the result of misuse (e.g., incorrect use, overuse, or underuse) of antibiotics. It is believed that 50% of all antibiotic use in the United States can be characterized by misuse in one form or another, and efforts to reduce surgical site infections include appropriate prophylactic antibiotic use in surgical patients. It is estimated that half of all antibiotic prescriptions written are not warranted. During antibiotic therapy, the patient may have retained a few resistant organisms. By natural selection, as the susceptible organisms are killed, the resistant organisms multiply and become predominant. Failure to perform sensitivity testing along with inappropriate dosing can contribute to resistance. Although some surgical complications are unavoidable, surgical care can be improved through decisions and subsequent care focusing on evidence-based practice recommendations. Research shows that delivering antibiotics to a patient within 1 hour of beginning surgery can dramatically decrease SSI rates, yet this practice is not followed in all situations.
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a.Anthrax, tuberculosis, C. difficile, tularemiab.Smallpox, plague, botulism, tularemiac.Smallpox, monkeypox, avian influenza, anthraxd.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.
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a.Contact Precautions with eye protection.b.both Standard Precautions and Contact Precautions.c.body substance isolation.d.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.
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a.Plague and tuberculosisb.Smallpox and tuberculosisc.Ebola virus and anthraxd.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.
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a.create mild air turbulence to prevent dust from settling on surfaces.b.augment the oxygen-enriched environment with dust-free air.c.flow clean air over the patient and prevent corridor air intake.d.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).
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a.mobilize resting dust from these surfaces.b.contaminate sterile areas.c.disrupt the unidirectional airflow.d.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.
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a.Surround the patient with a forced air–warming blanket and foil head covering.b.Set the ambient room temperature between 68° and 73° F and limit exposure.c.Line the OR bed with a circulating fluid mat and insert a rectal temperature probe.d.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).
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a.Time, temperature, and steam pressureb.Reduced and limited mitosis within the bioburdenc.Saturated vaporization of the microbial cytoplasmd.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.
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a.Steam saturation; not kill microorganismsb.Steam distribution; promote microbial killc.Sterilization; kill all microorganisms to 106d.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 necessary.
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a.97% or greater.b.100%.c.<3% of the mixture is liquid water.d.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.
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a.handled without gloves and prepared for sterilization.b.free of bioburden and safely handled with gloves.c.clean at a high level of disinfection.d.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.
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a.Cost, good barrier, lint-free writable surfaceb.Good steam penetration and removal, good barrier, aseptic presentationc.Aseptic presentation, event-related sterility indicators, writable surfaced.Stackable in sterilizer/storage shelf, comparable cost, low toxicity
To be effective, packaging material should have the following characteristics: allows for adequate steam penetration and removal; provides an adequate microbial barrier; resists tearing or punctures; has proven seal integrity (i.e., does not delaminate when opened and does not allow a reseal after opening); allows for aseptic delivery of package contents; is free of toxic ingredients and nonfast dyes; is low-linting; is cost-effective by cost and value analysis.
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a.Air-dry, inventory, inspect, lubricate, assemble and string instruments, wrap and tapeb.Inspect, unlock locked clamps, count and string instruments, place indicators, wrap and tapec.Inspect, unlock locked clamps, string instruments, inventory, replace missing items, wrapd.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.
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a.contact Precautions as well as Universal Precautions.b.hospital-grade disinfectant/sterilants.c.semicritical medical devices used for ambulatory procedures.d.agents to disinfect and eliminate most, if not all, pathogenic microbes.
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.
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a.time and pressure.b.pressure, steam, and temperature.c.temperature, time, and presence of steam.d.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.
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a.hydrogen peroxide gas plasma sterilization for everything.b.steam sterilization for the implant sets and paper inventory form, hydrogen peroxide gas plasma for the retractors, wrapped separately.c.steam sterilization for the implant sets, hydrogen peroxide gas plasma for the retractors and paper inventory form, wrapped separately.d.steam sterilization for everything with a shortened dry time.
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.
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a.The new prep area was not given time to dry.b.The time-out should have been repeated with the surgeon scrubbed.c.The patient should have been reprepped and redraped with all new drapes.d.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.
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a.At the vagina and perineum; the nurse should check with the anesthesia provider before touching the patientb.At the incision site to the periphery of the abdomen only the nurse should begin and complete perioperative documentation of skin preparation including wound classificationc.At the cleanest area first and proceeds to less clean areas (abdomen then vagina/perineum); a skin assessment should be performedd.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.
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a.it can only be used for the initial gloving.b.it requires two people to execute without contamination.c.there is a risk of contamination if the thumbs are not extended.d.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.
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a.Sterile talcum or corn starch powderb.Sterile petroleum-based oilsc.Sterile silicone filmd.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 others.
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a.Mask, gown, gloves, shoe coversb.Gown, lead apron, shoe covers, mask, glovesc.Mask, gown, hat, glovesd.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.
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a.Wipe gloves clean, untie side gown closure, grasp gown at one shoulder seam.b.Wipe gloves clean, grasp gown at both shoulder seams, pull over and off arms.c.Unfasten gown back closures, grasp gown at one shoulder seam, pull down over both arms and gloves while everting glove cuffs.d.Grasp both gown shoulders, slide gown down over arms, grasp gloves inside gown sleeves and pull gown and gloves off together.
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
a.Remove both gloves together using the gloved fingers of one hand to secure the everted cuffs of the other hand, turning both gloves inside out. Discard gloves in regular trash since they are inside out. Remove mask by the ties and wash hands.b.Using the gloved fingers of one hand to secure the everted cuff, remove the glove, turning it inside out. Discard appropriately. Using the ungloved hand, grasp the fold of the everted cuff of the other glove and remove the glove, inverting the glove as it is removed. Discard in biohazard trash. Remove mask by the ties and discard. Wash hands.c.Both practices are appropriate.d.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 forearms.
REF: Pages 100-101
a.surgically clean.b.free of transient microorganisms, dirt, and skin oils.c.coated with residual antimicrobial residue to prevent microbial regrowth.d.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 present.
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a.Alcohol-based hand rubb.Anatomic counted strokes with 4% chlorhexidine gluconate brushc.Anatomic timed strokes with povidine iodine sponged.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.
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a.Wash hands and wrists, remove jewelry, replace mask and eye protection, contain hair.b.Contain hair and earrings in hat, wash hands and clean under nails, place mask and eye protection, remove jewelry.c.Remove jewelry, contain hair, don fresh mask and eye protection, wash hands and forearms.d.Don fresh mask, contain hair, place eye protection, clean under nails.
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
a.reglove with open-glove or assistive glove technique.b.reglove with closed-glove technique.c.remove gown and gloves and regown and reglove.d.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.
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a.The Centers for Disease Control and Prevention (CDC) endorses double gloving for all surgery and invasive procedures.b.Wearing two glove layers permits regloving using the closed-glove technique for a contaminated glove.c.Wearing a glove liner between both layers of gloves may eliminate the risk of perforation to the inner glove, protecting the wearer from sharps injury.d.The AORN publication titled Recommended Practices for Prevention of 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.
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a.Provide barrier protection from microorganisms, fluid, and particulate matterb.Limit environmental impact and flammabilityc.Ensure a fiscally responsible cost/benefit ratio and reduce glared.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.
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a.The circulating nurse should monitor the scrub person’s gowned arms when reaching over the unsterile parts of the patient.b.Gently shake and fan out the drapes to open up the folds before approaching the patient.c.Drape the patient starting with the incision area and proceeding to the periphery.d.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.
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a.The patient should have been taken to a second available OR, not the room with the liver dissection underway, since it was being split for two patients.b.The patient should have been held in preoperative holding until the liver was split and the second segment placed back into the cooler.c.The back table should have been covered with sterile drapes and moved to a second available room.d.The surgeon should proceed with splitting the liver, replacing the segment for the second patient back into the cooler, and storing the cooler in the back of the OR for the second transplant patient, whose procedure will follow in the same OR.
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.
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_____ 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.
1 = A
2 = G
3 = E
4 = D
5 = B
6 = F
7 = H
8 = C
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
a.All three are solid organs and very vascular.b.All three are metabolic organs.c.All three organs have terminal attachments to the duodenum.d.All 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 body.
REF: Pages 357-361
a.Kupffer cells; phagocytesb.sinusoid cells; lymphocytesc.hepatocytes; biled.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
a.Carbohydrate glucose substrateb.Glycogenc.Serum glucosamined.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
a.manufacture bile.b.convert bile salts into bile enzymes.c.store and concentrate bile.d.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
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 duodenum.
REF: Pages 359-360
a.immunologic; leukocytesb.metabolic; granulocytesc.anabolic; plasma cellsd.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
a.end-stage liver disease resulting from advanced hepatic cancer with metastasis.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
a.laparoscopic splenic resection with sutured mesh overlay.b.open splenic lobectomy with vascular ligation.c.open total splenectomy.d.open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.
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
a.left lobe of the liver; metastatic hepatocytomab.distal segment of the spleen; pancreatic metastasisc.inferior margin of the ligament of Treitz; pancreatic cancerd.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
a.the patient has undergone prior biliary surgery.b.a positive cholangiogram shows a CBD obstruction during an open cholecystectomy.c.laparoscopy technology is not available.d.All of the options are correct.
With the advent of endoscopic, percutaneous, and laparoscopic techniques (Figure 11-13), 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 performed.
REF: Page 378
a.tachycardia caused by peritoneal irritation from the CO2.b.CO2 absorption into the peritoneal capillaries, causing decreased oxygen saturation.c.bradycardia from CO2 pressure lower than 15 mm Hg.d.gas embolus into an exposed blood vessel during the procedure.
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
a.reviews his chart for bleeding and coagulation times and the platelet count.b.asks Steven his blood type and when he last donated blood.c.palpates Steven’s abdomen for left upper quadrant tenderness and liver margins.d.reviews the findings of his endoscopic retrograde cholangiopancreatoscopy (ERCP).
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
a.place two safety belts over the thighs and lower legs to prevent the patient from sliding out of position when the surgeon tilts the table for better exposure and access.b.place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant of the abdomen.c.abduct the patient’s right arm on an armboard at less than 90 degrees to allow an assistant to stand near the patient’s right upper quadrant and retract the liver with a wide Deaver retractor.d.place 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 cholecystectomy.
REF: Pages 362, 365-366
a.encourage verbalization of his fears and reinforce the standardized age-appropriate coping mechanisms.b.describe for him the steps of the operative procedure.c.offer emotional reassurance by using touch, assisting him to a position of comfort on the OR bed, and offering warm blankets (thermal comfort).d.share with 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
a.The tip of the dissector that was in the patient’s abdomen was not contaminated.b.The surgeon planned to remove the dissector after he finished dissecting and then dispose it.c.The surgeon’s gown was not touched, just the dissector connection to the robotic arm.d.The surgeon was not in contact with the sterile field because he worked from the robotic console.
The surgeon manages the robotic system from a console away from the operative field. With current robotic systems, the surgeon sits at an operative console with three-dimensional imaging and handheld controls. Movement of the controls follows the movement of the instrument’s tip. Robotic arms function just like a surgeon’s hands.
REF: Pages 377-378
a.Based on Joanne’s coagulation status, excess bleeding is not expected to be an issue.b.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.c.Any excess bleeding will be removed and returned to the patient through the autotransfusion system.d.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
a.Send a sterile urine sample for stat cytologic studies.b.Notify the scrubbed team of the urine color change and check the bladder for trauma.c.Stop the blood transfusion.d.Check the blood unit for patient-specific identification and expiration date.
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
a.The surgeon controls two instruments plus a camera while an assistant suctions and retracts.b.Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage.c.The magnified three-dimensional picture may reduce bile duct injuries during dissection.d.Robotic stapler and suture devices promote intracorporeal anastomotic techniques.
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
a.advise the anesthesia provider to premedicate with an H2 blocker, diphenhydramine, and prednisolone.b.alert the OR and postoperative recovery areas of his latex allergy, check the setup for latex-containing items, and replace those items with non-latex alternatives.c.transfer his care to the pediatric OR in the adjoining hospital where everything in the OR is latex-free.d.position code and latex carts outside of the OR and watch for signs of latex reaction; tape an epinephrine-filled syringe to the head of his transport vehicle.
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
a.substitute absorbable gelatin and oxidized collagen products; soak in thrombin.b.substitute absorbable gelatin and oxidized collagen products; use high ESU settings.c.substitute absorbable gelatin and oxidized collagen products; use regular ESU settings.d.substitute microfibrillar collagen soaked in thrombin; add epinephrine 1:1000.
These hemostatic products do not contain bovine products: absorbable gelatin, powder, or compressed forms (Gelfoam); purified porcine gelatin, beaten, dried, and heat-sterilized;and oxidized cellulose (Surgicel, Surgicel Nu-Knit); absorbable oxidation product of cellulose. These products are manufactured from bovine products: absorbable collagen (Collastat, Superstat, Helistat); bovine collagen origin. Collagen activates the coagulation mechanism, aggregation of platelets; microfibrillar collagen (Avitene, Instat), hydrochloric acid salt of purified bovine corium collagen; thrombin enzyme extracted from bovine blood.
REF: Page 368
a.vascular instruments, silk sutures and ties, sterile ice, flushing solution, and slush machine.b.flushing solution, ice chest, sterile ice, powered sternal saw, and long Kocher clamps.c.culture tubes, Wisconsin University forceps, Deaver retractors, and slush machine.d.toothed forceps, vessel loops, two sterile plastic draw-string bags, and flushing solution.
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
a.From neck to midthigh; midaxillary line to midaxillary lineb.From nipple line to pubis; bedline to bedlinec.From the neck to midthigh; bedline to bedlined.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
a.secure an order for social services consult.b.secure an order for a physical rehabilitation plan.c.provide Maryanne and Charles with the standard discharge education with emphasis on their concerns.d.elicit their abilities to provide for themselves and their resources of support.
ANS: C, D
The patients should be included in the decision-making about their 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
____ 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 report.
____ I. The circulating nurse identifies the box with a recipient patient label.
1 = E
2 = H
3 = A
4 = I
5 = B
6 = C
7 = G
8 = D
9 = F
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
a.body geometry.b.the anatomy and biology of tissue.c.form and function.d.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
a.reconstructive; reconstructive; reconstructiveb.reconstructive; cosmetic; reconstructivec.cosmetic; reconstructive; cosmeticd.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
a.epinephrine is contraindicated in areas with limited vascularity, such as the ears.b.Marla is complying with the surgeon’s standardized order on the preference list.c.epinephrine-induced vasoconstriction may interfere with normal tissue planes.d.pediatric heart rates are higher than adult heart rates and epinephrine can cause tachycardia.
Use of epinephrine is contraindicated in areas with limited vascularity, such as digits, the penis, nasal tip, and ears.
REF: Page 894
a.Use chlorhexidine gluconate (CHG) around the ears and eyes.b.Leave the eyebrows and eyelashes intact to preserve facial appearance and expression.c.Prep the skin graft and donor sites together with the same prep set and drape immediately.d.Isolate rashes, open sores, cuts, or lesions in the prep site with a sterile, clear adhesive patch.
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
a.repositioning one or more times during surgery.b.meticulous accounting of fluid loss and blood replacement.c.pressure dressings.d.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 surgery.
REF: Page 895
a.the skin is a good color match.b.the recipient site develops a new blood supply from the base of the wound.c.capillary refill returns within 24 hours.d.a split-thickness graft is able to regenerate in an area of full-thickness loss.
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
a.almost any body part of a child.b.proximal portion of the hand at palm level.c.distal to middle foot.d.distal to middle thigh.
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
a.2 mm.b.1.5 mm.c.1 mm.d.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
a.Le Fort I.b.Le Fort II.c.Le Fort III.d.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
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
a.Autologous human tissueb.Medical-grade sterile siliconec.Goldd.Polypropylene
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
a.CO2 laserb.Erbium:YAG laserc.Nd:YAG laserd.Excimer laser
The Nd:YAG laser is suited to ablate or remove benign pigmented lesions and red tattoos.
Common uses for lasers in plastic surgery include exfoliation, treatment of vascular malformations, removal of hair and tattoos, and tightening of collagen fibers in aging skin.
Candela dye, diode, and Q-Switch lasers are suited for pigmented benign lesions, tattoos, and hemangiomas.
REF: Pages 891-892, 922-923
a.sterile petroleum jelly and sterile impregnated gauze sheets.b.sterile mineral oil, tongue blades, and a mesher dermatome.c.sterile mineral oil and carriers.d.a nitrogen tank, sterile gauze fluffs, and antibiotic ointment.
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 mesher.
REF: Page 890
a.minor; 17%b.moderate; 17%c.minor; 9%d.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
a.Procure the allograft skin from the freezer and begin the thaw process.b.Procure a basic plastic instrument set plus a knife dermatome and sterile mineral oil.c.Prewarm the OR to above the ambient high temperature for an adult.d.Collaborate with the anesthesia provider to determine fluid replacement requirements.
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
a.Debridement and monitoring of full-thickness skin regenerationb.Debridement, allograft placement during initial healing, and later split-thickness (ST) and full-thickness (FT) skin graftingc.Allograft and xenograft placement as temporary dressings until secondary granulation beginsd.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
a.pedicle-based flap.b.free flap.c.mastopexy.d.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
a.Risk for Infection related to operative/invasive plastic/reconstructive procedure.b.Disturbed Body Image related to congenital or acquired defect or developmental abnormality.c.Risk for Ineffective Tissue Perfusion related to surgical intervention.d.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
a.An African-American outdoor sportsman and airline pilotb.A fair-complected surfer and beach lifeguard who wears sunblock-protective clothingc.A fair-complected person testing positive for exposure to human papillomavirusd.A dark-complected person testing positive for human immunodeficiency virus
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
Treated early, skin cancers such as squamous cell and basal cell carcinomas may be cured by simple excision and closure (with pathologic diagnosis to ensure disease-free margins).
Melanoma is treated much more aggressively because of its high mortality. The A-B-C-Ds of the warning signs for skin cancer stand for:
a.acute, borderline, color, dysplastic.b.asymmetry, blanching, cohesion, depth.c.aplastic, bilateral, chronic, dysplastic.d.asymmetry, border, color, diameter.
Any unusual skin conditions, especially a change in the size or color of a mole or other darkly pigmented growth or spot, should be suspicious of skin cancer. The mnemonic A-B-C-D stands for the following:
A: Asymmetry: One half of the lesion looks different from the other side.
B: Border irregularity: Instead of a smooth edge, the border is ragged or irregular.
C: Color: The color is usually irregular; may have a number of different hues and colors.
D: Diameter: Lesions larger than 6 mm have a greater chance of being a melanoma.
REF: Pages 898, 901
a.Mohs’ surgery is diagnostic, an ambulatory procedure, and a definitive treatment.b.Lesions are mapped, excised, and examined by frozen section until clear margins are found.c.The procedure can be very time-consuming to accomplish, but typically results in the preservation of the surrounding healthy tissue.d.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
a.The Joint Commission agency for sentinel eventsb.Original Equipment Manufacturer Device Tracking Commissionc.Food and Drug Administration Device Failure and Recall Actd.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
a.Flattened the bed to a horizontal plane with slight reverse Trendelenburg to prevent headaches and support her airwayb.Raised the head of the bead to low Fowler’s flex position to reduce the stretching on the abdominal donor graft wound sitec.Raised the foot of the bed to minimize deep vein thrombosis formationd.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
a.The nurse will monitor the patient for syncope, cough, and bounding pulse.b.The nurse will warm the tumescent solution and monitor fluid volumes.c.The nurse will communicate and verify with the surgeon and/or anesthesia provider the total lipoaspirate and volume of wetting solution used.d.The nurse will titrate the flow rate of the tumescent solution in coordination with aspirate outflow.
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
a.bupivicaine and lidocaine toxicity; airway supportb.local/subcutaneous infiltration; aspiration of gastric contentsc.lidocaine overdose; lipid emulsion infusiond.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.