Alexanders Care Of the Patient in Surgery 14th Edition Rothrock – Test Bank

Complete Test Bank With Answers

Sample Questions Posted Below

Rothrock: Alexander’s Care of the Patient in Surgery, 14^th Edition

Chapter 05: Positioning the Patient for Surgery

Test Bank

MULTIPLE CHOICE

1.Albert Janson, a 325-pound patient, is scheduled for a 6-hour abdominal surgery. While assessing Mr. Jennings in the preoperative holding area, the perioperative nurse is concerned about the risk for pressure injury because of the weight of the patient’s body pressing against the surface of the OR bed for a long surgery. Which of these other factors may also produce pressure?

ANS: B

Pressure is the force placed on underlying tissue. Pressure can occur from the weight of the body as gravity presses it downward toward the surface of the bed. Pressure also results from the weight of equipment resting on or against the patient, such as drills, Mayo stands, surgical instruments, rigid edges of the OR bed or its attachments, or vertical posts for self-retaining retractors.

REF: Page 144

2.After Mr. Jennings was asleep and intubated, the surgeon requested the patient to be placed in lithotomy position for a sigmoidoscopy before the open procedure. The team of five nonscrubbed persons lifted the patient with the lift sheet, slid the patient down toward the foot of the OR bed, and placed him into position. After the sigmoidoscopy, the perioperative nurse had the team roll the patient to his side for a skin assessment of his back before he was repositioned supine. What injury was the perioperative nurse concerned that she might see?

ANS: A

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

REF: Page 144

3.The perioperative nurse visited Mr. Jennings in the ICU the next day and noticed abrasions on his elbows. Mr. Jennings told her that the ICU nurses had difficulty pulling him back up in bed every time he slid down toward the bottom and he was not able to be much help in moving himself. This skin injury was probably the result of which physical force?

ANS: C

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

REF: Page 144

4.Select the nursing activity that would reduce the impact of an extrinsic factor that could cause a pressure injury to the patient.

ANS: D

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

REF: Page 147

5.Maria Faulkner is a 92-year-old frail nursing home patient admitted for dehydration, anemia, and respiratory symptoms. She has type 2 diabetes and low albumin levels, is underweight, and continues to smoke cigarettes when she is at home. Mrs. Faulkner is on complete bed rest in a hospital bed with an alternating pressure mattress overlay. She is not able to turn herself in bed and must be assisted to change position. Based on this description of Mrs. Faulkner, which factor classification dominates her vulnerability and risk for injury?

ANS: B

Intrinsic factors can lower a patient’s tissue tolerance to pressure and decrease the time and pressure required for tissue breakdown. Certain preexisting conditions are regarded as intrinsic risk factors for OR-induced pressure ulcer development. These conditions include respiratory and circulatory disorders, diabetes mellitus, anemia, malnutrition (serum albumin levels 3.5 g/dl or less), advanced age, body size (obesity; thin, frail build), body temperature (hypothermia), impaired mobility, and smoking.

REF: Page 147

6.Mrs. Faulkner’s Braden scale score is 11. This places her at __________ risk.

ANS: C

The lower the score, the greater the risk of developing pressure ulcers. The levels of risk according to scores are as follows (Braden and Maklebust, 2005): 19-23, not at risk; 15-18, mild risk; 13-14, moderate risk; 10-12, high risk; ≤9, very high risk.

REF:Pages 147-148

7.A patient undergoing a laparoscopic Nissen fundoplication procedure will be positioned in both high and low lithotomy during the procedure. After the patient is repositioned into low lithotomy, the perioperative nurse should:

ANS: D

The patient should be reassessed after any adjustment of the position and at appropriate intervals during long procedures as is possible with a draped patient. Assessment for pressure ulcer risk factors and development occurs during three periods: preoperative, intraoperative, and postoperative.

REF: Page 147

8.David Reese, a 14-year-old patient with marked scoliosis, is in prone position with gel rolls, gel pads, and pillows for a spinal fusion. Before the skin prep is begun, the perioperative nurse should check the positioning for pressure areas of the:

ANS: C

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

REF:Pages 156, 170

9.Tara Shaw, the circulating nurse, instructed the new anesthesia resident in the proper positioning of the arm and hands on the OR bed armboards. She cautioned him to avoid pressure on the elbow to prevent:

ANS: A

Isolated ulnar nerve injuries occur primarily from pressure on the vulnerable location of that nerve at the elbow. The ulnar nerve becomes quite superficial as it passes behind the elbow, nesting in the epicondyle groove of the humerus that makes up the cubital tunnel.

REF: Page 152

10.Prolonged lithotomy positioning can result in neuropathies of the legs. The most frequently injured nerves are the obturator, sciatic, femoral, and _____________ nerve, which can result in injury from ______________.

ANS: B

The common peroneal nerve branches from the sciatic nerve behind the knee and becomes superficial as it wraps around the lateral head of the fibula. At this level, it is quite vulnerable to direct compression by stirrup bars. This risk increases in extremely thin patients who have minimal overlying tissue in this area. Compressive leg wraps (i.e., pneumatic compressive devices, elastic wrappings, or stockings) also can apply pressure on this nerve if the wrapping is too tight in this area.

REF:Pages 153, 155

11.The lateral kidney position allows approach to the retroperitoneal area of the flank. To render the kidney region readily accessible, the _______________ is raised, and the bed flexed so that the area between the twelfth rib and the iliac crest is elevated. Compression of the ____________ can occur when the flank is raised too high.

ANS: C

Raising the kidney bridge depends on the cardiovascular response of the body to increased pressure. The bridge must be raised slowly and blood pressure monitored frequently by the anesthesia provider. Diaphragmatic movement is limited by increased intra-abdominal pressure from the kidney bridge and by flexion of the lower limbs toward the abdomen. Both the acute angulations of the body in the lateral kidney position and gravity may decrease blood return to the right side of the heart.

REF: Page 173

12.While Fowler’s position offers the best respiratory excursion for the patient, the patient is at higher risk for ____________________ because of dependent pooling in the hips and legs.

ANS: A

This position poses significant circulatory compromises and risks. Blood pooling occurs in the lower torso and legs, which causes significant orthostatic hypotension and diminished perfusion to the brain. Venous return from the lower extremities is impeded and such hindrance causes increased risk of VTE. SCDs or antiembolic stockings are used to support venous return.

REF: Page 168

13.Lateral, lateral chest, and lateral kidney positions all place pressure on structures of the dependent side: ears, shoulder, ribs, hips, greater femoral head, knees, and ankles. The potential for injury to the patient is significant, based on these pressure areas. Which resultant injury or harm could be related to these lateral positions?

ANS: D

A respiratory effect of this position is that the dependent lung is more perfused because gravitational pooling of blood occurs. The nondependent lung is more easily ventilated, however, because it is less compressed. The lower shoulder is brought slightly forward and an axillary roll is placed under the rib cage, posterior to the axilla. This places the weight of the chest on the rib cage instead of compressing the lower shoulder and axilla, which otherwise may injure the brachial plexus of the dependent arm.

REF:Pages 163, 172

14.While tucking the arms at the sides of the patient in supine position offers comfort, safety, and easy access to the patient by the scrubbed team, improper positioning and securing of the arms can result in significant injury. Injury can be avoided by tucking the draw sheet ________ the arm and under the _________.

ANS: A

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

REF:Pages 152-153

15.Jennifer Twist, a 3-year-old patient for bilateral myringotomy with tubes, is frantically screaming and thrashing on separation from her parents as the anesthesia provider carries her to OR 3. The perioperative nurse, pushing the empty transfer vehicle, identifies that Jennifer is at high risk for injury from _________, and is planning appropriate position-related protective measures: ________ ________. Select from the options to fill in the blanks.

ANS: B

Jennifer is at high risk for falls while being carried and transferred to the OR bed and during induction and anesthesia emergence. Falls are a risk during all stages of patient transfer and positioning. Falls can occur easily during transfers if the transport vehicle and OR bed are not locked. Falls also can occur while the patient is on the OR bed, whether awake or anesthetized. A team member must stand on either side of the patient until the safety strap is applied. Falls also are a risk during induction and emergence from anesthesia. The nurse remains at the patient’s side during both induction and emergence as a fall-prevention strategy and to assist the anesthesia provider in other activities.

REF:Pages 158-159

16.Susan Graton is a 52-year-old and 425-pound patient scheduled for surgery at the bariatric surgery center in 3 days. She has osteoarthritis and had a spinal fusion when she was 13. Cheryl, her long-time neighbor and a perioperative nurse at the bariatric center, has asked to be Susan’s circulating nurse and is contemplating Susan’s plan of care. Susan shared with Cheryl her concern that she would not be able to move herself over to the OR bed and would be embarrassed if the nurses could not lift her. Based on this information, Cheryl has identified this nursing diagnosis: ___________________ and these three positioning-relevant nursing interventions: _______ _______ _______. Select from the options to fill in the blanks.

ANS: A

Susan will not be able to transfer herself to the OR bed from the transport vehicle without considerable assistance. The following interventions can enhance the morbidly obese patient’s safety: Lock wheels of OR bed and transport vehicle. Provide OR bed made to accommodate patient’s size and weight or secure two OR beds together adjacently. Use transfer aids such as rollers or backboards. Have numerous staff members available to assist during transfer and positioning maneuvers.

REF:Pages 158-159

17.Myrna Powers is a frail and thin 91-pound, 83-year-old woman scheduled for a right pneumonectomy for non–small cell lung cancer. She will be positioned in left lateral position for her procedure. Based on the perioperative nurse’s preoperative assessment, identify three position-related nursing diagnoses ______ ______ _____ for this procedure and four relevant nursing interventions_____ ______ ______ ______. Select from the options to fill in the blanks.

ANS: D

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

REF:Pages 158-159

18.Positioning devices should be used according to the original equipment manufacturer’s instructions to reduce the capillary interface pressure to below:

ANS: B

In 1930 Lanis determined that 32 mm Hg is the average capillary pressure at arterial inflow. This value is still accepted as the threshold beyond which tissue trauma occurs.

REF: Page 145

19.Select three basic criteria requirements that an OR bed mattress must meet.

ANS: A

OR mattresses must meet certain basic characteristic requirements: durable, versatile, nonflammable, resistant to bacterial growth, radiolucent with low x-ray attenuation, compatible with warming and cooling devices, covered with flexible nonallergic antistatic fabric, have pressure-reduction capabilities, and preferably be constructed without latex.

REF: Page 161

20.Select the positioning devices and accessories commonly used for prone position.

ANS: D

When placed in prone position, the patient is placed on a laminectomy frame (such as a Wilson frame), or on chest rolls that extend lengthwise from the acromioclavicular joint to the iliac crest. The Jackson spinal surgery bed is also used in many hospitals for posterior spinal surgery when the opposite positioning effect is needed.

REF: Page 163

21.Select the positioning device and accessory commonly used for neurosurgical procedures.

ANS: C

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

REF:Pages 163, 168

22.Select the positioning devices and accessories commonly used for bariatric surgery.

ANS: D

An upper body ramp is designed to elevate the head, upper body, and shoulders to facilitate the airway when supine. Padded armboards match the higher elevation of the shoulders to avoid stretching the brachial plexus. Use transfer aids such as rollers or backboards. Have numerous staff members available to assist during transfer and positioning maneuvers.

REF:Pages 157-158

MULTIPLE RESPONSE

1.Morton White, a 68-year-old, ASA PS-2 male with early-stage prostatic cancer, was intubated and positioned for a robotic-assisted laparoscopic radical prostatectomy. The initial position for insertion of the trocars was supine with arms tucked and secured within under-mattress sled arm positioners padded with gel. His hands were placed in a natural position with the fingers wrapped around gauze rolls and touching his lateral thighs. The new anesthesia provider, who had never seen a robotic prostatectomy, was concerned about anesthesia implications when the patient would be repositioned into extreme Trendelenburg for the dissection and anastomosis. The circulating nurse assured her that they would implement protective measures and work together to ensure the best patient outcome. Select all of the potentially harmful effects of extreme 45-degree Trendelenburg in a robotic procedure.

ANS: A, C

The respiratory system can be compromised during positioning. In Trendelenburg, the abdominal viscera are shifted upward against the diaphragm, reducing tidal volume. Accidental deployment of the remote can cause significant injury and death. Facial edema is a result of prolonged dependent position of the head and pressure from abdominal viscera. The patient is at high risk for sliding off of the top of the OR bed toward the anesthesia provider.

REF: Page 156

2.The circulating nurse and anesthesia provider employed protective measures for their patient positioned in extreme 45-degree Trendelenburg for a robotic-assisted laparoscopic radical prostatectomy. These measures included (select all that apply):

ANS: A, B, D

Accidental deployment of the remote can cause significant injury and death; therefore the remote should be removed or locked. The patient is at high risk for sliding off of the top of the OR bed toward the anesthesia provider, and the upper body should be secured without pressure on the shoulders or chest compression. The arms should be tucked at the side in good alignment with padded sleds or a tucked lifting sheet over the arms and under the body.

REF: Page 156

OTHER

1.Number the sequence of steps for positioning a patient in supine position with urinary catheter insertion.

____ a. Abduct arms less than 90 degrees on padded armboards.

____ b. Place safety strap 2 inches above knees.

____ c. After anesthesia induction and intubation, prepare urinary catheter sterile equipment.

____ d. Place small pillow or headrest under head.

____ e. Flex legs in a frog-leg fashion, externally rotating the thighs. 

____ f. Transfer patient to lie with the back flat on the locked OR bed.

ANS:

1 = F 

2 = B 

3 = D 

4 = A 

5 = C 

6 = E 

The patient lies with the back flat on the OR bed. The arms may be tucked at the side or placed on armboards. A safety strap is placed approximately 2 inches above the knees. The head generally rests on a small pillow or head cushion to support cervical alignment, reduce occipital pressure, and reduce strain on neck muscles. When the arms are placed on armboards, the armboards are padded, with the pad level equal to that of the OR bed. Extension should be less than a 90-degree angle to prevent stretching and compression of the brachial plexus. Sometimes the patient’s legs need to be flexed in a frog-leg fashion to provide access to the groin, perineum, and medial aspects of the lower extremities. To do so, the thighs are externally rotated, and the knees are flexed and supported with a pillow under each leg.

REF: Pages 163-164, 168-171

2.Number the sequence of steps for positioning a patient in prone position.

____ a. The arms are placed on armboards or secured at the sides, lower legs are elevated on a pillow with gel padding under the knees and toes off of the bed surface; a leg strap is placed across thighs.

____ b. The transport vehicle is locked adjacent to the locked OR bed.

____ c. Pressure points are checked: the cheeks, eyes, ears, female breasts, male genitalia, knees, and toes.

____ d. Anesthesia is induced with the patient in supine position on the transport vehicle.

____ e. The anesthesia provider supports the head and neck during the turn.

____ f. Four people using the “log-roll” technique turn the supine patient to prone onto the OR bed prepared with gel rolls placed at the location for the patient’s shoulders and iliac crests.

ANS:

1 = B 

2 = D 

3 = F 

4 = E 

5 = A 

6 = C 

Anesthesia is induced with the patient in supine position, usually on the locked transport vehicle adjacent to the locked OR bed. Four people using the “log-roll” technique can accomplish turning the supine patient to prone position safely, smoothly, and gently. The anesthesia provider supports the head and neck during the turn. The arms are placed on armboards or secured at the sides. The following pressure points are checked: the cheeks, eyes, ears, female breasts, male genitalia, knees, and toes.

REF:Pages 163-171

3.Number the sequence of steps for positioning a patient in lithotomy position.

____ a. With the patient supine, the legs are raised simultaneously and abducted to expose the perineal region.

____ b. The leg section of the OR bed is removed and the leg section platform is lowered.

____ c. The thighs are elevated to the appropriate degree for the planned procedure.

____ d. Stirrups are checked before use to ensure they are securely fastened to the side rails of the OR bed.

____ e. The legs are placed in stirrups to maintain this position.

____ f. The sacral area is padded with a gel or foam pad.

ANS:

1 = D 

2 = A 

3 = E 

4 = C 

5 = F 

6 = B

Stirrups should be checked before use to ensure they are securely fastened to the side rails of the OR bed and are evenly measured to fit the patient’s leg length. With the patient supine, the legs are raised simultaneously and abducted to expose the perineal region. The legs are placed in stirrups to maintain this position. The thighs are elevated approximately 30, 45, or 90 degrees. The thighs are flexed toward the abdomen, the calves are suspended vertically, and the pelvis is flexed vertically at the spine, propped upward on a pillow or pad. When the legs are secured in the stirrups, the mattress of the leg section of the OR bed is removed and the leg section platform is lowered.

REF:Pages 162, 166-167

4.Number the sequence of steps for positioning a bariatric patient in supine position.

____ a. Place bariatric ramp or stacked bath blankets and towels to create elevation.

____ b. Place under-body forced air–warming blanket on OR bed.

____ c. Transfer patient to OR bed and place 2 leg safety straps across thighs and lower legs.

____ d. Select weight- and size-appropriate OR bed and lock in place.

____ e. Apply SCD wraps to legs and support knees with pillows under knees.

____ f. Pad armboards to match elevated level of patient’s shoulders.

ANS:

1 = D 

2 = A 

3 = B 

4 = C 

5 = F 

6 = E

Bed selection and placement of ramp and under-body warming blanket must be done before patient transfer. Raising arms to prevent shoulder injury takes priority over placing SCDs and knee pillow. Use two safety straps if patient size exceeds the limit for regular-sized safety strap. Place one safety strap across the thighs and the other over the lower legs. Elevate the head, upper body, and shoulders to facilitate the airway when supine. Pad armboards to match the higher elevation of the shoulders to avoid stretching the brachial plexus. Support the knees with pillows to reduce strain on back. Use SCDs or antiembolism stockings on lower extremities. With ramping, the three axes align, forming the shortest distance and straightest line from the incisor teeth to the glottis opening.

REF: Page 158

5.Number the sequence of steps for positioning a patient in lateral position for a right nephrectomy.

____ a. After induction, intubation, and urinary catheter insertion, prepare for lifting.

____ b. Transfer patient to locked OR bed and place in supine position.

____ c. Slowly elevate kidney bridge, flex bed to lower legs, and create horizontal line between hip and shoulder; tape hip to OR bed underside.

____ d. Using at least 4 people, lift patient and turn lateral, left side down with iliac crest below lumbar break.

____ e. Select OR bed and check mobility/operation of kidney bridge before patient transfer.

____ f. Place leg strap across mid thighs and abduct arms less than 90 degrees.

____ g. Secure right arm in an elevated armboard.

____ h. Elevate right leg with pillows, maintaining straight alignment; bend left leg and pad dependent bony prominences; secure with leg strap.

ANS:

1 = E 

2 = B 

3 = F 

4 = A 

5 = D 

6 = H 

7 = G 

8 = C

The lateral kidney position allows approach to the retroperitoneal area of the flank. While being turned from supine to lateral position, the anesthetized patient is positioned so that the lower iliac crest is just below the lumbar break where the kidney bridge is located. To render the kidney region readily accessible, the kidney bridge is raised, and the bed flexed so that the area between the twelfth rib and the iliac crest is elevated. The bridge must be raised slowly and blood pressure monitored frequently by the anesthesia provider. The bed is flexed to lower the patient’s head and legs. The patient’s affected side presents a straight horizontal line from shoulder to hip. Wide adhesive tape is placed across the hips and secured to the undersides of the OR bed. Before wound closure, the adhesive strap is released, the kidney bridge lowered, and the bed straightened to facilitate approximation of wound edges.

REF:Pages 163, 172-173

6.Number the sequence of steps for positioning a patient in Fowler’s position.

___ a. Slowly raise the upper body section to desired height and angle.

___ b. Flex the knees as the leg section is lowered.

___ c. Secure head in the appropriate headrest.

___ d. Rest arms on patient’s lap with a pillow or on armboards.

___ e. Place a footrest at the bottom of the leg section.

___ f. Initial position is in appropriate supine for induction and intubation.

ANS:

1 = F 

2 = A 

3 = B 

4 = E 

5 = D 

6 = C

This position is accomplished initially with the patient supine. Slowly, the upper body section of the OR bed is raised 90 degrees, while the knees are slightly flexed as the leg section is lowered. A footrest prevents footdrop. The arms either rest in the lap on a pillow with the elbows flexed at 90 degrees or less, or are on padded armboards. When this position is used for posterior fossa craniotomy or cranial ventricular procedures, a special craniotomy headrest is used to secure and immobilize the head.

REF: Page 168