- The primary use for suture is essentially to:
| a. | strengthen, re-form, and close tissue. |
| b. | ligate, suture, and close tissue. |
| c. | ligate, strengthen, and stop bleeding. |
| d. | clamp, divide, and attach tissue. |
ANS: B
Suture is a generic term for all materials used to sew severed body tissues together and to hold these tissues in their normal position until healing takes place; to suture is to stitch together cut or torn edges of tissue. A ligature is a strand of suture material used to tie off (seal) blood vessels for the prevention of minor bleeding, or to isolate a mass of tissue for excision (cut out). A variety of suture materials are available for ligating, suturing, and closing the wound.
REF: Page 174
- The ideal suture material is one that has handling characteristics such as:
| a. | memory. |
| b. | slickness. |
| c. | ease of tying. |
| d. | removable knots. |
ANS: C
Key features used to evaluate the general properties of suture material are (1) physical characteristics, (2) handling characteristics, and (3) tissue reaction characteristics. Handling characteristics of suture material are related to pliability (how easily the material bends) and the coefficient of friction (how easily the suture slips through tissue and can be tied).
REF: Page 174
- Tissue reaction characteristics are important in a suture material because:
| a. | the suture should absorb and nourish the healing tissue. |
| b. | the suture should not cause tissue inflammation or an allergic response. |
| c. | the suture should not support infection. |
| d. | the suture should not cause tissue inflammation or an allergic response and the suture should not support infection |
ANS: D
The ideal suture material is one that causes minimal inflammation and tissue reaction while providing maximal strength during the lag phase of wound healing. Tissue reaction characteristics include inflammatory and fibrous cell reaction, absorption, potentiation of infection, and allergic reaction.
REF: Pages 174-176
- The surgeon needs a suture material that will not degrade over time, but becomes encapsulated and supports a tissue structure that will continue to be exposed to pressure and stretching forces throughout the patient’s life. These physical properties are best described by a suture that:
| a. | is nonabsorbable, has good tensile and knot strength, and is the appropriate diameter for the tissue. |
| b. | has a large diameter, is nonabsorbable, is highly reactive, and is a monofilament. |
| c. | is a monofilament, is synthetically manufactured, is absorbable, and has a large diameter. |
| d. | has good tensile strength, memory, and ease of tying and is absorbable. |
ANS: A
Physical characteristics of sutures can be measured or visually determined and include the following properties: Diameter (size) is measured in millimeters, and expressed in USP sizes with zeroes. The finer diameter (smaller size) provides better handling qualities and small knots. Improved suturing techniques are possible with sutures of finer diameter. Tensile strength is defined as the amount of weight (breaking load) necessary to break a suture (breaking strength); it varies according to the type of suture material. Knot strength is the force necessary to cause a given type of knot to slip, either partially or completely. The most common nonabsorbable suture materials are silk, nylon, polyester fiber, polypropylene, and stainless-steel wire.
REF: Pages 176-179
- Dr. Garrison was teaching the new residents as he closed the muscle and fascia layer following an open cholecystectomy. He stated that he liked the tensile strength of this monofilamented synthetic suture and also liked the pretty blue color, but it was hard to manage with its memory and slipperiness and normally needed six surgeon’s knots to hold. He was using:
| a. | Ethilon. |
| b. | Prolene. |
| c. | Sofsilk. |
| d. | Monocryl. |
ANS: B
Prolene (polypropylene) is a clear or pigmented polymer. This monofilament suture material (Prolene, Surgilene, Surgipro, Dermalene) is used for cardiovascular, general, and plastic surgery. Because polypropylene is a monofilament and is extremely inert in tissue, it may be used in the presence of infection. It has high tensile strength and causes minimal tissue reaction. Sizes range from 10-0 to #2.
REF: Page 180
- Dr. Schumann, an older surgeon who was educated in Germany, explains his justification for his suture choice to the new perioperative nurse in the scrub role. He prefers to suture his intestinal anastomosis with a suture that has multiple filaments braided together because it ties well and holds the knot, which tightens when the thread absorbs the tissue fluids. He also needs a strand that is easy to see and only needs to retain its tensile strength for about 1 year, at which time the intestinal junction will be healed, even though this suture is considered nonabsorbable. He will ask the nurse for a 24-inch 4-0:
| a. | Vicryl. |
| b. | Prolene. |
| c. | Monocryl. |
| d. | Sofsilk. |
ANS: D
Silk (Sofsilk) is prepared from thread spun by the silkworm larva while making its cocoon. Top-grade raw silk is (1) processed to remove natural waxes and gum, (2) manufactured into threads, and (3) colored with a vegetable dye. The strands of silk are twisted or braided to form the suture, which gives it high tensile strength and better handling qualities. Silk handles well, is soft, and forms secure knots. Because of the capillarity of untreated silk, body fluid may transmit infection along the length of the suture strand. Silk is not a true nonabsorbable material. When buried in tissue, it loses its tensile strength after about 1 year and may disappear after several years.
REF: Page 179
- Dan Clements had a vasectomy in his urologist’s office. The small incision was closed with sutures that are synthetic and will “dissolve and fall out” after 2 to 3 weeks. As the procedure ended, he heard the doctor ask the nurse for 5-0:
| a. | silk. |
| b. | polyglactin. |
| c. | plain gut. |
| d. | chromic gut. |
ANS: B
To produce synthetic absorbable sutures, specific polymers are extruded into suture strands. The base material for synthetic absorbable sutures is a combination of lactic acid and glycolic acid polymers (Vicryl, Dexon, and Polysorb). The molecular structure of these products has a tensile strength sufficient for approximation of tissues for 2 to 3 weeks, followed by rapid absorption, which combine the desirable qualities of extended wound support and eventual absorbability.
REF: Page 178
- Linda, a veteran perioperative nurse, remembers a time when all suture needles had eyes and she even had her own needle rack. She hand-threaded all sutures according to the surgeon’s preference. The newer sutures were originally called “atraumatic” sutures because they did not double back through a needle eye and cause tissue trauma during pulling or suturing through the tissue. Today, we call this manufacturing process of connecting the suture thread to the needle:
| a. | engineered crimp. |
| b. | controlled release. |
| c. | reverse cutting. |
| d. | swaged. |
ANS: D
The swaged needle is the most universally used needle type, eliminating threading eyed needles before and during surgery. A single strand of suture material is drawn through the tissue, and tissue damage is minimized (atraumatic). The swaged needle may need to be cut off with suture scissors or swaged for controlled release of the suture (semi-swaged).
REF: Page 181
- When creating a vascular or intestinal anastomosis (connecting two tubular structures together) the surgeon will typically suture one half of the anastomosis with one half of the suture and the other half of the anastomosis with the other half of the suture. This technique minimizes the drag and wear on the suture material and needle. The correct name for this type of suture and needle is:
| a. | controlled release. |
| b. | retention. |
| c. | double-armed. |
| d. | multi-strand cardiovascular. |
ANS: C
A double-armed suture is a strand of suture material with a needle on each end. These are typically used in vascular surgery for anastomoses. During initial count, the scrub person counts the needles depicted on the outside of the package and recounts with the circulating nurse when the package is opened.
REF: Page 188
- This hemostatic device offers a rapid and secure method of clamping arteries, veins, nerves, and other small structures. They will remain in the patient, are not counted, and are made of a metal that is compatible with MRI. Select the correct hemostatic device that fits this description.
| a. | Hemostat |
| b. | Alligator forcep |
| c. | Ligating clip |
| d. | Bulldog clamp |
ANS: C
Ligating clips are available in several sizes. These clips are available in individual sizes that must be loaded by the scrub person or as preloaded, disposable, prepackaged units. There are multiple sizes and lengths of clips that can be used in both open and endoscopic procedures. Ligating clips afford a rapid and secure method of achieving hemostasis when arteries, veins, nerves, and other small structures are ligated. Since the introduction of minimally invasive endoscopic surgery, the need for ligating clips that can be applied through a trocar has emerged.
REF: Page 187
- These hemostatic devices date back to a period in time when they consisted of a product that was harvested from the ocean. They continue to be used today in every surgical procedure where a considerable amount of bleeding may be encountered and are still made of a natural product, but not from the ocean. Select the appropriate hemostatic device that fits this description.
| a. | Laparotomy sponges |
| b. | Green towels |
| c. | Bovine thrombin |
| d. | All of the options are correct. |
ANS: A
Surgical sponges are used to affect hemostasis via direct pressure, absorb intraoperative blood loss and drainage, act as aids to blunt dissection, pack the viscera from the field, and keep areas of the wound moist. Laparotomy sponges (also referred to as “laps,” “lap pads,” or “tapes”) are either square or oblong and have a loop of colored twill tape with a radiopaque marker sewn to one corner. Used for major surgical procedures with large incisions, laparotomy sponges are presented to the surgeon either moist or dry.
REF: Page 187
- The instrument devices depicted below are designed to ligate, divide, resect suture, and anastomose tissue. They are commonly called:
| a. | endomechanical clamps. |
| b. | stapling instruments. |
| c. | surgical staplers. |
| d. | stapling instruments and surgical staplers. |
ANS: D
Various instruments to suture tissue mechanically are used for ligation and division, resection, anastomoses, and skin and fascia closure. Employed in many surgical specialties, the mechanical application of these instruments reduces tissue manipulation and handling.
REF: Pages 198-199
- Surgical instruments that do not fall under the category of clamps, retractors, or cutting instruments, but are used in most procedures, are typically included within the category of:
| a. | specialty instruments. |
| b. | microsurgical instruments. |
| c. | endomechanicals. |
| d. | accessory and ancillary instruments. |
ANS: D
Accessory and ancillary instruments are designed to enhance the use of basic instrumentation or to facilitate the procedure. These include suction tips and tubing; irrigators-aspirators; electrosurgical devices; and special-use devices, such as probes, dilators, mallets, and screwdrivers.
REF: Page 198
- Dr. Schuman decided to convert to an open instead of the laparoscopic approach for the colectomy because the patient was morbidly obese and he needed a larger incision. He asked the circulating nurse to bring the largest self-retaining retractor in the sterile storage room. Select the appropriate retractor.
| a. | Large wide Deavers |
| b. | Bookwalter |
| c. | Weitlaner |
| d. | Balfour |
ANS: B
Retractors are used to hold back the wound edges, structures, or tissues to provide exposure of the operative site. A surgeon needs the best exposure possible that inflicts a minimal degree of trauma to the surrounding tissue. Retractors are self-retaining or manually held in place by a member of the surgical team. The two types of self-retaining retractors are: (1) retractors with frames to which various blades may be attached, and (2) retractors with two blades held apart with a ratchet. An example of the latter is a Weitlaner retractor. Other very large self-retaining retractors, such as the Omni or Bookwalter, are equipped with multiple blades and attachments of varying lengths and sizes.
REF: Pages 196-197
- During the draping procedure, Dr. Martin Newhouse (the anesthesia provider) asked the scrub person for two towel clamps to secure the top of the drape to the IV poles. The scrub person had two penetrating and two nonpenetrating clamps on her back table. She knew she would need to secure the suction and electrosurgical pencil to the sterile field as soon as draping was finished. How should the scrub person respond to Dr. Newhouse’s request for towel clips?
| a. | Refuse to give him any towel clamps because they are counted. |
| b. | Give him two Allis clamps instead. |
| c. | Give him the penetrating towel clamps. |
| d. | Give him the nonpenetrating towel clamps. |
ANS: C
Towel clamps also are considered holding instruments. Of the two basic types, one is a nonpenetrating towel clamp used for holding draping materials in place. The other has sharp tips used to penetrate drapes and tissues, and it is damaging to both. The use of sharp towel clamps to secure drapes is highly discouraged because they penetrate the sterile field.
REF: Page 196
- The circulating nurse received the trauma call from the emergency department and called sterile supply to assemble the instruments for an abdominal trauma case with possible aortic rupture. When the cart arrived, she saw the vascular set; however, the most important instrument set was missing. What important instrument set was needed for this procedure besides the vascular set?
| a. | Sternal saw and blades |
| b. | Basic laparotomy set |
| c. | Basic laparoscopy set |
| d. | Minor set |
ANS: B
Designated OR or central supply personnel arrange the various instruments into trays or sets. The trays are named according to their functions. Tray/set names and instrument composition will vary by institution, but three basic OR instrument sets are the minor/plastic, the basic laparotomy, and the dilation and curettage (D&C). A minor (or plastic surgery) set includes instruments needed for simple superficial incision, excision, and suturing. A basic laparotomy set includes instruments to open and close the abdominal cavity and repair any gross defects in the major body musculature.
REF: Page 199
- The scrub person, Toby, was precepting a surgical technology student, Mandy, on her first orthopedic case, a tibial IM rodding. Toby explained the importance of keeping the instruments free of blood and bioburden during the procedure and demonstrated the best practice and how to:
| a. | dip and agitate the instruments in saline after the surgeon returns them. |
| b. | wipe the instruments with a sponge moistened with sterile water after each use. |
| c. | rinse or soak the instruments in sterile water and dry them before placing on the back table. |
| d. | wipe the instruments with a sponge moistened with sterile water after each use and rinse or soak the instruments in sterile water and dry them before placing on the back table |
ANS: D
Instruments must be handled gently. Bouncing, dropping, and setting heavy equipment on top of them must be avoided. During the procedure, the scrub person should wipe the used instruments with a damp sponge or place them in a basin of sterile distilled water to prevent blood from drying on the surfaces and in the box locks. Saline solution should never be used on instruments because the salt content is corrosive and accelerates rusting or deterioration of the metal. As time allows during the procedure, the scrub person should rinse and dry the used instruments and replace them on the back table to facilitate wound closure closing counts.
REF: Page 200
- The safest practice for passing sharps and instruments is to:
| a. | use a “no-touch” technique by passing all instruments and sharps with a sponge forceps. |
| b. | establish a neutral zone on the closest corner of the Mayo stand. |
| c. | employ a robotic arm designed to deliver sharps and instruments to the surgeon. |
| d. | None of the options are best practices. |
ANS: D
Use a neutral zone or hands-free method for passing sharps. Establish the neutral zone before the initial surgical incision (a magnetic pad or basin may be used to create the neutral zone; if a basin is used, it should be placed on the sterile field). Dedicate the neutral zone for sharps only and only one sharp at a time should be in the neutral zone. Avoid handling suture needles manually whenever possible, using a needle holder, forceps, or suturing assist device. Announce the transfer of a sharp before placing it in the neutral zone. The scrub person and surgeon or assistants should communicate about the best placement of sharps in the neutral zone.
REF: Page 192
- The perioperative nurse and the surgical technologist have a responsibility to maintain a safe environment of care for the surgical patient. A surgical complication concerning surgical counts that poses serious harm for the patient and potential consequences for the involved staff is called:
| a. | a malpractice suit. |
| b. | a retained foreign object. |
| c. | “res ipsa loquitur.” |
| d. | criminal negligence. |
ANS: B
In 2002 the AORN initiated its Patient Safety First Program and has continued to assist perioperative nurses in maintaining a safe environment for surgical patients. Retained foreign objects after surgery are a complication with serious potential consequences for the people involved.
REF: Page 202
- Careful counting (according to established policy), situational awareness, and conscientious and meticulous attention to the field are believed to prevent miscounts and lost items. A recent patient safety statement about preventing retained foreign objects recommends which of these practices?
| a. | Consistent practice according to a routine |
| b. | Good communication among the team |
| c. | Wound exploration by the surgeon before closure |
| d. | All of the options are best practices. |
ANS: D
In 2005 the American College of Surgeons issued a patient safety statement regarding the prevention of retained foreign objects after surgery. Paramount to preventing retained foreign bodies are good communication, consistent practices, and wound exploration before closure of the surgical site (ACS, 2005).
REF: Page 202
Rothrock: Alexander’s Care of the Patient in Surgery, 14th Edition
Chapter 07: Surgical Modalities
Test Bank
MULTIPLE CHOICE
- An endoscope is a diagnostic or therapeutic instrument that enters the body through a:
| a. | natural orifice. |
| b. | small incision into a body compartment. |
| c. | externalized sinus tract. |
| d. | All of the options are correct. |
ANS: D
An endoscope is a tube inserted into a natural body orifice or through a small incision to access internal organs or structures. Endoscopes are flexible, rigid, or semirigid. Flexible endoscopes include angioscopes, bronchoscopes, choledochoscopes, colonoscopes, cystonephroscopes, hysteroscopes, mediastinoscopes, ureteroscopes, and ureteropyeloscopes. Rigid endoscopes include cystoscopes, laparoscopes, sinuscopes, arthroscopes, bronchoscopes, laryngoscopes, and hysteroscopes.
REF: Page 204
- The light transmission through an endoscope is achieved by way of:
| a. | a charge-coupled device chip in the tip of the scope. |
| b. | a chain of small connected micro light bulbs. |
| c. | bundles of fiberoptic glass rods. |
| d. | electrified silicon cables. |
ANS: C
Endoscopic light is often referred to as cold light, meaning that the heat from the light source is not transmitted through the length of the scope. Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers. In 1966 the rod-lens system designed by the British optical physicist Hopkins improved brightness and clarity.
REF: Pages 204-205
- Endoscopic instruments are designed to perform the intervention at the target tissue site through the tubular endoscope. The endoscopic instrument is considered:
| a. | an instrument on a stick. |
| b. | an extension of the surgeon’s hand. |
| c. | a means to perform hands-free surgery. |
| d. | surgery without tactile sensation. |
ANS: B
Endoscopic minimally invasive surgery (MIS) instrumentation has been designed to correspond with the surgical site and the technique used while functioning as an extension of the surgeon’s hand. The length and working end of the instrument must be adequate to perform surgery at the target site.
REF: Page 206
- Flexible fiberscopes and flexible videoscopes share many of the same components; however, in a video gastroscope, the eyepiece and lens of the fiberscope are replaced by a:
| a. | CCD image intensifier. |
| b. | high-definition monitor. |
| c. | video camera. |
| d. | light-guided sensor. |
ANS: C
There are two types of flexible endoscopes: fiberoptic endoscopes and videoscopes.
Fiberoptic endoscopes have an eyepiece with a lens for visualization; the image is carried through the endoscope via a bundle of tiny glass fibers. Videoscopes have, at their distal end, a video chip that provides an image that is directly viewed on a monitor; a videoscope does not have an eyepiece for direct viewing; the eyepiece is replaced with an endoscopic video camera.
REF: Page 204
- The design of laparoscopic instruments aims to provide a clamping, cutting, dissecting, electrocoagulating, suturing, or stapling instrument on the tip of a shaft that is long or short enough to reach the target tissue. The hand control on the surgeon’s end of the instrument is engineered to provide:
| a. | ergonomic comfort and control. |
| b. | smooth operation of the lubricated instrument tips to prevent tissue adherence or entrapment. |
| c. | a perception of haptic and tactile sense to prevent crushing or losing tissue. |
| d. | adaptors for monopolar electrosurgery connection and laser fibers. |
ANS: A
The length and working end of the instrument must be adequate to perform surgery at the target site. The hand control is ergonomically designed for the operator’s maximum comfort and reduced fatigue. Graspers and other instrumentation used by the assistant in surgery often are built for a shorter hand span because many women function in this role.
REF: Page 206
- The instrument tips in laparoscopic instruments are designed to produce the same tissue effects as a traditional instrument used for open surgery. Because of the process challenges of the laparoscopic approach, it is time-consuming to insert and withdraw instruments repeatedly during the procedure. Instrument manufacturers have attempted to make their products efficient by combining functions. An appropriate combined function for a laparoscopic instrument would be:
| a. | ultrasound capability in a suturing forceps. |
| b. | electrosurgery conduction through the tips of a Babcock grasper. |
| c. | blunt dissection with the smooth, rounded edge of the closed endoscopic scissors. |
| d. | suction and irrigation combined with an argon beam coagulation handpiece. |
ANS: C
Dissecting instruments are used to cut, divide, or separate tissue. Scissors and dissectors that are similar to their open-procedure counterparts have been designed for use in MIS procedures. Scissors are available for blunt or sharp dissection. They can be straight or curved (including hook scissors), depending on the location of the target tissue and technique used. Scissors usually have a rounded tip when closed so that they also can be used to manipulate tissue without trauma. When open, both jaws of the scissors should be visualized to prevent inadvertent injury. Some scissors are designed to be connected to an electrosurgical energy source so that coagulation can be provided during cutting. Dissectors are used to separate or divide tissue. Many different tip shapes are available to dissect, spread, divide, grasp, retract, and coagulate structures.
REF: Page 206
- The challenge of suturing intra-abdominally is not as great as the process needed to tie and tighten the surgical knot. The knot-tying process can be achieved within or outside of the abdominal compartment. One technique uses laparoscopic grasping forceps and a laparoscopic needle holder only, and another uses the same instruments plus two obturator sleeves to push, slide, and tighten the knot into place. When sutures are tied and knotted during an open procedure, the surgeon may tie the knot with gloved fingers, called a one- or two-handed tie, or wrap the suture around the tip of a needle holder and grasp the other end of the suture to pull it through the wrapped coils; this is called an instrument tie. The intracorporeal suture technique uses the suture-tying process analogous to the:
| a. | instrument tie. |
| b. | two-handed tie. |
| c. | one-handed tie. |
| d. | All of these techniques could be accomplished through the intracorporeal approach. |
ANS: A
Extracorporeal Sutures: Tissue can be approximated intra-abdominally when the knot is tied extracorporeally (i.e., outside the body). To accomplish this, endoscopic swaged sutures are used. The suture is grasped proximally to the needle, and both are inserted through one of the obturator sleeves into the abdomen. The needle is held with the grasper or laparoscopic needle holder and driven through the desired tissue. A second grasper or needle holder inserted through a second obturator sleeve is used to assist. The needled end of the suture is pulled through the tissue and out through the sleeve. The needle is removed, and the surgeon’s fingers are used to tie a knot extracorporeally. The knot is advanced down the sleeve and onto the tissue. The suture is cut with laparoscopic scissors. The three types of knots tied extracorporeally are the slip knot, the fisherman’s knot, and the surgeon’s knot.
Intracorporeal Sutures: A suture ligature also can be passed through the obturator sleeve to be tied while it is inside the body. The tissue is approximated in the same fashion but tied intracorporeally (i.e., inside the abdomen) using grasping forceps or laparoscopic needle holders.
REF: Page 211
- To help visualize abdominal structures and to enhance safety during laparoscopic procedures, a pneumoperitoneum is created. After Veress needle confirmation, insufflation tubing is connected and the process begun. CO2 gas is used to insufflate the abdominal cavity at an ideal flow rate of ___________ to achieve an ideal intra-abdominal pressure of ____________.
| a. | 14 to 16 L/min; 9 mm Hg |
| b. | 10 to 12 mm Hg; 10 L/min |
| c. | 14 to 16 mm Hg; 9 L/min |
| d. | <9 L/min; 10 to 12 mm Hg |
ANS: C
The surgeon makes a paraumbilical incision and inserts an insufflation (Veress) needle into the abdomen. After needle confirmation, insufflation tubing is connected and the process begun. CO2 gas is used to insufflate because it does not support combustion, can be absorbed at large volumes per minute without serious side effects, and is fairly inexpensive. The peritoneal cavity is filled, first at a low flow rate that is increased to a high flow rate of at least 9 L/min ideally. Flow rate refers only to how quickly a predetermined intra-abdominal pressure can be reached. Intra-abdominal pressure is the actual measure that must be closely monitored and should be maintained between 14 and 16 mm Hg.
REF: Pages 224-225
- The new general surgery fellow placed the three trocar ports for the laparoscopic appendectomy. She was focused on the concept of exact geometric triangulation of the three port accesses, to avoid the concept of sword fighting after inserting her instruments. She knew she had to proceed with caution and determination since this hospital was not able to provide the protected blade trocars she was used to using at the university medical center. The procedure was completed without incident; however, on postoperative day 1, the patient demonstrated signs and symptoms of sepsis. What might have been the unusual occurrence that could have resulted in patient sepsis?
| a. | Unrecognized appendiceal rupture |
| b. | Significant break in sterile technique |
| c. | Inadvertent trocar puncture through the bowel on insertion |
| d. | Recent H1N1outbreak on the surgery unit at the hospital |
ANS: C
The needle safely enters the peritoneum positioned at a 45-degree angle. Placement is confirmed by negative bowel and blood return on aspiration and by saline instillation that meets no resistance. This is a relatively blind procedure because no scope can be introduced until pneumoperitoneum is established. A new laparoscopic trocar system has been introduced in which the obturator tip, instead of a needle, is inserted with minimal penetration into the peritoneum, and then rapid insufflation is provided.
REF: Page 224
- The OR was trialling a new insufflation system and the vendor representative was out of the room taking a phone call. The perioperative nurse was concerned that the flow rate was well above 14 L/min and the pressure had risen to 16 mm Hg. She alerted the surgeon and reduced the rate and pressure because she feared that the elderly patient was at high risk for:
| a. | gastroesophageal reflux. |
| b. | hypercarbia. |
| c. | postoperative nerve damage and shoulder pain. |
| d. | All of the options are correct. |
ANS: D
Overpressurization can be extremely hazardous to the patient. Excess pressure can force CO2 to diffuse into the blood, resulting in hypercarbia. End-tidal CO2 monitoring becomes a crucial assessment parameter to detect increased CO2 absorption. Excess pressure also increases diaphragmatic pressure, which can cause gastric regurgitation and aspiration of stomach contents. It also can reduce intrathoracic space, resulting in decreased respiratory effort and cardiac output. The phrenic nerve innervates the diaphragm and is responsible for some motor activity associated with respiration. CO2 gas can irritate this nerve, causing postoperative pain in the shoulder and neck. Excessive pressure could cause tremendous postoperative discomfort and severe nerve damage.
REF: Page 225
- High-pressure insufflation rates can cause increased intra-abdominal pressure that can result in life-threatening sequelae. The perioperative nurse reduces the flow rate in collaboration with the surgeon, while monitoring the patient for signs of:
| a. | CO2 gas embolism. |
| b. | hemostasis. |
| c. | deep vein thrombosis (DVT). |
| d. | hypoxia. |
ANS: A
CO2, highly soluble in blood, generally is not hazardous when used during laparoscopic insufflation, as it is rapidly absorbed in the splanchnic vascular region. Excessive intra-abdominal pressure or any anesthetic technique that reduces splanchnic blood flow, however, could increase the potential for CO2 gas emboli. That in turn could lead to circulatory collapse. CO2 also could advance from the heart to the pulmonary circulation, causing acute pulmonary hypertension with right-sided heart failure. If these effects are undetected and CO2 insufflation continues, cardiac arrest and death may occur. If there are signs of CO2 embolus, intraoperative hypotension can result from excessive bleeding, excessive intra-abdominal pressure, and hypoxia. CO2 insufflation rates may need to be reduced.
REF: Pages 225-226
- The surface tissue effect of the CO2 laser serves as the laser of choice for:
| a. | urologic lithotripsy. |
| b. | plastic surgery or dermatologic removal of tattoos. |
| c. | laparoscopic cholecystectomy. |
| d. | endoscopic ablation of Barrett’s esophageal dysplasia. |
ANS: B
The CO2 laser is characterized by its superficial tissue interaction (0.1 to 0.2 mm) because the beam is highly absorbed by water. The degree of tissue response is related to the photothermal effect (the amount of heat buildup) from absorption of the CO2 laser beam. The longer the CO2 beam is in contact with tissue, as with other laser wavelengths, the more destruction occurs. With the CO2 beam a greater depth of penetration can be achieved. Tissue reaction is visible and has been described as “what you see is what you get.”
REF: Page 230
- Clair Townsend arrived at the endoscopy center 2 days before her scheduled interventional bronchoscopy to receive an injection of a photosensitive intravenous dye that the pulmonologist explained would highlight the dysplastic tissues of her bronchi that were precancerous. He scheduled her for an ablative procedure called photodynamic therapy (PDT), where the highlighted tissues would be affected by the laser light that is color-specific for uptake of the dye. Select the laser that would be appropriate to use on this patient during a PDT bronchoscopy.
| a. | CO2 laser through a beam splitter |
| b. | KTP laser using a Nd:YAG beam passed through a fiber delivery system |
| c. | Argon beam coagulation with the bronchoscopy handpiece |
| d. | Holmium laser with a short cleaved lithotripsy fiber |
ANS: B
The frequency-doubled YAG (KTP) laser is often utilized for the ablation of hypertrophied prostatic tissue. An Nd:YAG beam of 1064 nm is passed through a potassium titanyl phosphate (KTP) crystal to produce an intense green laser light of 532 nm. Delivering the Nd:YAG incident beam of 1064 nm through the KTP crystal shortens the wavelength by half, to 532 nm, while doubling the beam’s frequency. The 532-nm wavelength responds to tissue in the same manner as the argon beam. It is color selective and highly absorbed by hemoglobin, melanin, and other similar pigmentation. The beam is conducted to tissue through a fiber, and this wavelength can be transmitted through clear solutions and structures. The depth of penetration is approximately 1 to 2 mm.
REF: Page 231
- The nursing research and practice committee searched the scientific literature for information on smoke evacuation, as they planned for a unit-wide initiative to use this safety measure on all procedures where smoke or plume is generated. Their main concern is that the surgeons will not be as willing to comply as the staff. Select the safety measure that will be the most critical and most challenging to enforce.
| a. | Change the smoke evacuation filter according to the manufacturer’s written instructions. |
| b. | Hold the smoke evacuation suction tube close (<1 inch away) to the tissue interaction site to remove as much plume as possible. |
| c. | Evacuate surgical smoke generated during endoscopic or laparoscopic procedures. |
| d. | Wear a surgical mask that provides adequate filtration to protect against residual smoke particulate that has not been evacuated. |
ANS: B
Use the appropriate smoke evacuation system, depending on the amount of plume generated. Hold the smoke evacuation suction tube close (<1 inch away) to the tissue interaction site to remove as much plume (odor and particulate matter) as possible. The surgeon may perceive that the close proximity of the smoke evacuation to active ESU or laser electrode is obstructive. Continuing education helps healthcare personnel to understand the hazards of surgical smoke and encourages the use of appropriate methods for evacuation.
REF: Page 239
- Lasers, dependent on their wavelength, can produce absorption, reflection, transmission, and scatter. The effect of scatter does not have any therapeutic benefit at this time and can be destructive to both staff and instruments. Select a safety measure that would prevent inadvertent scatter of laser energy during a surgical procedure.
| a. | Ebonize the surface of laser mirrors that are used in laparoscopic cholecystectomies. |
| b. | Surround the surface drapes with moist sterile towels and cover the glass windows. |
| c. | Advance the laser fiber at least 1 cm beyond the tip of the endoscope within operator’s view. |
| d. | Cover the laser fiber with medical-grade tubing along its entire length. |
ANS: C
Special precautions should be followed when using the laser during an endoscopic procedure. When a laser fiber is introduced through the biopsy port of a flexible or rigid endoscope, the operator must view at least 1 cm of the tip of the fiber before activating the laser. If the end of the fiber is still within the sheath of the endoscope and the laser is fired, the heat from the laser energy quickly damages the optics and channel of the endoscope. A length of medical-grade tubing can be placed over the fiber with the tip recessed within the sheath, but tubing must be withdrawn sufficiently to expose the end of the fiber.
REF: Page 237
- Susie Reynolds, a 9-year-old softball player, has arrived in the OR for emergency repair of superficial facial and deep arm lacerations when she ran into the chain link fence during practice after school. The perioperative nurse discovers that Susie has diabetes and has an insulin pump that should remain connected during the short procedure. The best option for energy-generated hemostasis is:
| a. | battery-generated eye electrosurgery. |
| b. | bipolar electrosurgery. |
| c. | hemoelectrocoagulated plasma capacitor. |
| d. | monopolar electrosurgery. |
ANS: B
In a bipolar system, a dispersive electrode is not needed because electrical energy flows from one tine (or prong or blade) of the bipolar instrument to the other tine as it passes through the tissue located between these tines (Figure 7-66). Energy returns directly through the instrument to the generator to complete the circuit, eliminating flow of current through the patient. The flow of monopolar energy through an implanted electronic defibrillator could reprogram the sensitivity of the device.
REF: Page 246
- The surgeon used the ESU in monopolar mode to cut and coagulate through the subcutaneous tissue on opening the abdomen during a bariatric bypass procedure. As she began to proceed through the muscle and fascia layer, she asked the circulating nurse to increase the cut and
coagulation modes on the ESU. What measure could the scrub person take to enhance energy delivery?
| a. | Unwrap the ESU cord from around the towel clamp handle. |
| b. | Clean the charred tissue from the active electrode blade. |
| c. | Remind the surgeon that adipose tissue offers less impedance than muscle. |
| d. | Replace the active electrode blade with a coated blade. |
ANS: B
In a monopolar system, electrical energy flows from the generator through an active electrode to the patient. If energy is concentrated in a small area, and the tissue provides increased impedance, controlled heat is generated and cutting or coagulation is achieved. Tissue type also influences tissue effect. Tissue that is not well vascularized, such as adipose tissue, offers more impedance. As a result, electrical energy is not conducted as well, and higher power settings may be required. Muscle tissue is well vascularized and requires less power to achieve a tissue effect. Charred tissue on the active electrode blade can impair energy delivery.
REF: Page 246
- The perioperative manager and the nurse-educator uncrated the new cryosurgery generator on the loading dock. The generator had been ordered for the OR, but there was no information on who ordered it. The perioperative manager and nurse-educator were new in their positions in this newly opened surgical oncology inpatient unit. The machine was large and on wheels and included an adaptor for a liquid nitrogen tank and a box of protective goggles and gloves. They called Dr. Wheeler, the liver surgeon, and Dr. Chandler, the dermatology plastic surgeon, to ask if they were aware of the delivery or had ordered the device. The most obvious destination for the transfer and placement of this device, after it is uncrated, is:
| a. | the dermatology clinic. |
| b. | biomedical clinical engineering, and then the dermatology clinic to be examined and tested. |
| c. | the liver OR after it is examined, tested, and released by biomedical clinical engineering. |
| d. | the liver OR. |
ANS: C
Cryosurgery is used to destroy small quantities of unwanted tissue, such as skin tumors, and to ablate larger tissue targets, such as liver tumors, prostatic cancer, and cervical dysplasia. Cryosurgery causes tumor death by freezing. When internal tumors (e.g., liver cancer) are treated, dead tumor cells eventually are absorbed into surrounding tissue. To freeze tissue properly, a cooling device or cryosurgical probe must produce an ice ball capable of destroying tissue at approximately -50° C and colder. The cooling source is usually gaseous nitrogen or supercooled liquid nitrogen.
REF: Page 248
- Dr. Wheeler prefers the argon beam coagulator for dissection in his liver procedures because the liver bleeds easily and traditional monopolar electrosurgery often causes more bleeding than it stops. What is the application characteristic of the argon beam coagulator that enhances liver tissue hemostasis?
| a. | Combined argon gas with electrosurgical energy with rapid coagulation |
| b. | Argon gas is heavier than air, inert, and noncombustible and does not tear tissue |
| c. | Decreased chance of combustion, formation of surgical smoke, and burned tissue |
| d. | Noncontact tissue coagulation with reduced risk of rebleeding |
ANS: D
The argon beam coagulator is an argon-enhanced ESU device that combines argon gas with electrosurgical energy to improve the effectiveness of the electrosurgical current. The flow of argon gas also clears the surgical site of blood and fluids, allowing for greater visibility of the bleeding site or target area, and disperses oxygen, decreasing the chance of combustion and formation of surgical smoke. Benefits of argon-enhanced electrosurgery include rapid coagulation with reduced blood loss and reduced risk of rebleeding, noncontact tissue coagulation, reduced depth of penetration by electrical energy, and less adjacent tissue damage.
REF: Page 246
- Dr. Wheeler’s patient, a 72-year-old man with a single early-stage liver tumor, has an implanted automatic internal defibrillator that the anesthesia provider has decided not to disarm for the procedure. What energy-generated dissection device should Dr. Wheeler use to replace the argon beam coagulator?
| a. | An ultrasonic dissector |
| b. | A monopolar suction-irrigator |
| c. | A monopolar hydrodissector |
| d. | A CO2 laser with articulating arm and handpiece |
ANS: A
Vibrating energy devices provide a safe option for cutting and coagulation. High-frequency sound waves are propagated to a blade tip to produce ultrasonic energy. The following are advantages of using an ultrasonic device to cut and coagulate: No surgical plume or odor is generated; only a small amount of aerosolization is created. Less adjacent tissue is damaged compared with laser and ESU devices. Tactile feedback is retained. No nerve or muscle stimulation occurs because no electrical current is delivered to the target area. No stray electrical or laser energy is produced. Precise cutting and control are offered.
REF: Page 247
- The original equipment manufacturer (OEM) instructions that came with the new rigid endoscope system did not recommend a particular sterilization modality; however, high temperatures and ultrasonic cleaning were discouraged and the facility recently removed the ethylene oxide sterilizers from the sterile processing department. The perioperative nurses and surgical technologists in the minimally invasive surgery (MIS) service collaborated on developing a processing procedure for their new equipment. What modality is their best option?
| a. | Outsource to a facility that uses ethylene oxide or gamma radiation. |
| b. | Sterilize the entire set in the low-temperature plasma sterilization system. |
| c. | Perform high-level disinfection in glutaraldehyde. |
| d. | Steam-sterilize the metal components and soak the nonmetal components in glutaraldehyde. |
ANS: B
The low-temperature plasma sterilization system uses hydrogen peroxide gas plasma, which sterilizes within 50 to 75 minutes and dissociates into nontoxic by-products. Understanding the advantages and limitations (e.g., lumen restrictions) of this system is important when determining if it would meet the needs of endoscope or instrument sterilization. Generally, flexible endoscopes cannot be sterilized in this system, but shorter rigid scopes with larger lumens can. The low-temperature requirement for this system could also address the lenses of the rigid telescopes and video components.
REF: Page 215
- The new physician-owned endoscopy and surgery center opened with ample sized procedure rooms and a larger sterile storage core than the former unit. The gastroenterologists had a busy and financially profitable practice. They used the best and most expensive reusable endoscopic biopsy forceps on every gastroscopy and colonoscopy. The endoscope processing and decontamination room used the same manufacturer’s endoscopic cleaning brushes on every scope. These devices received considerable use and abuse and were often discarded after one or a few uses. Based on the characteristics of the new center and the gastroenterology practice, what would be the best option for the biopsy forceps and cleaning brushes?
| a. | High-level disinfect the forceps and brushes in the same cycle with the scope for efficiency. |
| b. | Secure a contract with a repair company to facilitate ongoing repair of the brushes and forceps. |
| c. | Buy more reusable brushes and biopsy forceps and only open them when needed. |
| d. | Trial several manufacturers’ single-use biopsy forceps and cleaning brushes. |
ANS: D
Many facilities use a combination of reusable and single-use laparoscopic instruments. Advantages of single-use items include sharpness, reliability related to function, guaranteed sterility, and safety. Indirect advantages include no reprocessing, no repair costs, and comparable levels of patient care. Upgraded designs are more easily accepted when the device is labeled for single use. Disadvantages include the need for increased storage space, budgetary implications, and environmental concerns related to disposal of biohazardous waste.
REF: Page 215
MULTIPLE RESPONSE
- Select the statements that best reflect the benefits of laser surgery for the surgical services department.
| a. | Decreases postoperative scarring that could lead to stenosis. |
| b. | Reduces operative and anesthesia time. |
| c. | Sterilizes tissue from the heat generated at the laser-tissue impact site. |
| d. | Allows a shift to more ambulatory surgery procedures. |
ANS: B, D
While positive patient outcomes benefit the surgical services department, lasers may provide financial benefits in increasing productivity and advancing the marketing of profitable centers. The following are some advantages that have been associated with laser technology with a focus on the business end of healthcare: reduced operative and anesthesia time, a shift to more ambulatory surgery procedures, more use of local anesthetics instead of general anesthetics, and quicker recovery and return to daily activities.
REF: Page 232
- The new endoscopy and surgery center called in an outsource company to present the options and advantages of reprocessing single use devices at their staff meeting. Select the appropriate questions that the staff should ask before making their decision.
| a. | Can the disposable device be adequately cleaned? |
| b. | Is the device tested and checked for form and function after cleaning? |
| c. | Can the device withstand disinfection or sterilization? |
| d. | How many times can a device be reprocessed and reused? |
ANS: A, B, C, D
Questions to ask when determining whether to reprocess single-use items include the following: Can the disposable device be adequately cleaned? Can the device withstand disinfection or sterilization? Can the item be adequately aerated if ethylene oxide sterilization is used? Is the device tested and checked for proper form and function after cleaning has been completed? Has device integrity been destroyed during reprocessing or is equipment available to test the integrity of the device? How is the integrity of insulation checked on an electrosurgical instrument? Can the device be returned to its original intended use? Will cost savings be passed on to the patient, if appropriate? What is the maximum number of safe reuses, as determined through comprehensive testing? How is the number of reuses indicated on the device? Should the patient be informed that a reprocessed device may be used?
REF: Page 216
MATCHING
Flexible endoscopes, whether they are a fiberscope with an eyepiece lens or a videoscope, have four distinct components. Match each component with its descriptive statement by drawing a line from the component part name below to the appropriate component part on the image.
| a. | Control body |
| b. | Insertion tube |
| c. | Light guide connector |
| d. | Bending section |
- Distal tip, flexible movement, lenses, air-water nozzle, CCD chip
- Flexible tube with channels for suction, biopsy, irrigation, light
- Angulation knobs, air-water channel buttons, biopsy port
- Suction, air, water, and light connection adaptors to energy source
- ANS: D REF: Pages 204-205
- ANS: B REF: Pages 204-205
- ANS: A REF: Pages 204-205
- ANS: C REF: Pages 204-205
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