Deck 6: Positioning the Patient for Surgery

Question 1

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

A) Shearing force factors
B) Intrinsic factors
C) Bed rest precaution factors
D) Extrinsic factors

Answer 1

B
Intrinsic factors lower a patient's tissue tolerance to pressure and decrease the time and pressure required for tissue breakdown.Certain preexisting conditions are regarded as intrinsic risk factors for OR-induced pressure ulcer development.These conditions include diabetes mellitus,smoking,peripheral vascular disease,cerebral vascular disease,urinary or fecal incontinence,anemia,malignancy,sepsis,steroid use,morbid obesity,malnutrition (serum albumin levels less than 3.5 g/dL),advanced age,body size (obesity as well as thin,frail build),and impaired mobility.

Question 2

A 14-year-old patient with marked scoliosis is in prone position with gel bolster 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 on the:

A) genitals, knees, toes, and eyes.
B) breasts, forehead, and knees.
C) genitals, breasts, toes, eyes, and all areas in contact with the OR bed or accessories.
D) forehead, toes, and knees.

Answer 2

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.

Question 3

Recent studies on the relevance of the Braden pressure ulcer risk scale in the perioperative and critical care setting are inconclusive.In which perioperative setting would the Braden scale be most predictive as a baseline metric?

A) Postoperative
B) Intraoperative
C) Preoperative
D) Ambulatory

Answer 3

C
Although not specifically developed for the perioperative setting,the Braden Scale,as part of a comprehensive assessment,may be used as a preoperative baseline for predicting at risk perioperative patients.

Question 4

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

A) Air-filled, roller, or slider transfer device
B) Lower body ramp
C) Elevated padded heel supports with footboard
D) Abduction pillow

Question 5

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

A) Cavitron ultrasonic surgical aspirator (CUSA) head positioner
B) Crutchfield cranial tongs
C) Mayfield head positioner
D) Cushing head stabilizer

Question 6

While basic positioning prevention strategies apply to all robotic-assisted procedures,in steep Trendelenburg with severe head-down position,strategies to prevent the patient from slipping toward the head of the OR bed must be considered.These strategies include:

A) tucking the patient's arms in anatomic alliance.
B) use of beanbag positioning systems.
C) avoidance of dorsal extension.
D) use of protectors on the elbows and under the arms.

Question 7

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

A) Nonallergenic, pressure-reduction capabilities, radiolucent
B) Electrically conductive, latex-free, black
C) Nonflammable, compatible with warming/cooling devices, black
D) Fluid resistant, bactericidal, pressure-reduction capabilities

Question 8

A 325-lb male is scheduled for a 6-hour abdominal surgery.While assessing the patient in the preoperative holding area,the perioperative nurse is concerned about the risk for pressure injury because of the weight of the patient's body pressing against the surface of the operating room (OR)bed for a long surgery.Which of these other factors may also produce pressure?

A) The scrub person leaning with his or her forearm on the Mayo stand.
B) A self-retaining retractor post clamped to the OR bed rail and tightened against the patient's side.
C) A Deaver retractor and two right angle clamps placed on the patient's thighs when draped.
D) Full-leg sequential compression wraps on both legs throughout the entire surgery.

Question 9

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.

A) head; vena cava
B) foot; dependent ureter
C) kidney bridge; vena cava
D) kidney bridge; renal artery

Question 10

A 52-year-old 425-lb male patient is scheduled for surgery at the bariatric surgery center in 3 days.He has osteoarthritis and had a spinal fusion when he was 13.His long-time neighbor,a perioperative nurse at the bariatric center,has asked to be the patient's circulating nurse and is contemplating his plan of care.He shared his concern that he would not be able to move himself over to the OR bed and would be embarrassed if the nurses could not lift him.Based on this information,the nurse has identified this nursing diagnosis: ___________________ and these three positioning-relevant nursing interventions: _______ _______ _______.Select from the options to fill in the blanks.

A) impaired transfer ability; lock OR bed and transport vehicle during transfer; use at least four people to assist with lift and transfer; use OR bed to accommodate patient weight and size
B) anxiety; reassure patient with calm and appropriate touch; remain at patient's side during induction; use at least four people to assist with lift and transfer
C) impaired physical mobility; reassure patient with calm and appropriate touch; remain at patient's side during induction; use OR bed to accommodate patient weight and size
D) impaired physical mobility; lock OR bed and transport vehicle during transfer; reassure patient with calm and appropriate touch; remain at patient's side during induction

Question 11

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:

A) position the patient back in supine before repositioning in low lithotomy.
B) reposition as quickly as possible to avoid pressure latency.
C) reprep and redrape after repositioning.
D) reassess the patient for body alignment, tissue integrity, and pressure areas.

Question 12

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?

A) Diminished lung capacity of nondependent lung
B) Celiac plexus injury
C) Decreased blood return to the right side of the heart
D) Scalene node rupture

Question 13

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.

A) venous thromboembolism (VTE)
B) sacral ischemia
C) diminished tidal volume
D) compartment syndrome

Question 14

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

A) tibial; hyperextension
B) common peroneal; full leg pneumatic compression sleeves
C) iliopsoas; hyperabduction and contact with candy cane stirrup pole
D) patellar; deep tissue injury from contact pressure with underside of Mayo stand

Question 15

A frail and thin 91-lb,83-year-old woman is 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.

A) Risk for Falls; Impaired Comfort; Impaired Physical Mobility
B) Risk for Perioperative Hypothermia, Risk for Impaired Skin Integrity; Impaired Comfort
C) Risk for Impaired Skin Integrity; Risk for Falls; Impaired Comfort
D) Risk for Perioperative Hypothermia; Risk for Impaired Skin integrity; Risk for Falls

Question 16

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 _________.

A) around; patient's body
B) under; mattress
C) over; mattress
D) around; OR bed rail

Question 17

The circulating nurse instructed the new anesthesia resident in the proper positioning of the arm and hands on the OR bed arm boards.She cautioned him to avoid pressure on the elbow to prevent:

A) ulnar nerve injury.
B) radial artery tension.
C) radial nerve compression.
D) pressure sore of the elbow.

Question 18

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

A) Assisting the anesthesia provider with checking and hanging albumin before anesthesia induction
B) Washing the patient's back, heels, scapulae, and elbows with chlorhexidine gluconate (CHG) wipes before transfer to the OR bed
C) Fluffing the surface of the OR bed with warm bath blankets and egg crate foam before patient transfer to the OR bed
D) Removing all but one layer of linen from the dry polymer elastomer gel mattress surface of the OR bed before patient transfer

Question 19

A 325-lb male is undergoing a 6-hour abdominal surgery.While asleep and intubated,the surgeon requests the patient to be placed in lithotomy position for a sigmoidoscopy before the open procedure.The team of five nonscrubbed persons lifts the patient with the lift sheet,slides the patient down toward the foot of the OR bed,and places him into position.After the sigmoidoscopy,the perioperative nurse has the team roll the patient to his side for a skin assessment of his back before he is repositioned supine.What injury is the perioperative nurse concerned that she might see?

A) A shearing force injury to the tissue from having been slid into position
B) A peripheral nerve injury related to lithotomy position
C) Pressure alopecia
D) Side-to-side striations across his back and buttocks from the lifting sheet

Question 20

The perioperative nurse noticed abrasions on a patient's elbows when she visited him in the intensive care unit (ICU)the day after his 6-hour abdominal surgery.The patient told her that the ICU nurses had difficulty pulling him back up in bed every time he slid down toward the bottom,and he was not able to be much help in moving himself.This skin injury was probably the result of which physical force?

A) Heat and moisture from prolonged bed rest
B) Pressure of his elbows resting on the bed for 2 days
C) Friction from his elbows rubbing over the sheets when slid up in bed
D) Negativity from the bath blankets the nurses stacked to make arm rests for the patient

Question 21

Pressure injury assessment tools designed specifically for use in the perioperative population include the:

A) Scott Triggers Tool, Braden Scale.
B) Braden Scale, Munro Pressure Ulcer Risk Scale.
C) Munro Pressure Ulcer Risk Scale, Scott Triggers Tool.
D) ASA Physical Status Classification, Braden Scale.

Question 22

A 68-year-old,American Society of Anesthesiologists (ASA)physical status (PS)-2 male with early-stage prostatic cancer,was intubated and positioned for a robotic-assisted laparoscopic radical 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.

A) Respiratory compromise and ventilation resistance
B) Pelvic pressure from abdominal organs
C) Shearing injury to soft tissues
D) Heel pressure injury from stirrup boot

Question 23

A circulating nurse and anesthesia provider employed protective measures for a 68-year-old,ASA PS-2 female positioned in extreme 45-degree Trendelenburg for a robotic-assisted laparoscopic hysterectomy.These measures included :

A) locking the remote control for the OR bed and placing it in a secured area.
B) placing the patient directly on gel overlay without a sheet.
C) using a vacuum-packed positioning device (beanbag).
D) using a of a padded footboard.
E) using padded cross-chest straps secured to the bed.