Deck 5: Positioning the Patient for Surgery

Question 1

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.

Answer 1

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.

Question 2

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:

A) genitals,knees,toes,and eyes.
B) breasts,forehead,and knees.
C) genitals,eyes,and all areas that are in contact with the OR bed or accessories.
D) tension on the urinary catheter and SSEP electrode wires.

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

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;dependant ureter
C) kidney bridge;vena cava
D) kidney bridge;renal artery

Answer 3

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.

Question 4

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) over;body
B) under;mattress
C) over;mattress
D) around;OR bed rail

Question 5

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 CHG wipes before transfer to the OR bed
C) Fluffing the surface of the OR bed with warm bath blankets and eggcrate 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 6

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?

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 7

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:

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

Question 8

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 dependent lung
B) Brachial plexus injury
C) Venous pooling shifts toward dependent side with DVT in lower extremities
D) All of the options are correct.

Question 9

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) restless leg syndrome
D) compartment syndrome

Question 10

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.

A) Anxiety;lock OR bed and transport vehicle during transfer;remain at patient side during transfer and induction
B) Falls;lock OR bed and transport vehicle during transfer;remain at patient side during transfer and induction
C) Impaired transfer ability;reassure patient with calm and appropriate touch;remain at patient side during transfer and induction
D) Anxiety;reassure patient with calm and appropriate touch;remain at patient side during transfer and induction

Question 11

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?

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 Mr.Jennings

Question 12

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?

A) A shearing force injury to the tissue from having been slid into position
B) Skin creases from wrinkled sheets
C) Incontinence from an inadequate bowel prep
D) Side-to-side striations across his back and buttocks from the lifting sheet

Question 13

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

A) Nonallergic,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 14

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 __.

A) tibial;hyperextension
B) common peroneal;full leg sequential compression wraps
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

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?

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

Question 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.

A) Impaired transfer ability;lock OR bed and transport vehicle during transfer;use at least 4 persons 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 side during induction;use at least 4 persons to assist with lift and transfer.
C) Impaired physical mobility;reassure patient with calm and appropriate touch;remain at patient 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 side during induction.

Question 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.

A) Falls;pain;Impaired physical mobility;remain at patient side during induction;use under- and over-body forced air-warming blanket;prevent fluid pooling under dependent areas;pad all bony prominences with foam or gel pads
B) Hypothermia,impaired skin integrity;impaired comfort;use under- and over-body forced air-warming blanket;prevent fluid pooling under dependent areas;pad all bony prominences with foam or gel pads;unlock OR bed and transport vehicle after transfer.
C) Impaired skin integrity;falls;pain;remain at patient side during induction;use at least 4 persons to assist with lift and transfer;pad all bony prominences with foam or gel pads;unlock OR bed and transport vehicle after transfer.
D) Hypothermia;impaired skin integrity;falls;remain at patient side during induction;use under- and over-body forced air-warming blanket;use at least 4 persons to assist with lift and transfer;pad all bony prominences with foam or gel pads.

Question 18

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

A) TSRH-Cobbs frame
B) Wilson frame
C) Jackson spinal surgery bed
D) Wilson frame and Jackson spinal surgery bed

Question 19

Mrs.Faulkner's Braden scale score is 11.This places her at __ risk.

A) low
B) mild
C) high
D) very high

Question 20

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

A) 40 mm Hg.
B) 32 mm Hg.
C) 50 mm Hg.
D) 100 mm Hg.

Question 21

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

A) CUSA head positioner
B) Crutchfield cranial tongs
C) Mayfield head positioner
D) Cushing head stabilizer

Question 22

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.

Question 23

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):

A) locking the remote control for the OR bed and placing it in a secured area.
B) tucking and securing arms within under-mattress arm sled positioners padded with gel.
C) placing a leg strap across the chest and securing a footboard at the head of the OR bed.
D) securing the chest and shoulders with gel and foam-padded wide tape.

Question 24

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.

A) Respiratory compromise and ventilation resistance,patient sliding,facial edema
B) Pelvic pressure from abdominal organs,finger injury from hands pressed against thighs,popliteal pressure within stirrups
C) Accidental deployment of unlocked OR bed remote control while instruments are inside patient,causing external and internal tissue injury
D) Heel pressure injury from stirrup boot,hyperabduction injury to the arms,pulmonary embolism

Question 25

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.

Question 26

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.

Question 27

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.

Question 28

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.

Question 29

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

A) Air-filled,roller,or slider transfer device
B) Upper body ramp
C) Elevated padded armboards
D) All of the options are correct

Question 30

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.