Deck 11: Surgery of the Liver, Biliary Tract, Pancreas, and Spleen

Question 1

The liver is essential in the metabolism of carbohydrates,proteins,and fats,generating nutrient stores of which substance that supplies energy sources to the brain and body?

A) Carbohydrate glucose substrate
B) Glycogen
C) Serum glucosamine
D) Bile salts

Answer 1

B
The liver is essential in the metabolism of carbohydrates,proteins,and fats.It metabolizes nutrients into stores of glycogen,used for regulation of blood glucose levels and as energy sources for the brain and body functions.

Question 2

An example of an indication for liver transplantation would be:

A) end-stage liver disease resulting from advanced hepatic cancer with metastasis.
B) acute fulminant biliary disease of unknown origin.
C) infection caused by untreated cystic anomalies.
D) primary hepatic cancer.

Answer 2

D
Liver transplantation is indicated for patients with primary hepatic cancer,chronic hepatocellular disease,chronic cholestatic disease,metabolic liver disease,acute fulminant liver disease,and inborn errors of metabolism.When malignancies are the cause of end-stage liver disease,the right upper quadrant may be radiated intraoperatively-after hepatectomy and before transplantation.

Question 3

The liver,pancreas,and spleen share many similarities.Select the statement about these organs that is true.

A) All three are solid organs and very vascular.
B) All three are metabolic organs.
C) All three organs have terminal attachments to the duodenum.
D) All of the options are false.

Answer 3

A
All three organs are solid (not hollow or collapsible)organs.A pathologic condition in the liver,biliary tract,pancreas,or spleen often requires surgical intervention.These organs are highly vascular and control many metabolic and immune functions of the body.

Question 4

Marvin Townsend is a 29-year-old man with paraplegia caused by spinal cord injury from a diving accident 4 years ago.He is transported into the trauma ED after being hit by a car as he was crossing the street in his wheelchair.He has a possible rupture of his liver and is scheduled for surgery.The perioperative nurse,on response to the trauma call,meets him in the ED to conduct a preoperative assessment and prepare for his procedure.Marvin tells the nurse that he is latex-sensitive because he was told that as a spinal cord injured person he should always be considered latex-allergic.An appropriate risk reduction strategy for Marvin's latex sensitivity/allergy would be to:

A) advise the anesthesia provider to premedicate with an H2 blocker,diphenhydramine,and prednisolone.
B) alert the OR and postoperative recovery areas of his latex allergy,check the setup for latex-containing items,and replace those items with non-latex alternatives.
C) transfer his care to the pediatric OR in the adjoining hospital where everything in the OR is latex-free.
D) position code and latex carts outside of the OR and watch for signs of latex reaction;tape an epinephrine-filled syringe to the head of his transport vehicle.

Question 5

Luanne Williamson,a 39-year-old,248-lb mother of 4 children,is assisted with transfer from a transport vehicle to the OR bed for laparoscopic cholecystectomy,operative cholangiogram,and possible common bile duct exploration.The perioperative nurse determined that Luanne is at risk for positional injury related to her size and the positional requirements and OR bed manipulations required for this procedure.An appropriate nursing implementation for positioning this patient would be to:

A) place two safety belts over the thighs and lower legs to prevent the patient from sliding out of position when the surgeon tilts the table for better exposure and access.
B) place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant of the abdomen.
C) abduct the patient's right arm on an armboard at less than 90 degrees to allow an assistant to stand near the patient's right upper quadrant and retract the liver with a wide Deaver retractor.
D) place two safety belts over the thighs and lower legs to prevent the patient from sliding out of position when the surgeon tilts the table for better exposure and access,and place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant of the abdomen.

Question 6

What technologic characteristic of robotic surgery provides a superior indication for robotic-assisted laparoscopic cholecystectomy?

A) The surgeon controls two instruments plus a camera while an assistant suctions and retracts.
B) Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage.
C) The magnified three-dimensional picture may reduce bile duct injuries during dissection.
D) Robotic stapler and suture devices promote intracorporeal anastomotic techniques.

Question 7

The head of the pancreas is fixed to the:

A) spleen.
B) duodenum.
C) stomach.
D) biliary tree

Question 8

An example of a potential risk associated with pneumoperitoneum would be:

A) tachycardia caused by peritoneal irritation from the CO₂.
B) CO₂ absorption into the peritoneal capillaries,causing decreased oxygen saturation.
C) bradycardia from CO₂ pressure lower than 15 mm Hg.
D) gas embolus into an exposed blood vessel during the procedure.

Question 9

Open common bile duct (CBD)exploration may be indicated in some cases where:

A) the patient has undergone prior biliary surgery.
B) a positive cholangiogram shows a CBD obstruction during an open cholecystectomy.
C) laparoscopy technology is not available.
D) All of the options are correct.

Question 10

Jan Stuyvesant,a perioperative nurse,was the scrub person during a robotic-assisted laparoscopic cholecystectomy.She locked the robotic endoscissor into the adaptor on the robotic arm and positioned the tip end into the trocar port in order for the surgeon to dissect the cystic duct and artery,while the surgical assistant placed the clips on the cystic duct and artery.As she reached across the sterile field to insert the cholangiocatheter through the port,the anesthesia provider accidentally made contact with the distal end of the catheter as he stood up to reach the monitor controls.The contaminated end of the catheter touched the endoscopic clip applier,the endoscissor connector that the surgeon was using,the glove of the assistant,and Jan's gown sleeve.The surgeon ordered everyone to change their gown and gloves and covered the port area with a sterile towel.What was the rationale for the surgeon to continue to dissect and not change his attire?

A) The tip of the dissector that was in the patient's abdomen was not contaminated.
B) The surgeon planned to remove the dissector after he finished dissecting and then dispose it.
C) The surgeon's gown was not touched,just the dissector connection to the robotic arm.
D) The surgeon was not in contact with the sterile field because he worked from the robotic console.

Question 11

Jarvin Patel,a 42-year-old woman from Mumbai,India,is visiting her daughter and new grandson.She is a devout follower of Hindu religious practices and has been diagnosed with splenomegaly,possibly from idiopathic thrombocytopenia.Jarvin is scheduled for a total splenectomy.During the preoperative assessment,the perioperative nurse,an observant Hindu herself,is concerned about the possibility of significant bleeding because of Jarvin's coagulopathy and the need for hemostatic agents that are typically used to stop bleeding.Many of these products are manufactured from bovine source products and it would be in conflict with Jarvin's religion to use products from a cow.An appropriate risk reduction strategy for selection of hemostatic agents that would not be in conflict with Jarvin's belief system would be:

A) substitute absorbable gelatin and oxidized collagen products;soak in thrombin.
B) substitute absorbable gelatin and oxidized collagen products;use high ESU settings.
C) substitute absorbable gelatin and oxidized collagen products;use regular ESU settings.
D) substitute microfibrillar collagen soaked in thrombin;add epinephrine 1:1000.

Question 12

The functional units of the liver are the lobules.The functional cells of the liver are the __ and they manufacture ___.

A) Kupffer cells;phagocytes
B) sinusoid cells;lymphocytes
C) hepatocytes;bile
D) portal triad cells;ductal epithelium

Question 13

Matthew Ryan,a 9-year-old boy,is admitted to the emergency department for a sledding accident,when he lost control of his sled and crashed into a tree.He is pale and in pain;his abdomen is tender and firm to palpation.The CT scan suggests rupture of the spleen with internal bleeding.Matthew's scheduled surgery will most probably be a(n):

A) laparoscopic splenic resection with sutured mesh overlay.
B) open splenic lobectomy with vascular ligation.
C) open total splenectomy.
D) open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.

Question 14

During an emergent total open splenectomy on a patient with blunt force trauma to the abdomen,the circulating nurse and anesthesia provider noticed rust-colored urine in the urinary collection container.They had just hung the third unit of whole blood.What nursing action is the first priority?

A) Send a sterile urine sample for stat cytologic studies.
B) Notify the scrubbed team of the urine color change and check the bladder for trauma.
C) Stop the blood transfusion.
D) Check the blood unit for patient-specific identification and expiration date.

Question 15

The Whipple procedure is the removal of the head of the pancreas,the entire duodenum,a portion of the jejunum,the distal third of the stomach,and the as a surgical treatment for.

A) left lobe of the liver;metastatic hepatocytoma
B) distal segment of the spleen;pancreatic metastasis
C) inferior margin of the ligament of Treitz;pancreatic cancer
D) lower half of the common bile duct;pancreatic cancer

Question 16

While the pancreas' function is carbohydrate metabolism with the production of insulin and digestive enzymes,the spleen's function is primarily ___ with the production of ___.

A) immunologic;leukocytes
B) metabolic;granulocytes
C) anabolic;plasma cells
D) as a blood reservoir;phagocytes

Question 17

Joanne Grizwald,a 24-year-old woman with type 1 diabetes who is in end-stage kidney failure,is scheduled for a combined kidney-pancreas transplant.She is relatively healthy and at normal weight for her height in spite of her disease process.Her bleeding time and coagulation parameters are within normal limits.The circulating nurse has set up the autotransfusion system,verified Joanne's blood type,and crossmatched blood availability.The scrub person,while organizing the sterile back table,identified several instruments that she will not need.She organizes those instruments on the most distant part of the back table.What instruments is the scrub person unlikely to need during this procedure?

A) Based on Joanne's coagulation status,excess bleeding is not expected to be an issue.
B) Hemostasis will be achieved by the use of microfibrillar collagen agents that do not leave electrosurgical eschar (burned tissue) on the bleeding surfaces,thereby reducing the chance of infection.
C) Any excess bleeding will be removed and returned to the patient through the autotransfusion system.
D) The transplant procedure is an open approach and laparoscopic instruments (the insulated electrosurgical-adapted scissors,graspers,and the endoscopic suction tips) are not needed.

Question 18

Steven Morganstein,a 51-year-old male with hepatobiliary disease,is scheduled for surgery.The perioperative nurse,during the preoperative assessment,questions and examines the patient for signs and symptoms of jaundice,petechiae,and lethargy and:

A) reviews his chart for bleeding and coagulation times and the platelet count.
B) asks Steven his blood type and when he last donated blood.
C) palpates Steven's abdomen for left upper quadrant tenderness and liver margins.
D) reviews the findings of his endoscopic retrograde cholangiopancreatoscopy (ERCP).

Question 19

The circulating nurse approaches the preoperative holding lounge to see her next patient,Alfred Neumann,a 57-year-old nurse newly diagnosed with pancreatic cancer.He had an ERCP 1 week ago and,based on the findings,was scheduled for surgery at the comprehensive cancer center,where he works in the interventional endoscopy unit.He is aware of the poor prognosis for this disease and his nurse has recorded his nursing diagnosis as:Anxiety related to impending surgical procedure,perioperative events,and surgical outcome.An appropriate nursing action for Alfred would be to:

A) encourage verbalization of his fears and reinforce the standardized age-appropriate coping mechanisms.
B) describe for him the steps of the operative procedure.
C) offer emotional reassurance by using touch,assisting him to a position of comfort on the OR bed,and offering warm blankets (thermal comfort).
D) share with Alfred his nursing diagnosis and reinforce the desired nursing outcome related to anxiety.

Question 20

The biliary system (also called the biliary tree)drains bile from the gallbladder to the ampulla of Vater.The primary function of the gallbladder is to:

A) manufacture bile.
B) convert bile salts into bile enzymes.
C) store and concentrate bile.
D) contract to secrete bile into the hepatic duct.

Question 21

The recipient liver OR is arranged for a major laparotomy and vascular procedure with customized instruments,supplies,and sutures according to the transplant surgeon's preference.In addition to the general patient care accessories,equipment,and supplies needed for any large surgery,also included are intraoperative laboratory testing and an autotransfusion system.Describe the boundaries of the surgical skin prep for the patient about to receive a liver transplant.

A) From neck to midthigh;midaxillary line to midaxillary line
B) From nipple line to pubis;bedline to bedline
C) From the neck to midthigh;bedline to bedline
D) From nipple line to midthigh;midaxillary line on the patient's left side,and bedline on the right

Question 22

Number the sequence of critical steps for receiving,checking,and verifying the transplant organ.
A.The organ arrives at the OR.
B.The circulating nurse and a second RN verify the organ tag with the preliminary crossmatch report to ensure the following match:the recorded ABO type of the recipient is the same or is compatible with the recorded ABO type of the donor,the UNOS (United Network for Organ Sharing)number on the organ is the same as the UNOS number on the Preliminary Crossmatch Report.The two RNs then identify the patient according to hospital policy and sign the Transplant Verification form.
C.The transplant surgeon verifies that the UNOS number on the Preliminary Crossmatch Report is the same as the UNOS number on either the organ container or the paperwork provided and verifies the compatibility of the organ and the patient by ABO blood type.The transplant surgeon signs the Transplant Verification form.
D.The Transplant Verification form and Preliminary Crossmatch Report are placed on the permanent part of the patient's medical record.
E.Crossmatch and ABO reports from the human leukocyte lab and blood bank are received.
F.The Transplant Verification form (deceased donor)is attached to the record.
G.Once the patient is taken into the OR,a time-out is taken with the OR team according to OR policy and procedure.
H.The OR charge nurse verifies the recipient's preliminary crossmatch and ABO report.
I.The circulating nurse identifies the box with a recipient patient label.

Question 23

The donor liver OR is prepared for an open laparotomy procedure with basic laparotomy and vascular instruments and accessories.A second sterile instrument table is set up to receive and prepare the procured liver.Select the additional instruments and accessories needed on the donor organ preparation table.

A) vascular instruments,silk sutures and ties,sterile ice,flushing solution,and slush machine.
B) flushing solution,ice chest,sterile ice,powered sternal saw,and long Kocher clamps.
C) culture tubes,Wisconsin University forceps,Deaver retractors,and slush machine.
D) toothed forceps,vessel loops,two sterile plastic draw-string bags,and flushing solution.

Question 24

Both Maryanne and Charles Rigler had surgery 6 days ago.Charles had a living-related donor liver transplant and Maryanne,the matched donor,provided a segment of her healthy liver for her husband.They have both recovered as expected and are preparing for discharge.They are concerned about who will be the primary caregiver,since they are both recovering at the same time and rate.They also realize that they will need clear and realistic instructions and support because of their unique situation.They are most concerned about incision care,side effects that could mean complications,nutrition,and activity restrictions and escalation.An appropriate risk reduction strategy for Maryanne and Charles would give first priority to (select all that apply):

A) secure an order for social services consult.
B) secure an order for a physical rehabilitation plan.
C) provide Maryanne and Charles with the standard discharge education with emphasis on their concerns.
D) elicit their abilities to provide for themselves and their resources of support.