Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

Test bank Alexander’s Care of the Patient in

Surgery 16th Edition Rothrock

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Chapter 11: Gastrointestinal Surgery
Rothrock: Alexander’s Care of the Patient in Surgery, 16th Edition

MULTIPLE CHOICE

1. Exposure of intra-abdominal anatomy in laparoscopy is crucial to safe surgery and

employs varied instruments, applications of highly technical energy sources, patient
manipulations, light, and imaging. Review the list below and select the technique that is
initiated to promote exposure.
a. Insertion of self-retaining retractors
b. Employing the Hasson technique
c. Establishing pneumoperitoneum
d. Insertion of fan retractor
ANS: C
The general progression of a laparoscopic procedure includes gaining abdominal access,
establishing pneumoperitoneum, exposing the targeted organ, completing the critical steps
of the procedure, extracting a specimen, irrigating the wound, and closing the incisions.

2. When compared with open and laparoscopic techniques, the potential benefits of natural
orifice transluminal endoscopic surgery (NOTES) include no visible scars, possibly less
pain, and potentially shorter hospital stays. Select a complication that is the most typical
risk associated with NOTES.
a. Colitis
b. Peritonitis
c. Paralytic ileus
d. Intestinal obstruction
ANS: B
NOTES appears to be a promising alternative approach for GI surgery in the future.
However, the surgeon must open a closed viscera intentionally to access the abdomen.
Complications related to the failure of that opening to heal after closure can result in
peritonitis.

3. As the surgeon prepared to clamp and transect the bowel during a small bowel resection
for tumor, the scrub person transferred instruments from the Mayo stand to the back table
and prepared the sterile field for bowel isolation technique. Review the list below and
select the nursing diagnosis that is most closely related to bowel isolation technique.
a. Risk for surgical site infection
b. Risk for metastasis
c. Risk for tissue injury
d. Risk for ineffective gastrointestinal perfusion
ANS: A
 Bowel technique, also referred to as contamination or isolation technique, prevents
cross-contamination of the wound or abdomen with bowel organisms. To implement
proper technique, the surgical team must keep clean and dirty items separate during open
bowel procedures. Instruments used for bowel resection and anastomosis are kept separate
from the rest of the sterile back table. Contaminated GI tract instruments are handed off or
left on a separate Mayo stand. After wound irrigation, the surgical team dons fresh gowns
and gloves. Clean instruments are used for closure. Planning during preoperative setup
includes having additional drapes, towels, gowns, gloves, and the necessary extra
instruments to accommodate bowel technique.

4. During a laparoscopic colectomy, the scrub person carefully placed the endoscopic
electrosurgery instruments on the Mayo stand after inspecting the integrity of the
insulation along the shaft. This practice is designed to meet the expectation for the
following nursing outcome: the patient will be free from injury due to:
a. impaired thermoregulation.
b. thermal burns and adhesions.
c. impaired tissue integrity.
d. thermal burns and adhesions and impaired tissue integrity.
ANS: C
The patient is at risk for impaired tissue integrity due to lasers, thermal devices,
electrosurgery, radiation, or chemical solutions. To protect the patient from impaired tissue
integrity, follow institutional practice guidelines.

5. A 72-year-old male is scheduled for a total colectomy with ileostomy in the morning. The
wound ostomy care nurse (WOCN) has consulted the patient to initiate his ostomy
teaching, answer his questions, and mark the site on his abdomen that would be the ideal
placement for the ileostomy. An appropriate nursing diagnosis for the patient at this time
would be:
a. ineffective self-health management.
b. deficient diversional activity.
c. disturbed body image related to intestinal diversion.
d. impaired social interaction.
ANS: C
The patient may have body image concerns about his postoperative appearance. This is a
nurse-sensitive condition that can be addressed with education and caring behaviors.

6. Which statement about the McBurney incision is most correct?

a. It is an oblique inguinal incision in the left lower quadrant.
b. It is the incision of choice to repair a direct inguinal hernia.
c. It is an oblique inguinal incision in the right lower quadrant.
d. The direction is more transverse than oblique.
ANS: C
Use of the McBurney muscle-splitting incision is common for open appendectomy. In the
lower right abdomen, the surgeon incises the skin along the skin tension lines at a point
one-third of the distance between the anterior iliac spine and the umbilicus.
7. Triangular orientation is a term used to describe the method used to provide instrument
access to the anatomy during abdominal surgery. It is uniquely associated with which
surgical incision?
a. Mid-epigastric transverse incision
b. Left paramedian incision
c. Thoracoabdominal incision
d. Laparoscopic port incisions
ANS: D
Traditional laparoscopic port placement, via triangulation, is the fundamental concept of
laparoscopic surgery. It places the instruments on planes where they meet to effectively
support dissection with adequate visualization and identification of anatomy and
pathology. Incorrectly placed ports can cause sword-fighting instruments and indirect
access to the operative anatomy.

8. When setting up for a Billroth I gastrectomy, the scrub person will ensure that the
appropriate vascular instruments are available to clamp and ligate the:
a. epiploic branches of the peritoneal artery.
b. gastric branches of the gastroepiploic vessels.
c. gastric branch of the peritoneal artery.
d. Treitz arterial stump.
ANS: B
In a Billroth I gastrectomy, the surgeon opens and explores the abdomen through an
epigastric midline incision. A self-retaining retractor is positioned to optimize exposure.
Mobilization of the greater curvature of the stomach begins with sharp entry into the
gastrocolic ligament, midway along the greater curvature. Working toward the duodenum,
the surgeon frees the stomach from the gastrocolic omentum by ligating and dividing the
gastric branches of the gastroepiploic vessels close to the gastric wall, leaving the
gastrocolic omentum. This occurs with clamps and ties, hemostatic clips, ultrasonic sheers,
or with a sealing bipolar instrument.

9. Two patients are scheduled to have a gastrojejunostomy for obstruction. How will
perioperative planning differ for a patient weighing 280 lb. as compared to that for a
120-lb patient?
a. The ligament of Treitz will not need to be identified in a lighter person.
b. Intraoperative warming devices are more important for a lighter patient.
c. The anastomosis will require sutures rather than staples for the heavier patient.
d. Deaver retractors will replace Richardson retractors with the heavier patient.
ANS: D
All larger patients undergoing surgery need special consideration because they usually
have associated serious comorbidities that place them at heightened risk during the
procedure. The larger patient will require longer instruments, deeper retractors, and
extra-large blood pressure cuffs.
10. A 42-year-old woman has been diagnosed with severe gastroesophageal reflux disease
(GERD) without the dysplastic changes of Barrett’s esophagus. Her GERD is
unresponsive to proton pump inhibitors and histamine blockers. She also has a history of
endometriosis with multiple surgeries for ablation of endometrial implants on her small
bowel and adhesiolysis. Her surgeon is hesitant to pursue an open or a laparoscopic Nissen
fundoplication surgical approach. Which procedure might her surgeon consider in lieu of a
Nissen?
a. Thoracoabdominal partial esophagectomy
b. Endoscopic mucosal resection
c. Intraluminal plication of the lower esophageal segment
d. Heller’s myotomy
ANS: C
Intraluminal plication is an antireflux procedure that can be performed endoscopically.
The EsophyX technique endoscopically creates a 260-degree internal plication of the
gastric fundus to create a neogastroesophageal valve.

11. Pure natural orifice transluminal endoscopic surgery (NOTES) procedures are procedures
performed using flexible endoscopes and instruments passed through the scopes’ working
channels. Many surgeons use a hybrid NOTES technique. What is the difference between
the pure NOTES and hybrid technique?
a. Pure NOTES does not use the rectal approach.
b. Hybrid NOTES is laparoscopic assisted.
c. Pure NOTES does not use the vaginal approach.
d. Hybrid NOTES considers the umbilicus a natural orifice.
ANS: B
Many surgeons use a hybrid NOTES technique that combines laparoscopic visualization
with natural orifice access. Using a transvaginal hybrid NOTES technique, the surgeon
inserts a 3- or 5-mm access port at the umbilicus to create a pneumoperitoneum. The
surgeon next inserts a rigid laparoscope into the abdominal access port to visualize entry
of the vaginal access port from inside the abdomen and then moves the laparoscope to the
vaginal access port.

12. Select the diagnosis/procedure option that pairs the correct surgical diagnosis with the
surgical/endoscopic procedure for diseases of the esophagus.
a. Barrett’s dysplasia of the distal esophagus/endoscopic mucosal resection (EMR)
b. GERD/photodynamic therapy (PDT)
c. Zenker’s diverticulum/Ivor Lewis esophagectomy
d. Esophageal varices/Heller myotomy
ANS: A
EMR is the excision of dysplastic lesions related to Barrett’s esophagus (BE).

13. Review the list below and select the answer that reflects the correct match between the
procedure and the disease.
a. Duodenoscopy for gastric reflux disease and hiatal hernia
b. Roux-en-Y for gastritis
c. Esophagogastroduodenoscopy (EGD) for gastric ulcer disease
d. Small bowel enteroscopy for ulcerative colitis
 ANS: C
Common GI endoscopy procedures used to establish a diagnosis or monitor gastric disease
include EGD (also referred to as gastroscopy or upper endoscopy).

14. A 12-year-old girl with a history of weight loss and stomach upset and pain after eating is
also small for her age. Her pediatrician suspects celiac disease. The patient has arrived at
the pediatric endoscopy unit for a procedure that is less invasive and will also have the
benefit of spending the next few hours in the mall across from the hospital with her mom
until the procedure is over. What is her scheduled procedure?
a. GI manometry
b. Small bowel enteroscopy
c. Capsule endoscopy
d. Stretta procedure
ANS: C
Capsule endoscopy is a noninvasive diagnostic test that uses a small wireless camera in the
shape of a capsule about the size of a large vitamin. It is swallowed with a few sips of
water and propelled along the GI tract by normal peristalsis. The capsule glides down the
esophagus, taking two color digital pictures per second, which it transmits to a recording
device worn by the patient. This device is suitable for imaging the mucosal surface of the
esophagus, stomach, and small intestine.

15. Select the option that pairs the correct surgical diagnosis with the surgical/endoscopic
procedure for diseases of the abdomen.
a. Colon cancer/laparoscopic Roux-en-Y (RNY)
b. Ascites/hyperthermic intraperitoneal antibiotic therapy (HIAT)
c. Obesity/laparoscopic adjustable gastric banding (LAGB)
d. Esophageal varices/photo dynamic therapy (PDT)
ANS: C
Bariatric surgery, also termed weight loss or weight reduction surgery, is surgical
treatment of obesity. There are three categories of bariatric procedures: restrictive (such as
laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy),
malabsorptive, or a combination of both. Restrictive procedures reduce the size of the
stomach.

16. A 38-year-old female has been admitted through the emergency department (ED) for
severe abdominal pain, distended abdomen, and fever. The surgery service has been
consulted and has scheduled her for exploratory surgery. The patient has undergone two
open abdominal surgeries in the past for “female problems” and states that she has a
tendency to form keloids. Review the list below and select the most likely preoperative
diagnosis for the patient based on her surgical history and symptoms.
a. Keloidal mass of the mesentery
b. Endometriosis plaques on the small bowel
c. Small bowel obstruction with torsion
d. Ruptured appendix
ANS: C
 Adhesions can form between the peritoneal surfaces of the abdominal wall and its
underlying abdominal structures, or they can form between adjacent structures within the
abdomen such as the omentum, small bowel, and colon. Adhesions may be asymptomatic
but often result in complications that can occur in the early postoperative stage or years
after an abdominal surgery. Complications include small bowel obstruction,
abdominal/pelvic pain, and infertility.

17. A 55-year-old woman has arrived for an outpatient esophagogastroduodenoscopy. She is

assessed by the perioperative nurse to be in good health and is listed as American Society
of Anesthesiologists (ASA) class I. The patient changes into her gown and awaits transfer
to the procedure room when she is informed that she will not be transferred to the
procedure room until __________ and must wait for ________.
a. she is typed and screened; type and crossmatch
b. her ride home arrives; a responsible adult
c. she is NPO for 2 more hours; a bowel prep
d. her esophagus is cleansed; return of gag reflex
ANS: B
The patient will be sedated during the procedure, so she will need a responsible adult to
accompany her to the facility, drive her home, and remain with her for 24 hours.

18. A patient consulted a noted colorectal surgeon after experiencing episodes of rectal
bleeding over the last 2 weeks. The patient had a screening colonoscopy 5 years ago with
several adenomatous polyps and mild diverticular disease. She presents to the endoscopy
suite after a successful bowel prep and NPO since midnight. The GI endoscopist is
confident that he will find tumor growth in the rectum and decides to employ further
diagnostic applications to determine potential for metastasis. Which of the following
endoscopic procedures best describes the patient’s procedure?
a. Endoscopic mucosal resection (EMR) with photodynamic therapy (PTD)
b. Rectal manometry with dilatation
c. Flexible sigmoidoscopy with endoscopic mucosal dissection (ESD)
d. Colonoscopy with endoscopic ultrasound (EUS)
ANS: D
Colonoscopy provides endoscopic visualization of the colon from the rectum to the
ileocecal valve. The clinician inspects the mucosa for abnormalities such as sites of
bleeding, polyps, inflammation, ulceration, or tumors during both insertion and withdrawal
of the colonoscope. Colonoscopy can be diagnostic and therapeutic. An endoscopic
ultrasound (EUS) combines endoscopy and ultrasound, using sound waves to generate an
image of the histologic layers of the esophageal, gastric, and intestinal walls. EUS is
critically important in staging GI malignancies and determining surgical options and
potential for therapeutic resection. The frequencies used, higher than those used in
traditional ultrasound, provide highly accurate depths of any mucosal invasion.

19. A 19-year-old male has suffered from subsacral pain and swelling for 2 weeks and finally
was referred to a colorectal surgeon for care. He is currently in the ambulatory surgical
center operating room (OR) bed positioned in the jackknife position. The perioperative
nurse has gently but firmly taped his buttocks laterally to the rails of the OR bed to
promote exposure to the surgical site. Which procedure is the patient prepared to undergo
based on his symptoms and the surgical preparation?
 a. Internal hemorrhoidectomy
b. External hemorrhoidectomy
c. Removal of rectal foreign body
d. Pilonidal cystectomy
ANS: D
Excision of a pilonidal cyst and sinus is removal of the cyst with sinus tracts from the
intergluteal fold on the posterior surface of the lower sacrum. A pilonidal cyst and sinus,
which may be congenital in origin, rarely become symptomatic until the individual reaches
adulthood, most commonly in young men. The patient is placed in the jackknife position
with the buttocks taped open laterally and secured to the sides of the OR bed.

MULTIPLE RESPONSE

1. Select the statement/s that best describe the properties of the gastrointestinal (GI) tract.
(Select all that apply.)
a. The omentum is a double layer of fatty peritoneum attached along the concave
margin of the stomach.
b. The GI tract creates a complex microbiologic ecosystem to support and maintain
essential life-sustaining digestive and protective functions.
c. The nerve supply of the esophagus is from branches of the vagus nerve and the
sympathetic nervous system.
d. The function of the esophagus is dependent on gravity.
e. The longest part of the GI tract is the small intestine which begins at the pylorus
and ends at the ileocecal valve.
ANS: B, C, E
The GI tract, or alimentary canal, is a continuous, tube-like structure that spans the human
torso. It includes the mouth; pharynx; esophagus; stomach; small intestine, consisting of
the duodenum, jejunum, and ileum; and large intestine. The large intestine consists of the
cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and
anus. The omentum is a double layer of fatty peritoneum attached along the greater curve
of the stomach. It drapes down loosely over the intestines and then folds posteriorly on
itself before sweeping upward to attach along the transverse colon. The GI tract creates a
complex microbiologic ecosystem to support and maintain essential life-sustaining
digestive and protective functions. Substantial populations of microorganisms exist in the
intestinal lumen. The esophagus is a collapsible musculomembranous tube through which
ingested material moves, by peristalsis, from the pharynx to the stomach. Its nerve supply
is from branches of the vagus nerve and the sympathetic nervous system. Functionality of
the esophagus is not dependent on gravity. Food can be moved from the mouth to the
stomach, even if a person is standing on her head. The longest part of the GI tract is the
small intestine which begins at the pylorus and ends at the ileocecal valve. There is
variation in length of the adult small intestine but typically it is about 3 m long with a
diameter of approximately 2.5 cm. The small intestine consists of three parts: the
duodenum (20 cm), the jejunum (110 cm), and the ileum (155 cm).

2. The stomach receives ingested food from the esophagus to begin the digestive process. In
anticipation of receiving ingested material, the stomach prepares for its role in digestion
by: (Select all that apply.)
a. decreasing motility.
Test bank Alexander’s Care of the Patient in Surgery 16th Edition Rothrock

b. releasing pepsinogen.
c. releasing mucus.
d. increasing motility.
e. secrete digestive enzymes.
ANS: B, C, D
The stomach receives ingested food from the esophagus to begin the digestive process; it
then propels partially digested food, or chyme, into the duodenum through the pylorus. In
anticipation of receiving ingested material, the stomach prepares for its role in digestion by
increasing motility, producing gastric acid, and releasing pepsinogen, intrinsic factor,
gastric fluids, and mucus.

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