Question 1

As the perioperative nurse gathers information that is important to planning patient care,he or she should inquire about a patient's tobacco use (including the use of cigars,pipes,tobacco,or controlled substances)and any exposure to secondhand smoke within the home and/or workplace and reinforce the need to abstain following surgery.Patients might be sensitive about smoking history because of the assumed relationship between smoking and lung disease.Select the best approach the nurse could use in assessing a patient's smoking history.

Accepted Answer

The nurse should phrase questions in a way that will not result in guilt about smoking habits or assumptions that the diagnosed condition is associated with smoking,phrasing questions in a nonjudgmental manner to respect any feelings the patient may have.

Question 2

Lung volume reduction surgery (LVRS)is an alternative surgical treatment for patients with which pulmonary condition?

Accepted Answer

Lung volume reduction surgery (LVRS)is an alternative surgical treatment for patients with chronic pulmonary emphysema.The surgery is intended to increase expiratory airflow,maximal exercise capacity,and respiratory muscle strength,thereby relieving dyspnea.The procedure may also be referred to as lung volume reduction,or pneumoplasty.Candidates for the procedure are those who have progressive,severe dyspnea secondary to pulmonary dysfunction; those whose medical management is ineffective; and those in whom disease distribution is limited to target areas of severity.

Question 3

Direct visualization of the mucosa of the trachea,the main bronchi and their openings,and most of the segmental bronchi may also include the removal of material for microscopic study and is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing,hemoptysis,obstruction,and abnormal roentgenographic changes.What diagnostic modality has been described?

Accepted Answer

Standard bronchoscopy is the direct visualization of the mucosa of the trachea,the main bronchi and their openings,and most of the segmental bronchi.It also includes removal of material for microscopic study if necessary.Bronchoscopy is an integral part of the examination of patients with pulmonary symptoms such as persistent cough or wheezing,hemoptysis,obstruction,and abnormal roentgenographic changes.

Question 4

A 46-year-old man with early-stage lung cancer was listening to his surgeon describe the surgical plan in preparation for signing the informed consent.The surgeon described a procedure that would be done before the thoracoscopic lung surgery.The surgeon described an examination of the middle chest lymph nodes and the area below where the bronchi branch into the right and left lungs,and possibly taking biopsies of suspicious tissue.The procedure uses a hollow lighted tube with fiberoptic light-carrying fibers.Which diagnostic procedure will precede the patient's thoracoscopic lung surgery?

Accepted Answer

Mediastinoscopy is the direct visualization and possible biopsy of lymph nodes or tumors at the tracheobronchial junction,under the carina of the trachea,or on the upper lobe bronchi or subdivisions.Mediastinoscopy may precede an exploratory thoracotomy in known cases of lung carcinoma or may be completed to assist in accurately staging the patient's lymph node status.The mediastinoscope is a hollow tube with a fiberoptic light carrier.A fiberoptic light source with a light-intensity dial provides power and control of illumination.

Question 5

Patients with lung cancer may have specific treatment based on their tumor,node,and metastasis (TNM)characteristics.An example of a true statement about the TNM system is:

Accepted Answer

Staging is based on TNM findings.According to the TNM system,lung cancer has the following three stages: Stage I disease includes tumors classified as T₁ with or without metastasis to the lymph node in the ipsilateral hilar region.Stage II disease includes those tumors classified as T₂,with metastasis only to the ipsilateral hilar lymph nodes.Stage III includes all tumors more extensive than T₂ or any tumor with metastasis to the lymph nodes in the mediastinum with distant metastasis.

Question 6

A 52-year-old school teacher diagnosed with early stage nonsmall cell lung cancer is scheduled for a lung resection.She is selected for the ambulatory surgery center's fast track recovery and discharge program.Which of the following statements describes a component of an ERAS care approach for thoracic surgery?

Accepted Answer

As with all specialties,patient education is a critical component to the success of ERAS program in thoracic surgery.Cessation of smoking and participation in an exercise regimen preoperatively are required in most programs.Early ambulation is critical and patients are informed that they will walk a short distance within the first hour after extubation in the PACU.All interventions from the timing of extubation to pain management are designed to facilitate early ambulation,to facilitate pulmonary hygiene and maximum lung expansion.Discharge occurs when patients are hemodynamically stable,tolerating their usual diet,with pain controlled by oral medication.The chest tube is removed if there is no air leak and the quality and amount of discharge is within normal limits.The presence of an air leak does not necessarily preclude discharge and patients may be discharged home with the chest tube in place,with instructions on its care.

Question 7

The nerves of the lungs are a part of the autonomic nervous system.Which structures are constricted and relaxed by their influence?

Accepted Answer

The nerves of the lungs are a part of the autonomic nervous system.They regulate constriction and relaxation of the bronchi and of the blood vessels within the lungs.

Question 8

Inspiration normally takes place when the intrathoracic pressure is slightly below atmospheric pressure and when a partial vacuum exists between the parietal and visceral pleural (intrathoracic)surfaces.As the muscles of inspiration contract to enlarge the chest cage,which action by the lungs occurs to facilitate air intake?

Accepted Answer

As the muscles of inspiration contract to enlarge the chest cage,the lungs passively follow the diaphragm and chest wall because of decreased intrathoracic pressure.The acts of inspiration and expiration are the result of air moving in and out of the lung,causing pressure to equalize with that of the atmosphere at the end of expiration.

Question 9

A patient's mediastinal node biopsies were sent for immediate frozen section and revealed metastasis of the primary tumor of the left upper lobe to the ipsilateral mediastinal nodes.The patient's TNM and staging classification is:

Accepted Answer

T₄: A tumor of any size that invades the mediastinum,heart,great vessels,trachea,esophagus,vertebral body,or carina; or presence of malignant pleural or pericardial effusion; or satellite tumor nodules within the ipsilateral primary tumor lobe of the lung.N₂: Metastasis to ipsilateral mediastinal lymph nodes and subcarinal lymph nodes.M₁: Distant metastasis is present.Stage IV: Any T,any N,and M₁.Patients with lung cancer may have specific treatment based on their TNM characteristics.

Question 10

Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved spontaneous pneumothorax.The end point goal of a pleurodesis is to:

Accepted Answer

Pleurodesis is undertaken as a treatment for malignant pleural effusion and for unresolved T-type spontaneous pneumothorax.A variety of chemical agents are used to cause adherence of the pleural layers.Adherence of the pleural layers is thought to prevent the accumulation of pleural fluid in the case of pleural effusion and to prevent subsequent pneumothorax.

Question 11

Of all the equipment,tools,and studies available during the patient's preoperative diagnostic phase,which exam is the most indispensable diagnostic tool to outline thoracic lesions and define space-occupying nature and shape?

Accepted Answer

The chest X-ray film remains an indispensable diagnostic tool and is needed in the operating room (OR).This film outlines the lesion,if any is present,and defines its shape and space-occupying nature (e.g.,tracheal shift).The presence of air in the hilar region,pleural effusion,or atelectasis may also be confirmed by radiologic evidence.

Question 12

Video-assisted thoracic surgery (VATS)is a minimally invasive operative technique that has evolved over the past decade.It uses an endoscopic approach to visualize the thoracic cavity for diagnosis of pleural disease or treatment of pleural and lung conditions.In the adult,the surgeon creates a 2- to 3-cm incision between the ________ intercostal spaces for insertion of the 10- or 12-mm trocar.The trocar sites can also be used for insertion of a ____________.

Accepted Answer

The surgeon creates a 2- to 3-cm incision between the fifth and seventh intercostal spaces for insertion of the 10- or 12-mm trocar.The zero-degree telescope is inserted to view the site so that the approach can be determined.After the selected procedure,the surgeon inserts a chest tube through one of the surgical puncture sites and secures it to the skin.Trocar sites are closed,and small dressings or adhesive skin tapes are applied.

Question 13

A 59-year-old retired roofer with mesothelioma is scheduled for a left pleurodesis for malignant pleural effusion and unresolved spontaneous pneumothorax.The perioperative nurse responsible for the thoracic surgery service has consulted with the surgeon and determined that talc will be used.What are the nursing implications related to the use of talc?

Accepted Answer

The aim of pleurodesis is to produce fusion between the visceral and parietal pleural surfaces and so prevent the accumulation of air or fluid in the pleural space.In a chemical pleurodesis,this fusion is generally achieved by the instillation of agents that induce an inflammatory response on the pleural surfaces.These agents can be introduced into the pleural space through a chest tube at the bedside or during thoracoscopy/thoracotomy.Talc is currently the preferred agent for pleurodesis and may be administered as a poudrage,aerosol,or slurry.

Question 14

What is the ideal position for bronchoscopy?

Accepted Answer

Bronchoscopy is usually performed in the supine position,commonly with a shoulder roll.

Question 15

Thoracotomy can be performed with the patient in one of three common positions.Which of these positions is used for an anterolateral approach?

Accepted Answer

The type of position used in thoracic surgery is determined by the operative procedure planned.Thoracotomy can be performed with the patient in one of three common positions: (1)lateral for the posterolateral approach,(2)semilateral for the anterolateral approach,and (3)supine for the median sternotomy approach.

Question 16

During an endoscopic thoracic sympathectomy for hyperhidrosis,what action by the anesthesia provider ensures exposure and minimizes damage to the lung?

Accepted Answer

The anesthesia care provider deflates the patient's lung as directed by the surgeon.Video monitors are placed on each side of the patient to allow the surgeon an unobstructed view from either side,because the procedure is performed bilaterally.

Question 17

After reviewing the laboratory results and assessing the patient,the perioperative nurse determines that the patient's nursing diagnosis is impaired gas exchange related to surgical intervention.Select the appropriate nursing intervention that is related to assisting the patient to experience adequate gas exchange during the surgical procedure.

Accepted Answer

The nurse should collaborate in positioning the patient to provide access to the endotracheal tube,enable efficient ventilatory function,and prevent injury.The nurse should verify that a double-lumen endotracheal tube with a soft,inflatable cuff is available for the anesthesia provider.The nurse should collaborate in obtaining equipment and monitoring arterial blood gases (ABGs)and document ABG results.The nurse should assist with patient preparation for hemodynamic monitoring: electrocardiogram (ECG),CO₂ analyzer,pulse oximeter,arterial pressure line,and central venous pressure line.The nurse should collaborate with the anesthesia provider in evaluating results provided by these monitoring devices during the procedure.

Question 18

During electromagnetic navigation bronchoscopy (ENB),the surgeon uses electromagnetic sensors to:

Accepted Answer

ENB is newer technology that entails a minimally invasive approach to allow access to difficult to reach areas of the lung for biopsy.Standard flexible bronchoscopy is augmented with an image-guided localization device that assists in placing endobronchial accessories in the peripheral target areas of the lung.The electromagnetic system guides and steers the catheters beyond the reach of the bronchoscope to allow the surgeon to reach the lesion and obtain a biopsy of it.

Question 19

The great vessels of the head,neck,and arm pass through a junction bound anteriorly by the manubrium,anterolaterally by the first ribs,and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space.Which syndrome is caused by the compression of these structures?

Accepted Answer

The thoracic outlet is a junction bound anteriorly by the manubrium,anterolaterally by the first ribs,and posteriorly by the first thoracic vertebrae and posterior angles of the first ribs of the space.The great vessels of the head,neck,and arm pass through this space.Compression of these structures may cause thoracic outlet syndrome.

Question 20

The indications for single-lung transplantation (SLT)include restrictive lung disease,emphysema,pulmonary hypertension,and other nonseptic end-stage pulmonary diseases,while the indications for double-lung transplantation (DLT)includes patients with:

Accepted Answer

DLT is indicated for patients with cystic fibrosis or patients with a chronic infection in end-stage pulmonary failure.Developments in SLT include donor contribution from living relatives for patients who have chronic disease and a high risk for death while waiting on the donor transplantation list.Contraindications for transplantation include history of carcinoma or sarcoma,significant renal dysfunction,or cigarette smoking within 3 or 4 months.

Quiz 23: Thoracic Surgery

Lung volume reduction surgery (LVRS) is an alternative surgical treatment for patients with which pulmonary condition?

Patients with lung cancer may have specific treatment based on their tumor,node,and metastasis (TNM) characteristics.An example of a true statement about the TNM system is: