Question 1

Assessment of the skin and the patient's general condition is important in preventing perioperative complications.The nurse should assess the patient's smoking history (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 statement that best reflects an appropriate strategy that the nurse could use in assessing the 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.The nurse should also assess the patient's pain tolerance to determine necessary teaching or tools that will assist in achieving positive postoperative outcomes.

Question 2

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

Accepted Answer

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 pneumothoraces.

Question 3

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,what 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 4

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.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);document results.Obtain equipment and 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 5

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.
Endoscopic thoracic sympathectomy (ETS)is a thoracoscopic intervention used to surgically treat hyperhidrosis.The surgeon needs an unobstructed view from either side,because the procedure is performed bilaterally.

Question 6

The nerves of the lungs are a part of the autonomic nervous system.What 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 the blood vessels within the lungs.

Question 7

What is the ideal position for bronchoscopy?

Accepted Answer

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

Question 8

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.Flexible bronchoscopy on an adult patient may be completed after induction of local anesthesia or monitored anesthesia care;a child usually receives a general anesthetic.Patients undergoing rigid bronchoscopy should be paralyzed and ventilation continued to minimize trauma.

Question 9

Patients having thoracic surgery share a common nursing diagnosis of Risk for Impaired Skin Integrity related to surgical positioning,length of surgical intervention,or use of chemical antimicrobial agents on the skin.The type of position used in thoracic surgery is determined by the operative procedure planned.In addition to placing the patient in appropriate body alignment,what other interventions can ensure that the patient's skin integrity is maintained?

Accepted Answer

Adequate padding and safe transfer should be implemented to prevent pressure injury.
Apply principles of positioning for efficient circulatory function for lateral or supine position during the procedure;pad and protect vulnerable neurovascular bundles and dependent pressure areas.Position the patient in the best possible body alignment to allow visualization of the operative field.Observe and document skin integrity and condition postoperatively and compare with preoperative status.

Question 10

Roger Waring,a 46-year-old male 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 Roger's 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.What diagnostic procedure will precede Roger'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 bronchial 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 11

Roger Waring'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.Roger's TNM and staging classification are:

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 tumor,node,metastasis (TNM)characteristics.

Question 12

Pneumonectomy is removal of an entire lung,usually to treat malignant neoplasms.What structures are excised or resected in order to remove the entire lung and complete the surgery?

Accepted Answer

Other resections are often combined with pneumonectomy,such as resection of mediastinal lymph nodes,resection of portions of the chest wall or diaphragm,and removal of parietal pleura.If a rib is to be excised,bone instruments are required.The surgeon frees any peripheral adhesions to mobilize the lung and divides the pulmonary ligament.The superior pulmonary vein is gently retracted,and the pulmonary artery is dissected.The surgeon clamps and divides the branches of the pulmonary artery and vein of the involved lobe.The inferior pulmonary vein is exposed by incising the hilar pleura and retracting the lung anteriorly.The inferior pulmonary vein is clamped,doubly ligated,and divided.The surgeon divides the bronchus near the tracheal bifurcation.The lung is removed from the chest.

Question 13

An example of a true statement about TNM and staging diagnostic classification for lung cancer 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 14

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

Accepted Answer

The National Emphysema Treatment Trial (NETT)suggests the following criteria as patient eligibility for LVRS:high-resolution computed tomography evidence of moderate to severe bilateral heterogeneous emphysema or moderate to severe bilateral homogeneous emphysema;no previous laser surgery or LVRS;no giant bulla.LVRS is an alternative surgical treatment for patients with chronic pulmonary emphysema.

Question 15

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.What syndrome is caused by the compression of these structures?

Accepted Answer

Compression of these structures causes thoracic outlet syndrome.

Question 16

Aaron Greenberg,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 to determine which agent will be used.She has an unsterile product that has been typically used in the past,but sterile processing informs her that they do not have the capacity to sterilize this agent.She also notes that the OR does not have a policy or guidelines for the administration of chemotherapeutic antineoplastic agents or safety training and a spill kit.Based on these conditions,what agent will the surgeon and nurse select for Mr.Greenberg's procedure?

Accepted Answer

Perioperative nurses should consult with the surgeon before the procedure to determine the agent used.Silver nitrate coagulates cellular protein to form pleural eschar.Talc stimulates mesothelial cells to coordinate an inflammatory response.Facial talc is unsterile,contains asbestos,and requires stringent sterilization technique.Commercially available sterile talc is preferable.Bleomycin is an antineoplastic requiring special handling to reduce personal exposure.Cyclines indirectly stimulate pleural macrophages,activating pleural mesothelial cells.

Question 17

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 18

Thoracotomy can be performed with the patient in one of three common positions:lateral,semilateral,and supine.While the supine position is used for the median sternotomy approach,which of the lateral 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 19

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 will be needed in the 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 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)include patients with:

Accepted Answer

Double-lung transplantation (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 22: Thoracic Surgery