Deck 20: Orthopedic Surgery

Question 1

An objective assessment of the patient's condition,in terms of assigning an appropriate preoperative surgical diagnosis and plan of care,would be obtained from:

A) the physician consult with history, physical, and medical clearance.
B) the patient's own statements about symptoms, pain, onset, and disability.
C) the marking of the surgical site.
D) X-rays and imaging studies.

Answer 1

D
Radiographic films and imaging studies are objective measures of surgical pathology in terms of attaining a presurgical diagnosis.Assessment of the orthopedic patient is dynamic,beginning with initial patient consultation.The history and physical are done in the usual fashion.The signed operative consent provides information to confirm the scheduled procedure(s)and verify the operative site and side.The consent is usually obtained before admission to the surgery suite and should be reviewed for accuracy and completeness.Additional measures that should be undertaken to verify the correct operative side and site include marking the surgical site and having the patient verify the site with the surgeon during the marking process and using a verification checklist,which includes documents such as the medical record,X-ray films,and imaging studies.

Question 2

While not as prevalent as arthroplasty of the shoulder,knee,or hip,total elbow replacement is indicated for patients with traumatic lesions or excessive bone loss from rheumatic or degenerative arthritis,resulting in elbow instability and pain or bilateral elbow ankylosis.The prosthesis may be used with or without PMMA,depending on the quality of the diseased bone and the design of the implant.If PMMA is not used,what replacement product,element,or substance is used?

A) Synthetic bone putty
B) Autologous local bone graft
C) Hemostatic gel sponge with thrombin
D) Side plates, screws, and circumferential wires

Answer 2

B
If PMMA is not employed,bone grafting with local bone that has been resected may be used to help seat the ulnar component snugly and achieve adequate bony contact against the porous coating of the metal ulnar component.The design of implants and methods of fixation for postoperative stability have presented challenges that have been overcome in arthroplasty of other joints but remain a challenge in elbow arthroplasty.Postoperative stability of the elbow implant depends largely on the soft tissues surrounding the joint.Patients with degenerative arthritis generally have better results from elbow arthroplasty than those undergoing this procedure after injury to the elbow joint.

Question 3

A 50-year-old woman with degenerative rheumatoid arthritis is having a two-joint metacarpophalangeal implant of her left hand.The pneumatic tourniquet is applied to the patient's upper left arm and has been inflated to 280 mm Hg for 38 minutes.The surgery is advancing as planned,and the surgeon is preparing to insert the second implant.The perioperative nurse circulator has set the time threshold for 60 minutes.During her preoperative assessment,the nurse noted no contraindications to pneumatic tourniquet use.While the surgery is going well,and the nurse is confident that the second implant will be inserted and the wound closed before the tourniquet alarms,which risk reduction strategy would be appropriate for the nurse to employ?

A) Be prepared to increase the time threshold to 90 minutes.
B) Suggest a let-down procedure to resanguinate the limb at 60 minutes if the second implant is not yet inserted.
C) Wait until the 60-minute alarm sounds.
D) Monitor duration and remind team before 1 hour is reached.

Answer 3

D
Duration of tourniquet inflation should be kept to a minimum.It is recommended in the average,healthy 50-year-old person to apply continuous tourniquet pressure less than 1 hour on the upper extremity and less than 2 hours on the thigh.

Question 4

The scaphoid,also called the navicular,links the proximal row of carpal bones as it:

A) articulates with each metacarpal head.
B) attaches its rough surfaces to the ligaments.
C) stabilizes and coordinates the movement of the proximal and distal rows.
D) articulates proximally with its matching carpal row.

Question 5

Polymethylmethacrylate (PMMA,or bone cement)is an acrylic,cement-like substance composed of a liquid methyl methacrylate monomer and a powder methyl methacrylate-styrene copolymer.What element is added to the powder component by the manufacturer to make the finished product radiopaque?

A) Microfibrillar collagen
B) Polycrylate sodium
C) Barium
D) Granular allograft bone

Question 6

The vertebral bodies are connected by several cartilaginous joints.What purpose does this connection enable?

A) Communication between the spinous processes and vertebral bodies
B) Vertebral flexion, rotation, and extension
C) Vertebral flexion and torsion
D) Maintenance of integrity and spinal support

Question 7

Colles' (wrist)fracture is a dorsally angulated fracture of the distal end of the radius.Most of these fractures can be managed successfully with closed reduction and immobilization,but external fixation is especially useful in the case of a comminuted intra-articular fracture.Internal fixation with Kirschner wires (K wires)is indicated when the distal end of the radius is severely comminuted and displaced.Select the nursing considerations for a patient with a Colles' fracture fixation.

A) Position in modified semi-Fowler with the hand table and tourniquet at the operative side.
B) Provide soft tissue instruments in the OR and external fixation frame.
C) Place tourniquet cuff at mid-forearm level and set to systolic blood pressure level.
D) Position affected wrist and take an anteroposterior and lateral film before surgeon's arrival.

Question 8

Bone grafting using allografts or autografts may be used to fill cavities after removal of large amounts of bone that might result in instability,or to fill bony defects and to promote the union of fractures at the time of open reduction.Banked bone is available in many shapes of cortical and cancellous tissue.The American Association of Tissue Banks (AATB)accredits and periodically inspects bone-banking programs to ensure that specific standards are followed in the retrieval,processing,storage,and distribution of bone grafts.Bone graft that is sealed in a sterile labeled envelope from a tissue transplant company and stored in a vacuum-sealed freezer,monitored with an alarm,would be considered a(n):

A) reengineered human tissue product.
B) allograft.
C) xenograft.
D) autograft.

Question 9

Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone,which leads to a reduced absorption of calcium and phosphorus.This malabsorptive condition is due to a deficiency of ______________ that can be treated by __________________.

A) calcium; nutritional diet and mineral supplements
B) vitamin D; dietary supplements and exposure to sunlight
C) phosphorus; nutraceuticals and exposure to therapeutic radiation
D) soy protein; weight-bearing exercise and sunlight

Question 10

Paget's disease is a disorder affecting older adults.The bones are weak and poorly constructed.This degenerative process results in:

A) weak and nonsupported bone matrix.
B) replacement of cancellous bone with cortical bone.
C) rapid, disorganized bone remodeling.
D) immature bone cells with airspaces.

Question 11

Vertebroplasty and kyphoplasty are used for the treatment of vertebral compression fractures attributable to osteoporosis or pathologic conditions.Bone cement is injected into the vertebral body to decrease back pain and prevent further vertebral body height loss.Equipment includes C-arm,radiolucent OR bed,and X-ray vests for staff as well as bone biopsy needles,vertebroplasty system,and cement injection system.An important nursing consideration relevant to this interventional radiology-assisted procedure would be to:

A) shield the patient with a lead apron, covering from thyroid to reproductive organs.
B) have a spinal fixation system available outside of the room.
C) position patient in prone body alignment with padding to prevent skin and nerve injury.
D) abduct both arms less than 90 degrees on attached arm boards.

Question 12

A long bone fracture in a child can have devastating consequences in terms of the child's skeletal maturity and potential for limb shortening and malformation when the fracture line involves the:

A) epiphysis.
B) diaphysis.
C) epiphyseal plate.
D) cancellous bone.

Question 13

Before surgery,the perioperative nurse reviews the patient record,noting relevant aspects of the history and physical examination; the nature of the problem and its onset; and results of radiographic studies,laboratory data,and other findings.The nurse investigates the patient's range of motion,neurovascular status,and general condition.The patient's perception and understanding of the surgical procedure and postoperative rehabilitation is determined,and patient education is begun.Such activities reflect which important part of the nursing process?

A) Assessment
B) Nursing diagnosis
C) Planning
D) Implementation

Question 14

The rotator cuff consists of which group of muscles?

A) Deltoid, teres major, and teres minor
B) Supraspinatus, infraspinatus, teres minor, and subscapularis
C) Latissimus dorsi, deltoid, and teres major
D) Supraspinatus, subscapularis, pectoralis major, and deltoid

Question 15

Open reduction and internal fixation (ORIF)is a method of providing exposure of the fracture site and using pins,wire,screws,a plate and screw combination,rods,or nails to correct the fracture.Surgeons use ORIF when they are unable to reduce a fracture by closed methods,and skeletal traction is not indicated.What would be an advantage for an open rather than a closed fracture reduction technique?

A) Direct observation and verification of fracture alignment
B) Decreased opportunity for surgical site infection
C) Improved bone union outcomes
D) Ability to rule out comminuted or compound fractures without imaging

Question 16

Identify the layer of connective tissue that covers all bone.

A) Periosteum
B) Ligament
C) Cartilage
D) Fascia

Question 17

Osteoporosis is one of the most common and serious bone diseases and is responsible for more than 2 million fractures a year.Osteoporosis-related fractures most commonly occur in the hip,spine,and wrist,but any bone can be affected.The excessive reduction of total bone mass in osteoporosis is due to:

A) the loss of calcified matrix and collagenous fibers.
B) the lack of exercise and weight-bearing physical activity.
C) the loss of estrogen and testosterone.
D) the loss of calcium or vitamin D.

Question 18

The term "hammer toe" is most often used to describe an abnormal flexion posture of the proximal interphalangeal joint of one of the four lesser toes.A bunion (hallux valgus)is a soft tissue or bony mass at the medial side of the first metatarsal head.Both of these deformity conditions of the feet share similar surgical positions,instrumentation for fixation,and recovery plans.What nursing consideration is also shared by both procedures?

A) Perform skin preparation on only the affected toes.
B) Position patient supine and apply tourniquet.
C) Provide epinephrine for injection into the toes to decrease bleeding.
D) Position the patient prone in normal body alignment with foot elevated on a gel roll.

Question 19

Select the true statement about application and operation of the pneumatic tourniquet.

A) The tourniquet cuff should not overlap less than 3 inches or more than 6 inches.
B) The interval between inflation and deflation should be 5 minutes for every 60 minutes of tourniquet ischemia to minimize effects on muscle and nerves.
C) In a healthy person, inflation time for an arm should not exceed 30 minutes.
D) Pneumatic tourniquets are contraindicated in patients with bleeding tendencies.

Question 20

The surgeon may treat distal limb fractures with a closed reduction,rather than open or external fixation,manipulating the fragments into position without incising the skin.When possible,this is the treatment of choice because it decreases the opportunity for infection,improves results (including bone union of the fracture),and minimizes the recovery period.Closed reduction with local or light anesthesia may permit ambulatory surgery.Select a situation where closed reduction would be performed in addition to open reduction and fixation surgery to a distal limb.

A) Significant bone comminution
B) Where periosteal damage is evident
C) Before an open procedure to reduce the fracture site
D) When soft tissue entrapment is suspected

Question 21

In an open anterior cruciate ligament (ACL)repair,an examination under anesthesia (EUA)is performed immediately after induction of anesthesia,when the ligaments are completely lax,to evaluate the severity of the injury.The surgeon then makes a straight midline or slightly medial incision across the knee.Arthroscopic repair causes less patellar pain and decreased disturbance of extensor mechanisms.What preoperative indicators contribute to selecting the surgical approach (open or arthroscopic)of choice?

A) Classification and severity of the tear or capsular instability
B) Surgeon experience and preference
C) Patient history of a prior failed repair or gross knee joint disruption
D) Surgeon's choice of whether to use autograft or allograft to replace the torn ligament.

Question 22

Bone healing follows a logical sequence beginning with the formation of a hematoma.Select the action that typically occurs after formation of a hematoma.

A) Remodeling
B) Invasion of osteoblasts
C) Fibrin network formation
D) Callus formation

Question 23

Ligaments are best defined as:

A) bands of dense connective tissue that hold bone to bone.
B) layers of elastic, resilient supporting tissue found at the end of bones.
C) tough, long strands of fibers that form the ends of muscles.
D) layers of connective tissue that nourish the bone.

Question 24

A 68-year-old retired woman has chronic joint pain in both knees and hips.She does not have osteoarthritis but is overweight and sedentary.While she believes she needs to convince her orthopedic surgeon that she should be considered a candidate for joint replacement surgery,her neighbor,a perioperative orthopedic nurse,is teaching her about the role of cartilage in the joints and how to prevent further injury.The neighbor has convinced the patient to join her in stretching exercises and a daily walk through the neighborhood.This program can help prevent degenerative conditions because:

A) exercise makes the cartilage more vascular.
B) exercise restores water to the cartilage intracellular compartment.
C) weight-bearing activities and joint movement prevent cartilage from becoming thin or damaged.
D) exercise and joint movement will increase joint lubrication and pain threshold.

Question 25

A cancellous bone graft consists of spongy bone usually taken from the anterior or posterior crest of the ilium.A cortical bone graft,consisting of hard,dense bone,is removed from the crest of the ilium or the tibia.Why is the ilium a desirable site for graft harvest?

A) It is subcutaneous, making it easily exposed without difficulty.
B) It is not a weight-bearing joint.
C) It is an articulating joint.
D) It has both cortical and cancellous bone.
E) It has both allograft and autograft bone.