CCI CNOR Exam Questions

Correct answer: Brush biopsy

As part of the plan of care for a patient experiencing persistent lower respiratory infection, bronchoscopy with biopsy is indicated. Brush biopsy can be performed during bronchoscopy by passing a stiff brush through the bronchoscope and into the bronchial tree, where samples can be obtained from the lower respiratory tract. This method helps to decrease the incidence of contamination of the sample when compared to collection of a sputum sample through traditional means.

Aspiration biopsy is typically used to obtain samples from fluid-filled cysts or lesions, or a joint or body cavity. In this biopsy method, the fluid is obtained by aspirating the lesion using a small-gauge sterile needle and syringe.

Frozen section is a biopsy method in which a surgeon cuts out a small portion of tissue from the suspicious area and sends it immediately to the pathology laboratory for processing without applying any preservative, such as formalin, to the sample.

Percutaneous needle biopsy involves the collection of a tissue sample from a solid organ or mass by passing a hollow needle through the body using imaging to guide the placement of the needle.

Correct answer: The informed consent

The perioperative nurse is responsible for completing many aspects of the preoperative preparation and preadmission procedures, including:

• Baseline vital signs
• Preoperative phone call several days before surgery
• Plan of care
• Preoperative assessment
• Nursing diagnoses
• Expected surgical outcomes
• Preoperative education
• Discussion of the perioperative procedure with the patient and his family
• Preoperative assessment, and
• Preoperative interview, among others

The informed consent is obtained by the surgeon and is witnessed by the nurse.

Correct answer: Normal saline

Penrose drains are used therapeutically in the presence of purulent or necrotic material. Prophylactically, they may be inserted intraoperatively to evacuate fluids, including blood, or air from a wound or body cavity postoperatively. Before the surgeon places the drain, it is typically moistened with normal saline (NS) to reduce friction on delicate tissues during placement.

Alcohol or povidone-iodine (Betadine) would not be appropriate for this. Distilled water is generally considered sterile, so this could be an option if NS is unavailable. But, in general, NS is the solution of choice. 

Correct answer: The scrub nurse and circulating nurse

The cleaning of the OR environment is a critical task which should not be taken lightly, or looked down upon, by any member of the perioperative staff. A clean OR keeps a surgical patient safe from infection. 

The routine cleanup procedure can be accomplished expeditiously by the circulating nurse and the scrub person working cooperatively. They are responsible for completing the initial cleaning preparations in the OR at the completion of each case, and prior to the arrival of the next patient. While the circulating nurse secures the outer layer of dressing and prepares the patient for transport from the OR, the scrub person begins to dismantle the sterile field before removing gloves and gown. All instruments, supplies, and equipment should be properly cleaned (before being handled by other personnel for sterilization, etc), and after the patient leaves the operating suite, the room should be disinfected with an approved sporicidal. Room clean-up between patients is directed at the prevention of cross-contamination. 

Environmental services personnel are responsible for completing the terminal cleaning of the ORs at the end of each surgical day.

Correct answer: Perform chest compressions at the direction of the anesthesia provider

The circulating nurse bears responsibility for a number of tasks during a code situation in the OR. If the code takes place during non-business hours, such as in the evening or on a weekend, the circulating nurse typically has to take on additional code responsibilities due to the fewer number of perioperative staff available during these times. The circulating nurse is typically responsible for initiating the code and calling for help, as well as assigning roles to the other OR personnel, positioning of the patient to receive cardiopulmonary resuscitation, starting the code time-clock, taking on the role of recorder, controlling traffic in the OR, assisting with the placement of intravenous or arterial lines, maintaining the accuracy of all the counts, and documentation or recording of the code. However, while the scrub person is running to retrieve the code cart, the primary responsibility of the circulating nurse is administering chest compressions as directed by the anesthesia provider.

Correct answer: Class III wound 

A class III wound, otherwise known as a contaminated wound, is defined as one or more of the following: 

• an open fresh, traumatic wound of less than 4 hours' duration
• a wound in which a major break in sterile technique occurred (e.g., unsterile instruments used) during the surgical procedure
• acute, nonpurulent inflammation is present
• gross (visible) spillage / contamination from the gastrointestinal tract present
• Entrance into genitourinary or biliary tracts with infected urine or bile present

An open femoral fracture falls into this category of a class III contaminated wound. 

Correct answer: Stainless steel, titanium, Vitallium

The vast majority of surgical instruments are made of stainless steel, but titanium and Vitallium (cobalt-based alloy) instruments are also made to a lesser degree. The metals used must have specific properties to make them resistant to corrosion when exposed to blood or body fluids, cleaning solutions, sterilization, and the atmosphere. The manufacturer chooses the metal for its durability, functional capability, and ease of fabrication for the intended purpose. 

Nickel and chromium are used for coating or flash-plating instruments to create a shiny finish, although this technique is infrequently used today due to the susceptibility of the instrument to rupture, chip, peel, and/or corrosion when coated.

Correct answer: Embolectomy

An embolus is a mass of undissolved matter carried by the bloodstream until it lodges in a blood vessel or artery and occludes it. In this case, it is the leg, causing "cold leg" syndrome. An embolectomy (removal of the embolus/plaque) with possible revascularization grafting is the treatment of choice.

Both an aneurysmectomy and aortic abdominal aneurysm repair are performed for the abnormal dilation of an artery, not a revascularization procedure. A vena cava filter is inserted to prevent deep vein thrombosis (DVT) from traveling to the heart/lungs.

Correct answer: Inadequate fluid volume replacement

Patients who undergo open-heart cardiac procedures are at risk of developing both cardiac and noncardiac complications during the postoperative period. While some complications may occur shortly after the surgery and manifest in the postanesthesia care unit (PACU) or intensive care unit, because the in-hospital length of stay has significantly decreased over the last several years, many patients will not develop complications associated with cardiac surgery until after being discharged home. 

The patient and their family member(s) should be instructed on the signs and symptoms of potential complications and should be further instructed on how and where to follow up if any complications occur. Prerenal oliguria, as evidenced by a significant decrease in the urine output in conjunction with darker urine color, is most likely to occur after cardiac surgery as a result of inadequate fluid volume replacement during and after the surgery or as a result of decreased cardiac output. Laboratory studies are most likely to show an elevation in the blood urea nitrogen and serum sodium levels without any change in the serum creatine level. If prerenal oliguria is not treated, ideally with the administration of fluids to increase the blood volume, acute renal failure may occur. If prerenal oliguria is due to decreased cardiac output, the patient should be treated with inotropic agents (e.g., digoxin).

Correct answer: All the available methods are associated with adverse effects.

An anesthesia provider is responsible for monitoring the patient's eyes during surgery and for the implementation of ocular protective measures. Many ocular protective measures are available to the anesthesia provider, including tape applied to the eyelids (applied vertically or horizontally), lubricant gel, drops, or ointment, transparent bio-occlusive dressings, and goggles. Despite the many means at the disposal of the anesthesia provider, none of the methods are completely effective at preventing ocular injury, and all of the methods have associated adverse effects. 

If tape is applied to the eyelids, it should be applied horizontally.

Correct answer: Compromise of pulmonary function in the dependent lung

The lateral kidney position is used for procedures on the kidney and ureter and is not well tolerated. In this position, the skin and underlying tissues can be damaged by excessive pressure during flexion of the OR bed. Respiratory and cardiovascular compromise can occur, as well as venous compromise of the lower extremities as blood tends to pool in the lower arm and leg. The spine is stressed in a laterally flexed position, and it can cause strain on the vertebral structures as well.

Pressure to the breasts/chest, hip abduction, and sacral tissue ischemia will not occur, as the patient is lying laterally with knees together and therefore those parts of the body will not be affected.

Correct answer: The anesthesia provider

While the surgeon is responsible for writing the actual discharge/transfer orders which allows the post-surgical patient to move from the PACU to the inpatient unit, it is typically the anesthesia provider who actually grants permission for (or approves) the patient to be transferred, based upon the condition of the patient. The anesthesia provider is responsible for performing post-operative assessments of the patient during her PACU stay and makes a determination on eligibility for transfer based upon the patient's recovery from anesthesia.

Correct answer: It can prolong sedation and interfere with metabolism of some medications such as calcium channel blockers, warfarin (Coumadin, Jantoven), and some antibiotics; notify all perioperative staff members, including the anesthesia care provider and surgeon

Herbal supplements and their side effects can have negative interactions with other medications, and can cause serious complications such as bleeding. For this reason, patients are advised to report all herbal supplements prior to any surgical procedure. All perioperative staff including the anesthesia care provider and the surgeon should be reminded that the patient is on herbal supplements.

Ephedra (also known as ma huang) can cause cardiovascular instability and seizures. Licorice can cause hypokalemia, dysrhythmia, hypertension and edema. Vitamin E can cause bleeding, slow wound healing and collagen repair.

Correct answer: Surgical debridement

Non-healing or poorly healing chronic wounds that have not responded to more conservative treatment methods should be debrided to remove infectious material and dead or devitalized tissue that may serve as an area of infection within the wound. Debridement may also be utilized in conjunction with other wound management methods, including dressing changes, antibiotic therapy, hydrotherapy, and hyperbaric treatment. 

The patient in this scenario is not a candidate for further mechanical debridement of the wound, as the damp-to-dry dressing changes he has been receiving, which are a form of mechanical debridement, have been ineffective in resolving the wound. Enzymatic debridement agents cannot be used in heavily infected wounds and, while effective in wound debridement, require significant time to adequately debride a wound.  Biologic debridement agents (the sterile larva of the green bottle fly) are very effective at cleaning necrotic, infected wounds but are not typically agreed to by patients, most of whom are squeamish about the idea of maggots being placed inside their wounds. 

Surgical debridement, while often painful and likely to result in the removal of viable tissue along with the nonviable and infected tissue, is the best option for this patient.

Correct answer: Cover the sterile tables with sterile drapes and have a staff member maintain vigilance

Covering sterile tables prepared earlier for later use is not recommended as a general practice. However, if a sterile table is not used immediately after setup, it may be covered by a sterile drape placed halfway with a cuffed edge horizontally. A second sterile cuffed drape is placed from the opposite side completely overlapping the first cuff. When the case is ready to begin, the top drape is removed first without touching the second drape. The hands must remain under the cuffed edge as each drape is removed in succession. None of the edges of the drape that overhang the edges of the table may be brought over the table (sterile surface) when being removed. A single transparent drape made specifically to cover set-up tables is acceptable. It separates in the middle for removal.  

Sterile areas must continuously be kept in view. Someone must remain in the room to maintain vigilance when sterile packs are opened in a room, or a sterile field is set up and not immediately used. An unguarded sterile field should be considered contaminated and should not be used.

Taping the door shut is not a guarantee of continued sterility. According to facility policy, staff may tear down the setup, call for another case cart and reorganize to reopen later. If the delay is expected to be long, tearing down and reorganizing is an option. But, for a short delay, covering the sterile tables with sterile drapes and having a staff person watch the sterile field and room is cost-effective and the most appropriate option. The table should never be set up, covered, and moved to another area in the department.

Correct answer: Level the table 

With reverse Trendelenburg's position, patients lie in the supine position and the head of the OR bed is tilted 30 to 40 degrees, so the head is higher than the feet. This position is used for thyroidectomy, among other procedures, to facilitate breathing and to decrease blood supply to the surgical site (blood pools caudally). It is also used for laparoscopic gallbladder, biliary tract, and stomach procedures to allow the abdominal viscera to fall away from the epigastrium, providing access to the upper abdomen. 

Changing the position of the table so that the patient's head is level with the rest of the body may counter the hypotension an anesthetized patient may experience in this position.

Increasing the IV rate and preparing to administer blood products are not yet necessary at this point. Repositioning the patient to Trendelenburg is not appropriate. 

Correct answer: Manual, ultrasonic, and machine washer/sterilizer

Three ways to clean instruments include manual washing, ultrasonic cleaning, and washer/sterilizer or washer/decontaminator machines.

Enzymatic prerinse/presoak solutions can be used to prevent blood and debris from drying on instruments (keeping them wet), or to soften and remove dried blood and debris, making actual processing/cleaning procedures and steps more efficient.

Correct answer: Comfort measures provided, if applicable, before and after medication administration 

You should document the time the drug was administered, how it was given (route), the reason it was given (nature of pain, pain score), dosage, and the patient's response to the medication (e.g., pain was relieved or diminished).

Correct answer: Correct patient, correct procedure, correct site, correct position, correct equipment, correct implants, and correct images (as applicable)

Before making the incision, the entire team pauses for a "time out" as the surgical site listed on consent is read aloud and verified with the site-marking on the patient. This is referred to as "time out" for prevention of wrong site surgery. The entire team confirms that this is the correct information for the patient and that any images (scans or x-rays) reflecting the same body part are displayed in the correct orientation. The availability of the correct implants or special equipment is confirmed. This process should be documented in the patient's record by the circulating nurse.

The correct surgeon should already have been verified in the preoperative holding area. Correct allergy information should be discussed if it applies to anesthesia or intraoperative drugs, but it's not one of the 7 "corrects."

Correct answer: A representative of the manufacturer

Before handling new equipment, all patient care personnel on the perioperative team should be knowledgeable about its care and use. Representatives of the manufacturer are well-versed in the use and care of their company's equipment, so it would be the best choice in this situation.

Although the surgeon may be familiar with the use of the equipment, he or she is unlikely to be familiar with cleaning and storing procedures. The OR manager and a biomedical engineer may not have worked with this piece of equipment in the past.