Exam 2 Positioning Flashcards by Raymond Bas

What is the primary goal of Standard 8: Patient Positioning?

A. To ensure the patient is comfortable during the procedure
B. To collaborate with the surgical team to maintain proper body alignment and protect pressure points
C. To minimize the use of positioning devices
D. To reduce the duration of the surgical procedure

B. To collaborate with the surgical team to maintain proper body alignment and protect pressure points

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What is a key consideration when positioning an anesthetized patient?
A. The position should be as rigid as possible
B. Joints should always be aligned unless part of the surgical field
C. Safety belts should be placed as tightly as possible
D. Pressure points do not require padding

B. Joints should always be aligned unless part of the surgical field

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Where should safety belts/straps be placed to secure the patient and extremities? Select 2
a) adbominal area
b) chest area
c) thigh/knee area
d) pelvic area

a) adbominal area
d) pelvic area

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Why is interval positioning assessment important during surgery?
A. To ensure the patient remains awake
B. To prevent nerve damage and other injuries that can develop quickly
C. To adjust the surgical field for better access
D. To reduce the need for protective padding

B. To prevent nerve damage and other injuries that can develop quickly

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What is a critical precaution when using safety belts or straps?
A. Place them over the chest to secure the patient
B. Avoid placing them too tightly to prevent injury
C. Use them only in prone positioning
D. Ensure they are placed directly over pressure points

B. Avoid placing them too tightly to prevent injury

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What is the primary cardiac effect of supine positioning during surgery?
A. Decreased venous return (VR) due to gravitational effects
B. Transient increase in venous return (VR), preload, SV, and CO
C. Increased sympathetic nervous system (SNS) outflow to the heart
D. Decreased atrial natriuretic peptide (ANP) release

B. Transient increase in venous return (VR), preload, SV, and CO

slide 4

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How does supine positioning affect baroreceptor activity in the cardiovascular system?

A. It inhibits baroreceptors in the aorta and carotid sinuses, increasing SNS outflow
B. It activates baroreceptors in the aorta (via vagus nerve) and carotid sinuses (via glossopharyngeal nerve), decreasing SNS outflow
C. It only activates mechanoreceptors in the atria, bypassing baroreceptors
D. It has no effect on baroreceptor activity

B. It activates baroreceptors in the aorta (via vagus nerve) and carotid sinuses (via glossopharyngeal nerve), decreasing SNS outflow

↑BP activates afferent baroreceptors from aorta (via vagus nerve) and carotid sinuses (via glossopharyngeal nerve) and mechanoreceptors from the atria and ventricles, to decrease SNS outflow to muscle and splanchnic vascular beds

slide 4

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What role do atrial reflexes play in response to supine positioning during surgery?
A. They increase renin and vasopressin levels to elevate blood pressure
B. They regulate renal sympathetic activity, renin, ANP, and vasopressin levels to maintain homeostasis
C. They directly reduce cardiac output (CO) to prevent hypertension
D. They inhibit atrial mechanoreceptors, reducing preload

B. They regulate renal sympathetic activity, renin, ANP, and vasopressin levels to maintain homeostasis

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Why does supine positioning during surgery lead to decreased tidal volume (TV) and functional residual capacity (FRC)?
A. Due to increased diaphragmatic movement and lung expansion
B. Due to cephalad displacement of the diaphragm, compressing the lungs
C. Due to increased intrathoracic pressure from enhanced venous return
D. Due to decreased activity of the respiratory muscles

B. Due to cephalad displacement of the diaphragm, compressing the lungs

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What is the recommended arm abduction angle in the supine position?

A. Greater than 90 degrees
B. Less than 90 degrees
C. Exactly 90 degrees
D. Arms should not be abducted

B. Less than 90 degrees

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How should the arms be positioned when abducted in the supine position?

A. Palms down to avoid nerve compression
B. Palms up with padded arm boards
C. Pronated with no padding
D. Neutral position without straps

B. Palms up with padded arm boards

slide 6

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What is a common complication of the supine position if the arms are abducted greater than 90 degrees?

A. Ulnar nerve injury
B. Sciatic nerve injury
C. Brachial plexus or axillary nerve injury
D. Common peroneal nerve injury

C. Brachial plexus or axillary nerve injury

slide 8

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What is a potential consequence of pronating the hand/arm in the supine position?

A. Pressure alopecia
B. Ulnar nerve injury
C. Backache
D. Brachial plexus stretch

B. Ulnar nerve injury

arms should be supine (palms up) to avoid this injury

slide 6

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How should patients with kyphosis or scoliosis be managed in the supine position?

A. Avoid padding to maintain spinal alignment
B. Use extra padding or slight flexion at the hip and knee
C. Keep the spine in a rigid position
D. Place the patient in a prone position instead

B. Use extra padding or slight flexion at the hip and knee

slide 9

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Which nerve injury has historically been the most common in the supine position under general anesthesia?

A. Ulnar neuropathy
B. Sciatic nerve injury
C. Brachial plexus injury
D. Common peroneal nerve injury

A. Ulnar neuropathy

Ulnar nerve injury if hand/arm is pronated (palm down), slide 8

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what is the most common surgical position?
a) Trendelenburg
b) Prone
c) Supine
d) Lithotomy

c) supine

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What are transient CV effects of supine positioning? Select 4

a) increased CO
b) increased preload
c) normal/increased SV
d) increased venous return
e) increased PVR

a) increased CO
b) increased preload
c) normal/increased SV
d) increased venous return

“…activated baroreceptors from aorta (via vagus nerve) and carotid sinuses (via glossopharyngeal nerve) and mechanoreceptors from atria/ventricles ultimately returns CV function back to baseline”

slide 4

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what regulates renal sympathetic activity, renin, ANP, and vasopressin levels?

a) Kidneys
b) Atria
c) Baroreceptors
d) Brain

b) atria

slide 4

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what are pulmonary effects of supine positioning? Select 2
a) increased PVR
b) increased TV
c) decreased TV
d) decreased FRC
e) increased ERV

c) decreased TV
d) decreased FRC

due to cephalad displacement of diaphragm

slide 4

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what is the correct positioning of the arm and forearm in arm adduction? Select 2

a) palms down forearm supine
b) palms up forearm supine
c) palms toward the body forearm prone
d) palms toward the body forearm supine

b) palms up forearm supine
d) palms toward the body forearm supine

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T/F: patient arm may be tucked in in arm adduction if the surgeon must stand on one side

True

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what are complications of supine positioning? select 5
a) backache
b) pressure alopecia
c) brachial plexus injury
d) ulnar nerve injury
e) stretch injury
d) peroneal injury

a) backache
b) pressure alopecia
c) brachial plexus injury
d) ulnar nerve injury
e) stretch injury

ensure arm abduction < 90 degrees, hands supine/palms up, and neck neutral and not hyperextended

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historically, what has been the most common nerve injury with supine positioning?
a) peroneal nerve injury
b) cervical nerve injury
c) ulnar nerve injury
d) brachial plexus injury

c) ulnar nerve injury

Ulnar neuropathy has historically been the most common nerve injury
assoc w/GA, although more recent data shows brachial plexus injuries
are the leading injury, slide 9

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normal lumbar ____ curvature is often lost due tolaxity in the ____ muscles

normal lumbar lordotic curvature is often lost due tolaxity in the paraspinous muscles

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What is a key precaution to prevent cephalad shifting in the Trendelenburg position? A. Use shoulder braces B. Use a non-sliding device or pad C. Place the patient in a sitting position D. Avoid padding the pressure points

B. Use a non-sliding device or pad

To assess for sliding throughout the case while the patient is in T-burg position, the CRNA should place a ____ at the head

towel

What pathophysiological change occurs in the Trendelenburg position due to increased venous return? select 5 A. 9% decrease in CO B. 9% increase in CO C. increased ICP and IOP D. decreased ICP and IOP E. decreased intraabdominal pressure F. decreased FRC and lung compliance G. increased edema of face, conjuctiva, larynx, and tongue H. increased airway pressures with need for higher vent pressure I. decreased risk of endobronchial intubation

B. 9% increase in CO C. increased ICP and IOP F. decreased FRC and lung compliance G. increased edema of face, conjuctiva, larynx, and tongue H. increased airway pressures with need for higher vent pressure *there is **increased** intraabdominal pressure and **increased** risk for endobronchial intubation*

Why is the Trendelenburg position contraindicated in patients with increased intracranial pressure (ICP)? A. It decreases venous return B. It increases ICP and intraocular pressure (IOP) C. It reduces intraabdominal pressure D. It improves pulmonary compliance

B. It increases ICP and intraocular pressure (IOP)

What can be done to minimize postoperative visual loss (POVL) in the Trendelenburg position? A. Increase the tilt angle B. Periodically level the patient or decrease the tilt C. Use bean bags for stabilization D. Avoid monitoring head position

B. Periodically level the patient or decrease the tilt

What respiratory change is associated with the Trendelenburg position? A. Increased functional residual capacity (FRC) B. Decreased FRC and pulmonary compliance C. No change in lung compliance D. Improved tidal volume without higher pressures

B. Decreased FRC and pulmonary compliance

What is a primary pathophysiological concern in the **Reverse Trendelenburg** position? A. Increased intracranial pressure B. Hypotension due to decreased venous return C. Increased pulmonary compliance D. Edema of the face and larynx

B. Hypotension due to decreased venous return

if A-line monitoring is used, transducer should be zeroed at what level in the Reverse Trendelenburg position? A. At the level of the heart B. At the level of the Circle of Willis C. At the level of the lower extremities D. No monitoring is required

B. At the level of the Circle of Willis

What are pathophysiologic considerations for reverese T-Burg position? Select 2 a) Hypertension b) Hypotension c) Laryngeal edema d) Decreased cerebral perfusion

b) Hypotension d) Decreased cerebral perfusion

T/F: hypotension occurs in reverse T-burg position due to decreased SVR

**False** *Hypotension occurs due to **decreased venous return** - venous pooling in the lower extremities*

In Trendelenburg positioning, how does the cephalad shift of the diaphragm and carina impact mechanical ventilation? A) Increases tidal volume and improves oxygenation B) Reduces functional residual capacity and may increase risk of atelectasis C) Enhances airway clearance and reduces ventilation-perfusion mismatch D) Decreases peak inspiratory pressure and improves compliance

B) Reduces functional residual capacity and may increase risk of atelectasis

How does the cephalad shift of the carina in Trendelenburg positioning affect endotracheal tube placement during mechanical ventilation? A) Increases the risk of accidental extubation B) May cause the tube to migrate into the right main bronchus C) Improves tube stability and prevents migration D) Has no significant effect on tube placement

B) May cause the tube to migrate into the right main bronchus

What is a potential consequence of the diaphragm’s cephalad displacement in Trendelenburg positioning for patients on mechanical ventilation? A) Decreased work of breathing due to improved diaphragmatic excursion B) Increased risk of ventilator-associated pneumonia C) Reduced lung compliance and higher airway pressures D) Enhanced venous return leading to improved oxygenation

C) Reduced lung compliance and higher airway pressures

What is a critical consideration for head stabilization in the sitting position? select 2 A. The head should be turned to one side B. The head must be taped to a headrest or pinned C. No head stabilization is required D. The head should be hyperextended E. Hips must be flexed < 90 degrees and knees slightly flexed

B. The head must be taped to a headrest or pinned E. Hips must be flexed < 90 degrees and knees slightly flexed

In the sitting position, what is a key consideration to prevent damage to the **sciatic nerve**?

Hips must be flexed less than 90 degrees knees slightly bent

What is a major risk associated with the sitting position, particularly in craniotomies? A. Ulnar nerve injury B. Venous air embolism (VAE) C. Common peroneal nerve injury D. Back pain

B. Venous air embolism (VAE) *VAE is a concern in craniotomies bc surgical field above the heart and open dural venous sinuses VAE can cause arrhythmias, oxygen desaturation, pulmonary hypertension and cardiac arrest*

How should the distance between the chin and sternum be maintained in the sitting position? A. No distance is required B. At least two finger’s distance to allow adequate blood flow C. As close as possible to stabilize the neck D. Hyperextended to improve ventilation

b) At least two finger’s distance to allow adequate blood flow

What is the appropriate position for a right shoulder arthroscopy? a) supine b) lateral decubitus c) beach chair d) trendelenburg

c) beach chair *not the same as sitting. Less hip flexion and slight leg flexion*

What is a benefit of the sitting position for obese patients? A. decreased risk of hypotension B. improved ventilation C. decreased risk of nerve injury D. increased venous return

B. improved ventilation

What type of surgery increases risk for VAE in the sitting position? a) craniotomy b) endarterectomy c) CABG d) laparotomy

a) craniotomy *surgical field above the heart and open dural venous sinuses*

Venous Air Embolism (VAE) may cause what conditions? Select 4 a) arrhythmias b) decreased lung compliance c) desaturation d) pulmonary HTN e) arrest

a) arrhythmias c) desaturation d) pulmonary HTN e) arrest

what are the 5 risks of sitting position?

1. cerebral hypoperfusion/air emboli 2. pneumocephalus 3. quadriplegia/spinal infarction 4. cerbreal ischemia 5. sciatic nerve injury

What positions of the neck are avoided to prevent quadriplegia and spinal cord infarction? (3)

hyperextension hyperflexion excessive rotation

For positions where the level of the brain is higher than the heart, arterial monitoring must be done at the level of: a) the heart b) the brain c) in between the heart and brain d) arterial monitoring is not done

b) the brain *avoids cerebral ischemia due to hypotension*

what is the most common nerve injury in the sitting position? a) sciatic nerve injury b) peroneal nerve injury c) cervical plexus injury d) brachial plexus injury

a) sciatic nerve injury

How should the head be positioned in the prone position to avoid complications? A. Turned to the side to improve ventilation B. Supported in a neutral position without pressure on eyes, nose, or ears C. Hyperextended to avoid airway edema D. Placed without any support

B. Supported in a neutral position without pressure on eyes, nose, or ears

What is a potential complication of the prone position if the elbows are not padded? A. Sciatic nerve injury B. Ulnar nerve injury C. Common peroneal nerve injury D. Lateral femoral cutaneous nerve injury

B. Ulnar nerve injury

what position must the arms be in the prone position? select 2 a) tucked at the sides b) out > 90 degrees w/ elbows flexed c) out < 90 degrees w/ elbows flexed d) one arm < 90 degrees, elbows flexed and other arm tucked

a) tucked at the sides c) out < 90 degrees w/ elbows flexed

What pathophysiological change occurs in the prone position due to compression of the inferior vena cava? Select 3 A. Decreased venous return B. Decreased cardiac output C. Improved pulmonary compliance D. Decreased intraabdominal pressure E. Increased intraabdminal pressure

A. Decreased venous return B. Decreased cardiac output E. Increased intraabdminal pressure

What should be checked at the start and end of a case in the prone position to assess for airway edema? A. Blood pressure B. Cuff leak C. Oxygen saturation D. Intraabdominal pressure

B. Cuff leak

T/F: turning the head to the side in prone position increases risk for jugular or carotid occlusion

**True** *Keep head in **neutral** position*

In prone position, EKG leads are placed a) on the back b) on the front c) O2 probe on finger only

a) on the back

T/F: Patients are induced & intubated in the supine position before turning them prone

**True**

___ and ____ are the two most common nerve injuries in prone position

**ulnar nerve** and **brachial plexus** are the two most common nerve injuries in prone position *ulnar nerve if elbows are **not padded**, brachial plexus if the arms are bent **> 90 degrees***

Post-op visual loss is most commonly seen in what position? a) supine b) trendelenburg c) prone d) lateral decubitus

c) prone *due to decreased perfusion*

How does prone positioning affect V/Q ratio? a) no change b) improved V/Q rato c) decreased V/Q ratio

b) improved V/Q ratio V/Q shifts to dependent lung areas (anterior chest which has larger area)

In prone position, venous return ____ and therefore CO _____ a) decrease; decrease b) increase; increase c) increase; decrease d) decrease; increase

a) decrease; decrease *this occurs due to increased abdominal pressure which compresses the inferior vena cava*

How should the lower extremities be moved in the lithotomy position to prevent injury? A. Raised and lowered independently B. Raised and lowered in synchrony C. Kept rigid without movement D. Hyperextended to improve access

B. Raised and lowered in synchrony *prevents torsion and injury to the lumbar spine*

How are arms positioned in lithotomy position?

tucked to the side or most cmomonly on armboards *tucked to the side may put the fingers at risk of getting pinched by the bed*

What must be done if surgery in the lithotomy position is greater than 2-3 hours?

Periodically lower the legs

How are the legs positioned in the lithotomy position? a) Hips flexed ~90 deg and legs abducted 30-45 deg from midline, knees flexed b) Hips flexed >90 deg and legs abducted 15-20 deg from midline, knees flexed c) Hips flexed <90 deg and legs abducted 30-45 deg from midline, knees flexed

a) Hips flexed ~90 deg and legs abducted 30-45 deg from midline, knees flexed

Which nerve is particularly vulnerable in the lithotomy position due to compression between the **fibular head** and **leg support**? A. Ulnar nerve B. lateral femoral cutaneous nerve C. Common peroneal nerve D. Sciatic nerve

C. Common peroneal nerve *Peroneal nerve is vulnerable as it lies btw the fibular head and the area compressed from the leg support*

what nerve injuries can occur with lithotomy position? Select 4 a) cervical plexus b) brachial plexus c) ulnar nerve d) lateral cutaneous nerve e) common peroneal nerve

b) brachial plexus c) ulnar nerve d) lateral cutaneous nerve e) common peroneal nerve

What are other risks of lithotomy position? Select 2 a) back pain b) compartment syndrome c) sciatic nerve injury d) hypotension

a) back pain b) compartment syndrome *compartment syndrome in the calves from compression on the stirrups*

What respiratory change is associated with the lithotomy position? A. Increased lung compliance B. Decreased lung compliance and tidal volume C. No change in tidal volume D. Improved functional residual capacity

B. Decreased lung compliance and tidal volume *due to diaphragm being pushed cephalad*

what are other pathophysiologcal considerations for lithotomy position? Select 3 a) increased venous return/CO b) decreased venous return/CO c) increased ICP d) increased intraabdominal pressure e) increased SVR

a) increased venous return/CO c) increased ICP d) increased intraabdominal pressure *diaphragm is displaced cephalad*

What is the purpose of an axillary roll in the lateral decubitus position? A. To stabilize the head B. To prevent brachial plexus and vascular compression C. To improve venous return D. To reduce intraabdominal pressure

B. To prevent brachial plexus and vascular compression *Axillary roll placed btw chest wall and bed, caudal to axilla*

Where should SpO2 be monitored in the lateral decubitus position to detect compression? A. Nondependent arm B. Dependent arm C. Lower extremities D. No monitoring is required

B. Dependent arm *Sp02 should be monitored in the dependent arm for early detection of compression to axillary neurovascular structures*

What is a pathophysiological consideration in the lateral decubitus position? A. Improved ventilation to the dependent lung B. V/Q mismatch due to inadequate ventilation to the dependent lung C. Increased perfusion to the dependent lung D. No change in ventilation or perfusion

B. V/Q mismatch due to inadequate ventilation to the dependent lung *V/Q mismatch due to **inadequate ventilation to dependent lung** and **reduced perfusion to the nondependent lung*** *dependent lung has increased perfusion, independent lung has increased ventilation*

Where should the kidney rest be placed in the lateral decubitus position if used? A. Under the axilla B. Under the iliac crest C. Above the iliac crest D. Under the head E. Under the dependent leg

B. Under the iliac crest *Avoids compression of inferior vena cava* *Helps allow expansion of the dependent lung*

What are common nerve injuries seen in lateral decubitus position?

**ulnar nerve injury** - if elbows are not padded **brachial plexus injury** - if arms abducted > 90 degrees

Which leg is flexed in lateral decubitus position? a) independent leg b) dependent leg

b) dependent leg

T/F: to prevent venous pooling in lateral decubitus position, compression stockings are placed

**True**

What is a common mechanism of peripheral nerve injuries during positioning? A. Excessive muscle relaxation B. Stretch, pressure, or ischemia C. Increased venous return D. Improved pulmonary compliance

B. Stretch, pressure, or ischemia

How quickly can peripheral nerve injuries occur during improper positioning? A. Within 30 minutes B. After 6 hours C. Only after 12 hours D. They do not occur during surgery

A. Within 30 minutes

What type of nerve injuries are most common during surgical positioning? A. Motor only B. Sensory C. Combined sensory and motor D. No injuries occur

B. Sensory

Why do nerve injuries remain a major concern despite improved positioning standards? A. They are unavoidable in all cases B. They are a major cause of professional liability claims C. Positioning standards have not improved D. They only occur in prone positioning

B. They are a major cause of professional liability claims

What is a shared pathophysiological concern in the Trendelenburg, prone, and lithotomy positions? A. Increased intraabdominal pressure B. Decreased venous return C. Improved pulmonary compliance D. Decreased intracranial pressure

A. Increased intraabdominal pressure

What percentage of nerve injuries during anesthesia is attributed to the **ulnar nerve**? A. 10% B. 14% C. 19% D. 25%

B. 14%

Which of the following is a recommended action to prevent excessive pressure on the ulnar nerve? A. Keep the humerus and forearm pronated B. Avoid excessive pressure on the postcondylar groove of the humerus C. Use shoulder braces during positioning D. Abduct the arms greater than 90 degrees

B. Avoid excessive pressure on the postcondylar groove of the humerus

How should the hand and forearm be positioned to protect the ulnar nerve? A. Supinated or in a neutral position B. Pronated with no padding C. Extended with the palm down D. Flexed at the elbow without support

A. Supinated or in a neutral position

What is the percentage of nerve injuries attributed to the **brachial plexus**? A. 14% B. 19% C. 25% D. 18%

B. 19%

Which positioning technique should be **avoided** to prevent brachial plexus injury during a steep head-down (Trendelenburg) position? Select 2 A. Use of padded arm boards B. Use of shoulder braces and bean bags C. Taping the head to a headrest D. Flexing the hips less than 90 degrees E. Abduction of the arms

B. Use of shoulder braces and bean bags E. Abduction of the arms

In which positions should excessive lateral rotation of the head be avoided to protect the brachial plexus? A. Supine and prone positions B. Sitting and lateral decubitus positions C. Trendelenburg and reverse Trendelenburg positions D. Lithotomy and prone positions

A. Supine and prone positions

What should be done to the arm in the supine position to minimize brachial plexus risk? A. Limit abduction of the arm to < 90 degrees B. Abduct the arm to exactly 90 degrees C. Abduct the arm >90 degrees with padding D. Keep the arm adducted without support

A. Limit abduction of the arm to <90 degrees

What is the combined percentage of nerve injuries attributed to the spinal cord and lumbosacral nerve root or cord? A. 32% B. 43% C. 25% D. 18%

B. 43% (spinal cord 25% + lumbosacral 18%)

What is a key recommendation to locate the internal jugular vein for central line placement and protect the spinal cord? A. Use excessive cervical spine flexion B. Use ultrasound to locate the internal jugular vein C. Avoid padding under the shoulders D. Place the patient in a steep Trendelenburg without support

B. Use ultrasound to locate the internal jugular vein

What should be **avoided** during positioning to prevent injury to the spinal cord or lumbosacral nerve root? A. Increasing spinal curvature with padding B. Severe cervical spine flexion or extension C. Maintaining neutral head alignment D. Using a non-sliding mattress

B. Severe cervical spine flexion or extension

What should be done if a patient is receiving regional anesthesia to protect the spinal cord or lumbosacral nerve root? A. Follow current anticoagulant therapy guidelines B. Discontinue all anticoagulant therapy C. Avoid monitoring spinal alignment D. Use excessive hip flexion

A. Follow current anticoagulant therapy guidelines

What percentage of nerve injuries during anesthesia is attributed to the **common peroneal nerve**? A. 7% B. 14% C. 9% D. 25%

A. 7%

What must be done to minimize the risk of sciatic and peroneal nerve injury in lithotomy? A. Maintain the position for more than 6 hours B. Minimize the time in the lithotomy position C. Abduct the legs greater than 90 degrees D. Avoid using padded stirrups

B. Minimize the time in the lithotomy position

What anatomical area should be protected to prevent injury to the common peroneal nerve? A. The axilla B. The fibular head and the area compressed from leg support C. The brachial plexus D. The lumbar spine

B. The fibular head and the area compressed from leg support

What positioning technique should be avoided to prevent excessive pressure on the common peroneal nerve? A. Excessive flexion of the hips B. Excessive flexion of the lumbar spine C. Excessive flexion of the knees or torsion of the lumbar spine D. Neutral head alignment

C. Excessive flexion of the knees or torsion of the lumbar spine

Exam 2 Positioning Flashcards

(97 cards)