RNFA Master Questions and Answers: Suturing Techniques and Related Topics, Exams of Medicine

Download RNFA Master Questions and Answers: Suturing Techniques and Related Topics and more Exams Medicine in PDF only on Docsity! RNFA MASTER QUESTIONS AND ANSWERS Neuromuscular blockers - correct answer Tubocurarine Atracurium Cisatracurium Mivacurium Rocuronium Pancuronium Vecuronium Succinylcholine AchE inhibitors - correct answer Neostigmine Edrophonium Muscarinic Antagonists - correct answer Glycopyrrolate Spasmolytics - correct answer Dantrolene Diazepam Baclofen Tizanidine Gabapentin Progabide Glycine Idrocilamide Riluzole Dantrolene Botulinum toxin Cyclobenzaprine Neuromuscular blockers. - correct answer Used during surgical procedures and in intensive care units to cause paralysis. NONDEPOLARIZING BLOCKERS - correct answer • They are competitive antagonists. In small clinical doses they act predominantly at the nicotinic receptor site by competing with acetylcholine. Their action can be overcome by increasing the concentration of acetylcholine in the synaptic cleft; this RNFA MASTER QUESTIONS AND ANSWERS can be achieved, for example, by administration of acetylcholinesterase inhibitors such as neostigmine or edrophonium. Anaesthesiologists use this strategy to shorten the duration of the neuromuscular blockade. • In larger doses, nondepolarizing blockers also enter the pore of the ion channel to cause a more intense motor blockade. This further weakens neuromuscular transmission and diminishes the ability of acetylcholinesterase inhibitors to antagonize the action of nondepolarizing blockers. • Nondepolarizing blockers may also block prejunctional sodium channels. As a result, they reduce the release of acetylcholine at the nerve ending. • During anesthesia, the IV administration of a nondepolarizing blocker first causes motor weakness; ultimately, skeletal muscles become totally flaccid and inexcitable to stimulation. Larger muscles (e.g. those of the trunk) are more resistant to block and recover more rapidly than smaller ones (e.g. muscles of the hand). DEPOLARIZING BLOCKERS - correct answer Succinylcholine is the only depolarizing neuromuscular blocker used clinically in the USA. succinylcholine remains popular because it is the only RNFA MASTER QUESTIONS AND ANSWERS INTERMEDIATE-ACTING Atracurium Rocuronium Cisatracurium Vecuronium LONG-ACTING Tubocurarine Pancuronium METABOLISM - correct answer The duration of neuromuscular blockade produced by nondepolarizing relaxants is strongly correlated with the elimination half-life. Drugs that are excreted by the kidney typically have longer half-lives, leading to longer durations of action. Drugs eliminated by the liver tend to have shorter half- lives and durations of action. RNFA MASTER QUESTIONS AND ANSWERS Atracurium is inactivated by hydrolysis by non-specific plasma esterases and by a spontaneous reaction (Hoffman elimination). Duration of neuromuscular block produced by atracurium is not altered by the absence of renal function. One of atracurium metabolites is laudanosine. Laudanosine may cause transient hypotension and, in higher doses, seizures. Cisatracurium, a stereoisomer of atracurium, undergoes Hoffman elimination to form laudanosine. Because cisatracurium is more potent than atracurium and lower doses are required, laudanosine concentrations following cisatracurium administration are lower. Cisatracurium also causes less histamine release. Therefore, cisatracurium has largely replaced atracurium in clinical practice. Mivacurium has short duration of action. Hydrolysis by butyrylcholinesterase is the primary mechanism for inactivation of mivacurium. Not dependent on liver or kidney. Rocuronium has the most rapid onset among nondepolarizing blockers. Can be used as alternative to succinylcholine for rapid sequence intubation. RNFA MASTER QUESTIONS AND ANSWERS DEPOLARIZING BLOCKERS - correct answer The extremely short duration of action of succinylcholine (5-10 minutes) is due to its rapid hydrolysis by plasma (and hepatic) butyrylcholinesterase. Neuromuscular blockade by succinylcholine (and mivacurium) may be prolonged in patients with an abnormal variant of butyrylcholinesterase. Prolonged paralysis from succinylcholine caused by abnormal butyrylcholinesterase should be treated with continued mechanical ventilation until muscle function returns to normal. Because of the rarity of these variants, butyrylcholinesterase testing is not routine clinical procedure. ADVERSE EFFECTS - correct answer ... NON-DEPOLARIZING BLOCKERS - correct answer • Some benzylisoquinolines may produce hypotension due to histamine release and ganglionic blockade. • Some ammonio steroids may produce tachycardia due to blockade of muscarinic receptors, which may lead to arrhythmias. These drugs should be used cautiously in patients with cardiovascular disease. RNFA MASTER QUESTIONS AND ANSWERS damage produced by the unsynchronized contractions of adjacent muscle fibers. HYPERKALEMIA - correct answer Due to loss of tissue potassium during depolarization. Risk of hyperkalemia is enhanced in patients with burns or muscle trauma. Hyperkalemia may lead to cardiac arrest or circulatory collapse. INCREASED INTRAOCULAR PRESSURE - correct answer Due to extraocular muscle contractions. Despite this effect, the use of succinylcholine for eye operations is not contraindicated unless the anterior chamber is to be opened. INCREASED INTRAGASTRIC PRESSURE - correct answer In some patients, the fasciculations caused by succinylcholine cause an increase in intragastric pressure. This makes emesis more likely, with the potential hazard of aspiration of gastric contents. MALIGNANT HYPERTHERMIA - correct answer Malignant hyperthermia susceptibility, an autosomal dominant disorder of skeletal muscle, is one of the main causes of death due to anesthesia. The halogenated hydrocarbon anesthetics and succinylcholine alone have been reported to precipitate RNFA MASTER QUESTIONS AND ANSWERS the response; however, most of the incidents arise from the combination of succinylcholine and an halogenated anesthetic. Treatment of malignant hyperthermia entails IV administration of dantrolene; dantrolene prevents Ca2+ and calmodulin from activating the RyR-1, thus blocking release of Ca2+ from the SR. CNS EFFECTS - correct answer All neuromuscular blockers are virtually devoid of central effects following IV administration of ordinary clinical doses because of their inability to penetrate the blood- brain barrier. DRUG INTERACTIONS - correct answer ... ANESTHETICS - correct answer Inhaled anesthetics (e.g. halothane, isoflurane and enflurane) increase neuromuscular blockade evoked by nondepolarizing muscle relaxants. ANTIBIOTICS - correct answer Aminoglycosides produce neuromuscular blockade by inhibiting acetylcholine release from the preganglionic terminal (through competition with Ca2+) RNFA MASTER QUESTIONS AND ANSWERS and to a lesser extent by stabilizing the postjunctional membrane. Tetracyclines can also produce neuromuscular blockade, possibly by chelation of Ca2+. EFFECTS OF DISEASE AND AGEING ON DRUG RESPONSE - correct answer Several diseases can decrease or increase the neuromuscular blockade caused by nondepolarizing muscle relaxants. • Myasthenia gravis increases neuromuscular blockade caused by these agents. • Advanced age is often associated with a prolonged duration of action from nondepolarizing relaxants, probably due to decreased clearance of drugs by liver or kidneys. • Patients with severe burns and those with upper motor neuron disease are resistant to nondepolarizing muscle relaxants. This is probably because of proliferation of extrajunctional receptors, which requires additional nondepolarizing relaxant to block a sufficient number of receptors to produce neuromuscular blockade. DEPOLARIZING BLOCKERS: CONTRAINDICATIONS - correct answer • Succinylcholine is contraindicated in persons with personal or familial history of malignant RNFA MASTER QUESTIONS AND ANSWERS SPASMOLYTIC DRUGS - correct answer Spasticity is characterized by increase in tonic stretch reflexes and flexor muscle spasms together with muscle weakness. It is often associated with cerebral palsy, multiple sclerosis, and stroke. Drug therapy may ameliorate some of the symptoms of spasticity by modifying the stretch reflex arc or by interfering directly with skeletal muscle excitation- contraction coupling. DRUGS FOR CHRONIC SPASM - correct answer ... A. DRUGS THAT ACT IN THE CNS - correct answer ... DIAZEPAM - correct answer Benzodiazepines facilitate the action of GABA at GABAA receptors. Diazepam has useful antispastic activity. It can be used in patients with muscle spasm of almost any origin, including local muscle trauma. It produces sedation in most patients at the doses required to reduce muscle tone. RNFA MASTER QUESTIONS AND ANSWERS BACLOFEN - correct answer Baclofen (p-chlorophenyl-GABA) is an orally active GABA agonist at GABAB receptors. Activation of GABAB receptors in the brain by baclofen results in hyperpolarization, probably by increased K+ conductance. Baclofen is useful for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis. Baclofen may also be of some value in patients with spinal cord injuries and other spinal cord diseases. TIZANIDINE - correct answer Congener of clonidine. Agonist at α2- adrenergic receptors in the CNS. Reduces muscle spasticity. Short-acting. Assumed to act by increasing presynaptic inhibition of motor neurons. It also inhibits nociceptive transmission in the spinal dorsal horn. Used in spasticity associated with multiple sclerosis and spinal cord injury GABAPENTIN - correct answer Gabapentin is an antiepileptic drug that RNFA MASTER QUESTIONS AND ANSWERS has shown promise as spasmolytic and in patients with MS. Increases GABA release PROGABIDE - correct answer GABAA and GABAB agonist. Reduces spasticity. GLYCINE - correct answer Reduces spasticity. Inhibitory amino acid neurotransmitter. It appears to be active when given orally and readily passes the blood-brain barrier. IDROCILAMIDE & RILUZOLE - correct answer New agents for the treatment of amyotrophic lateral sclerosis that appear to have spasm- reducing effects, possibly by inhibiting glutamatergic transmission in the CNS. B. DRUGS THAT ACT ON THE SKELETAL MUSCLE - correct answer ... DANTROLENE - correct answer DANTROLENE Dantrolene interferes with the release of Ca2+ by binding to the ryanodine receptor in the SR of skeletal muscle. RNFA MASTER QUESTIONS AND ANSWERS interrupted suture line - correct answer used to close tissues under tension and to close infected tissues; interrupts the pathway of the bacteria localizing the area of infection to a smaller part of the wound traction sutures - correct answer used to retract a structure that may not be easily retracted with a conventional retractor instrument; a nonabsorbable suture is placed into or around the structure and the suture ends are clamped with a hemostatic clamp; the structure is then pulled to the side of the operative site drawstring or pursestring suture - correct answer placed in a circular fashion around a structure in such a way that pulling on the suture ends tightens and closes an opening secondary suture line - correct answer sutures placed to support and ease the tension on the primary suture line, thus reinforcing the wound closure and obliterating any dead spaces retention sutures - correct answer large-gauge, interrupted, nonabsorbable RNFA MASTER QUESTIONS AND ANSWERS sutures placed lateral to a primary suture line for wound reinforcement Bridges - correct answer plastic devices that bridge the closed incision Bolsters - correct answer pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied; once tied they cover retention sutures and prevent them from cutting into the skin Buttonholes - correct answer holes through which tendon sutures are pulled through and tied over a button to prevent tissue damage Split lead shots - correct answer may be clamped onto the ends of subcuticular sutures after skin closure umbilical tape - correct answer used for retraction and isolation of bowel, nerves, vessels, or ducts; used moist RNFA MASTER QUESTIONS AND ANSWERS vessel loops - correct answer thin strips made of silicone that can be placed around a vessel, nerve, or duct for the purposes of retracting or isolating; the loops are colored for easy identification of the retracted structures white and yellow loops - correct answer for nerves and ducts red loops - correct answer for arteries blue loops - correct answer for veins Skin closure tapes - correct answer adhesive-backed strips of nylon or polypropylene tapes used to reinforce a subcuticular skin closure to approximate wound edges of small incisions or superficial lacerations when sutures may not be necessary Skin adhesive - correct answer a sterile liquid that is applied topically; used on the surface of a wound that will not be under RNFA MASTER QUESTIONS AND ANSWERS They are not totally unconscious and they are able to control their airway. Local anesthesia - correct answer is used for minor surgeries. For local anesthesia, the services are included in the CPT® code for the surgical encounter. There would not be a separate code for anesthesia services. Anesthesiologist - correct answer A physician licensed to practice medicine and has completed an accredited anesthesiology program. These physicians may personally perform, medically direct, or medically supervise members of an anesthesia care team. CRNA - correct answer Certified Registered Nurse Anesthetist. A registered nurse who has completed an accredited nurse anesthesia-training program. The CRNA may be either medically directed by an anesthesiologist or non- medically directed. AA - correct answer Anesthesiologist Assistant. A health professional who has completed an accredited Anesthesia RNFA MASTER QUESTIONS AND ANSWERS Assistant training program. The AA may only be medically directed by an anesthesiologist Anesthesia resident - correct answer A physician who is completed his medical degree and is a residency program specifically for anesthesiology training. SRNA - correct answer Student Registered Nurse Anesthetist. A registered nurse who is training in an accredited nurse anesthesia program. One-Lung Ventilation - correct answer OVL. A term used in anesthesia related to thoracic surgery. is when the two lungs are not working together because either they are trying to protect one lung from either infection or blood. This would a be reported in the anesthesia records so it would be clear when the service is being provided. OLV occurs when one lung is ventilated and the other lung is collapsed temporarily to improve surgical access to the lung. Several anesthesia codes separately identify utilization of one-lung ventilation. Pump oxygenator - correct answer Is the bypass machine (cardiopulmonary RNFA MASTER QUESTIONS AND ANSWERS bypass machine, CPB) they put patients on during cardiac procedures when they are working on the heart. When a procedure code description states, "with pump oxygenator," this is when they put the patient on that heart and lung machine which is also known as the bypass machine. Describes when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart or great vessel surgery. Cpb maintains the circulation of blood and the oxygen content of the body. When a CPB machine is used, the anesthesia record should describe when the patient went on and off pump. When a pump oxygenator is not used, the surgeon is operating on a "beating" heart. Intraperitoneal - correct answer describes organs within the peritoneum. These procedures may be performed in both the upper and lower abdomen. Intraperitoneal organs in the upper abdomen include the stomach, liver, gallbladder, spleen, jejunum, and ascending and transverse colon. Intraperitoneal organs in the lower abdomen include the appendix, cecum, ileum, and sigmoid colon. Because the cecum and ileum are part of the small intestines and originate in the upper abdomen, these may be coded as upper abdomen. RNFA MASTER QUESTIONS AND ANSWERS Nerve Block codes - correct answer EX: 64415 Brachial plexus block. May be used as an adjunct to general anesthesia if placement is for postoperative pain management. Nerve block codes should not be reported separately if the block is the mode of anesthesia for a procedure being performed. EX: Carpal tunnel procedure performed with axillary block, code from anesthesia section ( 01810+related anesthesia time) is reported. No separate code is reported for axillary block. Services that are included with the anesthesia code - correct answer The preoperative and postoperative visits performed by the anesthesia provider, the anesthesia during the procedure, administration of fluids and/or blood and any usual monitoring services. Examples of usual monitoring are EKGs, blood pressures, and monitoring the patient's temperature. The unusual forms of monitoring include the intraarterial lines, also known as A lines; central venous lines, which are also known as CVPs; and Swan-Ganz catheters. These three items or these three services would also be coded in addition to the anesthesia code when they are provided. RNFA MASTER QUESTIONS AND ANSWERS Anesthesia references to help them with day-to-day coding. - correct answer The first manual is the Anesthesia Crosswalk. It is organized differently than CPT®. The Crosswalk is organized by surgical CPT® code. The anesthesia coder would look up the CPT® code for the surgery provided and that would give them what the anesthesia code is, that gives you a crosswalk. There are also some other products available by other vendors that do the same thing, but the ASA is the organization that publishes the Anesthesia Crosswalk. Anesthesia Relative Value Guide®, which gives the relative value for each one of the anesthesia codes. The relative value is a numeric ranking assigned to a procedure in relation to other procedures in terms of work and cost. The relative values are also referred to as base units. These values are important because they help us determine what the anesthesia units are for a case. This is also utilized in determining how to calculate our fees for anesthesia services. It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code. relative value - correct answer is a numeric ranking assigned to a procedure RNFA MASTER QUESTIONS AND ANSWERS in relation to other procedures in terms of work and cost. The relative values are also referred to as base units. These values are important because they help us determine what the anesthesia units are for a case. This is also utilized in determining how to calculate our fees for anesthesia services. It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code. Continuous catheter codes - correct answer Reported for continuous administration of anesthesia for postoperative pain management. If the infusion catheter is placed for operative anesthesia, the appropriate anesthesia code plus time is reported. If the continuous infusion catheter is placed for postoperative pain management, the daily postoperative management of the catheter is included. Code 01996 Daily hospital management of epidural.... - correct answer Assigned for daily hospital management of epidural or subarachnoid continuous drug administration. Continuous infusion by catheter such as femoral (64448) or sciatic (64446) is not an epidural catheter; 01996 is never reported with these codes. Anesthesiologists may report an appropriate E/M service to re-evaluate postoperative pain if documentation supports the level of service reported and billed. RNFA MASTER QUESTIONS AND ANSWERS Anesthesia Time - correct answer Begins when the anesthesiologist ( or anesthesia provider) begins to prepare the patient for the induction of anesthesia and ends when the anesthesiologist (or anesthesia provider) is no longer in personal attendance. Arterial Line - correct answer A catheter inserted into an artery. It is used most commonly to measure real-time blood pressure and to obtain samples for arterial blood gas. Base Unit Value - correct answer Value assigned to anesthesia codes for anesthetic management of surgery and diagnostic tests. Base unit values will vary depending on the difficulty of the surgery or diagnostic tests, and the management of anesthesia. Cardiopulmonary Bypass (CPB) - correct answer A technique used during heart surgery to take over temporarily the function of the heart and lungs. Central Venous Catheter - correct answer A catheter placed in a large vein such as the internal jugular, subclavian, or femoral vein with the RNFA MASTER QUESTIONS AND ANSWERS tip of the catheter close to the atrium, or in the right atrium fof the heart. What are considered unusual forms of monitoring - correct answer EX; arterial lines, central venous (CV) catheters and pulmonary artery catheter (eg, Swan- Ganz). These are not included in the base code but need to be coded as well and billed separately. How are base unit values determined - correct answer These are determined by the difficulty of the procedure. Specialty books specific to anesthesia coding contain base values for each anesthesia code. Medicare also publishes a list of base values, available on its website under Anesthesiologists Center. How are anesthesia charges calculated - correct answer Determining base value is first. Time reporting is second. How is anesthesia time calculated - correct answer Time begins when anesthesiologist begins to prepare patient for surgery in either the the operating room or an equivalent area. Pre-anesthesia assessment time is NOT part of the reportable time. It is considered part of the base value assigned. RNFA MASTER QUESTIONS AND ANSWERS Ending time is reported when anesthesiologist is no longer in personal attendance, usually when patient given over to post-operative care. Accrued time time reporting does not need to be continuous. EX; An axillary block may be performed in holding room ( if block is mode of anesthesia). Block took 15 mins to perform. When patient in operating room and anesthesiologist needed, time starts again for duration of surgery. Block- 15 mins +Surgery- 60 mins= 75 mins of time. Time reporting on claims may vary according to company. Some companies round to the nearest 5 min increment. Medicare does not round. They require exact time reporting. How does Medicare report time - correct answer They utilize exact time reporting and use a formula. EX: Time starts at 11:02 and ends at 11:59, the time is reported as 57 mins. Medicare divides that 57 mins by 15min increments, 57 divided by 15=3.8 units. If the procedure has a base value of 6 units, the time units are added for a total of 9.8 units, which is then multiplied by the Anesthesia Conversion Factor for geographic location. (Using 2012 Anesthesia Conversion Factor assigned to Salt Lake City, Utah of 21.44, the total Medicare payment is 210.11 [9.8 x 21.44=210.11] RNFA MASTER QUESTIONS AND ANSWERS P6- Declared brain-dead patient whose organs are being removed for donor purposes - No extra value added How to report Physical Status Modifier - correct answer The anesthesia code selected is appended with the appropriate P modifier. EX: Patient with severe systemic disease that is a constant treat to life is undergoing a direct coronary artery bypass graft (CABG) with a pump oxygenator is reported as 00567-P4 Calculating base plus time and physical status - correct answer CABG - 18 units. (per Medicare based unit value for anesthesia), Anesthesia time unit - 20, 2012 Anesthesia Conversion Factor ( Salt Lake City) - $21.44 Medicare ( no physical status recognized) payment: 18 + 20 x 21.44=814.72 Non- Medicare: 18 + 20 + 2 x 21.44 = 857.60 Qualifying Circumstances (QC) - correct answer Anesthesia add-on codes assigned to report anesthesia services performed under difficult circumstances affecting significantly the character of anesthesia services. Each code identifies a different circumstance and more than one may be used unless the reported code already contains the risk factor. Codes RNFA MASTER QUESTIONS AND ANSWERS have parenthetical reference underneath specifying the qualifying circumstance when the code is not reported with referenced code. These are not recognized by Medicare for additional payment and no base values are listed in CPT. ASA assigned base unit values for QC: +99100 - Anesthesia for patient of extreme age, younger than 1 yr and older than 70 yrs - 1 unit +99116 - Anesthesia complicated by utilization of total body hypothermia - 5 units +99135 - Anesthesia complicated by utilization of controlled hypotension - 5 units +99140 - Anesthesia complicated by emergency conditions (specify) - 2 units Documentation must support QC code reported. Emergency conditions do NOT apply to after normal-hour care or routine obstetric labor. Emergency definition (QC ) - correct answer Defined as existing when a delay in treatment of the patient would lead to a significant increase in the threat to the patient's life or body parts. Flat fee procedures - correct answer Time is not reported separately for RNFA MASTER QUESTIONS AND ANSWERS payment. Flat fee services are not included in the anesthesia time. EX: An epidural is placed for pain management prior to the induction of anesthesia, and an arterial line is also placed, the time for these services are not counted in total anesthesia time. EX: A CV catheter is inserted and used to thread a pulmonary artery catheter (PAC), only the PAC code 93503 [Insertion and placement of flow directed catheter (eg Swan-Ganz) for monitoring purposes] is reported. If a central venous cath and Swan-Ganz are separately placed, each procedure is reported. The central venous line will require Mod 59 to show it was completely separate and necessary. Payments for these services are based on the physician fee schedule , as are other surgical services. Monitoring is NOT reported separately. Common Codes reported in addition to anesthesia service - correct answer 31500 - Intubation, endotracheal, emergency procedure: Emergency intubation may be reported separately when an anesthesia provider is requesting to intubate a patient who is NOT undergoing anesthesia. Normal intubation is included in base value of anesthesia code. 36620 - Arterial Catheterization or cannulation for sampling monitoring or transfusions; percutaneous RNFA MASTER QUESTIONS AND ANSWERS procedure codes. Anesthesia providers do not report this modifier. Modifier 53 Discontinued service - correct answer This modifier may be reported to describe a procedure started and, due to extenuating circumstances, was discontinued. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued. Mod 59 Distinct procedural service - correct answer This modifier is used to indicate a procedure or service is distinct or independent from other Non-Evaluation and Management procedures. Documentation must support a different session, procedure, surgery, site, organ system, incision/excision, or injury. This modifier is often appended to post- operative pain management services to indicate it is separate from the anesthesia administered during the surgery. Mod 73 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia - correct answer This modifier is listed as approved for ASC and hospital outpatient use. Although this modifier is not strictly anesthesia related, carrier policy often identifies RNFA MASTER QUESTIONS AND ANSWERS this as the modifier to report when anesthesia services are discontinued after administration of anesthesia. NOTE: Physician reporting of discontinued procedures is referred to Mod 53. Mod 74 discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia - correct answer This modifier is listed as approved for ASC and hospital outpatient use. Although this modifier is not strictly anesthesia related, carrier policy often identifies this as the modifier to report when anesthesia services are discontinued after administration of anesthesia. Note: Physician reporting of discontinued procedures is referred to Mod 53. Medical Direction - correct answer Occurs when an anesthesiologist is involved in 2-4 anesthesia procedures at the same time; or a single anesthesia procedure with a qualified anesthesia resident, CRNA, or anesthesiologist assistant. When an anesthesiologist is medically directing, he must provide what 7 servcices - correct answer 1. Perform a pre-anesthetic examination and evaluation. 2. Prescribe the anesthesia plan. RNFA MASTER QUESTIONS AND ANSWERS 3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence. 4. Ensure that any procedures in the anesthsia plan that he or she does not perform are performed by a qualified anesthetist. 5. Monitor the course of anesthesia administration at frequent intervals. 6. Remain physically present and available for immediate diagnosis and treatment of emergencies. 7. Provide the indicated post anesthesia care. IF one or more of the above services are NOT performed by the anesthesiologist, then service is not considered medial direction. While Medically directing, anesthesiologist should not be providing services to other patients, however, they are allowed to provide what services without affecting their ability to provide medical direction - correct answer -Addressing an emergency of short duration in the immediate area. -Administering an epidural or caudal anesthetic to ease labor pain. - Monitoring an obstetrical patient periodically rather than continuously. RNFA MASTER QUESTIONS AND ANSWERS HCPCS medical supervision/direction modifiers for CRNA or anesthesiologist assistant - correct answer QX-CNRA service: with medical direction by a physician QZ-CNRA service: without medical direction by a physician *Note- State scope of practice may prohibit an anesthesiologist assistant from reporting claims with a non-medical direction modifier. *Note- If the provider (anesthesiologist) moves from QK to AD, the CRNA still reports QXas the CRNA would not necessarily know the number of cases the anesthesiologist is overseeing. Reporting placement of modifiers - correct answer Medical direction modifiers are associated with specific providers and are reported in the first position after the anesthesia code because payment often is related to the modifier reported. ( First rule of coding modifiers- modifiers affecting payment are always reported first) Additional anesthesia-related modifiers usually are reported in the second position after any related medical direction modifiers, as they are considered informational or statistical. RNFA MASTER QUESTIONS AND ANSWERS Physical status modifiers should be listed in 2nd or 3rd position, as applicable. EX; To report a personally performing physician service with a physical staus 3 patient, 00910-AA-P3. To report the medically directing physician and CRNA service with a physical status 3 patient under monitored anesthesia care (MAC), QK-QS-P3 and 00142 QX-QS-P3 Reporting MAC services HCPCS modifiers - correct answer QS- Monitored anesthesia care service G8- Monitored anesthesia care service for deep complex, complicated, or markedly invasive surgical procedure G9- Monitored anesthesia care for patient who has a history of severe cardiopulmonary disease *Note: When reporting G8 or G9 modifier, it is not necessary to report a QS seperately because the description is included already. Only report anesthesia modifiers with anesthesia codes. Anesthesia-related Teaching rules - correct answer www.cms.gov/manuals/downloads/clm104c12.pdf Full chapter to be reviewed prior to billing Medicare *Payment at Personally Performed Rate The Part B Contractor must determine the fee schedule payment, recognizing the base unit for the anesthesia RNFA MASTER QUESTIONS AND ANSWERS code and one time unit per 15 minutes of anesthesia time if: -The physician personally performed the entire anesthesia service alone -The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in &100, and the service is furninshed on or after January 1 1996; -The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case that is concurrent to another case paid under the medical direction rules. The physician meets the teaching physican criteria in &100.1.4 and the service is furnished on or after January, 1, 2010; _The physician is continuously involved in a single case involving a student nurse anesthetist; -The physician is continuously involved in one anesthesia case involving a CRNA (or AnesAss) and the service was furnished on or after January 1, 1998. If the physician is involved with a single case with a CRNA (or AA) service in accordance with the medical direction payment policy;or -The physician and the CRNA (or AA) are involved in one anesthesia case and the service of each are found to be medically necessary. Documentation must be submitted by both the CRNA and the physican to support payment of the full fee for each of the two providers. The physician RNFA MASTER QUESTIONS AND ANSWERS Knot strength is crucial to prevent knot disruption causing wound disruption. More stitches provide more security. Which of the following suture materials requires the most stitches for secure closure? fascial suture vascular suture dermal suture subcutaneous suture - correct answer Vascular suture Together in situ, suture and drains enhance wound healing by suppressing inflammatory response. obliterating dead space. holding tissues together. collecting serosanguineous fluid. - correct answer Obliterating dead space Of the following, which is supplied to reduce hand and tissue suture drag? petroleum jelly saline water RNFA MASTER QUESTIONS AND ANSWERS mineral oil - correct answer Saline Which of the following types of suture involves placing large-gauge, interrupted, nonabsorbable sutures lateral to a primary suture line to reinforce a wound? purse-string suture traction suture retention suture looped suture - correct answer Retention suture (Retention sutures, which are large-gauge, interrupted, and nonabsorbable, are used to reinforce wounds. They are placed lateral to a primary suture line and may be placed through all layers of tissue. This suture may be chosen by the surgeon depending on the patient's needs. For example, a surgeon may choose to use retention sutures on an immunocompromised or diabetic patient.) What special consideration should the surgical technologist remember when cutting internal sutures? Cut the suture ends with at least a 1/2-inch tag to prevent the knot from untying. Cut the suture just below the knot to decrease the risk of wound infection. RNFA MASTER QUESTIONS AND ANSWERS Cut short the ends of the suture to reduce foreign material left in the wound. Steady the scissors on the patient before cutting the suture. - correct answer Cut short the ends of the suture to reduce foreign material left in the wound. Which of the following is used instead of sutures to quickly occlude small vessels? pledgets Ligaclips Surgicel thrombin - correct answer Ligaclips What type of suturing technique requires the placement of multiple individual sutures? interlocking knotted interrupted mattress running subcuticular over-and-over running - correct answer Interrupted mattress RNFA MASTER QUESTIONS AND ANSWERS bridge silicone - correct answer Bridge Of the four basic histologic tissue types, where is absorbable suture most likely used? nerve epithelial connective muscle - correct answer epithelial Which of the following type of suture needles would be used in ophthalmic surgery to separate corneal and scleral tissue? French-eyed blunt trocar point spatula - correct answer Spatula When the surgeon needs to double ligate the superior trunk of the pulmonary artery while raising with a right angle, what suture is used and how is it delivered? RNFA MASTER QUESTIONS AND ANSWERS silk on passers polyglactin stick tie polypropylene stick tie silk free-hand tie - correct answer silk on passers For a left-handed surgeon, the needle holder should be loaded with the point of the needle toward the right. toward the left. at an upward angle. at a downward angle. - correct answer Toward the right. When closing the skin on a surgical incision, the surgeon will approximate and evert the skin edges with two Russian tissue forceps. Adson tissue forceps with teeth. 8" Debakey forceps. Cushing forceps. - correct answer Adson tissue forceps with teeth. RNFA MASTER QUESTIONS AND ANSWERS As the saphenous vein is being harvested for a coronary artery bypass, the surgeon will tie off several blood vessels. Which of the following techniques would facilitate repeated tying of the vessels? using stick ties using a ligature reel using free ties using a tie on a passer - correct answer Using a ligature reel Which type of needle is the least traumatic to tissue? taper. straight intestinal. eyeless. spring eye. - correct answer Eyeless The ability of a suture to return to a former condition is a physical characteristic known as pliability. memory. tensile strength. elasticity. - correct answer Memory RNFA MASTER QUESTIONS AND ANSWERS Before incising the renal pelvis, the surgeon may place two or three stay sutures on either side of the incision site. Which suture material will the surgeon use? polydioxanone polybutester polyglycolic acid chromic catgut - correct answer Chromic catgut Which of the following is the fastest absorbing suture? polyglecaprone polydioxanone chromic gut nylon - correct answer Chromic gut Which of the following types of staplers compress and approximate the tissue by tightening a wing nut before activating the firing mechanism? skin and fascia stapler end-to-end anastomosing stapler ligate and divide stapler thoracoabdominal stapler - correct answer Thoracoabdominal stapler RNFA MASTER QUESTIONS AND ANSWERS The amount of force that a suture strand will withstand before it breaks is referred to as elasticity. pliability. tensile strength. tissue drag. - correct answer Tensile strength A standard length of nonabsorbable suture ties in multistrand packaging is 54 inches. 12 inches. 30 inches. 60 inches. - correct answer 30 inches During a surgical procedure the surgeon asks the surgical technologist for a multifilament suture. Which of the following sutures would the technologist pass? polypropylene (Prolene) surgical stainless steel surgical silk RNFA MASTER QUESTIONS AND ANSWERS polydioxanone (PDS) - correct answer Surgical silk What technique is used for closure of the fascia in a thyroidectomy incision? continuous horizontal mattress interrupted horizontal mattress simple interrupted simple continuous - correct answer Interrupted horizontal mattress Controlled-release needles are often referred to as French-eyed needles. side-cutting needles. pop-off needles. closed-eye needles. - correct answer pop-off needles Surgical needles are classified according to their shape; a size of circle shaft within an x,y axis; their point; and their eye. In what type of closure will a 1/2-circle round taper needle be used? abdominal closure orthopedic closure RNFA MASTER QUESTIONS AND ANSWERS indicated for an older adult patient with traumatic brain injury, increased ICP, and a history of congestive heart failure (CHF) - correct answer Furosemide (Lasix) 20-80 mg IV; monitor for hypotension and note extent of diuresis Because herbal products are so readily available and have such widespread media attention, many people think that they can safely self-medicate. Why should the public be aware and educated about dietary supplements and potential harmful effects - correct answer Unknown substances may be present in these products. a possible benefit to the paramedian incision - correct answer decreased risk for hernia An example of an indication for liver transplantation would be - correct answer primary hepatic cancer he largest part of the mammary gland rests on the - correct answer Pectoralis major muscle and serratus anterior RNFA MASTER QUESTIONS AND ANSWERS During ventriculoperitoneal shunt placement, - correct answer The unit is soaked in NS & antibiotic solution, never lubricated. Patients with chronic venous insufficiency (CVI) are not typically treated surgically as often as patients with arterial disease because: - correct answer CVI is not life-threatening or limb- threatening 35% of the refractive power of the eye is credited to which part of the eye - correct answer Lens Oculocardiac reflex (OCR) is an intraoperative emergency that can occur during eye surgery. Select the definition of the response and contributing factor(s) - correct answer Trigeminal-vagal response caused by pressure on the globe or retrobulbar block The perioperative nurse must be prepared for which additional procedure when head and neck surgery is performed? - correct answer Tracheostomy RNFA MASTER QUESTIONS AND ANSWERS The perioperative nurse preparing for a procedure where STSGs will be taken to cover several large burn areas will need to have available: - correct answer sterile mineral oil, tongue blades, and a mesher dermatome the correct term to describe the inward turning of one or both eyes - correct answer Esotropia The nerve supply for the female pelvis comes from the autonomic nerves that enter the pelvis through the - correct answer Superior hypogastric plexus which surgical approach reduces the morbidity and mortality in removal of an acoustic tumor - correct answer Translabyrinthine approach Pt with hepatobiliary disease, The perioperative nurse, during the preoperative assessment, questions and examines the patient for signs and symptoms of jaundice, petechiae, and lethargy and: - correct answer review chart for bleeding and coagulation times and the platelet count. RNFA MASTER QUESTIONS AND ANSWERS The recommended length of time for inflation of an upper extremity tourniquet on a patient under 50 years old is_______while the recommended pressure is _____. - correct answer 1 hour; 250-300 mmHg continuous tourniquet pressure less than 1 hour on the upper extremity and less than 2 hours on the thigh. Tourniquet pressure should not exceed the recommended maximum cuff pressure limits of 300 to 350 mm Hg for the thigh and 250 to 300 mm Hg for the arm and the lower leg. the statement that reflects a true special consideration for skin preparation before facial surgery. - correct answer Leave the eyebrows and eyelashes intact to preserve facial appearance and expression. A minimally invasive video-assisted thyroidectomy (MIVAT) procedure relies on Miccoli instruments added to the standard thyroid or neck dissection setup, a 30- degree endoscope, and an ultrasonic (harmonic) scalpel with scissors to ligate and divide the vessels. An important risk reduction strategy for any minimally invasive procedure would be - correct answer consider and plan for the possibility of conversion to open thyroidectomy RNFA MASTER QUESTIONS AND ANSWERS he external ear, which includes the auricle (or pinna) and external auditory canal, is composed of cartilage covered with skin. The primary function of the auricle is to - correct answer concentrate and conduct incoming sound waves into the external auditory canal. Describe the internal inguinal ring - correct answer Structures that traverse the inguinal canal enter it from the abdomen by the internal ring, a natural opening in the transversalis fascia The perioperative nurse should plan to remain close to the elderly patient during induction because - correct answer Airway anatomy changes in the elderly The child inhales the favorite flavor while drifting off to sleep. This complementary therapy falls within the category of: - correct answer clinical aromatherapy Which of the following sulci is of particular anatomic importance during surgery? - correct answer Two sulci of particular anatomic importance during surgery are: (1) the lateral sulcus, or sylvian fissure, which divides the temporal lobe from the frontal and parietal lobes, and (2) the central sulcus, or RNFA MASTER QUESTIONS AND ANSWERS fissure of Rolando, which separates the frontal from the parietal lobe Which of the following associations is incorrect pertaining to the blood supply of the brain - correct answer Vertebral arteries --- supplies the occipital lobe TURP syndrome is often seen during the intraoperative period. Signs and symptoms exhibited by patients include - correct answer restlessness, apprehension, irritability, confusion, nausea, slow pulse rate, seizures, dysrhythmias, and rising blood pressure may be suggestive of TURP syndrome, he blood is oxygenated in the lungs and returns to the left atrium through the pulmonary veins. Where does the blood flow after leaving the left atrium - correct answer Through the mitral valve into the left ventricle Which of the following is not contained within the anterior mediastinum - correct answer Great Vessels RNFA MASTER QUESTIONS AND ANSWERS A vena cava filter (Greenfield filter) maintains a patent vena cava but prevents pulmonary emboli (PE) by trapping the emboli at the apex of the device. This procedure may be performed in the OR, radiology suite, or ICU for critical patients - correct answer Right jugular and right femoral There are several risk factors associated with dehiscence. Which of the following can be controlled by the RNFA - correct answer Sutures placed too close together Access to the substernal compartment is typically facilitated by: - correct answer using long instruments through a regular thyroid incision. Pressure against the skin above ____mm hg interferes with tissue perfusion - correct answer 32 Latex allergy reaction is best prevented by - correct answer limiting exposure to latex On postoperative day 2, a patient developed edema, redness, and purulent exudate that appeared to be RNFA MASTER QUESTIONS AND ANSWERS isolated to the subcutaneous plane above the sternum. What important criteria must be met to conclusively define this as surgical site infection (SSI)? - correct answer Positive diagnosis of the SSI by the surgeon or attending physician Suture can be used for more than repairing tissue. - correct answer ligate, suture, and close tissue. Which of the following absorbable suture has the best tensile strength - correct answer Polydioxanone The light transmission through an endoscope is achieved by way of - correct answer bundles of fiberoptic glass rods Precautions apply to blood, all body fluids, secretions, and excretions (except sweat), regardless of whether they contain visible blood, mucous membranes, and nonintact skin. - correct answer Standard On extubation, Daniel presented with coughing, wheezing, dyspnea, use of accessory muscles, and tachypnea. Daniel is presenting with _______ probably RNFA MASTER QUESTIONS AND ANSWERS caused by _______. - correct answer bronchospasm; aspiration The tensile strength of lactic & glycolic acid polymers is sufficient for approximation of tissues for _____ weeks. - correct answer 2-3 New synthetic polymers such as PDS provide wound support up to _____ months - correct answer 3 Proper care and handling of surgical specimens is imperative for correct diagnosis, treatment, and prognosis planning of the patient. Select the response that best reflects correct specimen care and handling - correct answer Avoid placing specimens for frozen section in formalin. Terminal cleaning and disinfection of the operating room should be done - correct answer daily when the areas are being used A needletype frequently used in microsurgery is - correct answer cutting taper RNFA MASTER QUESTIONS AND ANSWERS correct answer Keep a running total blood loss calculated from available sponges during procedure Laparoscopic procedures that emergently convert to open procedures place the patient at risk for unintentional retained foreign objects (RFOs). What new and evolving risk reduction strategy could prevent RFOs and frustrating, time-consuming miscount adventures at the end of these procedures? - correct answer Replacing or tagging sponges and laparotomy instruments with radiofrequency identification (RFID) chips A female patient with end-stage pancreatic cancer was admitted from hospice for a celiac plexus block to treat intractable pain. She had a Whipple procedure 18 months earlier and enjoyed a good quality of life until 3 weeks ago. She wanted to be able to complete "getting her things in order" and saying good-bye to her friends and family while enjoying her last days pain-free. The patient insisted that her Do Not Resuscitate (DNR) status NOT be rescinded. She was conscious and competent and knew what was best for herself. The patient was taking full advantage of what provision for her care? - correct answer PSDA and advance directives A patient was presented with the prepared informed consent form during the discussion with her surgeon RNFA MASTER QUESTIONS AND ANSWERS concerning her scheduled vaginal-assisted laparoscopic hysterectomy. She demonstrated and verbalized that she understood all of the tenets of the procedure, risks, expected outcome, complications, and procedural process. Before she signed the consent form, she informed the surgeon that she did not want any medical students or surgical residents performing any parts of the procedure other than assisting and did not want any photographs of her body taken. The surgeon agreed, and she crossed out those portions of the form and initialed them before she signed. The patient was exercising her: - correct answer right to informed consent. Early on, during the preliminary sponge count on closure of a repair of a ruptured abdominal aortic aneurysm, the circulating nurse was unable to account for 2 lap sponges. He had meticulously maintained accountability for all sponges and instruments discarded from the sterile field and bagged each sponge carefully. He immediately turned and addressed the entire team in a clear voice. Select the appropriate communication that the circulating nurse must employ during this count discrepancy. - correct answer "We have a count discrepancy. We started with 70 sponges and find only 68. We are missing 2 lap sponges. Everyone, please check your areas. The OR is a danger-prone area for both patients and staff. Providing a safe environment of care for the patient involves identifying, mitigating, and managing the RNFA MASTER QUESTIONS AND ANSWERS hazards inherent in surgical care. Choose the answer below that completes the blanks in this sentence: The risk of the surgical hazard of _________________ can be mitigated through _______________________. - correct answer wrong patient, wrong site, and wrong side surgery; site marking and presurgical checklists A patient was transferred to the postanesthesia care unit (PACU) by the anesthesia provider and perioperative nurse. A hand-off report was given, using situation, background, assessment, recommendation (SBAR) format, to the accepting PACU nurse. The first element of information that should be presented in the hand-off report is: - correct answer patient identification and procedure performed. If a staff person receives a needlestick injury, what is the first corrective action? - correct answer Wash wound with soap and water; flush mucous membranes. Contact with infected patients or infectious material places healthcare workers at risk for occupational- acquired infection. Which communicable disease are healthcare workers at risk for acquiring or transmitting? - correct answer Seasonal influenza RNFA MASTER QUESTIONS AND ANSWERS - correct answer Antibiotics given intravenously within 1 hour of the incision for every procedure with an incision or entered body system. With the production of more steam in the sterilizer chamber, the pressure increases as well. The steam should contain little or no entrapped liquid water. Steam quality is the term that describes the amount of water mixed with the steam. The constitution of high-quality steam would be measured by: - correct answer <3% of the mixture is liquid water. A 47-year-old man was admitted to the emergency department (ED) with respiratory symptoms, facial and upper body abrasions, burns, and moist lesions after a small package, delivered to his office, exploded and sprayed him dried powder and glass shards. In response to the reported mechanism of injury, the ED team sequestered him in a secluded area away from the rest of the patients. The team believed that this was highly suspicious of a bio-terrorism event. The epidemiologist was called, and the patient was transferred to a negative- pressure isolation room and placed on standard, contact, airborne, and droplet precautions. Based on these actions, which microorganism agents might be suspected to be involved? - correct answer Anthrax and smallpox RNFA MASTER QUESTIONS AND ANSWERS Qualities of an effective packaging material must include several key characteristics. Select the three most important qualities. - correct answer Good steam penetration and removal, good microbial barrier, aseptic presentation. The design of the physical space within an OR attempts to minimize horizontal surfaces by placing cabinets flush with the wall. This prevents dust settling on multiple surfaces and decreases the areas that have to be monitored and cleaned. Another concern with horizontal surfaces is that is turbulence from staff movement and activity plus door movement, when it opens and closes, can: - correct answer mobilizing resting dust from these surfaces. An 86-year-old male was admitted to the intensive care unit (ICU) 3 weeks ago for heart failure and intractable atrial fibrillation. He has had diarrhea for 4 days that has cultured C. difficile. The transmission-based precautions sign on the door to his room alerts the staff to employ which practice precaution? - correct answer Both standard precautions and contact precautions RNFA MASTER QUESTIONS AND ANSWERS Closed gloving is the technique of choice for the initial donning of sterile gloves by the scrubbed team member; however: - correct answer it can only be used for the initial gloving. the final step, after decontamination and before sterilization, is the prep, pack, and wrap process. The sterile processing technologist has taken the laparotomy set from the washer/decontaminator to prepare for sterilization. Select the most appropriate order that the instrument set must travel before reaching the steam sterilizer. - correct answer Inspect, inventory against list, assemble, place integrators, wrap and tape A patient undergoing a laparoscopic Nissen fundoplication procedure will be positioned in both high and low lithotomy during the procedure. After the patient is re- positioned into lo lithotomy, the perioperative nurse should: - correct answer reassess the patient for body alignment, tissue integrity, and pressure areas. A 68-year-old, American Society of Anesthesiologists (ASA) physical status (OS)-2 male with early-stage prostatic cancer, was intubated and positioned for a robotic-assisted laparoscopic radical prostatectomy. The initial position for insertion of the trocars was supine with RNFA MASTER QUESTIONS AND ANSWERS A frail and thin 91-pound, 83-year-old woman is scheduled for a right pneumonectomy for non-small cell lung cancer. She will be positioned in left lateral position for her procedure. Based on the perioperative nurse's preoperative assessment, identify three position-related nursing diagnoses for this procedure and four relevant nursing interventions. Select from the options to fill in the blanks. - correct answer Hypothermia; impaired skin integrity; falls; remain at patient's side during induction; use under- and over-body forced air warming blanket; use at least four people to assist with lift and transfer; pad all bony prominences with foam or gel pads. The lateral kidney position allows approach to the retro- peritoneal area of the flank. To render the kidney region readily accessible, the _________________ is raised, and the bed flexed so that the area between the twelfth rib and the iliac crest is elevated. Compression of the ________________ can occur when the flank is raised too high. - correct answer kidney bridge; vena cava A veteran perioperative nurse remembers a time when all suture needles had eyes, and she even had her own needle rack. She hand-threaded all sutures according to the surgeon's preference. The newer sutures were originally called "atraumatic" sutures because they did not double back through a needle eye and cause tissue RNFA MASTER QUESTIONS AND ANSWERS trauma during pulling or suturing through the tissue. Today, we call this manufacturing process of connecting the suture thread to the needle: - correct answer swaged The ideal suture material is one that has handling characteristics such as: - correct answer ease of tying Careful counting (according to established policy), situational awareness, and conscientious and meticulous attention to the field are believed to prevent miscounts and lost items. A recent patient safety statement about preventing retained foreign objects recommends which of these practices? - correct answer Verbal handoff must include count status at time of relief. An older surgeon explains his justification for this suture choice to the new perioperative nurse in the scrub role. He prefers to suture his intestinal anastomosis with a suture that has multiple filaments braided together because it ties well and holds the knot, which tightens when the thread absorbs the tissue fluids. He also needs a strand that is easy to see and only needs to retain its tensile strength for about 1 year, at which time the intestinal junction will be healed, even though this suture is considered nonabsorbable. He will ask the nurse for a RNFA MASTER QUESTIONS AND ANSWERS 24-inch 4-0: - correct answer Sofsilk Flat neurosurgical patties are flat sponges composed of soft compressed cotton or rayon with an embedded radiopaque element and string attached. They are often used in neurosurgical procedures. While used for hemostasis and exposure, what other use would be important in surgery? - correct answer Application of topical steroids the circulating nurse received the trauma call from the emergency department (ED) and called sterile supply to assemble the instruments for an abdominal trauma case with possible aortic rupture. When the cart arrived, she saw the vascular set; however , the most important set was missing. What important instrument set was needed for this procedure besides the vascular set? - correct answer Basic laparotomy set The primary use for suture is essentially to: - correct answer ligate, suture, and close tissue. Wound tissue healing is enhanced by the use of stapling instruments that mechanically apply internal staples for ligation and division, resection, and anastomoses. What feature of the mechanical process reduces tissue