GKA CRNA Board Questions

1.In the figure below, isoflurane is best represented by: B On this graph, line B best depicts the change in vapor pressure seen with the change in temperature of isoflurane. Note that at 20o C, the vapor pressure represented by line B is 238 mmHg, corresponding to the saturated vapor pressure of isoflurane at that temperature. Line A corresponds with desflurane, line C with halothane, line D with enflurane and line E with sevoflurane. pg. 669 Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

1.In the figure below, isoflurane is best represented by: a. A b. B c. D d. E

During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:(Enter numerical answer.)

3.0 - 4.4 kg Using cricoid yolk studies, the optimum force necessary to effectively occlude the esophagus without obstruction of the trachea is between 30 and 44 Newtons (3.0 - 4.4 kg). It is recommended that 2 kg of force be applied prior to loss of consciousness and that pressure be increased to 4 kg of force after loss of consciousness. pg. 420Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of: a. 20 - 30 mm Hg b. 35 - 45 mm Hg c. 50 - 60 mm Hg d. 90 - 100 mm Hg

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of: 50 - 60 mm Hg. Healthy young individuals tolerate mean arterial pressures as low as 50 - 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 - 30% below baseline. pg. 259 Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2017.

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by: 1. placing the grounding pad near the pacemaker 2. using infrequent bursts of longer duration 3. the use of a bipolar cautery 4. reducing the surface area of the return electrode

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by: the use of a bipolar cautery Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery. pp. 411-412 Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

A decrease in cerebral blood flow is seen after the administration of: 1. isoflurane 2. propofol 3. desflurane 4. ketamine

A decrease in cerebral blood flow is seen after the administration of: propofol The inhaled anesthetic agents and ketamine all increase cerebral blood flow (CBF). Benzodiazepines, etomidate, propofol and barbiturates all decrease CBF. Download CoreNotes http://www.ccanesthesiareview.com/QF/Anesthetics_CBF.pdf pg. 701Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A fresh E-cylinder of oxygen: 1. contains more liters of gas than an E-cylinder of nitrous oxide 2. contains about 90% liquid oxygen and 10% oxygen as a gas 3. contains about 660 liters of oxygen when at sea level 4. has a lower pressure than the pipeline oxygen supply

A fresh E-cylinder of oxygen: contains about 660 liters of oxygen when at sea level A fresh E-cylinder of oxygen contains about 660 liters of oxygen and is pressurized to 1900 psi. pg. 8Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.

A nonselective α-antagonist used in the preoperative preparation of a patient with pheochromocytoma is: 1. phenoxybenzamine 2. doxazosin 3. propranolol 4. terazosin

A nonselective α-antagonist used in the preoperative preparation of a patient with pheochromocytoma is: phenoxybenzamine Phenoxybenzamine is a nonselective α-antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and terazosin are selective α1-antagonists. Propranolol is a nonselective β-antagonist. In the preparation of patients with pheochromocytoma, α-blockade and intravascular volume replacement must precede β-blockade, so as to prevent the possibility of unopposed α-stimulation. pg. 315Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Absolute contraindications to electroconvulsive therapy (ECT) include: 1. congestive heart failure 2. pregnancy 3. myocardial infarction 5 months prior to therapy 4. increased intracranial pressure

Absolute contraindications to electroconvulsive therapy (ECT) include: increased intracranial pressure Absolute contraindications to ECT include recent MI (usually < 3 months), recent stroke (< 1 month), intracranial mass, or increased ICP from any cause. Relative contraindications include angina, CHF, significant pulmonary disease, bone fractures, osteoporosis, pregnancy, glaucoma and retinal detachment. pg. 628Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Absolute contraindications to the use of epidural anesthesia in the parturient include: (Select 2) 1. inability of the patient to cooperate 2. herniated lumbar disc 3. multiple sclerosis 4. patient refusal 5. history of previous cesarean section 6. aortic regurgitation

Absolute contraindications to the use of epidural anesthesia in the parturient include: inability of the patient to cooperate, patient refusal Absolute contraindications to epidural anesthesia/analgesia in the parturient include infection over the injection site, coagulopathy, thrombocytopenia, marked hypovolemia, true local anesthetic allergy, patient refusal and inability of the patient to cooperate. Preexisting neurological disease and back disorders are relative contraindications. Patients with aortic regurgitation usually benefit from the reduction in afterload seen after neuraxial anesthesia. pg. 867Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of: 13 - 15 9 - 12 6 - 9 less than 6

According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of: 9 - 12 According to the Modified Glasgow Coma scale, mild head injury is associated with a score of 13 - 15, moderate head injury is associated with a score of 9 - 12, and severe head injury is associated with a score of less than 8. pg. 1018Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

An increase in intraocular pressure has been associated with: (select 3) 1. nitrous oxide administration 2. succinylcholine administration 3. opioid administration 4. hyperventilation 5. laryngoscopy 6. hypoxemia 7. sevoflurane administration

An increase in intraocular pressure has been associated: succinylcholine administration, hypoxemia, laryngoscopy Succinylcholine increases intraocular pressure by 5 - 10 mm Hg for 5 - 10 minutes after administration. This increase is primarily the result of prolonged contracture of the extraocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetic agents and opioids have been associated with a reduction in intraocular pressure. Hypoxemia, hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation have all been shown to increase IOP. pp. 760-761Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of: 1. midazolam 2. rocuronium 3. fentanyl 4. succinylcholine

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of: fentanyl Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug. Download CoreNotes http://www.ccanesthesiareview.com/QF/Etomidate.pdf pg. 181Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2017.

An occurrence malpractice insurance policy: 1. offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed 2. offers coverage if the policy is in place at the time the claim is filed 3. is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy 4. is the most common form of malpractice insurance in place today

An occurrence malpractice insurance policy: offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed An occurrence policy offers coverage of an incident resulting in a claim, whenever that claim might be filed. The much more common claims-made policy covers claims that are filed only while the insurance is in force. Umbrella coverage is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy. Download CoreNotes http://www.ccanesthesiareview.com/QF/Malpractice.pdf pg. 38 Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include: 1. hypernatremia 2. hyperglycemia 3. difficulty with intubation and airway management 4.increased blood viscosity due to elevated hematocrit

Anesthetic complications associated with hypothyroidism include: difficulty with intubation and airway management Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication. pg. 821Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

Anesthetic implications of multiple sclerosis include: 1. the postponement of elective procedures during relapse 2. exacerbation induced by peripheral nerve block 3. exacerbation of symptoms secondary to hypothermia 4. the presence of significant peripheral neuropathy causing severe hyperkalemia after succinylcholine administration

Anesthetic implications of multiple sclerosis include: the postponement of elective procedures during relapse Surgery and other physiologically stressful events should be avoided during episodes of relapse. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia. pp. 620, 621Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to the relaxation of the: 1. genioglossus muscle 2. longitudinal muscle of the tongue 3. palatoglossus muscle 4. styloglossus muscle

Answer: genioglossus muscle The genioglossus muscle allows the tongue to be protruded and kept away from the posterior pharynx. It is innervated by the hypoglossal nerve. The palatoglossus muscle elevates the tongue and depresses the soft palate. The styloglossus muscle elevates and retracts the tongue. The superior longitudinal muscle of the tongue is an intrinsic muscle of the tongue that elevates the tip.

Average blood loss during a vaginal delivery is: a. 100 - 200 ml b. 400 - 500 ml c. 700 - 800 ml d. 1000 - 1500 ml

Average blood loss during a vaginal delivery is: 400 - 500 ml At term, blood volume has increased by 1000 - 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 - 500 ml, compared with 800 - 1000 ml for cesarean section. pg. 827Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Basal metabolic oxygen consumption in a 20-kg patient is approximately: _______ mL/min

Basal metabolic oxygen consumption in a 20 kg patient is approximately: 95 ml/min Basal metabolic oxygen consumption can be estimated using the following formula: pg. 175Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of: 1. isoflurane 2. desflurane 3. sevoflurane 4. nitrous oxide

Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of: nitrous oxide By irreversibly oxidizing the cobalt atom in vitamin B12, nitrous oxide inhibits vitamin B12 dependent enzymes. These enzymes include methionine synthetase and thymidylate synthetase. As a result of these enzyme inhibitions, prolonged exposure to nitrous oxide has been associated with bone marrow depression, megaloblastic anemia, peripheral neuropathy and teratogenicity. pp. 469, 472Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Changes found in banked blood include: (Select 2) 1. increased levels of 2,3-DPG 2. a left shift of the hemoglobin dissociation curve 3. decreased levels of potassium 4. formation of microaggregates 5. alkalosis secondary to the presence of citrate 6. increased intracellular ATP stores 7. thrombocytosis

Changes found in banked blood include: (Select 2) a left shift of the hemoglobin dissociation curve, formation of microaggregates Changes occurring in banked blood include: Depletion of 2,3-DPG Depletion of intracellular ATP Oxidative damage Increased adhesion to vascular endothelium Altered cell morphology Accumulation of microaggregates Hyperkalemia (as high as 17.2 mEq/L) Absence of platelets (after 2 days of storage) Hemolysis Accumulation of proinflammatory products

Characteristics of omphalocele include: (Select 2) 1. location lateral to the umbilicus 2. lacks a hernia sac 3. results from the failure of midgut migration into the abdomen 4. nitrous oxide should be used during the repair to ensure a rapid emergence 4. association with trisomy 21 5. results from abnormal development of the right omphalomesenteric artery

Characteristics of omphalocele include: association with trisomy 21, results from the failure of midgut migration into the abdomen Gastroschisis and omphalocele are characterized by defects in the abdominal wall that allow herniation of the viscera. Omphaoceles occur at the base of the umbilicus, have a hernia sac and are commonly associated with other anomalies. In contrast, gastroschisis is usually lateral to the umbilicus, lacks a hernia sac and is usually an isolated finding. Nitrous oxide is best avoided during repair as it may result in bowel distention making closure more difficult. pg. 901Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Cholinesterase inhibitors that freely cross the blood-brain barrier include: 1. neostigmine 2. pyridostigmine 3. physostigmine 4. edrophonium

Cholinesterase inhibitors that freely cross the blood-brain barrier include: physostigmine Physostigmine is a teritary amine and has a carbamate group, but no quaternary ammonium. Therefore, it is lipid soluble and is the only clinically available cholinesterase inhibitor that freely passes the blood-brain barrier. pg. 304Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Signs of cardiac tamponade include: (Select 2) 1. distended neck veins 2. increased QRS voltage seen on ECG 3. decreased central venous pressure 4. bradycardia 5. systemic vasoconstriction 6. an increase in systolic blood pressure during inspiration

Clinical signs of cardiac tamponade include: (Select 2) distended neck veins, systemic vasoconstriction Cardiac tamponade is indicated by the presence of neck vein distention, hypotension, muffled heart sounds (Beck's triad) and a greater than 10 mm Hg decline in blood pressure during spontaneous inspiration (pulsus paradoxus). Tachycardia and systemic vasoconstriction are present to maintain blood pressure with the associated decreased stroke volume. pp. 495-496Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Clinically significant histamine release has been associated with the use of: 1. vecuronium 2. rocuronium 3. cisatracurium 4. atracurium

Clinically significant histamine release has been associated with the use of: atracurium Atracurium has been associated with histamine release from mast cells and can result in bronchospasm, skin flushing and hypotension. pg. 536Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Concerning preoperative informed consent: 1. it should disclose only life-threatening complications 2. charges of assault and battery are possible if it is not obtained 3. oral consent is insufficient 4. it is not necessary if the procedure is done in an office setting

Concerning preoperative informed consent: charges of assault and battery are possible if it is not obtained Any procedure performed without the patient's consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed. pp. 29-30Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Correct location of the catheter tip of a central venous line is in the: 1. superior vena cava 2. right atrium 3. right ventricle 4. pulmonary artery

Correct location of the catheter tip of a central venous line is in the: superior vena cava The CVP catheter tip should not be allowed to migrate into the heart chambers to avoid arrhythmias and perforation. pg. 95Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

Correct statements concerning the use of benzodiazepines in the elderly include: 1. volume of distribution is increased 2. reduced pharmacodynamic sensitivity is observed 3. the elimination half-life of diazepam, but not midazolam, is increased 4. all of the above

Correct statements concerning the use of benzodiazepines in the elderly include: volume of distribution is increased Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-times. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-times of both diazepam and midazolam are increased. pp. 902, 903Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Correct statements regarding cerebral metabolism include: 1. the brain can only utilize glucose as an energy source 2. forty percent of brain glucose consumption is anaerobically metabolized 3. hyperglycemia can reduce the damage from focal hypoxic injury 4. the adult brain consumes approximately 50 ml/min of oxygen

Correct statements regarding cerebral metabolism include: the adult brain consumes approximately 50 ml/min of oxygen The adult brain consumes about 20% of the total body oxygen (50 ml/min). Neuronal cells normally utilize glucose as their energy source, but can also utilize ketone bodies and lactate. Hyperglycemia has been shown to worsen global and focal hypoxic brain injury. pg. 576Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the graph of cerebral blood flow below, PaO2 would best be represented by curve: 1. A 2. B 3. C 4. D

Curve A best represents the effects of changing oxygen tensions on cerebral blood flow. Hypoxemia causes a significant increase in CBF to meet the brain's metabolic demand. Hyperoxia, however, causes little change in CBF. pg. 1008Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Dextran 40 has been shown to improve microcirculation by: 1. reducing blood density 2. increasing blood density 3. decreasing blood viscosity 4. increasing blood viscosity

Dextran 40 has been shown to improve microcirculation by: decreasing blood viscosity Dextran 40 has been shown to improve microcirculation presumably by decreasing blood viscosity thereby improving laminar flow in the microcirculatory beds. Both Dextran 40 and Dextran 70 possess antiplatelet effects and may interfere with blood typing. pg. 1165Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Disodium edetate or sodium metabisulfite is added to formulations of propofol to: 1. enhance drug solubility 2. adjust pH 3. inhibit bacterial growth 4. increase drug potency

Disodium edetate or sodium metabisulfite is added to formulations of propofol to: inhibit bacterial growth Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth. pg. 181Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2017.

Droperidol: 1. has antiarrhytmic activity 2. causes shortening of the QT interval 3. causes peripheral vasoconstriction 4. is effective for blood pressure control in patients with pheochromocytoma

Droperidol: has antiarrhythmic activity Droperidol has mild alpha-blocking activity and causes vasodilation and has antiarrhythmic properties with prolongation of the QT interval. As a result of the prolongation of the QT interval, droperidol has been associated with torsades de pointes and should not be given to patients with QT intervals measuring more than 440 ms. Patients with pheochromocytoma should not receive droperidol because it can induce catecholamine release. pp. 678-679Hemmings, HC, Egan, TD. Pharmacology and Physiology for Anesthesia. Philadelphia: Elsevier, 2019.

Drugs that bind to the proton pump of gastric parietal cell and inhibit hydrogen ion secretion include: 1. ranitidine 2. cimetadine 3. famotidine 4. omeprazole

Drugs that bind to the proton pump of gastric parietal cell and inhibit hydrogen ion secretion include: omeprazole Omeprazole (Prilosec) inhibits the proton pump of the parietal cells of the gastric mucosa, decreases hydrogen ion secretion and increase pH. Cimetidine, ranitidine, and famotidine also increase gastric pH, however, their mechanism is through blockade of the H2 receptor. pg. 283 Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Drugs that inhibit coagulation through direct inhibition of thrombin include: 1. heparin 2. warfarin 3. bivalirudin 4. aprotonin

Drugs that inhibit coagulation through direct inhibition of thrombin include: bivalirudin Bivalirudin, hirudin, lepirudin and argatroban are anticoagulants that directly inhibit thrombin. These agents are most commonly used for cardiopulmonary bypass when heparin is contraindicated. No specific reversal agent is available and termination of effect occurs as a result of renal elimination of the drug. pg. 416Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of: a. 20 cmH2O b. 50 cmH2O c. 25 psi d. 50 psi

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of: 50 psi After the proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi. pg. 1237Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During fetal monitoring, Type III decelerations are thought to be related to: 1. head compression 2. umbilical cord compression 3. uteroplacental insufficiency 4. placental abruption

During fetal monitoring, Type III decelerations are thought to be related to: umbilical cord compression Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow. pg. 1167Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: (Select 3) - hypotension secondary to cement monomer absorption - hypoxemia secondary to air embolization - hypoxemia secondary to fat embolization - hypocarbia - decreased pulmonary artery pressure - increased end-tidal carbon dioxide

During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: hypotension secondary to cement monomer absorption, hypoxemia secondary to air embolization, hypoxemia secondary to fat embolization During hip replacement surgery, hypotension associated with the use of acrylic bone cement has been attributed to absorption of methyl methacrylate monomer, embolization of air and bone marrow, lysis of red cells and marrow and conversion of methyl methacrylate to methacrylic acid. Hypoxemia is common. Embolic events cause an increase in dead space with a reduction in ETCO2 with an increase in PaCO2. pg. 1454Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

During pregnancy, the minimum alveolar concentration (MAC): 1. decreases until the 20th week 2. increases until the 20th week 3. decreases throughout the pregnancy 4. increases throughout the pregnancy

During pregnancy, the minimum alveolar concentration (MAC): decreases throughout the pregnancy The MAC progressively decreases during pregnancy, at term by as much as 40%. MAC returns to normal by the third day after delivery. pg. 844Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

During surgical repair of a detached retina, 1 mL of sulfur hexafluoride is injected into the posterior chamber. If the patient is receiving 4% desflurane and a 2:1 ratio of N2O and O2, the pressure-volume relationship of the bubble will approximately: 1. decrease by one third 2. remain the same 3. double 4. triple

During surgical repair of a detached retina, 1 mL of sulfur hexafluoride is injected into the posterior chamber. If the patient is receiving 4% desflurane and a 2:1 ratio of N2O and O2, the pressure-volume relationship of the bubble will approximately: triple A sulfur hexafluoride gas bubble is sometimes used to support the retina after detachment. Diffusion of nitrous oxide into the bubble will cause expansion as nitrous oxide equilibrates with the gas bubble. A sixty-seven percent nitrous oxide concentration will cause the bubble to triple in its pressure-volume relationship in about 30 minutes and may double the intraocular pressure (IOP). In addition, when nitrous oxide is discontinued, the bubble will return to normal size, causing a fall in IOP and possible extension of the retinal tear. For these reasons, it is recommended that nitrous oxide be discontinued at least 15 minutes prior to the injection of a posterior chamber bubble. pg. 776Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

During the administration of general anesthesia for a radical prostatectomy, the rhythm strip below is obtained. The most appropriate therapeutic measures at this time would include: 1. initiation of a nitroglycerine infusion 2. administration of metoprolol 3. requesting the use of a bipolar cautery 4. engage the artifact filter on the ECG monitor

During the administration of general anesthesia for a radical prostatectomy, the rhythm strip below is obtained. The most appropriate therapeutic measures at this time would include: requesting the use of a bipolar cautery This rhythm strip indicates a paced rhythm with clearly visible pacer spikes. Electrical interference from the electrocautery can be interpreted as myocardial activity and can suppress the pacemaker generator. The use of a bipolar cautery will reduce the electrical interference produced; if that is not possible, then pure cut is better than "blend" or "coag." pp. 125-126, 1722Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Enoxaparin: 1. causes less platelet inhibition than heparin 2. is easily reversed with protamine 3. has a half-life that is 35% less than that of heparin 4. effects are monitored using the INR

Enoxaparin: causes less platelet inhibition than heparin Low molecular weight heparins (LMWH), such as enoxaparin, have greater activity against factor Xa than thrombin. As a result, the INR is not a reliable monitoring tool. The LMWHs cause less platelet inhibition and are associated with a lesser incidence of heparin induced thrombocytopenia. pg. 400Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009.

Examples of Type IV hypersensitivity reactions include: 1. contact dermatitis 2. hemolytic transfusion reactions 3. anaphylaxis 4. angioedema

Examples of Type IV hypersensitivity reactions include: contact dermatitis Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis. Download CoreNotes http://www.ccanesthesiareview.com/QF/Hypersensitivity_Reactions.pdf pg. 208Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2) 1. increased carbon dioxide levels 2. increased 2,3-DPG levels 3. increased pH 4. the presence of fetal hemoglobin 5. increased body temperature 6. the presence of hemoglobin-S

Factors increasing the affinity of hemoglobin for oxygen include: increased pH, presence of fetal hemoglobin Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus. Download CoreNotes http://www.ccanesthesiareview.com/QF/Oxyhemoglobin_Dissociation.pdf pp. 603-604Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: (Select 2) 1. high-frequency oscillation 2. inverse I:E ratio ventilation 3. airway pressure release ventilation 4. differential lung ventilation 5. high-frequency positive-pressure ventilation 6. pressure support ventilation

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: high-frequency oscillation, high-frequency positive-pressure ventilation High-frequency oscillation (HFO) creates a to-and-fro gas movement in the airway at rates of 400 - 2400 times/min. High frequency positive-pressure ventilation is delivered at a rate of 60 - 120 breaths/min. Tidal volume is at or below anatomic dead space. High-frequency ventilation techniques may be useful in cases of bronchopleural and tracheoesophageal fistulas. pg. 1062Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Highly specific preoperative screening tests have a: 1. low incidence of false-positives results 2. low incidence of false-negative results 3. result that is specific for one pathologic process 4. low sensitivity

Highly specific preoperative screening tests have a: low incidence of false-positives results The usefulness of a screening test depends on its sensitivity and specificity. Sensitive tests have a low rate of false-negative results, whereas specific tests have a low rate of false-positive results. Download CoreNotes http://www.ccanesthesiareview.com/QF/Test_Validity.pdf pp. 139, 299Polgar, S, Thomas, SA. Introduction to Research in the Health Sciences. Philadelphia: Churchill Livingstone, 2000.

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of: 1. isoflurane 2. sevoflurane 3. desflurane 4. nitrous oxide

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of: desflurane Volatile agents decrease the nondepolarizer dosage requirements. The degree of the augmentation of blockade depends on the inhalational agent, with desflurane > sevoflurane > isoflurane > nitrous oxide. pg. 213Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include: 1. a nitroglycerine infusion 2. inotropic support 3. afterload reduction 4. maintenance of adequate preload

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include: maintenance of adequate preload In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable. Download CoreNotes http://www.ccanesthesiareview.com/QF/Cardiomyopathy.pdf pg. 1084Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

In the fetus, the percentage of cardiac output directed to the placenta is approximately: a. 10% b. 25% c. 50% d. 100%

In the fetus, the percentage of cardiac output directed to the placenta is approximately: 50% In the fetus, the lungs receive little blood flow. The placenta receives nearly one-half of the fetal cardiac output and is responsible for respiratory gas exchange. pg. 854Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2017.

In the figure below, inspiratory capacity is best represented by: 1. A 2. A + tidal volume 3. B 4. B + tidal volume

In the figure below, inspiratory capacity is best represented by: A + tidal volume Inspiratory capacity is the sum of the inspiratory reserve volume (A) and the tidal volume. B represents the expiratory reserve volume, C represents the FRC, D represents the residual volume, E represents the vital capacity and F represents the total lung volume. pp. 278-279Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In the flow-volume loops below, chronic obstructive pulmonary disease is best represented by: A B C D

In the flow-volume loops below, chronic obstructive pulmonary disease is best represented by: A Obstructive disease is best represented by flow-volume loop A, which demonstrates increased FRC and TLC with decreased expiratory flow. pg. 611Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

In the graph of cerebral blood flow below, PaCO2 would best be represented by curve: A B C D

In the graph of cerebral blood flow below, PaCO2 would best be represented by curve: B Curve B best represents the effects of changing carbon dioxide tensions on cerebral blood flow. Between the ranges of 20 to 80 mm Hg a linear relationship exists between PaCO2 and CBF, such that a change in PaCO2from 30 to 60 mm Hg will double CBF. pg. 1007Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

In the neuromuscular junction, acetylcholine receptor binding sites are found on the: 1. α-subunits 2. β-subunits 3. δ-subunits 4. ε -subunits

In the neuromuscular junction, acetylcholine receptor binding sites are found on the: α-subunits Each acetylcholine (ACh) receptor in the neuromuscular junction consists of 5 protein subunits. Only the α-subunits are capable of binding ACh molecules. If both binding sites are occupied, the channel briefly opens. The α-subunits are also the site of action of neuromuscular blockers. pg. 529Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

In the pressure-volume loop below, cardiac work is best represented by: 1. the area of the curve 2. the slope of the line from points C to D 3. the distance of the line from points C to D 4. the slope of a line from points A to D

In the pressure-volume loop below, stroke work is best represented by: the area of the curve Stroke work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Stroke work is best represented by the area of the curve of a pressure-volume loop. pg. 288Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

In the thromboelastograms below, thrombocytopenia is best represented by: A B C D

In the thromboelastograms below, thrombocytopenia is best represented by: C Thrombocytopenia causes an overall reduction in clot strength shown as a narrowing in the thromboelastogram. pg. 1519Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above: a. 5 mm Hg b. 15 mm Hg c. 25 mm Hg d. 30 mm Hg

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above: 15 mm Hg Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above 15 mm Hg. Uncompensated increases in tissue or fluid within the rigid intracranial vault produce the sustained pressure elevations. Download CoreNotes http://www.ccanesthesiareview.com/QF/Intracranial_Hypertension.pdf pp. 871-874Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Key elements in the AANA's definition of wellness include: (Select 3) 1. effective adaptation 2. resilience 3. professionalism 4. competence 5. coping mechanisms 6. compassion 7. fortitude 8. perseverance

Key elements in the AANA's definition of wellness include: (Select 3) effective adaptation, resilience, coping mechanisms The AANA defines wellness as a positive state of the mind, body, and spirit reflecting a balance of effective adaptation, resilience, and coping mechanisms in personal and professional environments that enhance quality of life. "About Health and Wellness" URL: https://www.aana.com/practice/health-and-wellness-peer-assistance/about-health-wellness

Laminar flow in the airway occurs in the: (Select 2) 1. trachea main stem bronchi 2. terminal bronchiole 3. 3rd generation bronchus 4. respiratory bronchiole

Laminar flow in the airway occurs mostly in the: terminal bronchiole, respiratory bronchiole Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow. pp. 498-499Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Maternal mortality associated with amniotic fluid embolization is: a. 10 - 15% b. 20 - 25% c. 40 - 45% d. greater than 50%

Maternal mortality associated with amniotic fluid embolization is: greater than 50% Amniotic fluid embolism is rare with a occurrence of about 1:20,000. However, it carries a very high mortality; some studies quoting as much as 86%. Mortality within the first hour after onset is about 50%. pg. 867Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Nerves blocked with a fascia iliaca block include the: 1. sciatic nerve 2. femoral nerve 3. pudendal nerves 4. anterior tibial nerve

Nerves blocked with a fascia iliaca block include the: femoral nerve The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves. pp. 1003-1004Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Ninety percent of congenital diaphragmatic hernias occur: 1. through the left posterolateral foramen 2. through the right posterolateral foramen 3. through the anterior foramen 4. along the inferior vena cava

Ninety percent of congenital diaphragmatic hernias occur: through the left posterolateral foramen Left-sided herniation through the posterolateral foramen of Bochdalek accounts for 90% of diaphragmatic hernias. Hypoxia, scaphoid abdomen and evidence of bowel in the thorax are the hallmarks of diaphragmatic herniation. Peak airway pressures should not exceed 30 cm H2O to minimize the risk of pneumothorax during surgical correction. pg. 921Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

Pathophysiologic changes associated with ALI/ARDS include: (Select 2) 1. hypoxemia responsive to oxygen therapy 2. increased static compliance of the chest wall 3. diffuse alveolar edema 4. high dead space fraction 5. reduced mean pulmonary artery pressure 6. decreased intrapulmonary shunt

Pathophysiologic changes associated with ALI/ARDS include: (Select 2) diffuse alveolar edema, high dead space fraction ALI and ARDS are syndromes of acute, hypoxemic respiratory failure, with resulting increased lung permeability and diffuse alveolar edema. Clinically, ARDS and ALI are characterized by reduced static thoracic (lung and chest wall) compliance and severe impairment of gas exchange, including high intrapulmonary shunt and dead space fraction with pulmonary hypertension. The high level of intrapulmonary shunt results in hypoxia, which is relatively unresponsive to oxygen therapy. pp. 1594-1595Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pathophysiologic changes associated with liver disease include: (Select 2) 1. increased cardiac output 2. increased systemic vascular resistance 3. increased mean blood pressure 4. sodium-losing nephropathy 5. hyperkalemia 6. arterial hypoxemia

Pathophysiologic changes associated with liver disease include (Select 2):increased cardiac output, arterial hypoxemia Arterio-venous shunting, resulting from advanced liver disease, results in a decrease in systemic vascular resistance, a decrease in blood pressure and an increase in cardiac output. Arterial hypoxemia is common in patients with advanced liver disease and appears to be the result of ascites, hepatic hydrothorax and widespread pulmonary vasodilation. pp. 718-719Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

Pathophysiologic changes associated with metabolic alkalosis include: (Select 2) 1. compensatory hyperventilaton 2. hypokalemia 3. reduced tissue oxygen availability 4. ionized hypercalcemia 5. decreased digoxin effect 6. arterial hypoxemia

Pathophysiologic changes associated with metabolic alkalosis include: (Select 2): hypokalemia, reduced tissue oxygen availability Metabolic alkalosis is associated with hypokalemia, ionized hypocalcemia, secondary ventricular arrhythmias, increased digoxin toxicity, and compensatory hypoventilation (hypercarbia). Alkalemia may reduce tissue oxygen availability by shifting the oxyhemoglobin dissociation curve to the left and by decreasing cardiac output. pg. 385Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Physiologic derangements seen in the patient with scleroderma include: (Select 3) 1. pulmonary hypertension 2. esophageal dysmotility 3. excessive oral secretions and salivation 4. myocardial fibrosis 5. hypotension 6. spastic quadraparesis

Physiologic derangements seen in the patient with scleroderma include: pulmonary hypertension, esophageal dysmotility, myocardial fibrosis Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs. Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration. Systemic hypertension from renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement. pp. 208, 639Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Physiologic effects of electroconvulsive therapy (ECT) include an: 1. initial sympathetic response with sustained tachycardia 2. initial sympathetic discharge followed by a sustained parasympathetic response 3. initial parasympathetic discharge followed by a sustained sympathetic response 4. initial parasympathetic response with sustained bradycardia

Physiologic effects of electroconvulsive therapy (ECT) include an: initial parasympathetic discharge followed by a sustained sympathetic response An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased secretions can occur, which is then followed by hypertension and tachycardia. Patients scheduled for ECT are routinely given anticholinergic medication preoperatively. pg. 1207Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

Portal hypertension is defined as sustained portal vein pressure greater than: a. 5 mm Hg above hepatic vein pressure b. 10 mm Hg above hepatic vein pressure c. 15 mm Hg above hepatic vein pressure d. 20 mm Hg above hepatic vein pressure

Portal hypertension is defined as sustained portal vein pressure greater than: 5 mm Hg above hepatic vein pressure Portal hypertension is defined as a sustained portal vein pressure of 5 mm Hg or greater above hepatic vein pressure. This leads to the formation of portal-systemic collateral venous channels. pg. 1299Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Positive end expiratory pressure (PEEP): 1. decreases dead space 2.increases venous return to the heart 3. decreases intrapulmonary shunting 4. decreases extravascular lung water

Positive end expiratory pressure (PEEP): decreases intrapulmonary shunting The major effect of PEEP is to increase FRC and tidal ventilation above the closing capacity. This results in a decrease in intrapulmonary shunting. Neither PEEP nor CPAP decrease extravascular lung water. By increasing intrathoracic pressure, PEEP decreases venous return to the heart.

Pulmonary changes associated with Duchenne's muscular dystrophy include: 1. a restrictive ventilatory defect 2. an obstructive ventilatory defect 3. decreased pulmonary artery pressures 4. increased residual volume

Pulmonary changes associated with Duchenne's muscular dystrophy include: a restrictive ventilatory defect The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilatory defect in patients with Duchenne's muscular dystrophy. Pulmonary hypertension is also commonly seen. Download CoreNotes http://www.ccanesthesiareview.com/QF/Muscular_Dystrophy.pdf pg. 753Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Reactants that are regenerated during the absorption of carbon dioxide by soda lime include: 1. carbonic acid 2. sodium hydroxide 3. calcium hydroxide 4. calcium carbonate

Reactants that are regenerated during the absorption of carbon dioxide by soda lime include: sodium hydroxide Both water and sodium hydroxide are initially required during the absorption of carbon dioxide by soda lime, but then are regenerated. pg. 254Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

Respiratory parameters that are increased during pregnancy include: (Select 2) 1. airway resistance 2. tidal volume 3. oxygen consumption 4. plasma bicarbonate levels 5. functional residual capacity 6. PaCO2

Respiratory parameters that are increased during pregnancy include: (Select 2)tidal volume, oxygen consumption Respiratory/ventilatory effects of pregnancy include increased oxygen consumption, decreased airway resistance, decreased FRC, increased tidal volume and rate, increased PaO2, decreased PaCO2 and decreased serum bicarbonate. pg. 1129Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the: 1. internal laryngeal nerve 2. external laryngeal nerve 3. recurrent laryngeal nerve 4. glossopharyngeal nerve

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the: recurrent laryngeal nerve The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea. pg. 310Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Serotonin has vasodilatory properties in the: (Select 2) 1. renal vasculature 2. hepatic vasculature 3. skeletal muscle vasculature 4. pulmonary vasculature 5. coronary vasculature

Serotonin has vasodilatory properties in the: skeletal muscle vasculature, coronary vasculature Serotonin is a vasoconstrictor in most vascular beds, but has vasodilatory properties in the vasculature of the heart and skeletal muscle. pg. 284Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sickle hemoglobin: (Select 2) 1. has a lower P50 than hemoglobin A 2. releases oxygen less readily than hemoglobin A 3. is present in about 30% of African Americans 4. readily polymerizes and precipitates in the red cell 5. results from a single amino acid substitution on the α-chain 6. has decreased solubility as compared to hemoglobin A

Sickle hemoglobin: readily polymerizes and precipitates in the red cell, has decreased solubility as compared to hemoglobin A Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50(31 mm Hg) as compared to hemoglobin A (27 mm Hg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the β-chain. pg. 1177Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Termination of the effects of succinylcholine at the neuromuscular junction occurs as a result of: 1. succinylcholine hydrolysis by acetylcholinesterase 2. diffusion of succinylcholine away from the receptors 3. succinylchoine hydrolysis by hepatic esterases 4. the competition of succinylcholine with acetylcholine

Termination of the effects of succinylcholine at the neuromuscular junction occurs as a result of: diffusion of succinylcholine away from the receptors Because depolarizing muscle relaxants are not metabolized by acetylcholinesterase, they diffuse away from the neuromuscular junction and are hydrolyzed in the plasma by pseudocholinesterase. pp. 203-204Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to: a. 0.5 ppm b. 5 ppm c. 25 ppm d. 50 ppm

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to: 25 ppm NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used). pp. 652-654Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The addition of bicarbonate to a local anesthetic solution: 1. delays the onset of blockade 2. increases the concentration of the nonionic form of the local anesthetic 3. causes a fall in the pH of the solution 4. should only be done when using bupivacaine

The addition of bicarbonate to a local anesthetic solution: increases the concentration of the nonionic form of the local anesthetic The onset of neural blockade depends on the penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8. pg. 963Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The age group with the highest minimum alveolar concentration (MAC) of desflurane is: a. 2 - 3 months b. 1 - 2 years c. 25 - 30 years d. greater than 75 years

The age group with the highest minimum alveolar concentration (MAC) of desflurane is: 2 - 3 months The two-to-three-months-of-age group represents the highest MAC requirement. MAC subsequently decreases with advancing age. pg. 883Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from: 1. T4 - T8 2. T8 - L2 3. L2 - L4 4. L4 - S1

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from: T8 - L2 A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable origin from aorta, arising between T5 - T8 in 15%, between T9 - T12 in 60% and between L1 - L2 in 25% of individuals. pg. 486Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

The cardiovascular effects of pancuronium are caused by: (Select 3) 1. vagal blockade 2. stimulation of cardiac muscarinic receptors 3. ganglionic stimulation 4. decreased catacholamine reuptake 5. direct myocardial stimulation 6. blockade of cardiac slow calcium channels 7. central thalamic stimulation

The cardiovascular effects of pancuronium are caused by: vagal blockade, ganglionic stimulation, decreased catecholamine reuptake The cardiovascular effects of pancuronium are caused by the combination of vagal blockade and sympathetic stimulation. The latter is due to a combination of ganglionic stimulation, catecholamine release and decreased catecholamine reuptake. pp. 535,536Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017. pg. 217Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The effects of barbiturates on ischemic areas of the brain include: 1. vasoconstriction 2. vasodilation 3. redirection of blood flow to the ischemic areas 4. redirection of blood flow away from ischemic areas

The effects of barbiturates on ischemic areas of the brain include: redirection of blood flow to the ischemic areas Barbiturates cause cerebral vasoconstriction in normal areas. These agents tend to redistribute blood flow to ischemic areas in what is sometimes referred to as a reverse steal phenomenon or Robin Hood effect. Ischemic areas remain maximally dilated and unaffected by the barbiturate. pg. 500Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The elimination half-life of intravenously administered oxytocin in the parturient is approximately: a. 30 to 120 seconds b. 3 to 5 minutes c. 10 to 15 minutes d. 20 to 30 minutes

The elimination half-life of intravenously administered oxytocin in the parturient is approximately: 3 to 5 minutes Both endogenous and intravenously administered oxytocin have short elimination half-lives of about 3 to 5 minutes. As a result, oxytocin must be administered as a continuous infusion for the induction of labor. Download CoreNotes http://www.ccanesthesiareview.com/QF/PPHemmorhage.pdf pg. 835Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The essential component of cardioplegia solutions is: 1. mannitol 2. magnesium 3. potassium 4. corticosteroid

The essential component of cardioplegia solutions is: potassium High concentrations of potassium (20 - 30 mEq/L) are used in cardioplegia solutions. These solutions result in an increase in extracellular potassium and reduce transmembrane potential. This progressively interferes with the normal sodium currents of depolarization and eventually the sodium channels are completely inactivated. pg. 1092Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The highest incidence of muscle pain following the use of succinylcholine is seen in: 1. infants 2. octogenarians 3. outpatients 4. pregnant patients

The highest incidence of muscle pain following the use of succinylcholine is seen in: outpatients Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective. pg. 170Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The highest rate of systemic absorption of local anesthetic is seen with: 1. epidural injection 2. intercostal injection 3. caudal injection 4. brachial plexus injection

The highest rate of systemic absorption of local anesthetic is seen with: intercostal injection The rate of systemic absorption of local anesthetic is proportionate to the vascularity of the site of injection: intravenous > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > subcutaneous. pg. 573Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The highest level of protein binding is seen with: 1. procaine 2. lidocaine 3. mepivacaine 4. bupivacaine

The local anesthetic with the highest degree of protein binding is: bupivacaine The physicochemical property that determines the duration of action of a local anesthetic is lipid solubility, which is directly correlated with plasma protein binding. Bupivacaine and levobupivacaine have the highest degree of protein binding (97%). pg. 269Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the thromboelastogram below, clot strength is best represented by: A B E F

The maximum amplitude (E) is a measure of the strength of the fully formed clot. It reflects primarily platelet number and function although it also requires proper fibrin formation to achieve normal values. pg. 1519Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The maximum recommended occupational whole-body exposure to radiation is: a. 1 rem/year b. 5 rem/year c. 10 rem/year d. 20 rem/year

The maximum recommended occupational whole-body exposure to radiation is: 5 rem/year The intraoperative use of imaging equipment exposes anesthesia providers to ionizing radiation. The maximum recommended whole-body exposure to radiation is 5 rem/year. pg. 68Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The most frequent manifestation of sickle cell disease is: 1. pain 2. splenic sequestration 3. aplastic crisis 4. right upper quadrant syndrome

The most frequent manifestation of sickle cell disease is: pain The most frequent manifestation of sickle cell disease is pain. The pain is thought to be secondary to tissue ischemia and usually affects the back, chest, extremities and abdomen. pg. 635Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The most severe transfusion reactions are due to: 1. ABO incompatibility 2. Rh incompatibility 3. febrile reactions 4. non-ABO hemolytic reactions

The most severe transfusion reactions are due to: ABO incompatibility The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis. pg. 1201Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

The perception of an ordinarily non-noxious stimulus as pain is referred to as: 1. allodynia 2. anesthesia dolorosa 3. dysesthesia 4. hyperalgesia

The perception of an ordinarily non-noxious stimulus as pain is referred to as: allodynia Allodynia is the perception of non-noxious stimuli as pain. Dysesthesia is an unpleasant sensation without a stimulus. Hyperesthesia is an increased response to a mild stimulus. Anesthesia dolorosa is pain in an area that lacks sensation. pg. 509Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

The phrenic nerves arise from the: 1. nucleus ambiguous 2. C1 - C2 nerve roots 3. C3 - C5 nerve roots 4. C6 - T2 nerve roots

The phrenic nerves arise from the: C3 - C5 nerve roots The phrenic nerves arise from the C3 - C5 nerve roots. Unilateral phrenic nerve palsy only modestly reduces most indices of pulmonary function (about 25%). Bilateral phrenic nerve palsies produce more severe impairment, but accessory muscles may maintain adequate ventilation. Cervical cord injuries above C5 are incompatible with spontaneous ventilation. pp. 946-947Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The postretrobulbar block apnea syndrome: 1. is likely secondary to intravascular injection 2. most commonly occurs during or immediately after injection 3. is associated with unconsciousness 4. carries a high morbidity and mortality

The postretrobulbar block apnea syndrome: is associated with unconsciousness The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive. pg. 780Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

The potency of local anesthetics increases as the: 1. lipid solubility increases 2. pKa increases 3. number of double bonds in the anesthetic molecule increases 4. molecular weight decreases

The potency of local anesthetics increases as the: lipid solubility increases Local anesthetic potency correlates directly with lipid solubility. In general, lipid solubility increases with an increase in the total number of carbon atoms in the molecule and by adding a halogen to the aromatic ring. pg. 129Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The purpose of the ductus venosus in fetal circulation is to: 1. allow umbilical vein blood to bypass the liver 2. allow umbilical artery blood to bypass the liver 3. bypass the pulmonary circulation 4. divert portal vein blood to the placenta

The purpose of the ductus venosus in fetal circulation is to: allow umbilical vein blood to bypass the liver Up to 50% of the umbilical vein blood can pass directly into the inferior vena cava, bypassing the liver, through the ductus venosus. The remainder mixes with blood from the portal vein and passes through the liver prior to returning to the heart. pg. 1092Nagelhout, JJ, Elisha, S. Nurse Anesthesia. St. Louis: Elsevier, 2018.

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be: 1. between 300 and 400 2. between 200 and 300 3. between 100 and 200 4. less than 100

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be: less than 100 RSBI is frequently used to help predict who can be successfully weaned from mechanical ventilation. With the patient breathing spontaneously, the ventilatory rate is divided by the tidal volume (liters). Successful extubation can be predicted by an RSBI of less than 100. Crawford, J, Otero, R. "Rapid shallow breathing index a key predictor for noninvasive ventilation." URL: http://ccforum.com/content/11/S2/P169, March, 2007. pg. 1297Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The rhythm strip below is indicative of: 1. first degree block 2. second degree block, type I 3. second degree block, type II 4. bifascicular block

The rhythm strip below is indicative of: second degree block, type I Second degree block, type I, shows a progressive lengthening of the PR interval with each cycle until a QRS complex is dropped. This type of block indicates AV nodal disease and associated bradycardia usually responds to the administration of atropine. Download CoreNotes http://www.ccanesthesiareview.com/QF/AV_Block.pdf pg. 1711Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Topically applied ophthalmic medications are absorbed: 1. as quickly as intravenous administration 2. more quickly than subcutaneous administration 3. only minutely, with insignificant clinical effect 4. directly into the central nervous system through the optic nerve foramen

Topically applied ophthalmic medications are absorbed: more quickly than subcutaneous administration Topically applied ophthalmic medications are absorbed at a rate intermediate between intravenous and subcutaneous injection. Children and the elderly are at particular risk for the toxic effects of topically applied medications. pg. 776Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2018.

Type I pneumocytes: 1. prevent the passage of albumin into the alveolus 2. are more numerous than Type II pneumocytes 3. produce surfactant 4. are capable of rapid cell division

Type I pneumocytes: prevent the passage of albumin into the alveolus Type I pneumocytes are flat and form a tight junction with one another. This prevents the passage of oncotic molecules, such as albumin, into the alveolus. Type II pneumocytes are smaller, but more numerous, and produce surfactant. Unlike Type I pneumocytes, Type II pneumocytes are capable of cell division and can produce Type I pneumocytes when needed. pg. 490Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail's Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Ulnar nerve injury: 1. results in wrist drop and loss of sensation in the webspace between the thumb and index finger 2. occurs more frequently in males 3. manifests itself in the immediate postoperative period 4. is most commonly seen in the patient with a BMI of less than 18

Ulnar nerve injury: occurs more frequently in males Three attributes which are highly associated with development of postoperative ulnar nerve injury are:1) male sex - various reports suggest that 70 - 90% of patients with postoperative ulnar neuropathy are men2) high body mass index - BMI > or = 383) prolonged postoperative bed rest.Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury. pg. 815Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.

Venous irritation associated with the injection of diazepam and lorazepam is secondary to: 1. the high degree of water solubility of these agents 2. the presence of propylene glycol as a solvent 3. the presence of metabisulfite as a preservative 4. the low pH of these agents

Venous irritation associated with the injection of diazepam and lorazepam is secondary to: the presence of propylene glycol as a solvent The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation. pg. 499Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, Ortega, R.,Sharar, SR, and Holt, NF. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2017.'