Week 7
Which of the following is most consistent with Hyperglycemic Hyperosmolar State (HHS)? A. dehydration B. ketoacidosis C. hyperkalemia D. hypomagnesemia
The correct answer is A. Hyperglycemic hyperosmolar state, or HHS, is a condition that occurs most commonly in acutely ill patients older than 60 years of age who have type II diabetes. It is characterized by severe hyperosmolarity, hyperglycemia, and dehydration. Signs and symptoms include confusion, lethargy, coma, hypokalemia, a high incidence of thromboembolism, and a life-threatening dehydration. On average, patients with HHS have a water deficit of 9 liters. Ketoacidosis is rare in HHS.
What is the only additive to the local anesthetic for a Bier block that has been proven effective? A. ketorolac B. morphine C. fentanyl D. dexamethasone
The correct answer is A. Ketorolac 15-30 mg added to the local anesthetic has been shown to provide additional postoperative analgesia without increasing postoperative bleeding.
What is the only indication for intravenous levothyroxine? A. Myxedema coma B. Thyrotoxicosis C. TSH level of 5.0 milliunits/L D. Diastolic dysfunction related to hypothyroidism
The correct answer is A. Myxedema coma is the only true indication for intravenous administration of levothyroxine. It is administered as a 300-500 mcg loading dose followed by 50-200 mcg/day. A TSH level of 5.0 mU/L indicates a euthyroid state. Diastolic dysfunction in hypothyroid patients is often reversed by routine treatment with oral levothyroxine.
A patient undergoing surgical excision of an insulinoma is most likely to exhibit intraoperative A. hypoglycemia B. hyperglycemia C. hypertension D. hypotension
The correct answer is A. Neoplasm of the beta cells of the pancreas is referred to as insulinoma. The primary manifestation of this disorder is hypersecretion of insulin, resulting in severe hypoglycemia leading to mental depression, seizures, and coma. Surgical excision of the tumor is the primary form of treatment unless the patient has advanced metastatic disease.
Which of the following solutions has the highest sodium concentration? A. Normal saline B. Lactated Ringer's C. Plasma D. Normosol-R
The correct answer is A. Normal saline has a sodium of 154 mEq/L. Plasma has a sodium concentration of 142 mEq/L and Normosol-R contains 140 mEq/L of sodium. Lactated Ringer's solution has a sodium of 130 mEq/L
Which of the following statements is true of a full-term parturient? A. Basal oxygen consumption is increased by 33 percent B. The partial pressure of arterial carbon dioxide is increased C. The partial pressure of arterial oxygen is decreased D. Plasma bicarbonate increases 10 percent
The correct answer is A. Oxygen consumption increases by about 33 percent in the full-term parturient, but minute ventilation increases by 50 percent at term. The increased alveolar ventilation results in an increase in the PaO2 to about 106 mmHg and a decrease in the PaCO2 to about 30-32 mmHg. The plasma base (HCO3-) decreases from about 26 to 22 mEq/L, thus, the pH is essentially unchanged.
Which of the following cardiovascular abnormalities are consistent with morbid obesity? A. Eccentric left ventricular hypertrophy B. Concentric left ventricular hypertrophy C. Slower rise in cardiac output in response to exercise D. A compensatory decrease in systemic vascular resistance over the life of the patient
The correct answer is A. Patients with morbid obesity have a larger total blood volume than non-obese patients to supply the excess adipose tissue. The excess blood volume and resulting increase in preload causes ventricular dilation and increased left ventricular wall stress (eccentric hypertrophy). Obese patients have a faster rise in cardiac output in response to exercise than non-obese patients, fueled primarily by an increase in heart rate as the stroke volume changes little with exertion. The chronically elevated cardiac output and increased blood volume may result in an increase in the SVR over time.
Pain that persists more than three months after resolution of the rash associated with herpes zoster is referred to as A. postherpetic neuralgia B. trigeminal neuralgia C. zosteriform neuropathy D. dermatomal neuropathy
The correct answer is A. Postherpetic neuralgia is pain that persists more than three months after resolution of the rash associated with herpes zoster.
Which of the following 12-lead electrocardiographic changes would be most consistent with subendocardial injury? A. ST depression in lead II B. ST elevation in lead II C. Shortened PR interval in lead I D. ST elevation in lead I
The correct answer is A. ST depression that coincides in time with anginal symptoms is consistent with subendocardial injury.
Which of the following is a potential side effect of the addition of clonidine to an epidural used for postoperative pain management? A. Bradycardia B. Hypertension C. Hypokalemia D. Hyperventilation
The correct answer is A. The addition of clonidine to an epidural has been shown to significantly increase the quality and duration of pain relief. As it absorbs into the systemic circulation, it can produce bradycardia, hypotension, and sedation.
The dorsal horn of the spinal cord includes laminae A. I to VI B. I to IX C. VII to IX D. IX and X
The correct answer is A. The dorsal horn of the spinal cord is the major sensory component of the cord and includes laminae I through VI. Laminae VII to X are in the ventral horn. Laminae VII to IX are the primary motor component and laminae X is primarily involved in autonomic functions.
Click the Exhibit button at the top of the screen. The injection of local anesthetic into which location would result in numbness to the areas depicted in green in the exhibit? "palmar surface of the hand from thumb to middle finger, fingernails of dorsal surface" A. At the wrist between the flexor carpi radialis and palmaris longus tendons B. At the wrist between the ulnar artery and flexor carpi ulnaris tendon C. At the elbow just lateral to the medial epicondyle of the humerus D. Across the medial aspect of the upper arm just distal to the axilla
The correct answer is A. The nerve distribution shown is that of the median nerve, which can be blocked by the injection of local anesthetic at the wrist between the flexor carpi radialis and the palmaris longus tendons. An injection of local anesthetic both at the wrist between the ulnar artery and flexor carpi ulnaris tendon or at the elbow just lateral to the medial epicondyle of the humerus will anesthetize the ulnar nerve.
When is use of the oxygen flush control valve contraindicated in a mechanically-ventilated patient? A. During inspiration B. During expiration C. When the fresh gas flow rate is greater than the patient's minute ventilation D. When the fresh gas flow rate is less than the patient's minute ventilation
The correct answer is A. The oxygen flush control valve delivers oxygen at a rate of 35-75 L/min and a pressure of 50 psi. To avoid barotrauma, it should never be used when there is no outlet for excess gas pressure to escape. This situation exists when the patient is in the inspiratory phase of mechanical ventilation when the inspiratory valve is open to the patient but there is no vent for gases to escape.
Where in the popliteal fossa can the popliteal artery be found? A. immediately lateral to the semitendinosus tendon B. inferior to the head of the gastrocnemius muscle C. immediately lateral to the biceps femoris D. immediately to the right of the fibular head
The correct answer is A. The popliteal artery may be found immediately lateral to the semitendinosus tendon.
Click the Exhibit button at the top of the screen. Which image in the exhibit correctly depicts a Quincke spinal needle?
The correct answer is A. The primary difference noticed between the Quincke and its two counterparts are that it has a cutting needle while the latter both have blunt, non-cutting tips.
What nerve divides into the common peroneal and tibial nerves at the apex of the popliteal fossa? A. Sciatic B. Femoral C. Popliteal D. Obturator
The correct answer is A. The sciatic nerve divides into the common peroneal and tibial nerves at the apex of the popliteal fossa.
Which of the following statements is not true of a cervical plexus blockade? A. It produces adequate blockade of the carotid sinus reflex B. The sensory and motor fibers of the cervical plexus can be blocked separately C. The main risk of this procedure is vertebral artery injection D. Subarachnoid anesthesia is a potential risk of this procedure
The correct answer is A. The sensory and motor fibers of the cervical plexus originate from the cervical 2, 3, and 4 nerve roots and are unique in that the sensory fibers separate from the motor fibers early and can be blocked separately. The main potential risk of this procedure is vertebral artery injection, but if the needle is advanced too far medially into the vertebral foramen, epidural or even subarachnoid anesthesia is a potential risk as well, particularly because the dural sleeves of the cervical nerves are longer on these branches. A cervical plexus block does not protect against the carotid sinus reflex and local injection of the carotid sinus at the point where the carotid artery bifurcates is often necessary.
During the perioperative evaluation, you discover that a patient with a pacemaker occasionally experiences dizziness while exercising his chest muscles. Based on this finding, which of the following would you avoid during his anesthetic? A. Succinylcholine B. Reverse Trendelenburg position C. Hyponatremia D. Hyperventilation
The correct answer is A. This indicates that myopotentials may be inhibiting the pacemaker. From this information, you know that muscle fasciculations from succinylcholine should be avoided to prevent inadvertent pacemaker inhibition.
Which of the following side effects can occur due to the intravenous administration of mannitol? (select two) A. Exacerbation of congestive heart failure B. A transient decrease in the hematocrit C. Hypernatremia D. Hypokalemia
The correct answer is AB. Because the administration of mannitol results in an acute increase in plasma and extracellular osmolality, fluid shifts from the intracellular space into the extracellular space and eventually the intravascular compartment resulting in congestive heart failure. Additionally, the increase in plasma volume results in hemodilution which can present as transient hyponatremia and a drop in hematocrit.
Upon what receptors does nalbuphine act? (select two) A. Mu B. Kappa C. Alpha-1 D. Beta-1
The correct answer is AB. Nalbuphine is an opioid derivative that acts as a partial agonist at mu, kappa, and delta receptors. Nalbuphine acts to antagonize mu receptor activity, agonize delta receptors, and act as a partial agonist on kappa receptors.
What are the four types of burns? (select four) A. Thermal B. Scalding C. Chemical D. Electrical E. Epidermal F. Vasoreactive G. Inhalation H. Steam
The correct answer is ACDG. The four types of burns are: chemical, electrical, thermal, and inhalation.
Which of the following are symptoms associated with autonomic hyperreflexia? (select two) A. Hypertension B. Hypotension C. Tachycardia D. Bradycardia
The correct answer is AD. The hallmark cardiovascular symptoms of autonomic hyperreflexia are severe hypertension and bradycardia.
Which is NOT a document that gives one person the right to make medical decisions on behalf of a person who is incapable of making the decisions for themself? A. Durable power of attorney B. Sustainable attorney-in-fact C. Medical power of attorney D. Healthcare power of attorney
The correct answer is B. A durable power of attorney, medical power of attorney, and healthcare power of attorney are all terms that refer to the legal representative that can make medical decisions on behalf of another who is not able to make those decisions for themself.
A significant risk for perineal crush injury is associated with which of the following situations? A. In lithotomy position for hysteroscopy B. On traction table to reduce a femur fracture C. On Wilson frame for lumbar microdiscectomy D. In lateral decubitus position for shoulder arthroscopy
The correct answer is B. A traction table places the patient supine with one leg elevated and the affected leg placed in traction. A perineal post is positioned between the patient's legs to keep them stationary while the traction pulls on the leg. The elevated leg suffers the risk of hypoperfusion while the perineal post poses a risk of crushing the perineum
All of the following are required to be evaluated during monitored anesthesia care cases except A. Blood pressure B. Capnography C. Pulse oximetry D. Electrocardiogram
The correct answer is B. According to the standards set forth by the ASA, the patient's oxygenation, ventilation, and circulation shall be continually monitored. This includes pulse oximetry, ECG, and blood pressure (which must be assessed at least every five minutes). During monitored anesthesia care cases, capnography is not required, but ventilation must be assessed, at least, by continual observation of qualitative clinical signs (e.g. chest rise and breath sounds). The temperature is to be monitored any time clinically significant changes in body temperature are intended or anticipated
You are preparing to place an epidural catheter. About how far should the epidural catheter be advanced into the epidural space? A. 2 cm B. 5 cm C. 9 cm D. 12 cm
The correct answer is B. An epidural catheter should be advanced about 5 cm into the epidural space. Advancing it further will increase the likelihood that a complication will result such as the catheter forming a knot, entering a vein, or puncturing the dura.
Which of the following anesthetic preparations would NOT be a possible cause of methemoglobinemia? A. Benzocaine B. Etidocaine C. EMLA cream D. Prilocaine
The correct answer is B. Both benzocaine and prilocaine (a component of EMLA cream) are possible causes of methemoglobinemia while etidocaine is not.
Which diuretic works by decreasing sodium reabsorption and hydrogen ion secretion in the proximal tubules? A. Furosemide B. Acetazolamide C. Bumetanide D. Mannitol
The correct answer is B. Carbonic anhydrase inhibitors such as acetazolamide decrease sodium reabsorption and H+ secretion in the proximal tubules. They can result in a mild hyperchloremic metabolic acidosis.
All of the following are causes of chronic extrinsic restrictive lung disease except: A. Pectus carinatum B. Sarcoidosis C. Obesity D. Flail Chest
The correct answer is B. Chronic extrinsic restrictive lung disease is often due to deformities of the thoracic cage such as pectus carinatum, pectus excavatum, kyphosis, scoliosis, and flail chest as well as obesity and neuromuscular disorders. Sarcoidosis is a cause of chronic intrinsic restrictive lung disease
Heat loss from the patient to the cooler operating room table occurs through the process of A. convection B. conduction C. radiation D. evaporation
The correct answer is B. Conduction is the transfer of heat energy from one object to another through physical contact. This is the method of heat loss that occurs when a patient is placed on a cold operating room table. Heat from the patient is lost to the colder table surface
A patient undergoes a six hour long abdominal surgery in the dorsal decubitus (supine) position. On awakening, the patient exhibits loss of sensation in the web space between the thumb and index finger. You suspect damage to the A. ulnar nerve B. radial nerve C. median nerve D. long thoracic nerve
The correct answer is B. Damage to the radial nerve (arising from the C6-T1 nerve roots) can result in weak thumb abduction, inability to extend the metacarpophalangeal joints, and loss of sensation in the web space between the thumb and index finger. Common causes include pressure from the vertical bar of an anesthesia screen and excessive cycling of an automatic blood pressure cuff.
You are performing general anesthesia for a morbidly obese patient undergoing laparoscopic surgery. Which of the following is more likely to occur in this patient than in a patient of normal weight? A. The ST segment will become elevated during the procedure B. The endotracheal tube will become displaced C. Hemorrhage requiring transfusion D. The vital capacity of the patient will increase as a result of the pneumoperitoneum
The correct answer is B. It has been shown that the endotracheal tube has a higher likelihood of moving in laparoscopic surgeries in the morbidly obese patient population.
Which is a potential disadvantage of using nitroglycerin for controlled hypotension? A. It can result in myocardial ischemia B. It can increase intracranial pressure C. It can result in myoglobinuria D. It can produce methemoglobinemia
The correct answer is B. Nitroglycerin preserves cardiac perfusion well, but can increase intracranial pressure.
What diagnostic parameter is the most sensitive indicator of the effect of obesity on pulmonary function? A. Vital capacity B. Expiratory reserve volume C. Total lung capacity D. Minute ventilation
The correct answer is B. Obesity decreases respiratory compliance due to the accumulation of fat on the chest wall, diaphragm, and abdomen resulting in a decrease in functional residual capacity, vital capacity, and total lung capacity. The reduction in functional residual capacity is due to a reduction in the expiratory reserve volume, which is the most sensitive indicator of the effect of obesity on pulmonary function. Minute ventilation is increased in obese patients to meet the metabolic demand of excess fat.
Which of the following medications would be most effective in reducing the risk associated with reflux immediately prior to surgery? A. Oral aluminum hydroxide/Magnesium hydroxide B. Oral sodium citrate C. Intravenous cimetidine D. Oral ranitidine
The correct answer is B. Oral sodium citrate (Bicitra) reduces gastric acid content (raises gastric pH) rapidly. Oral aluminum hydroxide/magnesium hydroxide (Maalox, Gaviscon) also raises the pH rapidly, but it is a particulate solution which increases the risk for pulmonary problems should aspiration occur. H2-antagonists (whether IV or PO) are not very effective at raising the pH of the contents already in the stomach but reduce the amount of acid secreted into the stomach after their administration.
The use of desflurane and isoflurane with a dessicated CO2 absorbent can result in the production of A. compound A B. carbon monoxide C. free oxygen radicals D. increased serum fluoride levels in the patient
The correct answer is B. Prolonged exposure of desflurane or isoflurane to dessicated CO2 absorbent can result in the degradation of the anesthetic with the resulting production of carbon monoxide. Increased temperature and higher doses of anesthetic agent both increase the amount of carbon monoxide produced.
Which form of airway gas analysis involves energizing the gas sample with a laser and analyzing the intensity of light emitted when it returns to the unexcited state? A. Mass spectroscopy B. Raman scattering analysis C. Infrared absorption D. X-ray photography
The correct answer is B. Raman scattering analysis energizes the gas sample with a laser and measures the intensity of the light emitted when it returns to the unexcited state. Infrared monitors work in a manner similar to capnography monitors in that they detect gases based on the amount of infrared light that is absorbed by the sample. Mass spectrometers are typically very expensive and are shared among several operating rooms with samples analyzed and displayed every 1-2 minutes. The spectrometer uses a vacuum to draw a sample of the gas into the machine where it is ionized and passed through a magnetic field. The ions with the highest mass-to-charge ratio are deflected the least. The spectrum of deflection is used to determine the ratio of one gas to another.
Serotonin 5HT-3 receptor antagonists are used to treat A. depression B. nausea and vomiting C. carcinoid syndrome D. hypertension
The correct answer is B. Serotonin antagonists are used to treat nausea and vomiting and include the drugs ondansetron, dolasetron, granisetron, and palonosetron
The Diameter Index Safety System (DISS) is designed to handle pressures equal to or less than A. 1240 kPa B. 1380 kPa C. 1560 kPa D. 2000 kPa
The correct answer is B. The DISS is a non-interchangeable connection for medical gas lines at pressure of 1380 kPa (200 psi) or less.
You are evaluating a 5 month-old child prior to undergoing general anesthesia for placement of myringotomy tubes. The mother tells you she breastfed the child one hour ago. You should delay the case A. 1 hour B. 3 hours C. 5 hours D. 7 hours
The correct answer is B. The case should be delayed for three hours as the NPO time for breast milk is 4 hours.
With age, renal cortical mass decreases by as much as A. 15 percent B. 25 percent C. 35 percent D. 45 percent
The correct answer is B. The mass of the renal cortex lowers by 20-25 percent with age. Also, by age 80 approximately half of the glomeruli are lost.
Which areas of the lower leg would still have sensation after the successful performance of a popliteal block on a patient? (select two) A. The medial posterior calf B. The medial anterior calf C. The medial aspect of the foot D. The posterior sole of the foot
The correct answer is BC A popliteal fossa blockade can anesthetize the nerves of the lower leg. However, a supplementary femoral nerve block is required to block its terminal saphenous branch which innervates the medial anterior calf and the medial aspect of the foot.
Which of the following symptoms of cardiac tamponade are indications of ventricular discordance? (select two) A. Beck's triad B. Kussmaul's sign C. Decreased voltage on the electrocardiogram D. Pulsus paradoxus
The correct answer is BD. Kussmaul's sign and pulsus paradoxus are both indicative of ventricular discordance (also known as ventricular dyssynchrony) that occurs due to the opposing response of the ventricles to filling during the respiratory cycle.
Which of the following is NOT an associated consequence of severe acidosis? (select two) A. Insulin resistance B. Heightened threshold for ventricular fibrillation C. Hyperkalemia D. Hypoventilation
The correct answer is BD. Severe acidosis is associated with decreased cardiac contractility, decreased responsiveness to catecholamines, sensitization to re-entrant tachydysrhythmias, lowered threshold for ventricular fibrillation, hyperkalemia, hyperventilation, insulin resistance, and inhibition of anaerobic glycolysis
Which of the following represents a contraindication to nasotracheal intubation? A. Parietal fracture B. Mandibular fracture C. Maxillary fracture D. Temporal fracture
The correct answer is C. Relative contraindications to nasotracheal intubation include the setting of maxillary fractures and fractures to the base of the skull. Because it bypasses the gag reflex, it is generally tolerated better in the awake patient.
The termination of a large tidal volume breath by signals from stretch receptors within the lung tissue is a result of the A. Moro reflex B. Bainbridge reflex C. Hering-Breuer reflex D. Vasovagal reflex
The correct answer is C. The Hering-Breuer reflex terminates a large tidal volume inspiration by sending signals from stretch receptors in the lung tissue to the respiratory centers in the medulla. The Moro reflex is the startle reflex exhibited by newborns and the Bainbridge reflex increases the heart rate in response to increased venous return to the right atrium.
Which bispectral index (BIS) score is defined as representing a 'low probability of explicit recall and being unresponsive to verbal stimuli'? A. 100 B. 80 C. 50 D. 10
The correct answer is C. A BIS score of 100 indicates that the patient is awake and should respond to normal voice. A score of 80 is associated with light to moderate sedation, and the patient may respond to loud commands or mild prodding. A score of 60 represents general anesthesia with a low probability of explicit recall and being unresponsive to verbal stimuli. A score of 40 represents a deep hypnotic state. A score of 20 indicates probably burst suppression and a score of zero represents a flatline EEG.
Why is a Phase II block rarely seen with succinylcholine? A. Improved formulations have reduced the occurrence of the side effect B. It is now contraindicated in patients with Guillain-Barre, the population in which it occurred C. The doses required to produce a Phase II block are rarely administered D. Succinylcholine is now only used in emergency situations
The correct answer is C. A Phase II block is not seen often in modern practice because succinylcholine infusions and large bolus doses required to produce it (6-8 mg/kg) are rarely used anymore
Which of the following statements related to the administration of a general anesthetic in an MRI suite are true? A. Protective anti-radiation lead gowns should be provided to all healthcare providers in the suite B. A laryngeal mask airway is contraindicated during the procedure C. MRI contrast media often causes nausea D. An MRI only emits ionizing radiation
The correct answer is C. Because an MRI utilizes magnetic waves rather than ionizing radiation, protective lead gowns or aprons are not necessary in an MRI suite. A laryngeal mask airway is an effective method of airway management during MRIs so long as the patient meets the criteria for its use. MRI contrast utilizes gadolinium chelates which have much lower allergy rates than the contrast media used in CT scans, however, nausea is a frequent side effect.
Which opioid is currently recommended only for shivering? A. Remifentanil B. Fentanyl C. Meperidine D. Morphine
The correct answer is C. Because of the risk of seizures from the metabolite normeperidine, meperidine is now only recommended for the treatment of shivering.
Which of the following findings would warrant postponement of an elective procedure for further diagnostic evaluation? A. Longstanding atrial fibrillation B. Right bundle branch block without shortness of breath C. Symptomatic mitral stenosis D. Asymptomatic bradycardia
The correct answer is C. Conditions that warrant postponement of elective procedures for further evaluation include symptomatic mitral stenosis, new onset ventricular tachycardia, symptomatic ventricular arrhythmias, unstable angina, MI within the past 30 days, severe aortic stenosis, symptomatic bradycardia, and high-grade heart block.
Dressler's syndrome is A. blindness related to hypotension in the prone position B. ST segment depression during myocardial ischemia C. pericarditis following a myocardial infarction D. low serum cortisol levels following chronic exogenous steroid administration
The correct answer is C. Dressler's syndrome is a form of pericarditis seen following myocardial infarction.
Spinal shock is a condition that can last A. 1-3 hours B. 1-3 days C. 1-3 weeks D. 1-3 years
The correct answer is C. In patients who survive, spinal shock can last 1-3 weeks (some sources cite up to 6 weeks).
Local anesthetics exert their action by blocking A. calcium channels on the interior of the cell membrane B. potassium channels on the exterior of the cell membrane C. sodium channels on the interior of the cell membrane D. sodium channels on the exterior of the cell membrane
The correct answer is C. Local anesthetics bind to the alpha-subunit on sodium channels on the inside of the cell membrane and block the large influx of sodium into the cell associated with depolarization.
You are performing an anesthetic for a patient undergoing an MRI that is receiving gadolinium contrast dye. What are the most likely side effects of its administration? A. Tachycardia B. Hypotension C. Nausea D. Urticaria
The correct answer is C. MRI contrast is a chelated form of gadolinium that is administered intravenously. A common side effect is nausea.
Which of the following events would not be attributed to the effects of using methylmethacrylate to cement artificial components during a total hip arthroplasty? A. Pulmonary hypertension B. Systemic hypotension C. Impaired platelet aggregation D. Cardiovascular collapse
The correct answer is C. Methylmethacrylate use is associated with a decrease in blood pressure and possibly cardiovascular collapse due to vasodilation as well as pulmonary hypertension and a possible decrease in PaO2 due to embolization. Impaired platelet aggregation is not a finding associated with methylmethacrylate use.
A portosystemic shunt is performed to treat A. Hydrocephalus B. Tricuspid atresia C. Portal hypertension D. Intestinal obstruction
The correct answer is C. Portal hypertension develops when the splanchnic venous return to the heart becomes impeded. This results in congestion of the venous return and leads to esophageal varices. A portocaval or portosystemic shunt is performed to anastamose the portal vein to the inferior vena cava to decompress the portal venous system.
You are performing a general anesthetic for a patient undergoing a carotid endarterectomy. Which statement below best illustrates an understanding of how to manage the mean arterial blood pressure for this procedure? A. For severe hypotension, labetolol is the agent of choice B. The mean arterial pressure should be maintained at about 80 percent of the preoperative pressure C. For hypotension, ephedrine is preferred for its indirect, sympathomimetic activity D. A pure-alpha agonist such as phenylephrine is preferred for the treatment of hypotension
The correct answer is D. During a carotid endarterectomy, it is advised to maintain the patient's MAP slightly above their highest recorded preoperative pressure. For severe hypertension, labetolol may be used, but nitroglycerin is preferred for its swift onset and short duration of action as labetolol could result in postoperative hypotension due to its long duration of action. For hypotension, a pure alpha-agonist such as phenylephrine is preferred because it has minimal dysrhythmogenic potential.
When ventilating a patient with a self-inflating manual resuscitator, the risk of barotrauma from excessive airway pressure is highest when ventilating via a(n) A. mask B. laryngeal mask airway C. laryngeal tube D. endotracheal tube
The correct answer is D. High airway pressure is a hazard when using a self-inflating manual resuscitator if a pressure relief valve is not utilized. The risk is greater with endotracheal tubes than with mask or supraglottic devices such as the LMA or laryngeal tube which tend to leak at a lower pressure than an endotracheal tube
Which of the following agents would most readily cross the placenta? A. Succinylcholine B. Glycopyrrolate C. Cisatracurium D. Ketamine
The correct answer is D. Ketamine is very lipid soluble and quickly crosses from the placenta to the fetus. Induction doses of 0.5-1 mg/kg, however, do not compromise neonatal status at delivery. Uterine blood flow is maintained as well as uterine tone. Induction doses of 2-2.5 mg
Which of the following groups are at an increased risk for the development of latex allergy? A. Patients with Trisomy 18 B. Patients with a cephalosporin allergy C. Patients with an allergy to fish D. Patients with genitourinary defects
The correct answer is D. Spina bifida, spinal cord injury, and congenital abnormalities of the genitourinary tract are associated with an increased risk for developing latex allergy. Persons with chronic exposure to latex (healthcare workers and patients who undergo frequent urinary catheterization) are also at increased risk.
Click the Exhibit button at the top of the screen. Identify the cardiac rhythm depicted in the exhibit "If some P's don't get through, then you have a __________ ___" A. Normal sinus rhythm with premature ventricular contractions B. Second degree block type II C. Junctional (nodal) rhythm D. Second degree block type I
The correct answer is D. The lengthening of the PR interval over two or more beats and eventual complete block of a QRS occurring in a repeated cycle is the primary diagnostic indicator of second degree block type 1.
What is the perioperative mortality rate for a carotid endarterectomy? A. 20-25 percent B. 10-15 percent C. 3-5 percent D. 0.5-2.5 percent
The correct answer is D. The perioperative mortality rate for a carotid endarterectomy is 0.5-2.5 percent
You are performing general endotracheal anesthesia on a patient undergoing laparoscopic cholecystectomy with a cholangiogram study. During the procedure, the surgeon states that he is unable to perform the cholangiogram due to spasm of the Sphincter of Oddi. Which of the following medications below would NOT potentially relieve spasm of the Sphincter of Oddi? A. Naloxone B. Glucagon C. Nitroglycerin D. Morphine
The correct answer is D. The use of opioids such as morphine can produce spasm of the sphincter of Oddi, which can make the performance of a cholangiogram difficult. Meperidine is considered to be less likely to cause spasm of the sphincter of Oddi than other opioids. Drugs that have been used to treat the spasm include small amounts of naloxone, glucagon, and nitroglycerin.
A substance abuse issue occurs involving a colleague. No patient is currently at risk for harm. The facility does not yet have a substance abuse policy. What should you do first? A. Notify the state board of medicine B. Perform an intervention with the person C. Call 911 D. Call the AANA Peer Assistance Helpline
The correct answer is D. When a facility does not have a substance abuse policy already in place, you should call the AANA Peer Assistance Helpline at 800-654-5167. If there is a risk of imminent harm, you should call 911 immediately.
Match the diuretic with the portion of the nephron where it exerts its effects. Thick ascending loop of Henle to Collecting duct to Distal convoluted tubule to
The correct match is: Thick ascending loop of Henle to Loop diuretics Collecting duct to K+ sparing diuretics Distal convoluted tubule to Thiazide diuretics.
You are evaluating a patient who has survived breast cancer and is now presenting for a mammoplasty. Which of the following chemotherapy agents would warrant further investigation into her current hepatic function? A. Methotrexate B. Doxarubicin C. Cyclophosphamide D. Paclitaxel
You answered B. The correct answer is A. Methotrexate can produce renal and hepatic dysfunction. Doxarubicin (Adriamycin) can result in cardiomyopathy and congestive heart failure. Cyclophosphamide is an alkylating agent that can produce pulmonary toxicity and pulmonary fibrosis. Paclitaxel is a taxane that can produce peripheral neuropathy.
A trigger point injection would be most appropriate for the treatment of A. visceral pain B. pain along a group of nerve roots C. pain from trigeminal neuralgia D. myofascial pain
You answered B. The correct answer is D. A trigger point injection is the injection of local anesthetic in a muscle to treat myofascial pain
You have just intubated a 70 Kg patient suffering from severe burns of the face and head and entire anterior torso. You start an intravenous line and begin administering fluids. You know that the initial fluid resuscitation volume to be infused over the first 24 hours is about A. 5,000 mL B. 10,000 mL C. 12,500 mL D. 15,000 mL
You answered C. The correct answer is A. The most commonly used strategy for fluid resuscitation is to take the percent of body surface area burned, multiply it by 2-4 times the weight in kilograms, and administer that volume during the first 24 hours following the burn. This patient has suffered a 27% burn (18% for the anterior trunk and 9% for the face and head). This creates a range of fluid administration between 3780 and 7560 mLs, making 5,000 mLs the best answer.
Which statement indicates an incorrect understanding of the precordial doppler? A. The precordial doppler is the single most sensitive device for detecting venous air embolism B. The doppler should be placed over the right sternal border between the 3rd and 6th intercostal spaces C. Injection of mannitol can result in a false-positive result for venous air embolism D. The precordial dopper is noninvasive
You answered C. The correct answer is A. The transesophageal echocardiogram is the most sensitive device for detecting venous air embolism. The doppler is, however, the most sensitive non-invasive device for this purpose. The doppler should be positioned over the right sternal border between the 3rd and 6th intercostal spaces. The injection of mannitol through a central venous line may mimic the signal of a venous air embolism.
What surgical procedure would you expect to have the highest risk for the development of acute pancreatitis postoperatively? A. Intracranial surgery B. Cardiac thoracic surgery C. Caesarean delivery D. Lumbar fusion
You answered C. The correct answer is B. Pancreatitis may occur postoperatively in association with abdominal and thoracic surgery, particularly after cardiopulmonary bypass. It also occurs in 1-2 percent of patients who undergo an ERCP.
The risk associated with the development of CO2 emboli during laparoscopic surgery is potentially increased by A. the administration of nondepolarizing muscle relaxants B. electrolyte abnormalities due to bowel prep C. conversion to an open surgical procedure D. the use of nitrous oxide
You answered C. The correct answer is D. The use of nitrous oxide during laparoscopic procedures can potentially increase the risk associated with CO2 emboli by diffusing into small emboli, making them larger and more hazardous.
What are the symptoms of hyperglycemic hyperosmolar syndrome? (select four) A. Bradycardia B. Mesenteric thrombosis C. Hypertension D. Tachycardia E. Polyuria F. Polydipsia G. Metabolic alkalosis H. Plasma osmolarity < 300 mOsm/L
You answered CDEF. The correct answer is BDEF. Polyuria, polydipsia, hypotension, tachycardia, hyperosmolarity (>340 mOsm/L) and hypoperfusion of major organs. Intravascular coagulation and mesenteric thrombosis are a significant risk in hyperglycemic hyperosmolar syndrome.
Which of the following conditions are associated with a deficiency of alpha-1 acid antitrypsin? A. Acromegaly B. Diabetes mellitus C. Emphysema D. Sarcoidosis
You answered D. The correct answer is C. Alpha-1 antitrypsin protects the elastic tissue of the lungs from neutrophil elastase deficiency. Alpha-1 antitrypsin deficiency is a rare, homozygous syndrome in which a defective form of alpha-1 antitrypsin is produced by the liver. The defective form of alpha-1 acid antitrypsin accumulates in the liver, resulting in cirrhosis and the lack of the normal form in the lungs results in pulmonary diseases such as asthma and emphysema.
Match each cause of obstetric hemorrhage with its appropriate characteristic. Abnormal placental adherence to the myometrium to Separation of the placentae from the uterine wall to Covering of the cervical os by the placenta to
Abnormal placental adherence to the myometrium to Placenta accreta Separation of the placentae from the uterine wall to Abruptio placentae Covering of the cervical os by the placenta to Placenta previa.
Match the area of the lung with the location of West Zone III based upon the position of the patient. Dorsal recumbent to Trendelenburg to Reverse Trendelenburg to
Dorsal recumbent to Dorsal body wall Trendelenburg to Apices Reverse Trendelenburg to Lung bases
A postpartum patient presents for a tubal ligation. What is the most common form of anesthesia for this procedure? A. Local anesthesia B. General anesthesia C. Spinal anesthesia D. Epidural anesthesia
You answered C. The correct answer is A. Although general anesthesia, spinal anesthesia, and epidural anesthesia are all acceptable options, 75 percent of all tubal ligations are performed under local anesthesia.
Match the psychiatric medication with its salient characteristic. You matched: Requires tyramine-free diet to Can produce polyuria to Structurally similar to phenothiazines to
Requires tyramine-free diet to Monoamine oxidase inhibitor Can produce polyuria to Lithium Structurally similar to phenothiazines to Amitryptiline.
Many changes in organ function and composition occur by the eighth decade of life. Match the appropriate change with the organ system change or diagnostic characteristic with which it is associated. Serum creatinine concentration to Brain mass to Plasma catecholamine levels to Increases. Decreases Stays the same
Serum creatinine concentration to Stays the same Brain mass to Decreases Plasma catecholamine levels to Increases.
A gas occupies 100 mL at a temperature of 100 Kelvin. What is the temperature if the next measured volume is 175 mL? (calculate to nearest whole number)
The correct answer is 175. This problem is calculated using Charles' law which is represented as (V1/T1) = (V2/T2). Using this formula, we get (100/100) = (175/T2) where T2 = 175 Kelvin. You may also write this formula as V1T2 = V2T1 which just saves you one step.
What is the hourly maintenance fluid requirement for a 13 Kg child? (enter a whole number)
The correct answer is 46. The hourly fluid maintenance rate is calculated as 4 mL/kg/hour for the first 10 kg, 2 mL/kg/hour for the second 10 kilograms, and 1 mL/kg/hour thereafter. In this instance, the child weighs 13 Kg which you can think of as 10 kg + 3 Kg. The first 10 kilograms warrant 40 mL/hour and the remaining 3 kilograms warrant 6 additional mL/hour for a total of 46 mL/hour.
Which of the following laws explains how nitrous oxide can expand an existing pneumothorax? A. Fick's law B. Henry's law C. Graham's law D. The law of Brownian motion
The correct answer is A. Fick's law describes the diffusion of gases across biological tissues and states that the diffusion of a gas across a semipermeable membrane is directly proportional to the partial pressure gradient, the membrane solubility of the gas, and the surface area of the membrane and is inversely proportional to the thickness of the membrane and the molecular weight of the gas. Henry's law states that at constant temperature, the amount of gas dissolved in a liquid is directly proportional to the partial pressure of the gas above the gas-liquid interface. Graham's law states that the diffusion of a gas through an orifice is inversely proportional to the square root of the molecular weight of the gas. Brownian motion describes the mechanism by which the inherent kinetic energy of particles results in their random movement.
Induction of general anesthesia for which of the following procedures carries the highest risk for aspiration? A. Zenker's diverticulectomy B. Airway management for epiglottitis C. Tonsillectomy D. Parathyroidectomy
The correct answer is A. Although aspiration is a risk for all procedures for which intubation is performed, the disease process in this circumstance dictates a higher risk for patients with Zenker's diverticulum, which is a herniation of the mucosa through the posterior hypopharyngeal wall. Patients experience dysphagia, coughing, and regurgitation of undigested food as a result. Weight loss and aspiration pneumonia are seen in the more severe cases. If the diverticulum is positioned above the cricoid cartilage, cricoid pressure becomes useless as a tactic for reducing the risk of aspiration. Rapid sequence intubation is always indicated.
Which pulse oximetry site would respond the slowest to changes in oxygen saturation? A. Finger B. Ear C. Forehead D. Nose
The correct answer is A. Although it is the most commonly used location, the fingers respond slower to changes in oxygen saturation than more centrally placed locations such as the ear, nose, or forehead. The more central locations are also more resistant to vasoconstriction from cold or reduced perfusion.
You are preparing to anesthetize a pediatric patient with Arnold-Chiari malformation. Which of the following is true regarding the care of a patient with this condition? A. Extension of the neck should be avoided B. The pathology involves compression of the pituitary gland C. Surgical correction typically involves a parietal craniotomy D. It involves the cephalad displacement of the cerebellar vermis
The correct answer is A. Arnold-Chiari malformation almost always coexists with myelodysplasia and involves the caudal displacement of the cerebellar vermis, fourth ventricle, and lower brainstem below the level of the foramen magnum. Medullary cord compression can occur, particularly with extension of the neck, and patients may present with symptoms such as vocal cord paralysis, swallowing dysfunction, and chronic pulmonary aspiration. Surgical correction is usually performed by a decompressive suboccipital craniectomy with cervical laminectomies to relieve the compression. Because of cranial nerve and brainstem dysfunction, children with this disorder may have abnormal responses to hypoxia and hypercarbia.
All of the following physiologic parameters decrease in the elderly except A. Closing volume B. Renal mass C. Lean body mass D. Body water
The correct answer is A. Compared with younger adults, the geriatric population have a reduced lean body mass, decreased total body water, decreased serum albumin, decreased kidney mass, and decreased hepatic blood flow. Body fat and closing volume, however, increase with age.
Which of the following is false regarding disseminated intravascular coagulation? A. The most common cause related to septic shock is gram-positive organisms B. It may occur as a result of prolonged surgery C. It may occur as a result of placenta previa D. It may occur in association with tumor lysis syndrome
The correct answer is A. DIC is associated with a wide range of disorders including septic shock, placenta previa, abruption, amniotic fluid embolism, presence of a dead fetus late in pregnancy, and tumor lysis syndrome. Prolonged surgery and surgery for certain procedures such as prostatectomy for carcinoma, liver transplantation, and coronary bypass surgery are associated with significant bleeding abnormalities. When associated with septic shock, it is most often caused by gram-negative organisms.
Which of the following indicates a proper understanding of how to apply the thumb and forefinger against the cricoid cartilage when performing the Sellick maneuver? A. Pressing backward, downward, and to the left until the fingers blanch directly on the cricoid cartilage B. Pressing backward, upward, and to the left until the fingers blanch just above the cricoid cartilage C. Pressing backward, upward, and to the right until the fingers blanch directly on the cricoid cartilage D. Pressing backward, downward, and to the right until the fingers blanch just above the cricoid cartilage
The correct answer is C. Proper application of the Sellick maneuver calls for application of the BURP method (Back, Upward, and Rightward Pressure) directly on top of the cricoid cartilage until the fingers blanch. The reason for the directional component of this technique is because in about 75% of patients, the esophagus is slightly to the right of the trachea, so moving the cricoid cartilage downward, upward, and to the right should occlude the esophagus in most patients.
According to the AANA, institutional policies regarding advance directives (ADs) for patients undergoing anesthesia should be oriented towards A. maintaining the current AD until the patient arrives in PACU B. maintaining the AD throughout anesthesia C. suspending the AD until a specified time postop D. suspending the AD for 7 days postop
The correct answer is C. The AANA recommends that institutions form patient-centered policies and create documentation to help educate patients and their families with the goal of suspending advance directives during anesthesia and for a specified time postoperatively.
The term ED50 refers to A. the onset time of a drug B. the time it takes for 50% of a drug to be eliminated C. the plasma concentration at which half a drug's maximal effect is seen D. 50% of the lethal dose of a drug
The correct answer is C. The ED50 represents the site concentration at which a drug exhibits half of its maximal effect. The time it takes for 50% of a drug to be eliminated is referred to as its half-life. The LD50 is the dose that is lethal in 50% of the population.
When the anesthesia machine is connected to a pipeline gas supply, the backup gas cylinder valves should be kept in the closed position so that A. they don't exert damaging pressure into the pipeline supply B. the patient is not exposed to excessive airway pressures C. a pipeline oxygen failure will trigger an alarm more quickly D. frost will not form on the valves
The correct answer is C. When connected to a pipeline gas source, the cylinders should be kept closed so that a pipeline pressure failure would be detected earlier and to prevent pressure variations in the pipeline from draining oxygen from the cylinders.
Which of the following are characteristics of sevoflurane? (select two) A. It has a vapor pressure of 238 B. It is metabolized less than desflurane C. It has a molecular weight of 200.1 D. It contains more fluorine atoms than desflurane
The correct answer is CD. Sevoflurane has a vapor pressure of 157-170 at room temperature and an oil-gas partition coefficient of 47-54. The molecular weight of sevoflurane is 200.1. Sevoflurane contains 7 fluorine atoms while desflurane contains only 6. Sevoflurane undergoes metabolism at a rate of 5-8 percent and only trace amounts of desflurane are metabolized. Isoflurane has an oil-gas partition coefficient of 90.8 and a vapor pressure of 238.
The primary means a newborn infant has to respond to hypothermia is A. shivering B. vasoconstriction C. shunting blood to the peripheral tissues D. the increased release of norepinephrine
The correct answer is D. A newborn infant will respond to a 2 degree Celsius drop in temperature by releasing norepinephrine into the bloodstream which will cause lipolysis of brown adipose tissue. This is called nonshivering thermogenesis. The increased adipose metabolism will produce heat but will also produce ketones and increase oxygen consumption.
A patient presenting for carotid endarterectomy has amaurosis fugax. You know that this is A. hemiparesis of the extremities B. facial nerve paralysis C. memory loss due to chronic cerebral microemboli D. monocular blindness
The correct answer is D. Amaurosis fugax is monocular blindness that occurs in 25% of all patients with high-grade carotid stenosis. It is believed to be caused by emboli that migrate from the carotid lesion to the opthalmic artery.
You are using a circle anesthetic circuit and realize that the carbon dioxide absorbent has become exhausted. You decide to convert the circuit to an open configuration. What is the easiest way to do this during the case? A. Disconnect the patient from the circle circuit and replace it with a Mapleson D circuit B. Close the scavenger system C. Open the APL valve D. Increase the fresh gas flow rate above the patient's minute ventilation
The correct answer is D. An open circuit implies that the patient is not rebreathing any of the exhaled gases. Although this is wasteful, it can also be useful in the event the CO2 absorbent becomes exhausted during a case and you need to prevent the patient from rebreathing exhaled carbon dioxide. Increasing the fresh gas flows above the patient's minute ventilation will convert a circle system to an open configuration
Hepatic dysfunction due to biliary tract obstruction would be consistent with which laboratory finding? A. Decreased conjugated bilirubin B. Increased unconjugated bilirubin C. Markedly increased aminotransferase enzymes D. Markedly increased alkaline phosphatase levels
The correct answer is D. Biliary stones are considered a posthepatic cause of hepatic dysfunction and are associated with an increased conjugated fraction of bilirubin, normal to slightly increased aminotransferase enzymes, and most notably, markedly increased alkaline phosphatase levels.
Which of the following does not decrease significantly with age? A. Lean muscle mass B. Bone density C. The number of functioning nephrons D. Baseline hepatic function
The correct answer is D. By age 80, the number of functioning nephrons has decreased by 50 percent. Lean muscle mass decreases with age. Bone density decreases significantly with age, increasing the risk for fractures. Although hepatic mass decreases significantly, baseline hepatic function remains well preserved with age
Patients taking HMG-CoA reductase inhibitors may exhibit (select two) A. Elevated creatine kinase B. Decreased serum albumin levels C. Elevated serum aminotransferase activity D. Decreased white blood cell count
You answered AD. The correct answer is AC. HMG-CoA reductase inhibitors (statins) are used to treat elevated lipid levels and may result in elevated creatine kinase levels as well as serum aminotransferase activity that can be 2-3 times normal. The fibrate anti-lipid medications such as gemfibrozil and fenofibrate may result in decreased white blood cell counts
Which nondepolarizing muscle relaxant is metabolized predominantly by ester hydrolysis? A. Atracurium B. Cisatracurium C. Rocuronium D. Vecuronium
Which nondepolarizing muscle relaxant is metabolized predominantly by ester hydrolysis? A. Atracurium B. Cisatracurium C. Rocuronium D. Vecuronium
Which of the following is a cause of polycythemia without an increase in total red cell mass? A. Chronic lung disease B. Living at high altitude C. Hypovolemia D. Hypoxia
You answered A. The correct answer is C. Hypovolemia results in an elevated hematocrit because of the decreased volume in which the red cell mass resides without an actual increase in red cell mass. Chronic lung disease and living at high altitudes both result in a compensatory increase in red cell mass and an increased hematocrit as a compensatory mechanism to increase tissue perfusion in the face of decreased blood oxygen levels. Hypoxia is associated with an increased red cell mass.
