General Anesthesia ITE review
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Transcript General Anesthesia ITE review
General
Anesthesia ITE
review
Alexandru Apostol, M.D.
01/04/2013
Question 1
Which of the following is the BEST site to monitor
core temperature during general anesthesia?
A.
Axilla
B.
Bladder
C.
Nasopharynx
D.
Forehead
Answer 1
Correct answer is C
A. Core temperature can only be
estimated from this measurement site.
B. Changes in core temperature may
precede changes in bladder
temperature.
D. Core temperatures can only be
estimated from this measurement site.
Question 2
A patient with a bowel obstruction presents to the
operating room for an exploratory laparotomy. He has
metastatic colon cancer, and there is a do-notresuscitate (DNR) order on his chart. Which of the
following is the MOST appropriate action to take?
A.
Cancel the surgery.
B.
Suspend the DNR order.
C.
Do not treat intraoperative hypotension.
D. Discuss with the patient his wishes regarding
resuscitation during anesthesia.
Answer 2
Correct answer is D
A. Patients with DNR orders are appropriate
candidates for some surgical procedures, especially
palliative procedures that may improve the patient's
comfort or quality of life. In fact, approximately 15% of
patients with DNR orders undergo surgery.
B.
Policies that automatically suspend a DNR order
during surgery and anesthesia are not recommended
because such policies jeopardize the patient's
autonomy.
C. Intraoperative hypotension is often a transient
event that is precipitated by the surgery or anesthesia
and can easily be treated with a vasopressor.
Administration of a vasopressor in this situation is quite
different from most situations outside the operating
room that require this treatment. Many patients with a
DNR order would consent to and desire this treatment.
Question 3
A patient states that he has an allergy to penicillin and
describes a previous incident of hives and "throat tightness."
Which statement about prophylactic antibiotic administration
in this patient is MOST likely true?
A.
An acceptable alternative antibiotic is clindamycin.
B.
There is a 50% risk of anaphylactic reaction to a
cephalosporin.
C.
Administration of an intravenous "test dose" of a
cephalosporin is recommended in this patient.
D.
Pretreatment with diphenhydramine is an effective
prophylactic prior to cephalosporin administration in this
patient.
Answer 3
Correct answer is A
B. The risk of cross-reactivity of penicillin with
newer cephalosporins has been reported to
be at most 5% to 12%.
C. While allergy testing may be useful to
determine the presence of a true allergy,
administration of a small intravenous "test
dose" may precipitate an anaphylactic
response.
D. Pretreatment regimens are inconsistent
and not recommended.
Question 4
A 32-year-old woman with severe mitral regurgitation
secondary to mitral valve prolapse presents for an
abdominal hysterectomy under general anesthesia.
Her left ventricular ejection fraction is greater than
60%. Which of the following will MOST likely improve
her cardiac output?
A.
Phenylephrine
B.
Norepinephrine
C.
Dobutamine
D.
Esmolol
Answer 4
Correct answer is C
A. Phenylephrine, a direct-acting alpha1
agonist, may worsen mitral regurgitation by
increasing systemic vascular resistance and
decreasing heart rate.
B. Norepinephrine may cause modest increases
in heart rate via beta1 receptor activation, but its
predominant alpha1 activity increases systemic
vascular resistance, thereby worsening mitral
regurgitation.
D. Esmolol decreases heart rate, increasing the
amount of time spent in systole and increasing the
regurgitant fraction.
Question 5
A patient complains of pain in the
posterolateral aspects of his arm and forearm
with radiation into the index and middle finger.
On physical examination, there is weakness of
the triceps and the triceps reflex is absent. The
MOST likely cervical nerve root affected is
A C5.
B C6.
C C7.
D C8.
Answer 5
Correct answer is C
A. C5 lesions do not cause weakness of the
triceps. With C5 lesions, pain is more typically
referred to the shoulder girdle.
B. C6 lesions are associated with pain and
numbness in the thumb and middle fingers
and diminished biceps reflex.
D. C8 lesions cause pain in the medial arm
and forearm radiating into the little and ring
fingers.
Question 6
A previously healthy 45-year-old woman develops
bilateral lower extremity weakness 3 weeks after an
upper respiratory tract infection. Which of the following
is MOST likely to be present in a patient with GuillainBarré syndrome (GBS) at the time of diagnosis?
A.
Pain
B.
Hyperreflexia
C.
Fever
D.
Urinary incontinence
Answer 6
Correct answer is A
B. GBS is associated with decreased or absent
deep tendon reflexes, not hyperreflexia.
C. Although fever may occur during the
antecedent infection, it is uncommon at the time
of presentation in a patient with GBS. In fact, the
presence of a fever at the time of presentation
suggests that the diagnosis of GBS is less likely.
D. Although urinary retention and/or
gastroparesis may occur in severe cases of GBS,
neither bladder nor bowel incontinence is
commonly described at the time of presentation.
Question 7
The same patient in Question 6 Over the next 5 days the
patient's weakness progresses rapidly, and she is admitted to
the hospital after becoming unable to walk without
assistance. Assuming no aspiration or other concurrent
pulmonary problems, which of the following is likely to be the
EARLIEST indicator of the eventual need for mechanical
ventilation?
A.
Negative inspiratory force (NIF) of –30 cm H2O
B.
Partial pressure of carbon dioxide in arterial blood of
60 mm Hg
C.
Respiratory rate of 10 breaths/min
D.
Decline of vital capacity to 12 mL/kg
Answer 7
Correct answer is D
A. Respiratory muscle weakness leads to a
reduced NIF. Intubation and ventilation is
generally recommended if NIF is not more
negative than –20 cm H2O.
B. Hypercapnia is a relatively late finding in
patients with Guillain-Barré syndrome who
require mechanical ventilation.
C. Respiratory muscle weakness generally
leads to a decrease in tidal volume. In this
circumstance, respiratory rate is increased
rather than decreased.
Question 8
Same patient last 2 questions
Which of the following treatments is MOST likely to decrease
the likelihood that ventilatory assistance will be needed in a
patient with Guillain-Barré syndrome (GBS)?
A.
Oral administration of corticosteroids
B.
Intravenous administration of immunoglobulin
C.
Intramuscular administration of interferon beta-1a
D.
Exchange transfusion
Answer 8
Correct answer is B
A. Studies evaluating the effect of high-dose
corticosteroids on the course of GBS showed no
improvement in any outcome when the intravenous
route was used and a suggestion of worsened
outcome when the drugs were administered orally.
C. Although interferon beta-1a is effective in
treating patients with multiple sclerosis, it has not
been shown to be beneficial in treating GBS.
D. Although plasma exchange has been
demonstrated to be effective in decreasing the
need for ventilatory assistance, there have been no
studies conducted on exchange transfusion.
Question 9
A man who was severely burned in a house fire is suspected
of having cyanide toxicity. Which of the following is the MOST
reliable indicator of cyanide toxicity?
A.
Metabolic acidosis
B.
Decreased mixed venous oxygen saturation (S o2)
C.
Elevated serum cyanide levels
D.
Arterial blood appearing chocolate brown in color
Answer 9
B. Because cyanide blocks oxygen utilization by
the cells, S o2 and partial pressure of oxygen in
mixed venous blood (P o2) are elevated in the
presence of cyanide toxicity.
C. Blood levels of cyanide are not commonly
available and not particularly useful in diagnosing
cyanide toxicity, which depends on the total dose
of cyanide received and the rate of release.
D. Arterial blood that appears chocolate brown
is an indication of methemoglobinemia, not
cyanide toxicity.
Correct answer is A
Question 10
Administration of which of the following is MOST likely
to decrease cyanide toxicity through increased
renal elimination?
A.
Amyl nitrite
B.
Vitamin B12
C.
Sodium nitrite
D.
Sodium thiosulfate
Answer 10
A.
Amyl nitrite produces methemoglobin, which binds
cyanide to form cyanmethemoglobin. Because cyanide is
bound, cytochrome oxidase is restored and aerobic
metabolism can resume. Increased levels of methemoglobin
result in decreased oxygen-carrying capacity and oxygen
delivery. It does not produce its effect through increased renal
elimination.
B.
Vitamin B12 (hydroxycobalamin) inactivates cyanide by
chelating the cyanide ion. It does not produce its effect
through increased renal elimination.
C.
Sodium nitrite produces methemoglobin, which binds
cyanide to form cyanmethemoglobin. Because cyanide is
bound, cytochrome oxidase is restored and aerobic
metabolism can resume. Increased levels of methemoglobin
result in decreased oxygen-carrying capacity and oxygen
delivery. It does not produce its effect through increased renal
elimination.
Correct answer is D
Question 11
A 67-year-old man presents for coronary artery
bypass grafting. Intraoperatively, the surgeon places
the arterial cannula into the ascending aorta, the
venous cannula into the right atrium, and
cardiopulmonary bypass is initiated. Which of the
following is MOST consistent with a malpositioned
aortic cannula causing an aortic dissection?
A. Radial artery mean arterial pressure 15 mm Hg
B. Aortic cannula flow 4 L/min
C. Increased central venous pressure
D. Increased venous drainage to the reservoir
Answer 11
B. Aortic dissection due to a malpositioned
aortic cannula will result in reduced arterial
flow during cardiopulmonary bypass.
C. Aortic dissection due to a malpositioned
aortic cannula will result in decreased or
unchanged central venous pressure.
D. Venous drainage to the heart–lung
machine reservoir may decrease as
extraluminal blood is sequestered.
Correct answer is A
Question 12
Same patient from last Question
In this patient with an aortic dissection due to a
malpositioned aortic cannula, which of the following is the
MOST appropriate next step in managing his hypotension?
A. Administer phenylephrine.
B. Lower the arterial transducer to the level of the
heart‒lung machine.
C. Increase aortic cannula flow rate.
D. Cannulate the femoral artery.
Answer 12
A. For aortic dissection, mean arterial
pressure should not be increased until the
arterial cannula is repositioned.
B. The arterial transducer should be at the
level of the right atrium, even during
cardiopulmonary bypass.
C. For aortic dissection, increasing the aortic
cannula flow rate may extend the dissection
further.
Correct answer is D
Question 13
A 32-year-old primigravida at 28 weeks gestation has had increasing
headaches and now complains of double vision. Approximately 5 years
ago, a small meningioma was an incidental finding on a head computed
tomography (CT) scan after a motor vehicle crash. There was no follow-up.
The presumptive etiology of these symptoms is increased intracranial
pressure due to the tumor. Which of the following statements is MOST likely
true?
A.
Neurosurgical workup is not necessary.
B.
The administration of mannitol is considered safe during
pregnancy.
C.
Symptoms associated with intracranial lesions are much less likely
in pregnant than in nonpregnant women.
D.
All intravenous fluids should include glucose in a balanced salt
solution.
Answer 13
A. Treatment options require an accurate
assessment of her pathology. It is possible that
her symptoms reflect preeclampsia and not
an intracranial mass lesion.
C. The prevalence of symptoms in the
presence of intracranial pathology is the
same in pregnant and nonpregnant women.
D. When intracranial lesions are suspected,
intravenous fluids should not include glucose.
Balanced salt or isotonic saline solutions are
recommended.
Correct answer is B
Question 14
A 47-year-old man who underwent surgical repair of
a traumatic femur fracture requires admission to the
intensive care unit for acute dyspnea. Fat embolism
syndrome (FES) is suspected. Which of the following
findings is LEAST likely to be present in this patient?
A.
Petechial rash
B.
Bradycardia
C.
Hypoxemia
D.
Mental status changes
Answer 14
A.
FES is commonly associated with a
petechial rash.
C. FES is commonly associated with
hypoxemia.
D. FES is commonly associated with
mental status changes.
Correct answer is B
Question 15
Which of the following measures is MOST appropriate
in the management of right ventricular dysfunction
associated with fat embolism syndrome (FES)?
A.
Administration of a statin
B.
Infusion of dobutamine
C.
Placement of a left ventricular assist device
D.
Placement of an inferior vena cava filter
Answer 15
A. Statins are not the most appropriate
treatment for right ventricular dysfunction in FES.
C. Although a right ventricular assist device
might be helpful with right ventricular failure, a left
ventricular assist device is not appropriate for the
management of right ventricular dysfunction.
D. An inferior vena cava filter is used in patients
with lower extremity venous thrombosis in whom
anticoagulation is contraindicated. It is not useful
for the treatment of right ventricular dysfunction in
FES.
Correct answer is B
Question 16
A patient is admitted to the intensive care unit with
pneumonia. Over the next 24 hours, he develops fever,
leukocytosis, oliguria, and hypotension despite fluid
resuscitation (>4 L crystalloid over 24 hours). Which of the
following MOST accurately describes his clinical condition?
A.
Sepsis
B.
Sepsis-induced hypotension
C.
Severe sepsis
D.
Septic shock
Answer 16
A.
Sepsis is not associated with either
tissue dysfunction (oliguria) or
hypotension.
B. Sepsis-induced hypotension is not
associated with other evidence of
specific tissue dysfunction (oliguria).
C. Severe sepsis is not associated with
hypotension.
Correct answer is D
Question 17
An otherwise healthy 38-year-old woman at 33
weeks gestation has been diagnosed with severe
preeclampsia. Which of the following is MOST likely a
sign that the patient has compromised renal
function secondary to her preeclampsia?
A.
Serum creatinine level of 1.1 mg/dL
B.
Serum uric acid level of 2.0 mg/dL
C.
Blood urea nitrogen (BUN) level of 5 mg/dL
D.
Serum alanine transaminase level of 100 U/L
Answer 17
B. An increase, not a decrease, in serum uric
acid level is a manifestation of renal dysfunction in
preeclampsia.
C. A BUN level of 5 mg/dL is normal in pregnancy
and is not a manifestation of renal dysfunction.
D. An elevated serum alanine transaminase
level is a manifestation of hepatic dysfunction and
is one of the components of HELLP syndrome,
which is characterized by Hemolysis, Elevated Liver
enzymes and a Low Platelet count, but it is not a
manifestation of renal dysfunction.
Correct answer is A
Question 18
While attempting to place a 9 F pulmonary artery catheter
(PAC) introducer sheath into the right internal jugular vein of
an intubated and ventilated patient, the dilator is inserted to
the hub. After removal of the dilator and guidewire but before
placement of the PAC, the patient's blood pressure decreases
to 60/40 mm Hg and heart rate increases to 130 beats/min.
There is a simultaneous increase in peak inspiratory pressure.
The MOST appropriate next step is to
A.
remove the introducer and apply pressure.
B.
insert a pulmonary artery catheter.
C.
administer β-blocker therapy.
D.
place a thoracostomy tube.
Answer 18
A. The presentation is not really consistent with
insertion of the introducer sheath into the carotid
artery. If that had occurred, most recommendations
suggest that the catheter should be left in place
pending surgical consultation.
B.
Based on the scenario, it is likely that the
introducer sheath is not in the jugular vein.
Placement of a pulmonary artery catheter through
this introducer sheath is unlikely to be successful and
attempts to do so will delay emergency therapy.
C. β-Blockade would be contraindicated in this
setting.
Correct answer is D
Question 19
A patient taking the extended-release morphine/naltrexone
preparation marketed as Embeda is in a motor vehicle
accident and requires open laparotomy. Which statement
about how the naltrexone will affect the amount of opioids
required to control the patient's pain is MOST likely true?
A.
The naltrexone will decrease opioid requirements.
B.
The naltrexone will increase opioid requirements.
C.
The naltrexone will first decrease then increase opioid
requirements.
D.
The naltrexone will not influence opioid requirements.
Answer19
A. Naltrexone is an opioid antagonist and will
not decrease opioid requirements.
B. In the morphine/naltrexone preparation
currently marketed, the naltrexone is sequestered
behind a physical barrier and not bioavailable
unless the patient misuses the drug by chewing or
crushing it in an effort to obtain all of the
extended-release morphine as a bolus. When
used as directed, the naltrexone will not increase
opioid requirements.
C. The naltrexone will not first decrease then
increase opioid requirement.
Correct answer is D
Question 20
For an appropriately fasted patient who is not at an increased
risk for aspiration, which of the following BEST represents the
American Society of Anesthesiologists practice guidelines on
the use of pharmacologic agents to reduce the risk of
pulmonary aspiration?
A.
Preoperative administration of an anticholinergic is
recommended to reduce aspiration risk.
B.
Preoperative ondansetron administration is
recommended to reduce aspiration risk.
C.
Preoperative metoclopramide administration is
recommended to reduce aspiration risk.
D.
Routine preoperative use of multiple agents to
prevent aspiration is not recommended.
Answer 20
A. Routine preoperative administration of an
anticholinergic to reduce the risk of pulmonary
aspiration in healthy patients without risk factors for
aspiration is not recommended.
B. Routine preoperative administration of an
antiemetic to reduce the risk of pulmonary
aspiration in healthy patients without risk factors for
aspiration is not recommended.
C. Routine preoperative administration of
gastrointestinal stimulants such as metoclopramide
in healthy patients without risk factors for aspiration
is not recommended.
Correct answer is D
Question 21
Which of the following is the MOST likely
complication of chronic gabapentin therapy?
A.
Elevated serum creatinine
B.
Osteoporosis
C.
Jaw necrosis
D.
Weight gain
Answer 21
A. Gabapentin is eliminated by the kidney but
does not exhibit renal toxicity. Although gabapentin
may be associated with peripheral edema, this is not
due to renal toxicity, and there is no association
between the administration of gabapentin and
increased serum creatinine concentrations.
B.
First-generation anticonvulsants (eg, phenytoin)
used in the treatment of some chronic pain
conditions are associated with the development of
osteoporosis. Osteoporosis is not a complication of
gabapentin therapy.
C. Jaw necrosis is a well-documented
complication of bisphosphonate medications (eg,
alendronate), which are used to treat osteoporosis
and pain related to bony metastasis. Jaw necrosis is
not a complication of gabapentin therapy.
Correct answer is D
Question 22
Which of the following cardiovascular findings is
MOST consistent with hyperthyroidism?
A.
Increased systemic vascular resistance
B.
Decreased lusitropy (myocardial relaxation)
C.
Atrial fibrillation
D.
Pericardial effusion
Answer 22
A.
Hyperthyroidism is associated with a
decrease in systemic vascular resistance.
B. Hyperthyroidism is associated with
increased lusitropy.
D. Hypothyroidism, not hyperthyroidism, is
associated with an increased risk of
pericardial effusion.
Correct answer is C
Question 23
Which of the following is MOST likely to be increased
in a patient with idiopathic pulmonary fibrosis (IPF)?
A.
Pulmonary artery pressure
B. Diffusing capacity of lung for carbon
monoxide (DLCO)
C. Partial pressure of carbon dioxide in arterial
blood
D.
Forced vital capacity (FVC)
Answer 23
B.
IPF is characterized by decreased
DLCO.
C. Hypocapnia is more common in
patients with IPF.
D. Forced vital capacity is decreased in
patients with IPF.
Correct answer is A
Question 24
A 21-year-old man with an 8-cm anterior mediastinal
mass is scheduled for a mediastinoscopy and biopsy.
Chest computed tomography reveals 50% distal
tracheal compression from the mass. On physical
examination, several cervical lymph nodes are
palpable. Which of the following is the MOST
appropriate next management step for this patient?
A.
Initiation of femoral–femoral cardiopulmonary
bypass prior to induction of anesthesia
B.
Inhalational induction with sevoflurane
C.
Rapid sequence induction
D. Biopsy of cervical lymph nodes with local
anesthesia
Answer 24
A. While initiation of cardiopulmonary bypass
prior to induction of general anesthesia may be
reasonable, this would not be the most
appropriate management of this patient for this
procedure.
B. Inhalational induction with sevoflurane could
result in tracheal collapse and would not be the
most appropriate management of this patient for
this procedure.
C. Rapid sequence induction could result in
tracheal collapse; maintaining spontaneous
ventilation is generally considered preferable in
patients with tracheal compression due to an
anterior mediastinal mass.
Correct answer is D
Question 25
A 125-kg man is in the intensive care unit following repair of a
ruptured aortic aneurysm. Initial laboratory values in the
operating room at the start of the case included a serum
creatinine of 0.9 mg/dL and a blood urea nitrogen (BUN) level of
9 mg/dL. Which of the following is MOST likely to meet the Acute
Kidney Injury Network (AKIN) definition of acute kidney injury?
A.
Urine output of 75 mL/h for first 3 hours after surgery
B.
Serum creatinine of 1.1 mg/dL 24 hours after surgery
C.
Serum creatinine of 1.6 mg/dL 48 hours after surgery
D.
BUN of 30 mg/dL 72 hours after surgery
Answer 25
A. According to the AKIN, the urine output
must be less than 0.5 mL • kg–1 • h–1 for more
than 6 hours to meet the criteria for acute
kidney injury.
B. According to the AKIN, neither the
magnitude nor the duration of increase in
serum creatinine meets the criteria for acute
kidney injury.
D. According to the AKIN, BUN is not part of
the diagnostic criteria for acute kidney injury.
Correct answer is C
Question 26
A surgeon requests neuromonitoring for a patient who is
scheduled for clipping of a middle cerebral artery
(MCA) aneurysm. Which statement about providing
neuromonitoring services in this situation is MOST likely
true?
A.
Neuromonitoring can only be performed when
the anterior cerebral artery (ACA) is involved.
B.
Neuromonitoring requires scalp electrodes.
C. The standard stimulation site for sensory-evoked
potential stimulation would be the median nerve.
D. Latency changes will not be helpful in detecting
neurologic changes.
Answer 26
A. The MCA supplies the primary motor and
sensory areas of the face, throat, hand, and arm.
The ACA supplies primarily the frontal lobes, the
parts of the brain that control logical thought and
personality. The ACA also has a small distribution to
the lower extremity. Thus, neuromonitoring can in
theory be performed for MCA or ACA aneurysms.
B. When sensory cortex recordings or motor
cortex stimulation cannot be performed using
scalp electrodes, electrode strips placed directly
on the cortex can be substituted.
D. Prolonged conduction time, or latency, and a
decrease in response size are the measures of
changing neurologic function and injury.
Correct answer is C
Answer 27
Which statement about the anesthesia management for a 72year-old patient without coexisting disease is MOST likely true?
A.
Nondepolarizing neuromuscular blocking drugs have
a shorter duration of action in older adults than in younger
patients.
B.
Intravenous induction drugs have a more rapid onset
time in older adults than in younger patients.
C.
A decrease in volatile anesthetic minimum alveolar
concentration (MAC) of up to 30% occurs from 20 years of
age to age 80.
D.
The initial dose of opioids should be reduced by more
than 50% in older adult patients.
Answer 27
A. Data suggest that similar doses of
nondepolarizing neuromuscular blocking drugs
produce increased neuromuscular blockade in
older adults compared with younger patients.
B. Cardiovascular changes result in a longer
time to onset of hypnotic drug effects.
D. Some experts recommend administering the
same initial dose of opioids in older adult and
younger patients, with the dose, in part, based on
preoperative opioid use. Others recommend some
reduction in the initial opioid dose, but a reduction
of more than 50% is generally not recommended.
Correct answer is C
Question 28
Drug dosing based on which of the following indices
is MOST likely to result in administration of too small a
dose of any given anesthetic to a morbidly obese
patient?
A.
Ideal body weight (IBW)
B.
Lean body weight (LBW)
C.
Total body weight (TBW)
D.
Body surface area (BSA)
Answer 28
B. Because both cardiac output and drug
clearance are proportional to LBW, dosing
recommendations are commonly based on
LBW for most anesthetics.
C. Drug dosing based on TBW may result in
an overdose in a morbidly obese patient.
D. BSA calculations do not differentiate fat
mass from LBW. Few, if any, recommendations
for dosing of anesthetic drugs are based on
BSA.
Correct answer is A
Question 29
For morbidly obese patients, dosing based on ideal
body weight is MOST appropriate for which of the
following?
A.
Propofol
B.
Remifentanil
C.
Rocuronium
D.
Succinylcholine
Answer 29
A. For morbidly obese patients, it is generally
recommended that lean body weight be used for
induction doses of propofol and that dosing
during continuous infusion be based on total body
weight.
B. For morbidly obese patients, it is generally
recommended that lean body weight be used for
infusions of remifentanil.
D. For morbidly obese patients, it is generally
recommended that total body weight be used for
succinylcholine dosing.
Correct answer is C
Question 30
Which of the following is BEST characterized as a
direct thrombin inhibitor?
A. Clopidogrel
B.
Dabigatran
C. Ticlopidine
D.
Tirofiban
Answer 30
A.
Clopidogrel inhibits platelet
adenosine diphosphate receptors.
C. Ticlopidine inhibits platelet adenosine
diphosphate receptors.
D. Tirofiban is a platelet IIb-IIIa receptor
inhibitor.
Correct answer is B
Question 31
A 55-year-old man undergoing a coronary
artery bypass procedure is noted to have
massive hemoptysis from his tracheal tube
following separation from cardiopulmonary
bypass. You suspect pulmonary artery rupture
from the pulmonary artery catheter. The MOST
appropriate next step is to
A. re-initiate cardiopulmonary bypass.
B.
reverse heparin.
C. proceed with lung resection.
D.
re-intubate with a double lumen tube.
Answer 31
B.
In patients with minimal hemorrhage, correction
of the coagulopathy may be sufficient to control the
hemorrhage; there is no evidence that this is
effective in treating patients with massive
hemorrhage.
C. Lung resection should be reserved for
intractable bleeding, not as a first-line therapy
option.
D. Once the bleeding pulmonary segment has
been identified, lung isolation may commence with
a double lumen tube or placement of a bronchial
blocker. In this circumstance, controlling the
hemorrhage and protecting the uninvolved lung
may be better accomplished with a different
intervention.
Correct answer is A
Question 32
A 21-year-old woman with congenital long QT
syndrome presents for a knee arthroscopy.
Which of the following agents would be LEAST
likely to further lengthen the QT interval?
A. Ondansetron
B.
Succinylcholine
C. Combination of glycopyrrolate and
neostigmine
D.
Propofol
Answer 32
A. Ondansetron and other 5-hydroxytryptamine
type-3 antagonists have been shown to increase
the QT interval. Although there is no clear
association between the use of ondansetron and
torsade de pointes, it is recommended that this
agent be avoided in patients with congenital long
QT syndrome.
B. Succinylcholine administration has resulted in
prolonged QT intervals in patients with congenital
long QT syndrome, likely from potassium shifts and
autonomic effects.
C. The combination of glycopyrrolate and
anticholinesterase agents has been shown to
prolong QT intervals.
Correct answer is D
Question 33
At which of the following levels of
carboxyhemoglobin (COHb) would it be MOST
prudent to institute 100% oxygen therapy without
requiring hyperbaric oxygen?
A.
4%
B.
8%
C.
20%
D.
40%
Answer 33
A. Because a COHb level of 4% may be
considered "normal" for patients who are
cigarette smokers, this would not be
considered an indication for therapy with
100% oxygen.
B. Because a COHb level of 8% may be
considered "normal" for patients who are
cigarette smokers, this would not be
considered an indication for therapy with
100% oxygen.
D. At a carboxyhemoglobin level of 40%,
hyperbaric oxygen therapy is recommended.
Correct answer is C
Question 34
A 6-year-old inpatient with an intracranial tumor presents for a
1-hour magnetic resonance imaging (MRI) procedure in
preparation for tumor removal. He has been treated with
dexamethasone to reduce swelling and appears in no acute
distress. If the patient is allowed to breathe spontaneously
during the procedure, which of the following techniques is
MOST likely to maintain sedation and avoid increases in
intracranial pressure (ICP)?
A.
Propofol infusion
B.
Intravenous midazolam/fentanyl
C.
Dexmedetomidine infusion
D.
Oral chloral hydrate
Answer 34
A. Propofol is a respiratory depressant;
hypercapnia will produce an increase in ICP.
B. The intravenous midazolam/fentanyl
combination works synergistically to cause
respiratory depression; hypercapnia will
produce an increase in ICP.
D. Chloral hydrate is generally ineffective as
a sedative in children older than 3 years of
age.
Correct answer is C
Question 35
Which statement about cervical spine instability in patients
with Down syndrome (DS) is MOST likely true?
A.
Atlantoaxial instability is demonstrated in 50% of
cervical flexion/extension films in asymptomatic patients.
B.
The American Academy of Pediatrics recommends
lateral radiographs for all children with DS between 3 and 5
years of age.
C.
There are no reports in the medical literature of
iatrogenic cervical spinal cord injuries in patients with DS
undergoing surgery and anesthesia.
D.
The incidence of atlantoaxial instability is greater in
adults with DS than in children with DS.
Answer 35
A.
The rate of atlantoaxial instability in
patients with DS ranges from 7% to 36%.
C. At least 2 cases related to
laryngoscopy and several intraoperative
cases involving positioning have been
reported.
D. Although the literature reports
variable results, the rate of instability
appears to be the same in adults and in
children.
Correct answer is B
Question 36
For which of the following cases is lung separation
and intraoperative one-lung ventilation (OLV)
considered an ABSOLUTE indication?
A.
Pneumonectomy
B.
Upper lobectomy
C.
Bronchopleural fistula
D.
Esophageal resection
Answer 36
A.
Pneumonectomy is a relative but not
an absolute indication for OLV.
B. An upper lobectomy is a relative but
not an absolute indication for OLV.
D. An esophageal resection is a relative
but not an absolute indication for OLV.
Correct answer is C
Question 37
A 23-year-old, gravida 1, para 0 patient presents at 36 weeks
gestation to the triage area in active labor with ruptured
membranes and a breech presentation. She is 5-feet, 6-inches
tall and weighs 75 kg and is deemed to have a class I airway.
The obstetrician would like to perform an emergent cesarean
delivery. The patient reports a history significant for OslerWeber-Rendu (OWR) syndrome, also known as hereditary
hemorrhagic telangiectasia. Which statement about her
anesthetic management is MOST likely true?
A.
A nasal fiberoptic intubation would be the safest
technique.
B.
Peak airway pressures should be minimized during
general anesthesia.
C.
The risk of complications from OWR syndrome usually
declines during pregnancy.
D.
Cerebrovascular involvement in OWR syndrome is
extremely uncommon.
Answer 37
A.
Use of the nasal approach should be
avoided in this patient.
C. Pregnant women with OWR syndrome
are at increased risk of complications.
D. Up to 20% of patients with OWR
syndrome have at least 1 cerebral
arteriovenous malformation.
Correct answer is B
Question 38
Which of the following is MOST likely to occur in a
patient with a postdural puncture headache
(PDPH)?
A.
Tinnitus
B.
Photophobia
C.
Neck stiffness
D.
Hyperacusis
Answer 38
A. Tinnitus has been reported in patients with
PDPH, but other problems occur more commonly.
B. Visual manifestations, including photophobia,
diplopia, blurred vision, and difficulty
accommodating, are reported in up to 13% of
patients with PDPH, but it is not the most common
problem.
D. Hyperacusis has been reported in patients
with PDPH, but it is not the most common problem.
Correct answer is C
Question 39
In a patient taking lithium, the additional
administration of which of the following drugs
creates the GREATEST risk for toxicity?
A.
Acetazolamide
B.
Theophylline
C.
Ketorolac
D.
Spironolactone
Question39
A. Administration of acetazolamide is associated
with a decrease in serum levels of lithium and so
should result in a decreased risk of lithium toxicity.
B. Administration of theophylline is associated
with a decrease in serum levels of lithium and so
should result in a decreased risk of lithium toxicity.
D. Although administration of certain diuretics
can increase the risk of lithium toxicity, this effect
appears to be limited to sodium-wasting diuretics
(eg, loop diuretics). The effect does not appear to
occur with potassium-wasting diuretics such as
spironolactone.
Correct answer is C
Question 40
Which of the following is MOST likely to be the first
manifestation of oxygen toxicity in a normal patient
breathing normobaric 100% oxygen?
A.
Retrosternal tightness
B.
Decreased vital capacity
C. Increased carbon monoxide diffusing
capacity
D.
Seizures
Answer 40
B. Administration of 100% oxygen causes a
decrease in vital capacity, but it is not generally
evident for about 24 hours.
C. Administration of 100% oxygen causes a
decrease, not an increase, in carbon monoxide
diffusing capacity.
D. Although supplemental oxygen administration
can cause seizures, this occurs only when the
patient is exposed to a partial pressure of oxygen
in excess of 2 atmospheres.
Correct answer is A
Question 41
A 55-year-old woman for (MRI) of the head. The patient
uses a (CPAP) machine nightly for OSA and is being
treated with medical therapy for CAD She has a
permanent eyeliner. Which statement about the
management of this patient is MOST likely true?
A. The presence of permanent eyeliner is a
contraindication to MRI.
B.
Use of a laryngeal mask airway is a preferred
anesthetic technique.
C. Patient burns will only occur if monitoring
equipment that is not MRI-compatible is used.
D. Electrocardiographic (ECG) monitoring with ST
segment analysis is recommended.
Answer 41
A. The presence of permanent eyeliner is not a
contraindication to MRI. However, the patient and
physicians should be aware that it does contain iron
oxide and burns and swelling may rarely occur.
Image artifacts also are possible due to the presence
of the ferromagnetic substance.
C. Although much less common, burns can result
from patient contact with MRI-compatible
monitoring leads and cables. This risk can be
decreased by preventing looping of the wires and
minimizing the points of patient contact.
D. Due to superimposed voltages resulting from
blood flow within the magnetic field, ECG artifacts
occur frequently during MRI, and ST segment
interpretation is unreliable.
Correct answer is B
Question 42
Which of the following statements about the effects of
hyperoncotic (10%) hetastarch (HES) or hyperoncotic (25%)
albumin is MOST likely true?
A.
Hyperoncotic HES has no long-term effect on renal
function.
B.
When comparing hyperoncotic solutions of albumin
and HES, use of albumin decreases the odds of renal failure
in critically ill patients.
C.
When comparing hyperoncotic solutions of albumin
and HES, use of HES is associated with a lower mortality rate
in critically ill patients.
D.
Hyperoncotic albumin has no effect on the odds ratio
for mortality in critically ill patients.
Answer 42
A. A 2010 Cochrane Database report
determined that hyperoncotic HES increased
the odds of acute renal insufficiency.
C. A 2011 Cochrane Database report
determined that hyperoncotic HES increased
the odds of death compared with
hyperoncotic albumin.
D. A 2011 Cochrane Database report
determined that albumin reduced the odds
of death by 48%.
Correct answer is B
Question 43
Which of the following is the MAIN advantage
for selecting a retrobulbar block over a
peribulbar block?
A. Decreased risk of globe perforation
B.
Decreased onset time of block
C. Increased frequency of akinesia of the
eye
D.
Decreased risk of lid hematoma
Answer 43
A. Global perforation has been reported
after the performance of retrobulbar and
peribulbar blocks at similar but very low rates.
C. A retrobulbar block is associated with an
equal occurrence of complete akinesia of
the eye as a peribulbar block.
D. Lid hematoma is observed more often
after the performance of a retrobulbar block
than after a peribulbar block.
Correct answer is B
Question 44
A paraplegic patient undergoing a surgical procedure
receives a nondepolarizing neuromuscular blocking drug. A
(TOF) stimulus applied on the normal extremity reveals a T4/T1
ratio of 80%. Which of the following is MOST likely to be seen in
response to a TOF stimulus on the paretic extremity?
A.
T4/T1 ratio that is increased (eg, 100%) compared with
normal extremity
B.
T4/T1 ratio that is unchanged (eg, 80%) from normal
extremity
C.
T4/T1 ratio that is decreased (eg, 70%) compared with
normal extremity
D.
No visible response (markedly decreased compared
with normal extremity)
Answer 44
B. Patients with paraplegia have increased
TOF responses to peripheral nerve stimulation
in paretic extremities when compared with
normal extremities.
C. Patients with paraplegia have increased
TOF responses to peripheral nerve stimulation
in paretic extremities when compared with
normal extremities.
D. Patients have detectable changes in TOF
responses to peripheral nerve stimulation
when comparing normal with paraplegic
extremities.
Correct answer is A
Question 45
A child is undergoing general anesthesia that
includes nitrous oxide being delivered at 2 L/min
from an E cylinder. The tank pressure has just started
to decrease. Which of the following is the BEST
estimate of the remaining amount of time that
nitrous oxide can continue to be delivered?
A.
Unable to be determined
B.
Six hours
C.
Three hours
D.
One hour
Answer 45
A.
Incorrect. Please try again.
B. Incorrect. Please try again.
D. Incorrect. Please try again.
Correct answer is C
Question 46
A patient with a positive family history for (MH) has a
negative molecular genetic test result for susceptibility
to MH. Which of the following is the MOST appropriate
management in order to provide general anesthesia
for an elective surgical procedure in this patient?
A. Administer dantrolene prior to induction of
anesthesia.
B.
Delay the case to obtain a preoperative muscle
biopsy.
C.
D. Administer a balanced technique using volatile
agents.
Avoid all triggering anesthetic medications.
Answer 46
A. The preemptive administration of
dantrolene for the prevention of MH is never
indicated.
B. Delaying the case to obtain a
preoperative muscle biopsy is not the most
appropriate management for this patient.
D. The most appropriate anesthetic
management would be to avoid all
anesthetic triggering medications since a
negative molecular genetic test does not
exclude susceptibility to MH.
Correct answer is C
Question 47
In a patient with elevated carboxyhemoglobin
levels, which of the following BEST describes the
relationship between the conventional pulse
oximeter value and the oxyhemoglobin levels
measured by co-oximetry?
A.
There is no consistent relationship.
B.
The values are the same.
C.
The co-oximeter value will be lower.
D.
The co-oximeter value will be higher.
Answer 47
A.
Incorrect. Please try again.
B. Incorrect. Please try again.
D. Incorrect. Please try again.
Correct answer is C
Question 48
An unvaccinated health care worker is exposed
percutaneously to blood from a patient who has a
history of intravenous drug abuse. For which of the
following viruses would postexposure vaccination
MOST likely be indicated?
A.
Epstein Barr virus
B.
Hepatitis B
C.
Hepatitis C
D.
HIV
Answer 48
A.
Vaccines against Epstein-Barr virus are
still under development and vaccination
is not indicated in this clinical scenario.
C. Postexposure prophylaxis against
hepatitis C is not currently available.
D. Although antiretroviral therapy may
be initiated in this circumstance, there is
no vaccine currently available for HIV.
Correct answer is B
Question 49
A patient with hyperparathyroidism develops
cardiac dysrhythmias secondary to hypercalcemia.
Which of the following is the PREFERRED treatment
for hypercalcemia in this situation?
A.
Disodium etidronate
B.
Hydrochlorothiazide
C.
Mithramycin
D.
Hydrocortisone
Answer 49
B. Thiazide diuretics are generally considered to
be contraindicated in the treatment of
hypercalcemia because of their potential to
cause increased tubular reabsorption of calcium.
C. Although mithramycin may be used in the
treatment of hypercalcemia, it is not indicated for
the treatment of life-threatening hypercalcemia.
In addition, the side effects (eg,
thrombocytopenia, hepatotoxicity, nephrotoxicity)
limit its usefulness.
D. Although glucocorticoids may be useful in
lowering hypercalcemia, they are not the most
effective drug in this setting.
Correct answer is A
Question 50
According to the Revised Cardiac Risk Index (RCRI),
which of the following is MOST likely to be associated
with an increased risk of a major cardiac event in
the perioperative period?
A.
Age greater than 70 years
B.
Surgical procedure for hip fracture
C.
Preoperative hemoglobin less than 10 g/dL
D.
Preoperative use of insulin
Answer 50
A.
The RCRI does not consider age as a
risk factor.
B. According to the RCRI, only
intrathoracic, intraperitoneal, and aortic
surgery are associated with an increased
risk.
C. The RCRI does not consider
preoperative hemoglobin as a risk factor.
Correct answer is D
Question 51
In the middle of an open abdominal surgery on an 18year-old healthy male patient who has received a
propofol infusion, fentanyl, isoflurane anesthetic, the
patient's temperature is noted to be 34°C. Compared
with a patient at 37°C, there will MOST likely be a
significant increase in the
A.
plasma concentration of propofol.
B.
production of thrombin.
C. minimum alveolar concentration (MAC) of
isoflurane.
D. patient's hemodynamic responses to surgical
stimulation.
Answer 51
B.
Thrombin activity has been shown to
decrease in hypothermic conditions.
C. Hypothermia decreases the MAC of
isoflurane by approximately 5% for each
1°C drop in body temperature.
D. Patients have a blunting of their
responses to surgical stimulation under
hypothermic conditions.
Correct answer is A
Question 52
Which of the following factors is MOST likely
associated with an increased risk of developing
transient neurologic symptoms (TNS) following a
spinal anesthetic with lidocaine?
A.
Lithotomy versus supine position
B.
Use of 5% versus 1.5% lidocaine
C. Administration of 100 mg versus 50 mg of
lidocaine
D.
Use of hyperbaric versus isobaric drug
Answer 52
B. Studies have demonstrated that the risk
of TNS is independent of drug concentrations
ranging from 0.5% to 5.0%.
C. Studies have demonstrated that the risk
of TNS is independent of lidocaine dose.
D. Studies have demonstrated that the risk
of TNS is unchanged by the baricity of the
drug administered.
Correct answer is A
Question 53
Which statement about an adult with an
asymptomatic bicuspid aortic valve (BAV) is
MOST likely true?
A. The risk for coarctation of the aorta is
high.
B.
C. Life expectancy is shortened.
D. The patient should receive prophylaxis for
endocarditis.
The risk for aortic dissection is increased.
Answer 53
A.
The risk of coarctation of the aorta is
not increased in patients with a BAV.
C. Life expectancy is normal as long as
the BAV functions normally.
D. Endocarditis prophylaxis is not
recommended for BAVs.
Correct answer is B
Question 54
A 26-year-old woman with postpartum cardiomyopathy
presents for an open reduction and internal fixation of her
fractured femur following a motor vehicle collision. She has a
continuous-flow left ventricular assist device (LVAD) with a
remaining battery life of 3 hours. You are called to the
preoperative area because a blood pressure cannot be
obtained noninvasively and the patient has no palpable
pulse. The patient has a heart rate of 70/min on
electrocardiogram. She is conversing with her family and is in
no apparent distress. The MOST appropriate next step would
be to
A.
administer chest compressions.
B.
change the battery pack.
C.
increase the LVAD flow rate.
D.
proceed to the operating room.
Answer 54
A. Chest compressions are not warranted in
a patient who is awake and in no apparent
distress.
B. Three hours of battery life is consistent
with a fully charged battery pack, and
therefore it does not need to be changed at
this time.
C. Because the patient is awake and in no
apparent distress, alteration of the LVAD flow
rate is not warranted.
Correct answer is D
Question55
Which of the following processes at the initiation of
an action potential is blocked by local anesthetics?
A. The increased permeability of the membrane
to sodium
B. The decreased permeability of the
membrane to potassium
C.
The large efflux of sodium from the neuron
D.
The large influx of potassium into the neuron
Answer 55
B. At rest, the membrane permeability to
potassium is low but much higher than that of
other ions. During an action potential,
depolarization opens potassium ion channels,
resulting in an increased permeability of the
membrane to potassium.
C. During an action potential the opening of
sodium channels allows sodium to diffuse down
both its concentration and voltage gradients into
the neuron, resulting in a large influx of sodium into
the neuron.
D. During an action potential there is an efflux of
potassium from the neuron.
Correct answer is A
Question 56
Consider this capnograph tracing when answering.
Which of the following is BEST demonstrated in this tracing?
A.
"Curare cleft"
B.
Spontaneous respiratory efforts
C.
Cardiogenic oscillations
D.
Obstructed gas flow
Answer 56
A. A "curare cleft" is typically seen in the last
third of the plateau phase and is most
commonly due to inadequate reversal of
neuromuscular blockade.
C. Cardiogenic oscillations appear as small,
regular, tooth-like humps that are seen at the
end of the expiratory phase.
D. Obstruction to gas flow (eg, tracheal
tube obstruction, bronchospasm) causes a
prolonged upstroke on the capnogram.
Correct answer is B
Question 57
Following a motor vehicle collision, a patient develops
pain radiating from the neck and shoulder to the left
hand, primarily in the little finger. Over the next 2 days,
she notices progressive numbness in the medial forearm
and fifth finger and weakness in finger flexion. Which of
the following is MOST likely involved?
A.
C6 nerve root
B.
C8 nerve root
C.
Medial cord of the brachial plexus
D.
Ulnar nerve
Answer 57
A.
C6 nerve root injury is associated with numbness,
tingling, and pain radiating to the thumb side of the hand
and motor deficits in elbow flexion (biceps) and wrist
extension.
C.
The medial cord of the brachial plexus gives off the
ulnar nerve to the hand and medial antebrachial
cutaneous nerve to the medial forearm and could explain
many of the patient's symptoms. However, brachial plexus
injuries are not typically associated with neck pain. In
addition, the medial cord gives rise to many fibers of the
median nerve and would typically be associated with more
widespread sensory and motor symptoms.
D.
Ulnar nerve injury is characterized by weakness with
handgrip and by numbness, tingling, and pain in the little
finger side of the hand. However, it does not explain neck
pain or numbness in the medial forearm, which is
innervated by the medial antebrachial cutaneous nerve
from the medial cord of the brachial plexus.
Correct answer is B
Question 58
A 72-year-old man with a history of smoking and ischemic
heart disease is scheduled for a right upper lobectomy. He
has an implantable cardioverter-defibrillator (ICD) in place
and provides you with a device card containing a complete
generic defibrillator code of VVE-DDDRV. Which of the
following statements about his ICD is MOST accurate?
A.
It provides dual chamber defibrillation shocks.
B.
It provides hemodynamic-based tachycardia
detection.
C.
It provides ventricular chamber antitachycardia
pacing.
D.
It only senses ventricular impulses.
Answer 58
A. The V in the first position of the ICD code
indicates this device provides ventricular
defibrillation shock only.
B. The E in the third position of the ICD code
indicates this device provides
electrocardiogram tachycardia detection
not hemodynamic-based tachycardia
detection.
D. The D in the second position of the pacer
portion of this ICD code indicates this device
has both atrial and ventricular (dual) sensing.
Correct answer is C
Question 59
Which statement about the perioperative
management of this patient's ICD is MOST likely true?
A. No preoperative interrogation of the ICD is
recommended for this patient.
B. All antitachycardia functions should be
disabled.
C. Placement of a magnet will make the ICD
pace asynchronously.
D. All ICDs become disabled when a magnet is
placed over them.
Answer 59
A.
Preoperative integration would be
recommended for this patient.
C. Magnet placement will not
necessarily make an ICD pace
asynchronously.
D. Responses vary and some brands of
ICD can be programmed to have the
magnetic response disabled.
Correct answer is B
Question 60
The patient develops hypoxemia despite
administration of 100% oxygen. Which of the
following is the MOST appropriate initial
management?
A.
Administering albuterol
B.
Administering racemic epinephrine
C.
Providing a jaw thrust maneuver
D.
Reinserting the tracheal tube
Answer 60
A. Administering albuterol would be most
effective for a patient with bronchospasm.
B. Administering racemic epinephrine would
be most effective for a patient with croup or
postextubation edema.
D. Since the vocal cords are adducted in a
patient with laryngospasm, reinserting the
tracheal tube may not be possible and is not
the most appropriate initial therapy.
Correct answer is C
Question 61
Anesthesia is being induced in a 3-year-old
child with congenital heart disease using an
inhalation technique. Which of the following
congenital heart lesions is MOST likely to
slow the rate of induction of anesthesia?
A. Ventricular septal defect
B. Tricuspid atresia
C. Patent ductus arteriosus
D. Aortic coarctation
Answer 61
A. Ventricular septal defects cause left-toright shunting with minimal effect on
inhalational induction rate.
C. Patent ductus arteriosus causes left-to-right
shunting with minimal effect on inhalational
induction rate.
D. Aortic coarctation does not result in
shunting and will not affect the rate of an
inhalational induction.
Correct answer is B
Question 62
A 56-year-old man presents for resection of a
bronchial mass. He has been diagnosed with
Lambert-Eaton Myasthenic syndrome (LEMS).
Which of the following is MOST likely to be
present?
A. Proximal limb weakness
B. Preservation of autonomic function
C. Decreased muscle strength with activity
D. Resistance to depolarizing blockers
Answer 62
B. Autonomic dysfunction is common;
presenting complaints commonly include dry
eyes, dry mouth, or impotence. Orthostasis is
also often present.
C. Patients with LEMS have increased muscle
strength with activity.
D. Patients with LEMS demonstrate sensitivity
to both depolarizing and nondepolarizing
muscle relaxants.
Correct answer is A
Happy New Year
& Good Luck at the Exam