Anesthesia question of the day

In patients receiving Vecuronium, the greatest augmentation of neuromuscular blockade is seen the use of?
A. Isoflurane
B. Sevoflurane
C. Desfurane
D. Nitrous Oxide
C. Desflurane
Volatile agents decrease the non depolarizer dosage requirement. The degree of augmentation of blockade depend on the inhalation agent Desflurane >Sevoflurane> Isoflurane>Nitrous Oxide
Page 213 Morgan & Mikhail’s Clinical Anesthesiology

The addition of bicarbonate to a local anesthetic solution:
A. Delays the onset of blockade
B. Increases the concentration of the nonionic form of the local anesthetic
C. Causes a fall in eth pH of the solution
D. Should only be done when using bupivacaine
B. Increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on eth penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8
Page 963 Morgan & Mikhail’s Clinical Anesthesiology

During hip replacement surgery, cardiopulmonary changes associated with acrylic bone cement includes:
A-hypotension secondary to cement monomer absorption
B- Hypoxemia secondary to air embolization
C-Hypoxemia secondary to fat embolization
D-Hypocarbia
E-Decreased pulmonary artery pressure
F-Increased end-tidal carbon dioxide
A-Hypotension secondary to cement monomer absorption
B-Hypoxemia secondary to air embolization
C-Hypoxemia secondary to fat embolization

During hip replacement surgery, hypotension with the use acrylic bone cement has been attributed to absorption of methyl methacrylate monomer, embolization of air and bone marrow and conversion of Methyl methacrylate to methacrylic acid. Hypoxemia is common. Embolic event cause an increase in dead space with a reduction in ETCO2 with an increase in PaCO2.
Page 1454 Barash, Clinical Anesthesia.

Maternal mortality associated with amniotic fluid embolization is:
A- 10-15%
B- 20-25%
C- 40-45%
D- Greater than 50%
Maternal mortality associated with amniotic fluid embolization is:
A- 10-15%
B- 20-25%
C- 40-45%
D- Greater than 50%
Answer: D- Greater than 50%
Amniotic fluid embolism is a very rare occurrence of about 1:20,000. However, it carries a very high mortality; some studies quoting as much as 86%. Mortality within the first hour after onset is about 50%.

Page 867 Morgan & Mikhail’s Clinical Anesthesiology

Pulmonary changes associated with Duchenne's muscular dystrophy include:
A. A restrictive ventilator defect
B. An obstructive ventilator defect
C. Decreased pulmonary artery pressure
D. Increased residual volume
Pulmonary changes associated with Duchenne’s muscular dystrophy include:
A. A restrictive ventilator defect
B. An obstructive ventilator defect
C. Decreased pulmonary artery pressure
D. Increased residual volume
Answer: A restrictive ventilator defect
Pulmonary changes associated with Duchenne’s muscular dystrophy include: a restrictive ventilator defect.
The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilator defect in patients with Duchenne’s muscular dystrophy. Pulmonary hypertension is also commonly seen. (Page 753 Morgan & Mikhail’s Clinical Anesthesiology, 2013).
Muscular Dystrophy

Core Notes by Core Concepts Anesthesia Review, LLC

1. Duchenne muscular dystrophy (DMD) is the most common type of muscular dystrophy.
2. It is an X-linked disorder seen in males, appearing in childhood with progressive muscle wasting. Death usually occurs during adolescence.
3. Cardiac muscle is also affected and death usually results from cardiac and/or ventilator failure.
4. ECG changes appear as decreased R-wave amplitude and the appearance of Q waves.
5. Changes in the architecture of the thorax result in progressive and severe restrictive lung disease.
6. Severe hyperkalemia and rhabdomyolysis have resulted from the administration of succinylcholine. The use of succinylcholine is contraindicated in these patients.
7. Although once felt to be associated with MH, recent data suggest that this may not be true and deaths were likely the result of hyperkalemia.

DMD is the most common childhood muscular dystrophy. It is an X-linked recessive disorder appearing in between the ages of 3 – 5, with progressive weakness. It is sometimes referred to as pseudohypertrophic muscular dystrophy and is usually fatal by late adolescence as a result of ventilatory and/or cardiac failure. In addition, these young males suffer from contractures, marked scoliosis, restrictive lung disease, and cardiomyopathies; 50% of sufferers have a dilated cardiomyopathy by the age of 15.
The disease is a result of a lack of dystrophin, a protein that helps to hold muscle cells to the extra-cellular matrix. This leads to a weakening of the sarcolemma, which becomes increasingly permeable, with increased intracellular calcium levels.
Other less-common forms of muscular dystrophy also occur including: Emery-Dreifuss muscular dystrophy, limb-girdle muscular dystrophy, Becker’s muscular dystrophy,
oculopharyngeal muscular dystrophy, fascioscapulohumeral muscular dystrophy and congenital muscular dystrophy.
The most significant anesthetic complications in patients with DMD are the result of the actions of volatile anesthetics or neuromuscular blocking agents on the cardiac and skeletal muscle. Cases of cardiac arrest have been reported and are associated with severe hyperkalemia and rhabdomyolysis. In patients with muscular dystrophy, succinylcholine appears to damage the weakened sarcolemma causing release of intracellular contents and is absolutely contraindicated. Patients frequently have prolonged recovery from nondepolarizing relaxants. Anticholinesterase agents have also been implicated in muscle breakdown.

Additional Reading:
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia.
Philadelphia: Lippincott Williams & Wilkins, 2013:613

A 46-year old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately:
A. 2%
B. 5%
C. 10%
D. 25%
Answer:
C. 10%
Patient with acute hepatitis should have elective surgery postponed until the acute hepatitis has resolved. Studies indicate increased perioperative morbidity (12%) and mortality (10% with laparotomy) during acute hepatitis.

Pp. 1315-1316 Barash, Clinical Anesthesia.

An increase in intraocular pressure has been associated with: (select 3)
A. Nitrous oxide administration
B. Succinylcholine administration
C. Opioid administration
D. Hyperventilation
E. Laryngoscopy
F. Hypoxemia
G. Sevoflurane administration
Answer:
B. Succinylcholine administration
E. Laryngoscopy
F. Hypoxemia

An increase in IOP (intraocular pressure) has been associated with: succinylcholine administration, hypoxemia, and laryngoscopy
Succinylcholine increased intraocular pressure by 5-10 mmHg for 5 to 5 minutes after administration. This increase is primarily the result of prolonged contracture of the extrocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetics agents and opioids have been associated with a reduction in intraocular pressure. Hypoxemia, Hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation have all been shown to increase IOP.

Pp 760-761 Morgan $ Mikhail’s Clinical Anesthesiology

In the pressure-volume loop below, cardiac work is best represented by:
A. The area of the curve
B. The slope of the line from points C to D
C. The distance of the line form points C to D
D. The slope of a line from points A to D
In the pressure-volume loop below, cardiac work is best represented by:
A. The area of the curve
B. The slope of the line from points C to D
C. The distance of the line form points C to D
D. The slope of a line from points A to D
A. The area of the curve
Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Pg. 250 Barash, PG, Cullen, Clinical Anesthesia

Dextran 40 has been shown to improve microcirculation by:
A- Reducing blood density
B- Increasing blood density
C- Decreasing blood viscosity
D- Increasing blood viscosity
Answer: C- Decreasing blood viscosity

Dextran 40 has been shown to improve microcirculation presumably by decreasing blood viscosity thereby improving laminar flow in the microcirculatory beds. Both dextran 4o and Dextran 70 possese antiplatelet effects and may interfere with blood typing.

Page 1165 Morgan & Mikhail’s Clinical Anesthesiology

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

Thrombocytopenia cases an overall reduction in clot strength shown as a narrowing in the thromboelastogram.

Page 1519 Barash, Clinical Anesthesia

The highest level of protein binding is seen with:
A- Procaine
B- Lidocaine
C- Mepivacaine
D- Bupivacaine
The highest level of protein binding is seen with:
A- Procaine
B- Lidocaine
C- Mepivacaine
D- Bupivacaine
Answer: D Bupivacaine

The physicochemical property that determines the duration of action of local anesthetic is lipid solubility, which is directly correlated with plasma protein binding. Bupivacaine and Levobupivacaine have the highest degree of protein binding (97%).

Page 269 Morgan & Mikhail’s Clinical Anesthesiology

The highest rate of systemic absorption of local anesthetic is seen with:
A- Epidural injection
B- Intercostal injection
C- Caudal injection
D- Brachial plexus injection
The highest rate of systemic absorption of local anesthetic is seen with:
A- Epidural injection
B- Intercostal injection
C- Caudal injection
D- Brachial plexus injection
Answer:
B- Intercostal injection

The rate of systemic absorption of local anesthetic is proportionate to the vascularity of the site of injection: intravenous> tracheal> intercostal>caudal>paracervical>epidural>brachial plexus>subcutaneous.

Page 569 Barash, Clinical Anesthesia

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case?
A. Check oxygen cylinder supply
B. Check the carbon dioxide absorber
C. Performance of a machine low-pressure leak test
D. Calibration of the oxygen monitor
Answer:
B. Check the carbon dioxide absorber

Verification of the adequacy of the carbon dioxide absorber s suggested prior to every case. If the same anesthesia machine is being used by the same provide, E-cylinder pressure checks, machine low-pressure leak testing and calibration of the oxygen sensor need not be repeated after an initial check.

PP 84-85 Morgan & Mikhail’s Clinical Anesthesiology.

The addition of bicarbonate to a local anesthetic solution:
A. Delays the onset of blockade
B. Increases the concentration of the nonionic form of the local anesthetic
C. Causes a fall in the pH of the solution
D. Should only be done when using bupivacaine
Answer:
B. Increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on eth penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8

Page 963 Morgan & Mikhail’s Clinical Anesthesiology

A 55 year old 70 kg man with history of asthma and seasonal allergies has a sudden rise in peak inspiratory pressure intraoperatively. The patient is otherwise hemodynamically stable and you suspect bronchospasm. The following management options exist to treat bronchospasm EXCEPT:
A. Epinephrine
B. Isoflurane
C. Ketamine
D. Propranolol
Answer:
D. Propranolol

Propranolol is a non-selective beta blocker that would be contraindicated in bronchospasm as it may elicit bronchoconstriction via beta-2-blockade. Ketamine, inhalational agents, epinephrine, and even propofol all have bronchodilatory effects and may be used to treat intraoperative bronchospasm.
Perioperative considerations for the patient with asthma and bronchospasm.

J Anaesth 2009, 103

Lamina flow in the airway occurs in the: select 2
A. Trachea
B. Main stem bronchi
C. Terminal bronchiole
D. 3rg Generation bronchus
E. Respiratory bronchiole
Lamina flow in the airway occurs in the: select 2
A. Trachea
B. Main stem bronchi
C. Terminal bronchiole
D. 3rg Generation bronchus
E. Respiratory bronchiole
Answer:
C. Terminal bronchiole
E. Respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (<1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow.

Pages 498-499 Morgan & Mikhail’s Clinical Anesthesiology

Sickle hemoglobin: (select 2)
A. Has a lower P50 than hemoglobin A
B. Releases oxygen less readily than hemoglobin A
C. Is present in about 30% of African Americans
D. Readily polymerizes and precipitates in the red cell
E. Results from a single amino acid substitution on the Alpha chain
F. Has decreased solubility as compared to hemoglobin A
Sickle hemoglobin: (select 2)
A. Has a lower P50 than hemoglobin A
B. Releases oxygen less readily than hemoglobin A
C. Is present in about 30% of African Americans
D. Readily polymerizes and precipitates in the red cell
E. Results from a single amino acid substitution on the Alpha chain
F. Has decreased solubility as compared to hemoglobin A
Answer:
D. Readily polymerizes and precipitates in the red cell
F. Has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50 (31mm Hg) as compared to hemoglobin A (27 mmHg). HbS also has decreased solubility and readily polymerises and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the Beta-chain,

Pg 1177 Morgan & Mikhail’s Clinical Anesthesiology.

A 75 years old woman complains of loss of vision in one eye. She reports that she first noticed blurred vision in the right eye. This progressed to her bumping into objects on the right side. When she is asked to read, she can only read one half of sentences on a page. She has normal strength, coordination, reflexes and tone. Her cranial nerve exam shows that she cannot see a moving finger on the right filed in either eye. An occlusion of which major vessel is associated with these findings?
A. Basilar artery
B. Internal carotid artery
C. Middle cerebral artery
D. Posterior cerebral artery
Answer:
D. Posterior cerebral artery

The description of this patient suggests that she has a right visual filed deficit, in both eyes, as opposed to monocular blindness (the classic “anaurosis fugax” typically due to emboli from an internal carotid artery source). Although patients may describe not being able to see out of one eye, a cursory physical exa will reveal that the eye can see, but there may be significant field cut in both eyes. The neurological team for this sign is homonymous hemianopsia, and it is most commonly due to occipital lobe injury from a posterior cerebral artery infarction. Although field cuts can also occur with temporal or parietal lesions, there tends to be other associated findings not seen in this patient (such as neglect).

References: stroke and related disorders

A nonselective Alpha antagonist used in the preoperative preparation of a patient with pheochromocytoma is:
A. Phenoxybenzamine
B. Doxazosin
C. Propranolol
D. Terazosin
Answer:
A. Phenoxybenzamine (Dibenzyline)

Phenoxybenzamine is a non-selective alpha antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and Terazosin are selective alpha1 antagonists. Propranolol is nonselective beta blockade. In the preparation of patients with pheochromocytoma, alpha blockade and intravascular volume replacement must precede beta-blockade, so as to prevent the possibility of unopposed alpha stimulation.

Page 192 Nagelhout, JJ

While performing a nerve stimulator interscalene block, the patient’s diaphragm begins to twitch. In order to successfully perform the block, the needle should be redirected in the following manner
A. Advanced because the needle tip is too shallow
B. Redirected anteriorly because the needle tip is too posterior
C. Redirected posteriorly because the needle tip is too anterior
D. Withdrawn because the needle tip is too deep.
Answer:
C. Redirected posteriorly because the needle tip is too anterior

Nerves blocked with a fascia iliaca block include the:
A. Sciatic nerve
B. Femoral nerve
C. Pudendal nerve
D. Anterior tibial nerve
Nerves blocked with a fascia iliaca block include the:
A. Sciatic nerve
B. Femoral nerve
C. Pudendal nerve
D. Anterior tibial nerve
Answer:
B. Femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

PP 1003-1004 Morgan & Mikhails Clinical Anesthesiology

Average blood loss during a vaginal delivery is:
A. 100-200ml
B. 400-500ml
C. 700-800ml
D. 1000-1500ml
Answer:
B. 400-500ml

At term, blood volume has increased by 1000-1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400-500ml, compared with 800-1000 ml for cesarean section.

Page 827 Morgan & Mikhail’s Clinical Anesthesiology.

Example of type IV hypersensitivity reactions include:
A. Contact dermatitis
B. Hemolytic transfusion reactions
C. Anaphylaxis
D. Angioedema
Answer:
A. Contact dermatitis

Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis

Page 292 Barash, Clinical Anesthesia.

Name the different types of hypersensitivity reactions
Name the different types of hypersensitivity reactions
Answer:
There are 4 types of hypersensitivity reactions:
Type 1 reactions are immediate-type reactions, including anaphylaxis. Signs & symptoms are the result of the release of histamine and other autocoids from mast cells & basophils.

Type 2 reactions are cytotoxic reactions and cell mediated. ABO-incompatibility reactions are of this type.

Type 3 reactions are the result of soluble antigens and antibodies combining to form insoluble complexes. Neutrophils are activated and tissue damage results. Serum sickness and Arthus reactions are examples of Type 3 reactions.

Type 4 reactions are also known as delayed hypersensitivity reactions. These are the result of antigens reacting with sensitized lymphocytes. Contact dermatitis is an example of a Type 4 reaction.

The maximum recommended occupational whole body exposure to radiation is:
A. 1 rem/year
B. 5 rem/year
C. 10 rem/year
D. 20 rem/year
The maximum recommended occupational whole body exposure to radiation is:
A. 1 rem/year
B. 5 rem/year
C. 10 rem/year
D. 20 rem/year
Answer:
B. 5 rem/year

The intraoperative use of imaging equipment exposes anesthesia providers to ionizing radiation. The maximum recommended whole-body exposure to radiation is 5 rem/year. The United states unit of measurement for radiation dose is the rem (Roentgen Equivalent Man). Most other countries measure radiation dose using the metric system unit of Sieverts (Sv).
1000 mrem=1rem
1mSv=100 millrems
1000mSv= 1Sv

Page 65 Barash, Clinical Anesthesia.

Characteristics of omphalocele include (select 2):
A. Location lateral to the umbilicus
B. Lacks a hernia sac
C. Results from the failure of midgut migration into the abdomen
D. Nitrous oxide should be used during the repair to ensure a rapid emergence
E. Association with Beckwith-Wiedemann Syndrome (Trisomy 21)
F. Results from abnormal development of the right omphalomesenteric artery.
Characteristics of omphalocele include (select 2):
A. Location lateral to the umbilicus
B. Lacks a hernia sac
C. Results from the failure of midgut migration into the abdomen
D. Nitrous oxide should be used during the repair to ensure a rapid emergence
E. Association with Beckwith-Wiedemann Syndrome (Trisomy 21)
F. Results from abnormal development of the right omphalomesenteric artery.
Answer:
C. Results from the failure of midgut migration into the abdomen
E. Association with Beckwith-Wiedemann Syndrome (Trisomy 21)

Gastroschisis and omphalocele are characterized by defects in the abdominal wall that allow herniation of the viscera. Omphaloceles occur at the base of the umbilicus, have a hernia sac and are commonly associated with other anomalies. In contrast, gastroschisis is usually lateral to the umbilicus, lacks a hernia sac and is usually an isolated finding. Nitrous oxide is best avoided during repair as it may result in bowel distention making closure more difficult.

Page 901 Morgan & Mikhail’s Clinical Anesthesiology.

Absolute contraindications to the use of epidural anesthesia in the parturient include (select 2):
A. Inability of the patient to cooperate
B. Herniated lumbar disc
C. Multiple sclerosis
D. Patient refusal
E. History of previous cesarean section
F. Aortic regurgitation
Absolute contraindications to the use of epidural anesthesia in the parturient include (select 2):
A. Inability of the patient to cooperate
B. Herniated lumbar disc
C. Multiple sclerosis
D. Patient refusal
E. History of previous cesarean section
F. Aortic regurgitation
Answer:
A. Inability of the patient to cooperate
D. Patient refusal

Absolute contraindication to epidural anesthesia/analgesia in the parturient include infection over the injection site, coagulopathy, thrombocytopenia, marked hypovolemia, true local anesthetics allergy, patient refusal and inability of the patient to cooperate. Preexisting neurological disease and back disorders are relative contraindications. Patients with Aortic regurgitation usually benefit from the reduction in afterload seen after neuraxial anesthesia.
Page 849 Morgan & Mikhail’s Clinical Anesthesiology

Physiologic derangements seen in the patient with scleroderma include (select 3):
A. Pulmonary hypertension
B. Esophageal dysmotility
C. Excessive oral secretions and salivation
D. Myocardial fibrosis
E. Hypotension
F. Spastic quadraparesis
Physiologic derangements seen in the patient with scleroderma include (select 3):
A. Pulmonary hypertension
B. Esophageal dysmotility
C. Excessive oral secretions and salivation
D. Myocardial fibrosis
E. Hypotension
F. Spastic quadraparesis
Answer:
A. Pulmonary hypertension
B. Esophageal dysmotility
D. Myocardial fibrosis

Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs.
Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration.
Systemic hypertension form renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement.

Page 636, Barash, PG, Clinical Anesthesia.

Per Mayo clinic: Scleroderma is a group of rare, progressive diseases that involve the hardening and tightening of the skin and connective tissues. The fibers that provide the framework and support for your body.
Localized scleroderma affects only the skin. Systemic scleroderma also harms internal organs, such as the heart, lungs, kidneys and digestive tracts

Basal metabolic oxygen consumption in a 20 kg patient is approximately:
A. 50ml/min
B. 95ml/min
C. 150ml/min
D. 250ml/min
Answer:
B. 95ml/min

Basal metabolic oxygen consumption can be estimated using the following formula:
V02 = 10 Kg^3/4

1. Effects of lidocaine include:

A) increased intracranial pressure
B) lytic degeneration, edema and necrosis of skeletal muscle
C) increased refractory period of cardiac muscle
D) decreased fibrinolysis

Answer:
B) lytic degeneration, edema and necrosis of skeletal muscle

Intravenous lidocaine decreases cerebral blood flow unless seizure activity develops. Lidocaine decreases the refractory period of cardiac muscle and decreases platelet aggregation while enhancing fibrinolysis. Local anesthetics have been shown to cause lytic degeneration and necrosis of muscle fibers when directly injected into the muscle (trigger point injections)

2. Correct statements concerning the use of antidepressants in pain management include:

A) analgesic effects require a higher dose than that needed for antidepression
B) newer SSRIs are more effective analgesics than the older tricyclic antidepressants
C) analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake
D) antidepressants are not effective in neuropathic pain

Answer:
C) analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake

Antidepressants demonstrate an analgesic effect at doses lower that those needed for antidepressant effect. Both actions appear secondary to the block of the reuptake of serotonin and norepinephrine. Older tricyclic antidepressants seem more effective analgesics than the newer SSRIs. Antidepressants are most useful in patients with neuropathic pain.

3. The dibucaine number: 

A) is normally less than 60% 
B) reflects inhibition of pseudocholinesterase by dibucaine
C) is a quantitative assessment of pseudocholinesterase activity 
D) is inversely proportional to pseudocholinesterase function
3. The dibucaine number:

A) is normally less than 60%
B) reflects inhibition of pseudocholinesterase by dibucaine
C) is a quantitative assessment of pseudocholinesterase activity
D) is inversely proportional to pseudocholinesterase function

Answer:
B) reflects inhibition of pseudocholinesterase by dibucaine

Dibucaine, a local anesthetic, inhibits normal pseudocholinesterase. Homozygous patients with abnormal pseudocholinesterase characteristically have a dibucaine number of about 20%, heterozygous patients have numbers of 40 – 60% and normal patients usually have a dibucaine number of 80%. The dibucaine number is proportional to pseudocholinesterase function, but is independent of the amount of the enzyme.

4. The body mass index (BMI) associated with extreme obesity is:

A) > 30
B) > 45
C) > 35
D) > 40

Answer:
D) > 40

Overweight and obesity are classified using the BMI. Overweight is defined as a BMI > 24, obesity as a BMI > 30 and extreme obesity as a BMI > 40. BMI is calculated with the following formula:

BMI = Weight (kg) / Height (meters)2

5. Release of aldosterone by the adrenal cortex is stimulated by: (select 3) 

a) angiotensin I 
b) angiotensin II 
c) hypokalemia 
d) pituitary ACTH 
e) congestive heart failure 
f) hypervolemia
5. Release of aldosterone by the adrenal cortex is stimulated by: (select 3)

a) angiotensin I
b) angiotensin II
c) hypokalemia
d) pituitary ACTH
e) congestive heart failure
f) hypervolemia

Answer:
o b) angiotensin II
o d) pituitary ACTH
o e) congestive heart failure
Aldosterone release is stimulated by the renin-angiotensin system, but specifically by angiotensin II. Other causes of aldosterone release include hyperkalemia, ACTH release, hypovolemia, hypotension, CHF and the stress response

6. Renal blood flow: (Select 2) 

a) is largely determined by renal oxygen consumption 
b) accounts for 20 - 25% of the cardiac output 
c) is distributed mostly to juxtamedullary nephrons 
d) can be directed away from cortical nephrons by sympathetic stimulation 
e) is not autoregulated
6. Renal blood flow: (Select 2)

a) is largely determined by renal oxygen consumption
b) accounts for 20 – 25% of the cardiac output
c) is distributed mostly to juxtamedullary nephrons
d) can be directed away from cortical nephrons by sympathetic stimulation
e) is not autoregulated

Answer:
o b) accounts for 20 – 25% of the cardiac output
o d) can be directed away from cortical nephrons by sympathetic stimulation

The kidneys are the only organ for which oxygen consumption is determined by blood flow; the reverse is true in other organs. The kidneys receive 20 – 25% of the cardiac output with only 10 – 15% going to the juxtamedullary nephrons and 80% going to cortical nephrons. However, blood flow can be redirected to juxtamedullary nephrons by increased levels of catecholamines and angiotensin II. Autoregulation of RBF occurs between mean arterial pressures of 80 – 180 mmHg.

7. A 36-year-old female is scheduled for an elective cholecystectomy. Her past medical history is significant for depression treated with phenelzine (Nardil). Her anesthetic plan should include: (Select 2)

a) discontinuation of phenelzine for at least 2 weeks prior to surgery
b) the avoidance of indirect acting vasopressors
c) the avoidance of propofol
d) the avoidance of meperidine
e) the avoidance of nitrous oxide the avoidance of volatile anesthetic agents

Answer:
o d) the avoidance of meperidine
o b) the avoidance of indirect acting vasopressors

Phenelzine is a monamine oxidase (MAO) inhibitor. The practice of discontinuing MAO inhibitors prior to surgery is no longer recommended. The use of meperidine in patients receiving MAO inhibitors has been associated with hypertensive crisis and should be avoided. Additionally, indirect acting vasopressors have also been associated with hypertensive crisis and direct acting vasopressors should be used to treat hypotension.

8. Neuroleptic malignant syndrome: 

A) can be precipitated with the use of metoclopramide 
B) can be diagnosed with muscle biopsy
C) carries a mortality of over 80% 
D) can be treated with physostigmine administration
8. Neuroleptic malignant syndrome:

A) can be precipitated with the use of metoclopramide
B) can be diagnosed with muscle biopsy
C) carries a mortality of over 80%
D) can be treated with physostigmine administration

Answer:
A) can be precipitated with the use of metoclopramide

Neuroleptic malignant syndrome is a rare complication of antipsychotic therapy. Meperidine and metoclopramide can also precipitate the disorder which appears to be secondary to dopamine blockade in the basal ganglia. The disease has many characteristics in common with MH including increased temperature, metabolic derangement and hyperthermia. The mortality is 20 – 30%. Treatment with dantrolene and dopamine agonist, bromocripitine, appears effective.

9. The most common complication of thoracic paravertebral nerve block is: 

A) hypotension 
B) intravascular injection Top of Form
C) subarachnoid injection 
D) pneumothorax
9. The most common complication of thoracic paravertebral nerve block is:

A) hypotension
B) intravascular injection Top of Form
C) subarachnoid injection
D) pneumothorax

Answer:
D) pneumothorax

Pneumothorax is the most common complication of paravertebral block and a chest radiograph is needed upon completion of the block. Other complications include subarachnoid injection, epidural injection, intravascular injection, and hypotension.

10. The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately: 

A) 9 
B) 31
C) 15 
D) 23
10. The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately:

A) 9
B) 31
C) 15
D) 23

Answer:
D) 23

Dichotomous division, each branch dividing into two smaller branches, of the tracheobronchial tree is estimated to involve 20 – 25 divisions.

11. The largest fraction of carbon dioxide in the blood is in the form of:

A) carbamino compounds
B) carboxyhemoglobin
C) bicarbonate
D) dissolved gas

Answer:
C) bicarbonate

Nearly 90% of carbon dioxide in the blood is in the form of bicarbonate.

12. A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mmHg, the expected PaCO2 at the end of the apneic period would be: (Enter numerical answer on the line below.)

______ mmHg

Answer:
67 to 74 mmHg

The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10 – 20 minutes in most patients. Arterial PaCO2 rises 6 mmHg in the first minute followed by a rise of 3 – 4 mmHg during each subsequent minute. In this patient this will produce a 27 – 34 mmHg increase, resulting in a PaCO2 of 67 to 74 mmHg.

13. Stimulation of the parasympathetic nervous system results in: 

A) far vision accommodation 
B) contraction of the urinary sphincter
C) increased inotropy 
D) increased insulin secretion
13. Stimulation of the parasympathetic nervous system results in:

A) far vision accommodation
B) contraction of the urinary sphincter
C) increased inotropy
D) increased insulin secretion

Answer:
D) increased insulin secretion

Insulin secretion is increased by stimulation of the parasympathetic nervous system through the vagus nerves

14. The formation clinically significant amounts of carbon monoxide has been associated with:

a) the use of a non-rebreathing circuit b) the use of fresh carbon dioxide absorber
c) the use of desflurane
d) expiratory valve incompetence

Answer:
c) the use of desflurane

The formation of CO depends on the use of a volatile agent containing a difluoromethoxy moiety (desflurane, isoflurane, enflurane). This moiety can react with desiccated base (baralime or sodalime) to form CO. Fresh absorber has sufficient water to prevent the reaction. Clinically, CO intoxication occurs after a weekend when the flow of dry oxygen in the machine has desiccated the absorber and desflurane is being used.

15. Positive end expiratory pressure (PEEP): 

A) decreases dead space 
B) decreases extravascular lung water
C) increases venous return to the heart 
D) decreases intrapulmonary shunting
15. Positive end expiratory pressure (PEEP):

A) decreases dead space
B) decreases extravascular lung water
C) increases venous return to the heart
D) decreases intrapulmonary shunting

Answer:
D) decreases intrapulmonary shunting

The major effect of PEEP is to increase FRC and tidal ventilation above the closing capacity. This results in a decrease in intrapulmonary shunting. Neither PEEP or CPAP decrease extravascular lung water. By increasing intrathoracic pressure, PEEP decreases venous return to the heart.

16. The essential component of cardioplegia solutions is: 

A) mannitol 
B) corticosteroid
C) magnesium 
D) potassium
16. The essential component of cardioplegia solutions is:

A) mannitol
B) corticosteroid
C) magnesium
D) potassium

Answer:
D) potassium

High concentrations of potassium (10 – 40 mEq/L) are used in cardioplegia solutions. These solutions result in an increase in extracellular potassium and reduce transmembrane potential. This progressively interferes with the normal sodium currents of depolarization and eventually the sodium channels are completely inactivated.

17. Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: (Select 2)

a) high-frequency oscillation
b) inverse I:E ratio ventilation
c) airway pressure release ventilation
d) differential lung ventilation
e) high-frequency positive-pressure ventilation
f) pressure support ventilation

Answer:
o a) high-frequency oscillation
o e) high-frequency positive-pressure ventilation

High-frequency oscillation (HFO) creates a to-and-fro gas movement in the airway at rates of 180 – 3000 times/min. High frequency positive-pressure ventilation is delivered at a rate of 60 – 120 breaths/min. Tidal volume is at or below anatomic dead space. High-frequency ventilation techniques may be useful in cases of bronchopleural and tracheoesophageal fistulas.

18. In the absence of hypoxia or severe anemia, the best determinant of the adequacy of cardiac output is:

A) cardiac output
B) arterial oxygen content
C) cardiac index
D) mixed venous oxygen tension

Answer:
D) mixed venous oxygen tension

Both cardiac output and cardiac index have a wide range and may not reflect the adequacy of cardiac output against metabolic requirements. During periods of increased oxygen consumption, mixed venous oxygen tension is the best indicator of the adequacy of cardiac output.

19. The most significant preoperative cardiac risk factor is:

A) evidence of congestive heart failure
B) uncontrolled hypertension
C) renal failure
D) presence of pathological Q waves

Answer:
A) evidence of congestive heart failure

The two most important preoperative cardiac risk factors are evidence of CHF and unstable coronary syndrome

20. The incidence of chronic active hepatitis following infection with the hepatitis C virus is approximately:

A) 10%
B) 75%
C) 25%
D) 50%

Answer:
D) 50%

The incidence of chronic active hepatitis following hepatitis C infection is at least 50%; 3 – 10% following hepatitis B infection

21. Pulmonary changes associated with Duchenne’s muscular dystrophy include:

A) a restrictive ventilatory defect
B) increased residual volume
C) an obstructive ventilatory defect
D) decreased pulmonary artery pressures

Answer:
A) a restrictive ventilatory defect

The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilatory defect in patients with Duchenne’s muscular dystrophy. Pulmonary hypertension is also commonly seen

22. A 46-year-old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately:

A) 2%
B) 25%
C) 5%
D) 10%

Answer:
D) 10%

Patients with acute hepatitis should have elective surgery postponed until the acute hepatitis has resolved. Studies indicate increased perioperative morbidity (12%) and mortality (10% with laparotomy) during acute hepatitis.

23. An increase in intraocular pressure has been associated with: (select 3)

a) nitrous oxide administration
b) succinylcholine administration
c) opioid administration
d) hyperventilation
e) laryngoscopy
f) hypoxemia
g) sevoflurane administration

Answer:
o b) succinylcholine administration
o f) hypoxemia
o e) laryngoscopy

Succinylcholine increases intraocular pressure by 5 – 10 mmHg for 5 – 10 minutes after administration. This increase is primarily the result of prolonged contracture of the extraocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetic agents and opioids have been associated with a reduction in intraocular pressure. Hypoxemia, hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation have all been shown to increase IOP.

24. Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case?

A) Check oxygen cylinder supply
B) Calibration of the oxygen monitor
C) Check the carbon dioxide absorber
D) Performance of a machine low-pressure leak test

Answer:
C) Check the carbon dioxide absorber

Verification of the adequacy of the carbon dioxide absorber is suggested prior to every case. If the same anesthesia machine is being used by the same provider, E-cylinder pressure checks, machine low-pressure leak testing and calibration of the oxygen sensor need not be repeated after an initial check.

25. According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of:

A) 13 – 15
B) Less than 6
C) 9 – 12
D) 6 – 9

Answer:
C) 9 – 12

According to the Modified Glasgow Coma scale, mild head injury is associated with a score of 13 – 15, moderate head injury is associated with a score of 9 – 12, and severe head injury is associated with a score of less than 8.

26. The addition of bicarbonate to a local anesthetic solution:

A) delays the onset of blockade
B) should only be done when using bupivacaine
C) increases the concentration of the nonionic form of the local anesthetic
D) causes a fall in the pH of the solution

Answer:
C) increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on the penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8.

27. Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

a) increased carbon dioxide levels
b) increased 2,3-DPG levels
c) increased pH
d) the presence of fetal hemoglobin
e) increased body temperature
f) the presence of hemoglobin-S

Answer:
o c) increased pH
o d) presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus

28. Laminar flow in the airway occurs in the: (Select 2) 

a) trachea 
b) main stem bronchi 
c) terminal bronchiole 
d) 3rd generation bronchus 
e) respiratory bronchiole
28. Laminar flow in the airway occurs in the: (Select 2)

a) trachea
b) main stem bronchi
c) terminal bronchiole
d) 3rd generation bronchus
e) respiratory bronchiole

Answer:
o c) terminal bronchiole
o e) respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow

29. Sickle hemoglobin: (Select 2) 

a) has a lower P50 than hemoglobin A 
b) releases oxygen less readily than hemoglobin A 
c) is present in about 30% of African Americans 
d) readily polymerizes and precipitates in the red cell 
e) results from a single amino acid substitution on the ?-chain 
f) has decreased solubility as compared to hemoglobin A
29. Sickle hemoglobin: (Select 2)

a) has a lower P50 than hemoglobin A
b) releases oxygen less readily than hemoglobin A
c) is present in about 30% of African Americans
d) readily polymerizes and precipitates in the red cell
e) results from a single amino acid substitution on the ?-chain
f) has decreased solubility as compared to hemoglobin A

Answer:
o d) readily polymerizes and precipitates in the red cell
o f) has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50 (31 mmHg) as compared to hemoglobin A (27 mmHg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the ?-chain.

30. Nerves blocked with a fascia iliaca block include the: 

A) sciatic nerve 
B) anterior tibial nerve
C) femoral nerve 
D) pudendal nerves
30. Nerves blocked with a fascia iliaca block include the:

A) sciatic nerve
B) anterior tibial nerve
C) femoral nerve
D) pudendal nerves

Answer:
C) femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

31. Average blood loss during a vaginal delivery is:

A) 100 – 200 mL
B) 1000 – 1500 mL
C) 400 – 500 mL
D) 700 – 800 mL

Answer:
C) 400 – 500 ml

At term, blood volume has increased by 1000 – 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 – 500 ml, compared with 800 – 1000 ml for cesarean section.

32. Examples of Type IV hypersensitivity reactions include:

A) contact dermatitis
B) angioedema
C) hemolytic transfusion reactions
D) anaphylaxis

Answer:
A) contact dermatitis

Type IV hypersensitivity reactions are delayed and cell-mediated. Examples of Type IV reactions include contact dermatitis, tuberculin-type hypersensitivity and chronic hypersensitivity pneumonitis.

36. Basal metabolic oxygen consumption in a 20 kg patient is approximately:

A) 50 ml/min
B) 250 ml/min
C) 95 ml/min
D) 150 ml/min

Answer:
C) 95 ml/min

Basal metabolic oxygen consumption can be estimated using the following formula:

VO2 = 10Kg3/4

37. Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of:

A) Isoflurane
B) Nitrous oxide
C) Desflurane
D) Sevoflurane

Answer:
B) Nitrous oxide

By irreversibly oxidizing the cobalt atom in vitamin B12, nitrous oxide inhibits vitamin B12 dependent enzymes. These enzymes include methionine synthetase and thymidylate synthetase. As a result of these enzyme inhibitions, prolonged exposure to nitrous oxide has been associated with bone marrow depression, megaloblastic anemia, peripheral neuropathy and teratogenicity.

38. An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of:

A) Midazolam
B) Succinylcholine
C) Rocuronium
D) Fentanyl

Answer:
D) Fentanyl

Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug

39. Disodium edetate or sodium metabisulfite is added to formulations of propofol to:

A) enhance drug solubility
B) increase drug potency
C) adjust pH
D) inhibit bacterial growth

Answer:
D) inhibit bacterial growth

Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth

40. During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of: 

A) 20 cmH2O 
B) 50 psi
C) 50 cmH2O 
D) 25 psi
40. During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:

A) 20 cmH2O
B) 50 psi
C) 50 cmH2O
D) 25 psi

Answer:
B) 50 psi

After proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi.

41. Sensory innervation of the trachea and larynx below the vocal cords is supplied by the: 

A) internal laryngeal nerve 
B) glossopharyngeal nerve
C) external laryngeal nerve 
D) recurrent laryngeal nerve
41. Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

A) internal laryngeal nerve
B) glossopharyngeal nerve
C) external laryngeal nerve
D) recurrent laryngeal nerve

Answer:
D) recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea.

42. A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:

A) 20 – 30 mmHg
B) 90 – 100 mmHg
C) 35 – 45 mmHg
D) 50 – 60 mmHg

Answer:
D) 50 – 60 mmHg

Healthy young individuals tolerate mean arterial pressures as low as 50 – 60 mmHg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 – 30% below baseline.

43. Correct statements concerning the use of benzodiazepines in the elderly include:

A) volume of distribution is increased
B) the elimination half-life of diazepam, but not midazolam, is increased
C) reduced pharmacodynamic sensitivity is observed
d) all of the above

Answer:
A) volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased

44. Concerning preoperative informed consent:

A) it should disclose only life-threatening complications
B) it is not necessary if the procedure is done in an office setting
C) charges of assault and battery are possible if it is not obtained
D) oral consent is insufficient

Answer:
C) charges of assault and battery are possible if it is not obtained

Any procedure performed without the patient’s consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.

45. The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to:

A) 0.5 ppm
B) 50 ppm
C) 5 ppm
D) 25 ppm

Answer:
D) 25 ppm

NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used).

46. The highest incidence of muscle pain following the use of succinylcholine is seen in:

A) Infants
B) Pregnant patients
C) Octogenarians
D) Outpatients

Answer:
D) Outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

47. The cardiovascular effects of pancuronium are caused by: (Select 3)

a) vagal blockade
b) stimulation of cardiac muscarinic receptors
c) ganglionic stimulation
d) decreased catacholamine reuptake
e) direct myocardial stimulation
f) blockade of cardiac slow calcium channels
g) central thalamic stimulation

Answer:
o a) vagal blockade
o c) ganglionic stimulation
o d) decreased catecholamine reuptake

The cardiovascular effects of pancuronium are caused by the combination of vagal blockade and sympathetic stimulation. The latter is due to a combination of ganglionic stimulation, catecholamine release and decreased catecholamine reuptake.

48. Anesthetic implications of multiple sclerosis include: 

A) exacerbation induced by spinal anesthesia 
B) exacerbation of symptoms secondary to hypothermia 
C) exacerbation induced by epidural anesthesia 
d) all of the above
48. Anesthetic implications of multiple sclerosis include:

A) exacerbation induced by spinal anesthesia
B) exacerbation of symptoms secondary to hypothermia
C) exacerbation induced by epidural anesthesia
d) all of the above

Answer:
A) exacerbation induced by spinal anesthesia

Spinal anesthesia has been reported to cause exacerbation of the disease. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia.

49. Local anesthetics with the potential to form methemoglobin include: (Select 3)

a) EMLA topical anesthetic cream
b) Bupivacaine
c) Benzocaine
d) Ropivacaine
e) Prilocaine
f) Mepivacaine

Answer:
o a) EMLA topical anesthetic cream
o e) Prilocaine
o c) Benzocaine

EMLA cream contains both lidocaine and prilocaine. The metabolites of prilocaine can convert hemoglobin to methemoglobin. Benzocaine can also cause methemoglobinemia. Case studies have also associated methemoglobinemia with tetracaine and lidocaine use.

50. During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: (Select 3)

a) hypotension secondary to cement monomer absorption
b) hypoxemia secondary to air embolization
c) hypoxemia secondary to fat embolization
d) hypocarbia
e) decreased pulmonary artery pressure
f) increased end-tidal carbon dioxide

Answer:
o a) hypotension secondary to cement monomer absorption
o b) hypoxemia secondary to air embolization
o c) hypoxemia secondary to fat embolization

During hip replacement surgery, hypotension associated with the use of acrylic bone cement has been attributed to absorption of methyl methacrylate monomer, embolization of air and bone marrow, lysis of red cells and marrow and conversion of methyl methacrylate to methacrylic acid. Hypoxemia is common. Embolic events cause an increase in dead space with a reduction in ETCO2 with an increase in PaCO2.
(Nagelhout pg. 977, Barash pg. 1389)

What is auto regulation?
Answer:
Most tissue beds regulate their own blood flow (autoregulation). Arterioles generally dilate in response to reduced perfusion pressure or increased tissue demand. Conversely, arterioles constrict in response to increased pressure or reduced tissue demand. These phenomena are likely due to both an intrinsic response of vascular smooth muscle to stretch and the accumulation of vasodilatory metabolic by-products. The latter may include K+, H+, CO2, adenosine, and lactate.

Bone marrow depression and peripheral neuropathy have been associated with prolonged exposure to anesthetic concentrations of:
A. Isoflurane
B. Desflurane
C. Sevoflurane
D. Nitrous Oxide
Answer:
D. Nitrous Oxide

By irreversibly oxidizing the cobalt atom in vitamin B12, nitrous oxide inhibits vitamin B12 dependent enzymes. These enzymes include methionine synthetase and thymidylate synthetase. As a result of these enzyme inhibitions, prolonged exposure to nitrous oxide has been associated with bone marrow depression, megaloblastic anemia, peripheral neuropathy and teratogenicity.

Page 471. Clinical Anesthesia Barash.

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of:
A. Midazolam
B. Roruconium
C. Fentanyl
D. Succinylcholine
Answer:
C. Fentanyl

Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug. Page 185 Morgan & Mikhail’s Clinical Anesthesiology.

Disodium edetate or sodium metabisulfite is added to formulations of propofol to:
A. Enhance drug solubility
B. Adjust pH
C. Inhibit bacterial growth
D. Increase drug potency
Answer:
C. Inhibit bacterial growth

Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth.
Page 186 Morgan & Mikhail’s Clinical Anesthesiology

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:
A. 20cmH2O
B. 50cmH2O
C. 25psi
D. 50psi
Answer:
D. 50psi

After proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi

Page 1237 Morgan & Mikhail’s Clinical Anesthesiology

Sensory innervation of the trachea and larynx below the vocal cord is supplied by the:
A. Internal laryngeal nerve
B. External laryngeal nerve
C. Recurrent laryngeal nerve
D. Glossopharyngeal nerve
Sensory innervation of the trachea and larynx below the vocal cord is supplied by the:
A. Internal laryngeal nerve
B. External laryngeal nerve
C. Recurrent laryngeal nerve
D. Glossopharyngeal nerve
Answer:
C. Recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and the trachea.
Page 310 Morgan & Mikhail Clinical Anesthesiology

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

Healthy young individual tolerate mean arterial pressures as low as 50-60mmHg without complications. Chronically hypertensive patients have altered auto regulation of cerebral blood flow and may tolerate a mean arterial pressure of no more that 20-30% below baseline.
Page 262 Morgan & Mikhail’s Clinical Anesthesiology.

Correct statements concerning the use of benzodiazepines in the elderly include:
A. Volume of distribution is increased
B. Reduced pharmacodynamics sensitivity is observed
C. The elimination half-life of diazepam, but not midazolam, is increased
D. All of the above
Answer:
A. Volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamics sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased.
Page 895, Barash, Clinical Anesthesia

Concerning preoperative informed consent:
A. It should disclose only life-threatening complications
B. Charges of assault and battery are possible of it is not obtained
C. Oral consent is sufficient
D. It is not necessary if the procedure is done in an office setting
Answer:
B. Charges of assault and battery are possible of it is not obtained

Any procedure performed without the patient’s consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.
PP 29-30 Nagelhout Nurse Anesthesia.

The National Institute of Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to:
A. 0.5 ppm
B. 5 ppm
C. 25 ppm
D. 50 ppm
Answer:
C. 25 ppm

NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2ppm (0.5 ppm if nitrous oxide is also being used).
Page 652-654, Longnecker, Newman . Anesthesiology.

The highest incidence of muscle pain following the use of succinylcholine is seen in :
A. Infants
B. Octogenarians
C. Outpatients
D. Pregnant patients
Answer:
C. Outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of ages seem to be protective. Page 532 Barash, clinical Anesthesia

Anesthetic implications of multiple sclerosis include:
A. Exacerbation induced by spinal anesthesia
B. Exacerbation induced by epidural anesthesia
C. Exacerbation of symptoms secondary to hypothermia
D. All of the above
Anesthetic implications of multiple sclerosis include:
A. Exacerbation induced by spinal anesthesia
B. Exacerbation induced by epidural anesthesia
C. Exacerbation of symptoms secondary to hypothermia
D. All of the above
Answer:
A. Exacerbation induced by spinal anesthesia

Spinal anesthesia has been reported to cause exacerbation of the disease. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia

Local anesthetics with the potential to form methemoglobin include: (select 3):
A. EMLA topical anesthetic cream
B. Bupivacaine
C. Benzocaine
D. Ropivacaine
E. Prilocaine
F. Mepivacaine
Answer:
A. EMLA topical anesthetic cream
C. Benzocaine
E. Prilocaine

EMLA cream contains both lidocaine and prilocaine. The metabolites of prilocaine can convert hemoglobin to methemoglobin. Benzocaine can also cause methemoglobinemia.
Page 140 Nagelhout, Nurse Anesthesia

The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
A- 30-45%
B- 22-45%
C- 100%
D- 15-25%
Answer:
D- 15-25%
Passive flow accounts for about 75-80% of ventricular filling. The remaining 15-25% occurs as a result of atrial contraction, which is lost during atrial fibrillation.

Page 249. Barash, Clinical Anesthesia

During surgical repair of a detached retina, 1mL of sulfur hexafluoride is injected into the posterior chamber. If the patient is receiving 4% desflurane and a 2.1 ration of N2O and O2, the pressure-volume relationship of the bubble will approximately:
A. Decrease in to about 0.67
B. Remain the same
C. Double
D. Triple
Answer:
D. Triple

A sulfur hexafluoride gas bubble is sometimes used to support the retina after detachment. Diffusion of nitrous oxide into the bubble will cause expansion as nitrous oxide equilibrates with the gas bubble. A sixty-seven percent nitrous oxide concentration will cause the bubble to triple in its pressure-volume relationship in about 30 minutes and may double the intraocular pressure (IOP). IN addition, when nitrous oxide is discontinued, the bubble will return to normal size, causing a fall in IOP and possible extension of the retinal tear. For these reasons, it is recommended that nitrous oxide be discontinued at least 15 minutes prior to the injection of a posterior chamber bubble.

Page 762Morgan & Mikhail’s Clinical Anesthesiology

Topically applied ophthalmic medications are absorbed:
A. As quickly as intravenous administration
B. More quickly than subcutaneous administration
C. Only minutely, with insignificant clinical effect
D. Directly into the central nervous system through the optic nerve foramen
Answer:
B. More quickly than subcutaneous administration

Topically applied ophthalmic medications are absorbed at a rate intermediate between intravenous and subcutaneous injection. Children and the elderly are at particular risk for the toxic effects of topically applied medications. Page 762 Morgan & Mikhail’s Clinical Anesthesiology.

During pregnancy, the minimum alveolar concentration (MAC):
A. Decreases until the 20th week
B. Increases until the 20th week
C. Decreases throughout the pregnancy
D. Increases throughout the pregnancy
Answer:
C. Decreases throughout the pregnancy

D. Increases throughout the pregnancy
The MAC progressively decreases during pregnancy, at term by as much as 40%. MAC returns to normal by the third day after delivery. Page 826 Morgan & Mikhail’s Clinical Anesthesiolog.

The rhythm strip below is indicative of:
A. First degree block
B. Second degree block, type I
C. Second degree block, type II
D. Bifascicular block
The rhythm strip below is indicative of:
A. First degree block
B. Second degree block, type I
C. Second degree block, type II
D. Bifascicular block
Answer:
B. Second degree block, type I (Wenckebach)

Second degree block, type I, shows progressive lengthening of the PR interval with each cycle until a QRS complex is dropped. This type of block indicates AV nodal disease and associated bradycardia usually responds to the administration of atropine.

Page 1704 Barash, Clinical Anesthesia

The rhythm strip below is indicative of:
The rhythm strip below is indicative of:
Answer:
Sinus Bradycardia
A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be ‘normal’, but other causes may be due to increased vagal tone from drug abuse, hypoglycemia and brain injury with increase intracranial pressure (ICP) as examples
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – less than 60 beats per minute
• QRS Duration – Normal
• P Wave – Visible before each QRS complex
• P-R Interval – Normal
• Usually benign and often caused by patients on beta blockers

The rhythm strip below is indicative of:
The rhythm strip below is indicative of:
Answer:
Sinus Tachycardia

An excessive heart rate above 100 beats per minute (BPM) which originates from the SA node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger then medications may be required to suppress the rhythm
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – More than 100 beats per minute
• QRS Duration – Normal
• P Wave – Visible before each QRS complex
• P-R Interval – Normal
• The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise

The rhythm strip below is indicative of :
The rhythm strip below is indicative of :
Answer:
Supraventricular Tachycardia (SVT) Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in the ‘atria’ but is not under direct control from the SA node. SVT can occur in all age groups
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – 140-220 beats per minute
• QRS Duration – Usually normal
• P Wave – Often buried in preceding T wave
• P-R Interval – Depends on site of supraventricular pacemaker
• Impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node

The rhythm strip below is indicative of:
The rhythm strip below is indicative of:
Answer:
Atrial Fibrillation

Many sites within the atria are generating their own electrical impulses, leading to irregular conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be felt when palpating a pulse
It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain, or congestive heart failure.
Looking at the ECG you’ll see that:
• Rhythm – Irregularly irregular
• Rate – usually 100-160 beats per minute but slower if on medication
• QRS Duration – Usually normal
• P Wave – Not distinguishable as the atria are firing off all over
• P-R Interval – Not measurable
• The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Atrial Flutter

Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Around 110 beats per minute
• QRS Duration – Usually normal
• P Wave – Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F – 1QRS) but sometimes 3:1
• P Wave rate – 300 beats per minute
• P-R Interval – Not measurable
• As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case.

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals reach the ventricles. This rarely causes any problems by itself and often trained athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG.
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Normal
• QRS Duration – Normal
• P Wave – Ratio 1:1
• P Wave rate – Normal
• P-R Interval – Prolonged (>5 small squares)

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
• 2nd Degree Block Type 2

When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this intermittent occurance is said to be called second degree heart block. Electrical conduction usually has a constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed by ventricular contraction
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Normal or Slow
• QRS Duration – Prolonged
• P Wave – Ratio 2:1, 3:1
• P Wave rate – Normal but faster than QRS rate
• P-R Interval – Normal or prolonged but constant

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are ‘normal’ but no electrical conduction is conveyed to the ventricles. The ventricles then generate their own signal through an ‘escape mechanism’ from a focus somewhere within the ventricle. The ventricular escape beats are usually ‘slow’
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Slow
• QRS Duration – Prolonged
• P Wave – Unrelated
• P Wave rate – Normal but faster than QRS rate
• P-R Interval – Variation
• Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Bundle Branch Block

Abnormal conduction through the bundle branches will cause a depolarization delay through the ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle Branch Block (RBBB) indicates problems in the right side of the heart. Whereas Left Bundle Branch Block (LBBB) is an indication of heart disease. If LBBB is present then further interpretation of the ECG cannot be carried out.
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Normal
• QRS Duration – Prolonged
• P Wave – Ratio 1:1
• P Wave rate – Normal and same as QRS rate
• P-R Interval – Normal

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Premature Ventricular Complexes

Due to a part of the heart depolarizing earlier than it should
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – Normal
• QRS Duration – Normal
• P Wave – Ratio 1:1
• P Wave rate – Normal and same as QRS rate
• P-R Interval – Normal
• Also you’ll see 2 odd waveforms, these are the ventricles depolarizing prematurely in response to a signal within the ventricles.(Above – unifocal PVC’s as they look alike if they differed in appearance they would be called multifocal PVC’s, as below)

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Junctional Rhythms

In junctional rhythm the sinoatrial node does not control the heart’s rhythm – this can happen in the case of a block in conduction somewhere along the pathway. When this happens, the heart’s atrioventricular node takes over as the pacemaker.
Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – 40-60 Beats per minute
• QRS Duration – Normal
• P Wave – Ratio 1:1 if visible. Inverted in lead II
• P Wave rate – Same as QRS rate
• P-R Interval – Variable

Identify the following rhythm strip:
Identify the following rhythm strip:
Accelerated Junctional Rhythm

Identify the following rhythm strip
Identify the following rhythm strip
Answer:
Ventricular Tachycardia (VT) Abnormal

Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – 180-190 Beats per minute
• QRS Duration – Prolonged
• P Wave – Not seen
• Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Ventricular Fibrillation (VF) Abnormal

Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is indicated. This condition may occur during or after a myocardial infarct.
Looking at the ECG you’ll see that:
• Rhythm – Irregular
• Rate – 300+, disorganised
• QRS Duration – Not recognisable
• P Wave – Not seen
• This patient needs to be defibrillated!! QUICKLY

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Asystole – Abnormal

A state of no cardiac electrical activity, as such no contractions of the myocardium and no cardiac output or blood flow are present.
Looking at the ECG you’ll see that:
• Rhythm – Flat
• Rate – 0 Beats per minute
• QRS Duration – None
• P Wave – None
• Carry out CPR!!

Identify the following rhythm strip:
Identify the following rhythm strip:
Answer:
Myocardial Infarct (MI)

Looking at the ECG you’ll see that:
• Rhythm – Regular
• Rate – 80 Beats per minute
• QRS Duration – Normal
• P Wave – Normal
• S-T Element does not go isoelectric which could indicate

Physiologic effects of electroconvulsive therapy (ECT) include an:
A. Initial sympathetic response with sustained tachycardia
B. Initial sympathetic discharge followed by a sustained parasympathetic response
C. Initial parasympathetic discharge followed by a sustained sympathetic response
D. Initial parasympathetic response with sustained bradycardia
Answer:
C. Initial parasympathetic discharge followed by a sustained sympathetic response

An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased secretions can occur, which is then followed by hypertension and tachycardia. Patients scheduled for ECT are routinely given anticholinergic medication preoperatively.

Page 1277 Nagelhout, Nurse Anesthesia

The postretrobulbar block apnea syndrome:
A. Is likely secondary to intravascular injection
B. Most commonly occur during or immediately after injection
C. Is associated with unconsciousness
D. Carries a high morbidity and mortality
The postretrobulbar block apnea syndrome:
A. Is likely secondary to intravascular injection
B. Most commonly occur during or immediately after injection
C. Is associated with unconsciousness
D. Carries a high morbidity and mortality
Answer:
C. Is associated with unconsciousness

The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.
Page 766 Morgan & Mikhail’s Clinical Anesthesiology

Performing a retrobulbar block
Performing a retrobulbar block

A 76 year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electro cautery use in this patient can be minimized by:
A. Placing the grounding pad near the pacemaker
B. Using infrequent bursts of longer duration
C. The use of a bipolar cautery
D. Reducing the surface area o the return electrode
Answer:
C. The use of a bipolar cautery

Electrical interference from the electro cautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use of short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.

Page 403 Morgan & Mikhail’s Clinical Anesthesiology

Monopolar VS Bipolar cautery
Monopolar VS Bipolar cautery
Monopolar versus bipolar — Electrosurgery can be performed using either a monopolar or a bipolar instrument. The main difference between these two modalities is that in monopolar surgery, the current goes through the patient to complete the current cycle, while in bipolar surgery, the current only passes through the tissue between the two electrodes of the instrument.

More resources: Monopolar cautery Vs Bipolar cautery:

The mechanisms of MPC and BPC electric current conduction are quite different. For MPC, the current flows from the generator to the cautery pen (the active electrode) through the subject’s body to the inactive dispersive electrode, which is in contact with the subject, and then back to the generator. In BPC, the current flows only from one forceps tip to the other, and a limited amount of tissue is cauterized in between. Because of the difference in the mechanism, the power setting required for BPC is usually much lower than that for MPC

The arteria radicularis magna, or artery of Adamkiemicz, most commonly arises from:
A. T4-T8
B. T8-L2
C. L2-L4
D. L4-S1
The arteria radicularis magna, or artery of Adamkiemicz, most commonly arises from:
A. T4-T8
B. T8-L2
C. L2-L4
D. L4-S1
Answer:
B. T8-L2
A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable origin from aorta, arising between T5-T8 in 15%, between T9-T12 in 60% and between L1-L2 in 25% of individuals. Page 480 Morgan & Mikhail’s Clinical Anesthesiology.

Arteria radicularis
Arteria radicularis

The most severe transfusion reactions are due to:
A. ABO incompatibility
B. Rh incompatibility
C. Febrile reactions
D. Non-ABO hemolytic reactions
Answer:
A. ABO incompatibility

The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis. Page 1172 Morgan & Mikhail’s Clinical Anesthesiology

In the figure below. Isoflurane is best represented by:
• A
• B 
• D
• E
In the figure below. Isoflurane is best represented by:
• A
• B
• D
• E
Answer:
• B
On this graph, line B best depicts the change in vapor pressure seen with the change in temperature of Isoflurane. Note that at 20 degree C. the vapor pressure represented by line B is 238 mmHg, corresponding to the saturated vapor pressure of isoflurane at the temperature. Line A corresponds with Desflurane, line C with halothane, line D with Enflurane and line E with Sevoflurane.

Page 66 Anesthesia equipment Principles AND applications

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above:
A. 5mmHg
B. 15 mmHg
C. 25 mmHg
D. 30 mmHg
Answer:
B. 15 mmHg

Uncompensated increases in tissue or fluid within the rigid intracranial vault produce the sustained pressure elevations.
Pp 871-874 Longnecker, Anesthesiology

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be:
A. Between 300 and 400
B. Between 200 and 300
C. Between 100 and 200
D. Less than 100
Answer:
D. Less than 100

RSBI is frequently used to help predict who can be successfully weaned from mechanical ventilation. With the patient breathing spontaneously, the ventilator rate is divided by the tidal volume (liters). Successful extubation can be predicted by an RSBI of less than 100.

Page 1297. Morgan & Mikhail’s Clinical Anesthesiology

The perception of an ordinarily non-noxious stimulus as pain I referred to as:
A. Allodynia
B. Anesthesia dolorosa
C. Dysresthesia
D. Hyperalgesia
Answer:
A. Allodynia

Allodynia is the perception of non-noxious stimuli as pain. Dysesthesia is an unpleasant sensation without a stimulus. Hyperesthesia is an increased response to a mild stimulus. Anesthesia dolorosa is pain an area that lacks sensation.

Page 1649-1650 Barash, Clinical Anesthesia

Cholinesterase inhibitors that easily cross the blood brain barrier include:
A. Neostigmine
B. Pyridostigmine
C. Physostigmine
D. Edrophonium
Answer:
C. Physostigmine

Physostigmine is a tertiary amine and has a carbamate group, but no quaternary ammonium. Therefore, it is lipid soluble and is the only linically available cholinesterase inhibitor that freely passes the blood-brain-barrier.

Page 383 Barash, Clinical Anesthesia

Ninety percent of congenital diaphragmatic hernias occur:
A. Through the left posterolateral foramen
B. Through the right posterolateral foramen
C. Through the anterior foramen
D. Along the inferior vena cava
Ninety percent of congenital diaphragmatic hernias occur:
A. Through the left posterolateral foramen
B. Through the right posterolateral foramen
C. Through the anterior foramen
D. Along the inferior vena cava
Answer:
A. Through the left posterolateral foramen

Left-sided herniation through the posterolateral foramen of Bochdalek accounts for 90% of diaphragmatic hernias. Hypoxia, scaphoid abdomen and evidence of bowel in the thorax are the hallmarks of diaphragmatic herniation. Peak airway pressures should not exceed 30 cm H2) to minimize the risk of pneumothorax during surgical correction.

Page 899 Morgan & Mikhail’s Clinical Anesthesiology

During fetal monitoring, Type III decelerations are thought to be related to:
A. Head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Placental abruption
Answer:
B. Umbilical cord compression

Type III, or variable decelerations are the most common tpe of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

Page 1167 Barash, Clinical Anesthesia

Early deceleration
Early deceleration
The picture above is known as an “early decelerations”. The top line is monitoring the baby’s heart rate and the bottom line is monitoring mom’s contractions. On the bottom line (mom’s contraction), you can see that the line start to go up and then down…….this means mom is having a contraction. The top line (baby’s heart rate) then responds to this contraction and notice that it slightly dips down while mom is having her contraction.
The key to remembering if this an early deceleration is to see if the baby’s heart rate mirrors moms contraction and it does here. Plus look to see if the baby’s heart rate is staying within normal limits of 110-160 beats per minutes. The baby’s heart rate dips slightly at the same time the contraction starts and recovers to a normal range after mom’s contraction is over.
Early decelerations are nothing to be alarmed about. The reason the baby’s heart rate starts to slightly decrease is due to head compression (probably from the baby’s head being in the birth canal) causing the vagus nerve to be compressed which in turn decreases the heart rate. So if you see this on NCLEX or HESI the answer to the question will probably be continue to monitor and document the process of the labor or no nursing interventions are required right now but continue to monitor.

Variable deceleration
Variable deceleration
This crazy looking strip is called “variable decelerations”. I remember it because the dips in the fetal heart tones look like V’s. The v’s remind me that this is a “variable deceleration”. Variable decelerations are NOT good! Notice that every time mom has a contraction the baby’s heart rate majorly decreases. Remember a normal fetal heart rate is 110-160 bpms.
The cause of the decrease fetal heart rate is due to umbilical cord compression. So if you are presented with this type of strip on NCLEX or HESI some of the answers you would need to pick would be change mom’s position (moving her around could help relieve cord compression), administer Oxygen usually 10 L (because cord is being compressed which in turn is causing the baby to not receive enough Oxygen), stop Picotin infusion if running, and contact the doctor. Plus you may be asked on the exam what is causing this strip to look like this and the answer would be cord compression.

Late deceleration
Late deceleration
The picture above is known as “late decelerations”. The name tells you exactly what should be presented on the strip. Late decelerations are NOT good either just like variable decelerations. Notice that when mom has a contraction the baby’s heart rate goes down long after the beginning of mom’s contraction and recovers way after the contraction is over.
This is different from early decelerations because the baby’s heart rate went down at the same time the contractions happened and recovered to normal when the contraction ended. NCLEX and HESI may ask what is causing this type of strip and the answer would be uteroplacental insufficiency. Some nursing interventions include: turn mom onto her side, stop Picotin if infusing, administer 10 L of O2, maintain IV access, determine the Fetal Heart Rate variability, and contact doctor.

Pathophysiologic factor affecting the anesthetic management of patients with hypothyroidism include:
A. Hypernatremia
B. Hyperglycemia
C. Difficulty with intubation and airway management
D. Increased blood viscosity due to elevated hematocrit
Answer:
C. Difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

Pages 875-876 Nagelhout, JJ Nurse Anesthesia

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:
A. Genioglossus muscles
B. Longitudinal muscle of the tongue
C. Palatoglossus muscles
D. Styloglossus muscle
Answer:
A. Genioglossus muscles

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

The most frequent manifestation of sickle cell disease is:
A. Pain
B. Splenic sequestration
C. Aplastic crisis
D. Right upper quadrant syndrome
Answer:
A. Pain

The most frequent manifestation of sickle cell disease is pain. The pain is thought to be secondary to tissue ischemia and usually affects the back, chest, extremities and abdomen.
Page 631 Barash, Clinical Anesthesia

Reactants that are generates during the absorption of carbon dioxide by soda lime include:
A. Carbonic acid
B. Sodium hydroxide
C. Calcium hydroxide
D. Calcium carbonate
Answer:
B. Sodium hydroxide

Both water and sodium hydroxide are initially required during the absorption of carbon dioxide by soda lime, but they are regenerated
Page 269 Nagelhout , Nurse Anesthesia

During the administration of general anesthesia for a radical prostatectomy, the rhythm strip below is obtained. The most appropriate therapeutic measures at this time would include:
A. Initiation of a nitroglycerine infusion
B. Administration of metoprolol
C. Requesting the use of a bipolar cautery
D. Engage the artifact filler on the ECG monitor
Answer:
C. Requesting the use of a bipolar cautery

This rhythm strip indicates a paced rhythm with clerly visible pacer spikes. Electrical interference from the electrocautery can be interpreted as myocardial activity and can suppress the pacemaker generator. The use of a bipolar cautery will reduce the electrical interference produced; if that is not possible, the pure cut is better than “blend” or “coag.”

Pp 204-207, 1720 Barash, Clinical Anesthesia

The effects of barbiturates on ischemic areas of the brain include:
A. Vasoconstriction
B. Vasodilation
C. Redirection of blood flow to the ischemic areas
D. Redirection of blood flow away from ischemic areas
Answer:
C. Redirection of blood flow to the ischemic areas

Barbiturates cause cerebral vasoconstriction in normal areas. These agents tend to redistribute blood flow to ischemic areas in what is sometimes referred to as a reverse steal phenomenon or Robin Hood effect. Ischemic areas remain maximally dilated and unaffected by the barbiturate.

Page 485 Barash, Clinical Anesthesia

Venous irritation associated with the injection of diazepam and lorazepam is secondary to:
A. The high degree of water solubility of these agents
B. The presence of propylene glycol as a solvent
C. The presence of metabisulfite as a preservative
D. The low pH of these agents
Answer:
B. The presence of propylene glycol as a solvent

The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation.
Page 488 Barash, Clinical Anesthesia

In the thromboelatogram below, clot strengths is best represented by:
• A
• B
• E
• F
In the thromboelatogram below, clot strengths is best represented by:
• A
• B
• E
• F
Answer:
• E
The maximum amplitude (E) is a measure of the strength of the fully formed clot. It reflects primarily platelet number and function although it also requires proper fibrin formation to achive normal values.
Page 1519 Barash, Clinical Anesthesia

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include:
A. A nitroglycerine infusion
B. Inotropic support
C. Afterload reduction
D. Maintenance of adequate preload
In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include:
A. A nitroglycerine infusion
B. Inotropic support
C. Afterload reduction
D. Maintenance of adequate preload
Answer:
D. Maintenance of adequate preload

In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable.

Pages 1083-1084 Barash, Clinical Anesthesia

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

The adult brain consumes about 20% of the total body oxygen (50ml/min). Neuronal cells normally utilize glucose as their energy source, but can also utilize ketone bodies and lactate. Hyperglycemia has been shown to worsen global and focal hypoxic brain injury.

Page 576 Morgan & Mikhail’s Clinical Anesthesiologist.

In the graph of cerebral blood flow below, PaO2 would best be represented by curve:
• A
• B
• C
• D
In the graph of cerebral blood flow below, PaO2 would best be represented by curve:
• A
• B
• C
• D
Answer:
• A
Curve A best represents the effects of changing oxygen tensions on cerebral blood flow. Hypoxemia causes a significant increase in CBF to meet the brain’s metabolic demand. Hyperoxia, however, causes little change in CBF.

Page 999 Barash, Clinical Anesthesia.

Portal hypertension is defined as sustained portal vein pressure greater than:
A. 5mmHg
B. 10mmHg
C. 20mmHg
D. 25mmHg
Portal hypertension is defined as sustained portal vein pressure greater than:
A. 5mmHg
B. 10mmHg
C. 20mmHg
D. 25mmHg
Answer:
B. 10mmHg

Portal hypertension is defined as a sustained portal vein pressure of 10 mmHg or greater. This leads to the formation of porta-systemic collateral venous channels.

Page 1295 Barash, Clinical Anesthesia
Page 793 Morgan & Mikhail, Clinical Anesthesiology

Absolute contraindication to electroconvulsive (ECT) include:
A- Congestive heart failure
B- Pregnancy
C- Myocardial infarction 5 months prior to therapy
D- Increased intracranial pressure
Answer:
D- Increased intracranial pressure

Absolute contraindications to ECT include recent MI (usually less than 3 months), recent stroke (< than 1 month), intracranial mass, or increased ICP. Relative contraindications include angina, CHF, significant pulmonary disease, bone fractures, osteoporosis, pregnancy, glaucoma, and retinal detachment. Pg 628 Morgan & Mikhail's Clinical Anesthesiology

In the enuromuscular junction, acetylcholine receptor binding sites are found on the:
A- Alpha subunits
B- Beta subunits
C- Delta subunits
D- Gamma subunits
In the enuromuscular junction, acetylcholine receptor binding sites are found on the:
A- Alpha subunits
B- Beta subunits
C- Delta subunits
D- Gamma subunits
Answer:
A- Alpha subunits

Each acetylcholine (ACh) receptor in the neuromuscular junction consists of 5 protein subunits. Only the alpha-subunits are capable of binding ACh molecules. If both binding sites are occupied, the channel briefly opens. The alpha-subunits are also the site of action of neuromuscular blockers.

Page 527 Barash, Clinical Anesthesia

In the fetus, the percentage of cardiac output directed to the placenta is approximately:
A- 10%
B- 25%
C- 50%
D- 100%
In the fetus, the percentage of cardiac output directed to the placenta is approximately:
A- 10%
B- 25%
C- 50%
D- 100%
Answer:
C- 50%

In the fetus, the lungs receive little blood flow. The placenta receives nearly one-half of the fetal cardiac output and I responsible for respiratory exchange.

Page 836 Morgan & Mikhail’s Clinical Anesthesiology

the elimination half life of intravenously administered oxytocin in the parturient is approximately:
A- 30 to 120 seconds
B- 3 to 5 minutes
C- 10 to 15 minutes
D- 20 to 30 minutes
Answer:
B- 3 to 5 minutes

Both endogenous and intravenously administered oxytocin have short elimination half-lives of about 3 to 5 minutes. As a result, oxytocin must be administered as a continuous infusion for the induction of labor.

Page 835 Morgan & Mikhail’s Clinical Anesthesiology.

A fresh E-cylinder of oxygen:
A- contains more liter of gas than an E-cylinder of nitrous oxide.
B- contains about 90% of liquid oxygen and 10% oxygen as a gas.
C- contains about 660 liters of oxygen
D- has a lower pressure than the pipeline oxygen supply
Answer:

C- contains about 660 liters of oxygen.

a fresh E-cylinder of oxygen contains about 660L of oxygen and is pressurized to 1900 psi.
Page 8- Dorsch, A practical approach to anesthesia equipments

An 82 year old female arrives to the OR for open reduction of left intertrochanteric fracture. Significant past medical history include hypertension, moderate aortic stenosis, and dementia. The most appropriate anesthetic technique for this patient is:
A- opioid based general anesthesia
B- spinal anesthesia
C- volatile agent based general anesthesia
D- epidural anesthesia
Answer:
A- opioid based general anesthesia

In patients with mild to moderate aortic stenosis, a primarily based opioid technique results in minimal cardiac depression, less tachycardia and suppression of the sympathetic response to surgical stimulation. These are all desired effects as HTN and tachycardia may precipitate ischemia in these patients. Spinal or epidural anesthesia can cause a fall in afterload with resulting severe hypotension.

Page 501-502 Nagelhout Nurse Anesthesia.

What are the pharmacologic anticoagulation of the following drugs:
Warfarin
Hirudin
Heparin
Fondaparinux
Answers:
Warfarin: Vit K inhibition
Heparin: Anti Thrombin Activation
Hirudin: Thrombin Inhibition
Fondaparinux: Factor Xa Inhibition

Pages 439-440 Barash Clinical Anesthesia

Match the following hormones to the site of production in the adrenal gland:
Glucocorticoids----------Adrenal Medulla
Mineralocorticoids------Zona Reticularis
Sex hormones----------Zone Glomerulosa
Catecholamines-----Zona Fasciculata
Match the following hormones to the site of production in the adrenal gland:
Glucocorticoids———-Adrenal Medulla
Mineralocorticoids——Zona Reticularis
Sex hormones———-Zone Glomerulosa
Catecholamines—–Zona Fasciculata
Answer:
Zona Glomerulosa———–Mineralocorticoids
Zona Fasciculata————–Glucocorticoids
Zona Reticularis————–Sex Steroids
Adrenal Medulla————–Catecholamines

Page 772 Yao and Artusio’s Anesthesiology

During the delivery of an inhalation anesthetic using 6.5% desflurane in oxygen, nitrous oxide is introduced into the gas mixture. The effect of the addition of nitrous oxide on the concentration of desflurane delivered is:

A- to cause an increase in desflurane concentration
B- to cause a decrease in desflurane concentration
C- to cause no change in desflurane concentration
D- variable, depending on the ambient atmospheric pressure.

Answer:

B- to cause a decrease in desflurane concentration.

When a carrier gas other than 100% oxygen is used, a clear trend toward reduction in the desflurane vaporizer output is seen. This effect is thought to be secondary to the change in gas viscosity that occurs with the introduction of nitrous oxide and is most pronounced at low flow rates. A reduction of as much as 20% may be produced.

Page 669 Barash, Clinical Anesthesia

The area of myocardium most vulnerable to ischemia is the:
A- left ventricular epicardium
B- right ventricular epicardium
C- left ventricular subendocardium
D- right ventricular subendocardium
The area of myocardium most vulnerable to ischemia is the:
A- left ventricular epicardium
B- right ventricular epicardium
C- left ventricular subendocardium
D- right ventricular subendocardium
Answer:
C- Left ventricular subendocardium

The subendocardium of the left ventricle is most vulnerable to ischemia since this is an area of greater systolic shortening. In addition, left ventricular subendocardium perfusion is almost entirely restricted to diastole, in contrast to the subendocardium of the right ventricle that receives most of its perfusion during systole.

Page 244 Barash, Clinical Anesthesia

The formation of active metabolite has NOT been associated with the use of :
A- Vecuronium
B- Rocuronium
C- Pancuronium
D- Succinylcholine
Answer:
B- Rocuronium

The 3-OH metabolites of both Vecuronium and Pancuronium possess about 50% of the neuromuscular blocking activity of parent compound. Succinylcholine is metabolized to choline, succinic acid and succinylmonocholine. Succinylmonocholine also has some neuromuscular blocking activity. A small amount of rocuronium is metabolized to the 17-OH compound, which lacks activity. Most Rocuronium is excreted by the kidneys and liver as intact drug.

Pages 535- 538 Barash Clinical Anesthesia

The rate of seroconversion after exposure of mucous membranes to HIV-infected blood is approximately:
A- 0.03%
B- 0.09%
C- 0.3%
D- 0.9%
Answer:
B- 0.09%

Percutaneous exposure (needle stick) carries a risk of HIV-seroconversion of approximately 0.3% or about 1:300. Mucous membrane exposure carries a risk of approximately 0.09% or about 1:1100.

Page 77 Barash Clinical Anesthesia

Actuation of the oxygen flush valve delivers 100% oxygen at a rate of:
A- 10-20 L/min
B- 20-30 L/min
C- 35-75 L/min
D- 80-100 L/min
Actuation of the oxygen flush valve delivers 100% oxygen at a rate of:
A- 10-20 L/min
B- 20-30 L/min
C- 35-75 L/min
D- 80-100 L/min
Answer:

C- 35-75 L/min

The oxygen flush valve delivers 100% oxygen at a rate of 35-75 L/min with a pressure of 40-60 psi.

Page 64 Morgan & Mikhail’s Clinical Anesthesiology

A decrease in cholinesterase activity has been associated with:
A- Obesity
B- Thyrotoxocosis
C- Alcoholism
D- Burns
A decrease in cholinesterase activity has been associated with:
A- Obesity
B- Thyrotoxocosis
C- Alcoholism
D- Burns
Answer:
D- Burns

Burns, liver disease, 3rd trimester of pregnancy, carcinoma, renal failure and collagen diseases as well as certain drug therapy have been associated with a decrease in cholinesterase activity. Increased cholinesterase activity has been associated with obesity, alcoholism, thyrotoxicosis, nephrosis, psoriasis and electroconvulsive therapy.

Page 207 Morgan & Mikhail’s Clinical Anesthesiology

The incidence of headache with inadvertent dural puncture during epidural anesthesia is decreased:
A- with decreasing age
B- by keeping the patient supine for more than 12 hours following procedure
C- with the use of fluid, instead of air, for loss of resistance
D-by inserting the needle with the bevel aligned perpendicular to the long axis of the meninges
Answer:

C- with the use of fluid, instead of air, for loss of resistance.

The use of fluid instead of air has been associated with a significant reduction in the incidence of postdural puncture headache (PDPH). Other factors associated with a reduced incidence of PDPH are: increasing age, insertion of the bevel parallel to the long axis of the meninges and the use of smaller needles. There is no evidence that keeping the patient supine reduces the incidence of PDPH.

Page 926 Barash, Clinical Anesthesia.

Factors decreasing physiologic dead space include:
A- the supine position
B- anticholinergic agents
C- increasing age
D- emphysema
Factors decreasing physiologic dead space include:
A- the supine position
B- anticholinergic agents
C- increasing age
D- emphysema
Answer:
A- the supine position

Dead space is comprised of gases in non-respiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). The sum of the two is known as physiologic dead space. Certain factors affect dead space. the supine position is known to decrease dead space, whereas anticholinergic, Beta 2 sympathomimetic, advancing age and COPD all increase dead space.

Page 599 Nagelhout, Nurse Anesthesia

As compared with plasma osmolality, hypertonic crystalloid solutions include:
A- D5W
B- Ringer’s lactate
C- D5 0.25NS
D- D5 0.45NS
Answer:
D- D5 0.45NS

Normal plasma osmolality ranges between 280-290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOsm/L respectively. D5 0.45NS is hypertonic with a tonicity of 406-432mOsm/L.
Page 392 Nagelhout, Nurse Anesthesia

Selective adrenergic stimulation of the beta 2 receptor results in:
A- increased heart rate
B- increased insulin secretion
C- detrusor muscle contraction
D- pupillary constriction
Selective adrenergic stimulation of the beta 2 receptor results in:
A- increased heart rate
B- increased insulin secretion
C- detrusor muscle contraction
D- pupillary constriction
Answer:
B- Increased insulin secretion

Beta 2 receptor stimulation result in:
-insulin secretion
-bronchodilation
-increased salivary gland secretion
-decreased upper GI motility
-gluconeogenesis
-pupillary dilation
-detrusor muscle relaxation

Increased heart rate is a result of beat 1 receptor stimulation. Pupillary constriction (meiosis) is the result of parasympathetic stimulation.

Page 187 Nagelhout, Nurse Anesthesia

Role of beta 1 receptor
Role of beta 1 receptor

Pathophysiologic changes associated with liver disease include: (select 2)
Hyperkalemia
plasma volume depletion
metabolic alkalosis
hypoglycemia
hypotension
osteoporosis
hyponatremia
Answer:
metabolic alkalosis
osteoporosis

the clinical picture of hypercorticolism includes central obesity, hypertension, glucose intolerance, weakness, bruising and osteoporosis. Mineralocorticoid effects include fluid retention and hypokalemic alkalosis.
Page 865 Nagelhout. Nurse Anesthesia.

The most consistent clinical manifestation of aspiration pneumonitis is:
A- bronchospasm
B- arterial hypoxemia
C- pulmonary vasoconstriction
D- tachypnea
Answer:
B- arterial hypoxemia

Inhaled gastric fluid is rapidly distributed throughout the lungs, leading to destruction of surfactant producing cells, damage to the pulmonary capillary endothelium and resultant atelectasis and pulmonary edema.
Arterial hypoxemia is the most consistent clinical finding associated with aspiration pneumonitis. Tachypnea, bronchospasm, and pulmonary vasoconstriction with secondary pulmonary hypertension may also be present.

Page 640 Nagelhout, Nurse Anesthesia

A full-term, 4.2kg neonate is scheduled for a thoracotomy for resection of congenital lobar emphysema. the infant’s starting hematocrit is 48%. Estimated allowable blood loss to maintain a hematocrit at or above 38% is:?
Answer: 70- 110mL

The full-term neonate has approximately 85mL/kg total blood volume. Therefore:
4.2kg X 85mL/kg = 357 mL (blood volume)

MABL = blood volume X (HCT starting) – (HCT final) / HCT average

357mL X (48 – 38) / 43 = 83 mL

Page 1165- 1171 Nagelhout Nurse Anesthesia

Hormones released by the neurohypophysis include (select 2):
-thyrotropin
-growth hormones
-arginine vasopressin
-adrenocorticotropic hormones
-follicle stimulating hormones
-oxytocin
-prolactin
-luteinizing hormones
Hormones released by the neurohypophysis include (select 2):
-thyrotropin
-growth hormones
-arginine vasopressin
-adrenocorticotropic hormones
-follicle stimulating hormones
-oxytocin
-prolactin
-luteinizing hormones
Answer:
-oxytocin
-arginine vasopressin

The neurohypophysis is another term for the posterior pituitary gland. The hormones of the neurohypophysis, oxytocin and arginine vasopressin (vasopressin, ADH) , are synthesized in the hypothalamus and stored in the posterior pituitary. Stimulus for the release of arginine vasopressin arises from osmoreceptors in the hypothalamus that sense an increase in plasma osmolality.

Pages 843, 846-847 Nagelhout, Nurse Anesthesia.

hormones secreted by neurohypophysis (posterior pituitary) and adenohypophysis (anterior pituitary) are:
hormones secreted by neurohypophysis (posterior pituitary) and adenohypophysis (anterior pituitary) are:

Pituitary 1
Pituitary 1

Pituitary 2
Pituitary 2

Pituitary 3
Pituitary 3

Pituitary 4
Pituitary 4

Pituitary 5
Pituitary 5

Pituitary 6
Pituitary 6

Pituitary 8
Pituitary 8

Pancreatic somatostatin producing cells in the Islets of Langerhans are:
A- alpha cells
B- beta cells
C- gamma cells
D- delta cells
Pancreatic somatostatin producing cells in the Islets of Langerhans are:
A- alpha cells
B- beta cells
C- gamma cells
D- delta cells
Answer:
Delta cells

The Islets of Langerhans are comprised of four cell types: alpha cells producing glucagon, beta cells producing insulin, delta cells producing somatostatin and PP cells producing pancreatic polypeptide.

Page 789 Nagelhout, JJ and Plaus, KL. Nurse Anesthesia. St Louis: Elsevier, 2014

The Islet of Langerhans
The Islet of Langerhans

The hormones of the Pancreas
The hormones of the Pancreas

Congenital heart diseases associate with right-to-left shunting include: (select 3):
-tricuspid atresia
-hypoplastic left heart syndrome
-aortopulmonary window
-patent ductus arteriosus
-tetralogy of Fallot
-subvalvular aortic stenosis
ventricular septal defects
atrisal septal defects
Congenital heart diseases associate with right-to-left shunting include: (select 3):
-tricuspid atresia
-hypoplastic left heart syndrome
-aortopulmonary window
-patent ductus arteriosus
-tetralogy of Fallot
-subvalvular aortic stenosis
ventricular septal defects
atrisal septal defects
Answer:
-tricuspid atresia
-hypoplastic left heart syndrome
-tetralogy of Fallot

Right-to-left shunting (cyanotic) heart disease is associated with: Tetralogy of Fallot, pulmonary atresia, tricuspid atresia, transposition of the great vessels, truncus arteriosus, single ventricle, double-outlet ventricle, total anomalous pulmonary venous return and hypoplastic left heart.
With tricuspid atresia, blood can flow out of the right atrium only via a patent foramen ovale (PFO). A PDA or VSD is necessary for the blood to flow from the left ventricle to the pulmonary circulation.
Page 1181 Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St Louis: Elsevier, 2014

The recommended maximum leakage current allowed in operating room is:
A- 5mcA
B- 10 mcA
C- 1mA
D- 5mA
Answer:
B- 10mA

10mA has been established as the recommended maximum allowable leakage current. This amount of current is below the threshold of perception (1mA) as well as below the threshold for risk of microshock.

Page 192 Barash, Clinical Anesthesia

Causes of normal anion-gap acidosis include:
A-renal failure
B- starvation
C- diarrhea
D- lactic acidosis
Causes of normal anion-gap acidosis include:
A-renal failure
B- starvation
C- diarrhea
D- lactic acidosis
Answer:
C- diarrhea

Normal-anion-gap acidosis is also called hyperchloremic acidosis an results from the selective loss of bicarbonate anion or the introduction of large amounts of chloride anion. Common causes include: diarrhea, hypoaldosteronism, renal tubular acidosis and increased intake of chloride containing acids sometimes found in hyperalimentation.

Page 461 Longnecker, DE Brown, Anesthesiology

Carbonic anhydrase inhibitors are used in the treatment of:
A- acute glaucoma
B- renal tubular acidosis
C- diarrhea induced acidosis
D- acidosis resulting from hypoventilation
Carbonic anhydrase inhibitors are used in the treatment of:
A- acute glaucoma
B- renal tubular acidosis
C- diarrhea induced acidosis
D- acidosis resulting from hypoventilation
Answer:
A- acute glaucoma

Carbonic anhydrate inhibitors decrease the ability of the kidneys to reabsorb bicarbonate, resulting a hyperchloremic acidosis. As a result, carbonic anhydrase inhibitors would be avoided in patients with acidosis. Because bicarbonate is filtered by the ciliary process in the formation of aqueous humor, carbonic anhydrase inhibitors reduce the formation of aqueous humor and can be used to decrease intraocular pressure.

Page 1211, Longnecker, DE Brown, Anesthesiology

Pulmonary complications from advanced hepatic disease with cirrhosis include:
A- an obstructive ventilator defect
B- respiratory acidosis
C- increased intrapulmonary shunting
D- increased functional residual capacity
Pulmonary complications from advanced hepatic disease with cirrhosis include:
A- an obstructive ventilator defect
B- respiratory acidosis
C- increased intrapulmonary shunting
D- increased functional residual capacity
Answer:
C- increased intrapulmonary shunting

Pulmonary manifestations associated with cirrhosis include: increased intrapulmonary shunting, decreased FRC, pleural effusions, restrictive ventilator defect and respiratory alkalosis.

Page 774 Nagelhout, JJ, and Plaus, KL Nurse Anesthesia

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:
A- Echinacea
B- valerian
C- ginkgo
D- ephedra
An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:
A- Echinacea
B- valerian
C- ginkgo
D- ephedra
Answer:

B- valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

Page 346t Nagelhout, JJ and Plaus, K,L Nurse Anesthesia

Pge 585 Barash Clinical Anesthesia

A decreased in pseudocholinesterase activity has been associated with the use of : (select 3)
– pancuronium
– esmolol
– droperidol
– vecuronium
– metoclopramide
-magnesium sulfate
– dantrolene
– rocuronium
Answer:
– pancuronium
– esmolol
– metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, metoclopramide, esmolol, pancuronium and oral contraceptives . Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

Page 207 Morgan & Mikhail’s Clinical Anesthesiology

The formation of metanephrine is the result of:
A- catechol-O-methyltransferase metabolism of epinephrine
B- catechol-O-methyltransferase metabolism of norepinephrine
C- monoamine oxidase metabolism of norepinephrine
D- monoamine oxidase metabolism of epinephrine
Answer:

A- catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monoamine oxidase (MAO) further metabolizes metanephrine and noremetanephrine to vanillymandelic acid (VMA)
Page 868 Nagelhout, JJ, and Plaus, KL Nurse Anesthesia

Characteristics of human immunodeficiency virus neuropathy include (select 2):
- distal polyneuropathy
- rapid sudden onset
- proximal muscle weakness
- allodynia
- upper extremities most commonly involved
proximal to distal progression of symptoms
Characteristics of human immunodeficiency virus neuropathy include (select 2):
– distal polyneuropathy
– rapid sudden onset
– proximal muscle weakness
– allodynia
– upper extremities most commonly involved
proximal to distal progression of symptoms
Answer:
– distal polyneuropathy
– allodynia

Symptomatic neuropathy occurs in 10% to 35% of patients whoa re seropositive for human immunodeficiency virus (HIV). The sensory neuropathies associated with HIV include distal sensory polyneuropathy and antiretroviral toxic neuropathy (ATN) secondary to the treatment.
The clinical features of HIV sensory neuropathy typically include painful allodynia and hyperalgesia. The onset is gradual and most commonly involves the lower extremities. The neuropathy and dysesthesia progress from distal to the more proximal structures. There is minimal subjective or objective motor involvement and this is generally limited to the intrinsic muscles of the foot.

Page 1658 Barash, Clinical Anesthesia

An action potential characterized by a spike followed by a plateau phase is seen in:
A- peripheral sensory nerve cells
B-peripheral motor nerve cells
C- striated skeletal muscle cells
D- cardiac muscle cells
An action potential characterized by a spike followed by a plateau phase is seen in:
A- peripheral sensory nerve cells
B-peripheral motor nerve cells
C- striated skeletal muscle cells
D- cardiac muscle cells
Answer:
D- cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.
Page 345 Morgan & Mikhail’s Clinical Anesthesiology.

Autonomic hyperreflexia:
A- is common with cord lesions below T8
B- can precipitate pulmonary edema
C- is not effectively prevented by regional anesthesia
D- can be prevented with adequate intraoperative sedation
Autonomic hyperreflexia:
A- is common with cord lesions below T8
B- can precipitate pulmonary edema
C- is not effectively prevented by regional anesthesia
D- can be prevented with adequate intraoperative sedation
Answer:
B- can precipitate pulmonary edema

Autonomic hyperreflexia should be suspected in patients with lesions above T5-8. Regional anesthesia and deep general anesthesia are effective in preventing autonomic hyperreflexia. Surgical stimulation in these patients without adequate anesthesia can result in pulmonary edema, myocardial ischemia and cerebral hemorrhage.

Page 927 Nagelhout, JJ and Plaus. Nurse Anesthesia, St Louis

During placement of a lumbar epidural using a midline approach, the needle passes through the: (select 3)
- interspinous ligament
- anterior longitudinal ligament
- intervertebral disk
- supraspinous ligament
- ligamentum flavum
- facet joint
During placement of a lumbar epidural using a midline approach, the needle passes through the: (select 3)
– interspinous ligament
– anterior longitudinal ligament
– intervertebral disk
– supraspinous ligament
– ligamentum flavum
– facet joint
Answer:
– supraspinous ligament
– interspinous ligament
– ligamentum flavum

Passing anteriorly from the skin to the epidural space are the following structures: skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum.

Pages 941-942 Morgan & Mikhail’s Clinical Anesthesiology

Interpleural analgesia can be accomplished by placing local anesthetic:
A- along the cephalad border of the T6 rib
B- immediately deep to the parietal pleura
C- immediately deep to the visceral pleura
D- superficial to the internal intercostal muscle
Answer:
B- immediately deep to the parietal pleura

Interpleural analgesia is accomplished by placing an catheter between the parietal and visceral pleura. A loss of resistance technique is most commonly used at the T6 to T8 intercostal spaces, or the catheter can be placed under direct vision by the surgeon. Pneumothorax is a significant complication if the needle or catheter penetrates the visceral pleura.

Page 1069 Barash, Clinical Anesthesia.

In the CVP trace below, the v wave is caused by:
A- atrial contraction
B- ventricular contraction
C- atrial filling
D- opening of the tricuspid valve
In the CVP trace below, the v wave is caused by:
A- atrial contraction
B- ventricular contraction
C- atrial filling
D- opening of the tricuspid valve
Answer:
C- atrial filling

In the normal CVP tracing, the a wave is due to atrial systole. The c wave coincides with ventricular contraction. The v wave is the result of atrial filling prior to the opening of the tricuspid valve. The x descent is thought to be due to the pulling down of the atrium by ventricular contraction. The y descent corresponds to the opening of the tricuspid valve. Pages 298-300 Nagelhout Nurse Anesthesia

The synthesis of acetylcholine from acetyl coenzyme A and choline is catalyzed by:
A- free acetate anion
B- choline acetyltransferase
C- acetyl cholinesterase
D- pseudocholinesterase
The synthesis of acetylcholine from acetyl coenzyme A and choline is catalyzed by:
A- free acetate anion
B- choline acetyltransferase
C- acetyl cholinesterase
D- pseudocholinesterase
Answer:
B- choline acetyltransferase

The synthesis of acetylcholine occurs in the cholinergic nerve terminal. Acetyl Co-A and choline combine to form acetylcholine. This reaction is catalyzed by the enzyme choline acetyltransferase.

Page 819 Nagelhout, Nurse Anesthesia

The primary causative factor in the development persistent pulmonary hypertension (PPH) in the neonate is:
A- cystic fibrosis
B- pregnancy-induced hypertension
C- hypoxemia
D- right-to-left shunting through a patent ductus arteriosus
Answer:
C- Hypoxemia

Hypoxia or acidosis during the early neonatal period may predispose the infant to return to fetal circulation. This serious condition, previously known as persistent fetal circulation (PFC), is currently known as persistent pulmonary hypertension (PPH). Hypoxemia and/or acidosis promotes an increase in pulmonary vascular resistance which ultimately causes right to left shunting through the ductus arteriosus, foramen ovale, or both. Shunting causes continued hypoxemia, leading to a continued increase in pulmonary vascular resistance, and a vicious cycle ensues. Primary causes of hypoxemia in the neonate include pneumonia and meconium aspiration.

Page 1163-1164 Nagelhout, Nurse Anesthesia

Electrocardiographic changes seen with hypokalemia include:
A- peaked T-wave
B- increasingly prominent U-wave
C- shortening PR interval with P wave inversion
D- decreased QRS amplitude
Answer:
B- increasingly prominent U-wave

Electrocardiogram changes seen with hypokalemia include:
-T wave flattening/inversion
-ST segment depression
-increased P wave amplitude
-prolongation of the P-R interval
-increasingly prominent U wave

Pages 378, 1712 Barash, Clinical Anesthesia

Deleterious effect of hypothermia include: (select 2)
– impaired renal function
– right shift of the hemoglobin-oxygen saturation curve
– irreversible platelet dysfunction
– increased incidence of wound infection
– increased postoperative protein anabolism
Answer
– impaired renal function
– increased incidence of wound infection

Deleterious effects of hypothermia include:
– increased PVR
– left shift of the hemoglobin-oxygen saturation curve
– reversible platelet dysfunction
– postoperative protein catabolism
– altered mental status
– impaired renal function
– decreased drug metabolism
– poor wound healing
– increased incidence of infection
– cardiac arrhythmias

Pages 1235-1236 Nagelhout, Nurse Anesthesia

Prior to pneumonectomy, split lung function testing is indicated in a patient with:
A- an FEV1 of 2.2L
B- a PaCO2 of 49mmHg on room air
C- a PaO2 of 54 mmHg on room air
D- a maximum VO2 of 21mL/kg/min
Prior to pneumonectomy, split lung function testing is indicated in a patient with:
A- an FEV1 of 2.2L
B- a PaCO2 of 49mmHg on room air
C- a PaO2 of 54 mmHg on room air
D- a maximum VO2 of 21mL/kg/min
Answer:
B- a PaCO2 of 49 mmHg on room air

Split lung function testing is indicated in patient requiring pneumonectomy, but not meeting the recommended laboratory criteria. Current recommendations for patients requiring pneumonectomy are:
– PaCO2 < 45mmHg - FEV1 >2L
– Predicted post-op FEV1 >800mL
– Maximum VO2 > 15mL/kg/min
– FEV1/FVC > 50% predicted

Page 663- 665 Nagelhout, Nurse Anethesia

Mechanism of renal compensation during acidosis include:
A- decreased reabsorption of filtered bicarbonate
B- decreased excretion of hydrogen ions
C- increased production of ammonia
D- increased elimination of carbon dioxide
Answer:
C- increased production of ammonia

The renal response to acidemia is:
– increased reabsorption of bicarbonate ions
– increased excretion of hydrogen ions in the form of titratable acids
– increased production of anemia

Although increased carbon dioxide elimination is a compensatory mechanism in acidemia, it is accomplished by increased alveolar ventilation.

Page 734 Nagelhout nurse anesthesia.

Post intubation croup:
A- is secondary to inflammation of subglottic structures
B- is less common when cuffed endotracheal tubes are used
C- occurs most frequently in infants less than 4 months of age
D- is most often seen immediately upon extubation
Answer:
A- is secondary to inflammation of subglottic structures

Post intubation croup usually occurs at the level of the cricoid, since this is the narrowest part of the pediatric airway. Croup is less common with endotracheal tubes that are uncuffed and small enough to allow a gas leak at 10-25 cm H2O. Post intubation croup is associated with early childhood (1-4years). Unlike laryngospasm, post intubation croup is seen some time after extubation, usually within 3 hours.

Pages 463-464 Nagelhout, Nurse Anesthesia

Closing capacity is defined as:
A- closing volume + expiratory reserve volume
B- functional residual capacity - residual volume
C- closing volume + residual volume
D- residual volume + expiratory reserve volume
Closing capacity is defined as:
A- closing volume + expiratory reserve volume
B- functional residual capacity – residual volume
C- closing volume + residual volume
D- residual volume + expiratory reserve volume
Answer:
C- closing volume + residual volume

Closing capacity is the lung volume at which airways begin to close and is defined as the closing volume + residual volume.

Page 497 Morgan & Mikhail’s Clinical Anesthesiology

Describe lung capacities
Describe lung capacities
Four capacities have been describe based on the four lung volumes:
1- Inspiratory Capacity (IC) is the maximum volume of air that can be inhaled following a resting state. This can be calculated by the addition of tidal volume and the inspiratory reserve volume (IRV)
2- Vital Capacity (VC) is the maximum volume of air that can be exhaled following a deep inspiration. This is the total of IRV + TV+ ERV
3- Functional Residual Capacity (FRC) is the volume of air that remains in the lungs during quiet breathing FRC = ERV + RV
4- Total Lung Capacity (TLC) is the volume the whole respiratory system can accommodate. Therefore, TLC = IRV + TV + ERV + RV

lungs volume and capacities
lungs volume and capacities

Dantrolene: (select 2)
- depends on an extracellular mechanism to achieve muscle relaxation
- inhibits calcium ion release from the sarcoplasmic reticulum
- can also be used in the treatment of thyroid storm
- therapy should not be repeated after an MH episode has terminated
- has a half-life of approximately 12 hours
Dantrolene: (select 2)
– depends on an extracellular mechanism to achieve muscle relaxation
– inhibits calcium ion release from the sarcoplasmic reticulum
– can also be used in the treatment of thyroid storm
– therapy should not be repeated after an MH episode has terminated
– has a half-life of approximately 12 hours
Answer:
– inhibits calcium ion release from the sarcoplasmic reticulum
– can also be used in the treatment of thyroid storm

Dantrolene binds with the Ryr1 receptor and inhibits calcium ion release from the sarcoplasmic reticulum. Dantrolene’s effects are intracellular and may result in muscle weakness and ventilator insufficiency. The half-life of Dantrolene is approximately 6 hours. Dantrolene has also been used to treat neuroleptic malignant syndrome and thyroid storm.

Pages 1188-1190 Morgan & Mikhail’s Clinical Anesthesiology

The figure below shows a pulmonary artery catheter with the distal port in several locations. The measurement of the pressure in the distal port would most closely correlate with the left ventricular end-diastolic pressure when the catheter is placed in which position? (Make selection by clicking on the appropriate part of the figure)
The last picture D.
In the presence of a normal mitral valve, left atrial pressure approaches left ventricular pressure during diastolic filling. The distal lumen of a correctly wedged PAC is isolated from right-sided pressures and correlates with left ventricular end-diastolic pressure.

Renal effects of nitrous oxide include:
A- decreased renal blood flow secondary to decreased cardiac output
B- decreased renal blood flow secondary to increased renal vascular resistance
C- increased renal blood flow secondary to sympathetic stimulation
D- increased glomerular filtration with increased reabsorption
Renal effects of nitrous oxide include:
A- decreased renal blood flow secondary to decreased cardiac output
B- decreased renal blood flow secondary to increased renal vascular resistance
C- increased renal blood flow secondary to sympathetic stimulation
D- increased glomerular filtration with increased reabsorption
Answer:
B- decreased renal blood flow secondary to increased renal vascular resistance.

Nitrous oxide appears to decrease renal blood flow by increasing renal vascular resistance. This results in decreased glomerular filtration and decreased urine output.

Page 167 Morgan & Mikhail’s Clinical Anesthesiology

The elimination half-life of a drug:
A- is inversely proportional to the clearance
B- is inversely proportional to the volume of distribution
C- is directly proportional to clearance
D- is shortest in drugs that are rapidly redistributed
The elimination half-life of a drug:
A- is inversely proportional to the clearance
B- is inversely proportional to the volume of distribution
C- is directly proportional to clearance
D- is shortest in drugs that are rapidly redistributed
Answer:
A- is inversely proportional to the clearance

The elimination half-life of a drug is proportional to the volume of distribution and inversely proportional to the rate of clearance.
Page 165 Barash, Clinical Anesthesia

Personal notes:
Half life is determined by clearance (CL) and volume of distribution (VD) and the relationship is described by the equation above. In clinical practice, this means that it takes 4 to 5 times the half-life for a serum concentration to reach steady state after regular dosing is started, stopped, or the dose changed. So for example, Digoxin has a half life (or t 1/2) of 24-36h, this means that a change in the dose will take the best part of a week to take full effect. For this reason, drugs with a long half-life (e.g. Amiodarone, elimination t1/2 of about 58 days) are usually started with a loading dose to achieve their desired clinical effect more quickly.

Effects of Lidocaine include:
A- increased intracranial pressure
B- increased refractory period of cardiac muscle
C- decreased fibrinolysis
D- myonecrosis
Effects of Lidocaine include:
A- increased intracranial pressure
B- increased refractory period of cardiac muscle
C- decreased fibrinolysis
D- myonecrosis
Answer:
D- myonecrosis

Intravenous lidocaine decreases cerebral blood flow unless seizure activity develops. Lidocaine decreased the refractory period of cardiac muscle and decreased platelet aggregation while enhancing fibrinolysis. Local anesthetics have been shown to cause lytic degeneration and necrosis of muscle fibers when directly injected into the muscle (trigger point injections).

Pages 270- 274 Morgan & Mikhail’s Clinical Anesthesiology

Correct statements concerning the use of antidepressants in pain management include:
A- analgesic effects require a higher dose than the needed for antidepressant
B- analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake
C- antidepressants are not effective in neuropathic pain
D- newer SSRIs are more effective analgesics than the older tricyclic antidepressants
Answer:
B- analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake

Antidepressants demonstrate an analgesic effect at doses lower than those needed for antidepressant effect. Both actions appear secondary to the block of the reuptake of serotonin and norepinephrine. Older tricyclic antidepressants seem more effective analgesics than the newer SSRIs. Antidepressants are most useful in patients with neuropathic pain.
Page 1055 Morgan & Mikhail’s Clinical Anesthesiology

What is the mechanism of action of tricyclic antidepressants?
What is the mechanism of action of tricyclic antidepressants?
Tricyclic antidepressants (TCAs) are a group of drugs used to treat affective, or ‘mood’, disorders. Mood disorders are associated with reduced levels of monoamines in the brain. TCAs binding to 5-HT and noradrenaline re-uptake transporters prevents the re-uptake of these monoamines from the synaptic cleft and their subsequent degradation. This re-uptake blockade leads to the accumulation of 5-HT and noradrenaline in the synaptic cleft and the concentration returns to within the normal range.

Using the figure below, a block of the sural nerve would produce anesthesia of: (make your selection by clicking on the appropriate part of the figure)
Using the figure below, a block of the sural nerve would produce anesthesia of: (make your selection by clicking on the appropriate part of the figure)
The sural nerve is a continuation of the tibial nerve and enters the foot between the Achilles tendon and the lateral malleolus to provide sensation to the lateral foot.
Page 1015 Morgan & Mikhail’s Clinical Anesthesiology

Foot innervation
Foot innervation

Sensory innervation of ankle
Sensory innervation of ankle

The dibucaine number:
A- is normally less than 60%
B- is a quantitative assessment of pseudocholinesterase activity
C- is inversely proportional to pseudocholinesterase function
D- reflects inhibition of pseudocholinesterase by dibucaine
The dibucaine number:
A- is normally less than 60%
B- is a quantitative assessment of pseudocholinesterase activity
C- is inversely proportional to pseudocholinesterase function
D- reflects inhibition of pseudocholinesterase by dibucaine
D- reflects inhibition of pseudocholinesterase by dibucaine

Dibucaine, a local anesthetic, inhibits normal pseudocholinesterase. Homozygous patients with abnormal pseudocholinesterase characteristically have a dibucaine number of about 20%, heterozygous patients have number of 40-60% and normal patients usually have a dibucaine number of 80%.
The dibucaine number is proportional to pseudocholinesterase function, but is independent of the amount of the enzyme.
Page 207 Morgan & Mikhail’s Clinical Anesthesiology

The body mass index (BMI) associated with morbid obesity is:
A- Greater or equal to 30
B- Greater or equal to 35
C- Greater or equal to 40
D- Greater or equal to 45
The body mass index (BMI) associated with morbid obesity is:
A- Greater or equal to 30
B- Greater or equal to 35
C- Greater or equal to 40
D- Greater or equal to 45
Answer:
C- Greater or equal to 40

Overweight and obesity are classified using the BMI. Overweight is defined as a BMI greater or equal to 24, obesity as a BMI greater or equal to 30, morbid obesity as a BMI greater or equal to 40, super obesity as a BMI greater or equal to 50, and super-super obesity as a BMI greater than or equal to 60.
BMI is calculated with the following formula:
BMI = weight (kg) / Height (meters) squared.

Page 1050 Nagelhout Nurse Anesthesia.

Release of aldosterone by the adrenal cortex is stimulated by : (select 3)
- angiotensin I
- angiotensin II
- hypokalemia
- pituitary ACTH
- congestive heart failure
- hypervolemia
Release of aldosterone by the adrenal cortex is stimulated by : (select 3)
– angiotensin I
– angiotensin II
– hypokalemia
– pituitary ACTH
– congestive heart failure
– hypervolemia
Answer:
– angiotensin II
– pituitary ACTH
– congestive heart failure

Aldosterone release is stimulated by the renin-angiotensin system, but specifically by angiotensin II. Other causes of aldosterone release include hyperkalemia, ACTH release, hypovolemia, hypotension, CHF and the stress response.

Page 738 Morgan & Mikhail’s Clinical Anesthesiology

The adrenal Gland
The adrenal Gland
The adrenal gland is divided into the cortex and medulla. The adrenal cortex secretes androgens, mineralocorticoids (ex: aldosterone) and glucocorticoids (ex: cortisol). The adrenal medulla secretes catecholamine (primarily epinephrine, but also small amounts of norepinephrine and dopamine).

Aldosterone is primarily involved with fluid and electrolyte balance. Aldosterone secretion cases sodium to be reabsorbed in the distal renal tubule in exchange for potassium and hydrogen ions. The net result is an expansion in extracellular fluid volume caused by fluid retention, a decrease in plasma potassium, and metabolic alkalosis.
Aldosterone secretion is stimulated by the renin-angiotensin system (specifically, angiotensin II), pituitary adrenocorticotropic hormone (ACTH), and hyperkalemia.
Hypovolemia, hypotension, congestive heart failure, and surgery result in an elevation of aldosterone concentrations.
Blockade of the renin-angiotensin-aldosterone system with angiotensin-converting enzymes inhibitors or angiotensin receptor blockers, or both, is a cornerstone of therapy (and produces increased survival) in hypertension and chronic heart failure.
Aldosterone receptor blockers (spironolactone or eplerenone) added to standard therapy prolong survival in patients with chronic heart failure.

Renal blood flow: (select 2)
- is largely determined by renal oxygen consumption
- accounts for 20 - 25% of the cardiac output
- is distributed mostly to juxtamedullary nephrons
- can be directed away from cortical nephrons by sympathetic stimulation
- is not auto regulated
Renal blood flow: (select 2)
– is largely determined by renal oxygen consumption
– accounts for 20 – 25% of the cardiac output
– is distributed mostly to juxtamedullary nephrons
– can be directed away from cortical nephrons by sympathetic stimulation
– is not auto regulated
Answer:
– accounts for 20 0 25% of the cardiac output
– can be directed away from cortical nephrons by sympathetic stimulation

The kidneys are the only organ for which oxygen consumption is determined by blood flow; the reverse is true in other organs. The kidneys receive 20-25% of the cardiac output with only 10-15% going to the juxtamedullary nephrons and 80% going to cortical nephrons.
However, blood flow can be redirected to juxatmedullary nephrons by increased levels of catecholamine and angiotensin II. Auto regulation of RBF occurs between mean arterial pressures of 80-180 mmHg.

Pages 639-641 Morgan & Mikhail’s Clinical Anesthesiology

A 36 year old female is scheduled for an elective cholecystectomy. Her past medical history is significant for depression treated with phenelzine (Nardil). Her anesthetics plan should include: (select 2)
– discontinuation od phenelzine for at least 2 weeks prior to surgery
– the avoidance of indirect acting vasopressors
– the avoidance of propofol
– the avoidance of meperidine
– the avoidance of nitrous oxide
– the avoidance of volatile anesthetics
Answer:
– the avoidance of indirect acting vasopressors
– the avoidance of meperidine

Phenelzine is a monoamine oxidase (MAO) inhibitor. The practice of discontinuing MAO inhibitors prior to surgery is no longer recommended. The use of meperidine is patient receiving MAO inhibitors has been associated with hypertensive crisis and should be avoided. Additionally, indirect acting vasopressors have also been associated with hypertensive crisis and direct acting vasopressors should be used to treat hypotension.

Page 625 Morgan & Mikhail’s Clinical Anesthesiology

Neuroleptic malignant syndrome:
A- can be precipitated by the use of metoclopramide
B- carries a mortality of over 80%
C- can be treated with physostigmine administration
D- can be diagnosed with muscle biopsy
Neuroleptic malignant syndrome:
A- can be precipitated by the use of metoclopramide
B- carries a mortality of over 80%
C- can be treated with physostigmine administration
D- can be diagnosed with muscle biopsy
Answer:
A- can be precipitated by the use of metoclopramide

NMS is a rare complication of antipsychotic therapy (It may occur hours or weeks after drug administration). Meperidine and Metoclopramide can also precipitate the disorder which appears to be secondary to dopamine blockade in the basal ganglia and hypothalamus and impairment of thermoregulation. The disease has many characteristics in common with MH (Malignant Hyperthermia) including increased temperature, metabolic derangement and hyperthermia.
The mortality is 20 – 30%.
Treatment with Dantrolene (Dantrium) and Dopamine agonist, Bromocriptine, appears effective.

Differential diagnosis include malignant hyperthermia and serotonin syndrome.

Muscle rigidity, hyperthermia, rhabdomyolysis autonomic instability and altered mental status are see.

Page 626 Morgan & Mikhail’s Clinical Anesthesiology

Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome
The acute phase response. An inflammatory stimulus results in activation of monocytes and macrophages that release cytokines. The cytokines act on the liver to stimulate production of acute phase proteins. Cytokines, together with acute phase proteins, generate a systemic response, with neuroendocrine, metabolic, hematologic and biochemical changes. Features of the acute phase response that have been directly observed and measured in neuroleptic malignant syndrome are shown in boxes. Note: ACTH = adrenocorticotropic hormone, CPK = creatine phosphokinase, CRH = corticotropin-releasing hormone, CRP = C-reactive protein, IFN = interferon, IL = interleukin, TGF = transforming growth factor, TNF = tumour necrosis factor. (Portions of this illustration were reproduced with permission from Lianne Friesen and Nicholas Woolridge.)

The most common complication of thoracic paravertebral nerve block is:
A- hypotension
B- subarachnoid injection
C- pneumothorax
d- intravascular injection
The most common complication of thoracic paravertebral nerve block is:
A- hypotension
B- subarachnoid injection
C- pneumothorax
d- intravascular injection
Answer:
C- pneumothorax

Pneumothorax is the most common complication of paravertebral block and a chest radiograph is needed upon completion of the block. Other complications include subarachnoid injection, epidural injection, intravascular injection, and hypotension.

Page 1073 Morgan & Mikhail’s Clinical Anesthesiology.

What is thoracic paravertebral nerve block?
What is thoracic paravertebral nerve block?

In the diagram below, regional anesthesia of the area depicted by #1 can be accomplished with a block of the:
A- radial nerve
B- median nerve
C- ulnar nerve
D- coracobrachialis nerve
In the diagram below, regional anesthesia of the area depicted by #1 can be accomplished with a block of the:
A- radial nerve
B- median nerve
C- ulnar nerve
D- coracobrachialis nerve
Answer:
B- median nerve

The median nerve supplies innervation to the area marked as Number 1, the ulnar nerve to area #3 and the radial nerve to area # 2.

Pages 394-397 Morgan & Mikhail’s Clinical Anesthesiology.

Distribution of anesthesia anterior view
Distribution of anesthesia anterior view

Distribution of anesthesia posterior view
Distribution of anesthesia posterior view

The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately:
(enter numerical answer in box below)
The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately:
(enter numerical answer in box below)
Answer: 20 – 25

Dichotomous division, each branch dividing into smaller branches, of the tracheobronchial tree is estimated to involve 20-25 divisions.
Page 593 Nagelhout, Nurse Anesthesia

Anesthetic management of the patient with the pressure-volume loop shown below (yellow) should include:

 A- maintenance of a heart rate of < 50
 B- spinal or epidural anesthesia if possible
 C- vasodilator therapy
 D- treatment of hypotension with phenylephrine
Anesthetic management of the patient with the pressure-volume loop shown below (yellow) should include:

A- maintenance of a heart rate of < 50 B- spinal or epidural anesthesia if possible C- vasodilator therapy D- treatment of hypotension with phenylephrine

Answer:
D- treatment of hypotension with phenylephrine

This pressure-volume loop is indicative of aortic stenosis. Patients with severe aortic stenosis have a fixed stroke volume, and cardiac output is rate dependent. Both tachycardia and bradycardia are poorly tolerated. Vasodilation from regional anesthesia or volatile agents may precipitate severe hypotension. Treatment of hypotension should be prompt and accomplished with small doses of an alpha-stimulant such as phenylephrine.

pp. 483, 500-502
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The largest fraction of carbon dioxide in the blood is in the form of:
 A- carbamino compounds
 B- bicarbonate
 C- dissolved gas
 D- carboxyhemoglobin
The largest fraction of carbon dioxide in the blood is in the form of:
A- carbamino compounds
B- bicarbonate
C- dissolved gas
D- carboxyhemoglobin
Answer:
B- bicarbonate

Nearly 90% of carbon dioxide in the blood is in the form of bicarbonate.

pg. 605
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Metabolic Acidosis
Metabolic Acidosis

Metabolic Alkalosis
Metabolic Alkalosis

Respiratory/Renal Compensation/Metabolic Acidosis
•Rate and depth of breathing are elevated 
•As carbon dioxide is eliminated by the respiratory system, PCO2 falls below normal
•Kidneys secrete H+ and retain/generate bicarbonate to offset the acidosis
Respiratory/Renal Compensation/Metabolic Acidosis
•Rate and depth of breathing are elevated
•As carbon dioxide is eliminated by the respiratory system, PCO2 falls below normal
•Kidneys secrete H+ and retain/generate bicarbonate to offset the acidosis

Metabolic Alkalosis
•Pulmonary ventilation is slow and shallow allowing carbon dioxide to accumulate in the blood
•Kidneys generate H+ and eliminate bicarbonate from the body by secretion
Metabolic Alkalosis
•Pulmonary ventilation is slow and shallow allowing carbon dioxide to accumulate in the blood
•Kidneys generate H+ and eliminate bicarbonate from the body by secretion

Respiratory Acid-Base Regulation 
•Respiratory acidosis is the most common cause of acid-base imbalance
?Occurs when a person breathes shallowly, or gas exchange is hampered by diseases such as pneumonia, cystic fibrosis, or emphysema
Respiratory Acid-Base Regulation
•Respiratory acidosis is the most common cause of acid-base imbalance
?Occurs when a person breathes shallowly, or gas exchange is hampered by diseases such as pneumonia, cystic fibrosis, or emphysema

Respiratory alkalosis is a common result of hyperventilation
Respiratory alkalosis is a common result of hyperventilation

A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mm Hg, the expected PaCO2 at the end of the apneic period would be:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mm Hg

A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mm Hg, the expected PaCO2 at the end of the apneic period would be: 67 to 74 mm Hg

The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10 – 20 minutes in most patients. Arterial PaCO2 rises 6 mm Hg in the first minute followed by a rise of 3 – 4 mm Hg during each subsequent minute. In this patient this will produce a 27 – 34 mm Hg increase, resulting in a PaCO2 of 67 to 74 mm Hg.

pg. 561
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Stimulation of the parasympathetic nervous system results in:
A- far vision accommodation
B- increased inotropy
C- increased insulin secretion
 D- contraction of the urinary sphincter
Stimulation of the parasympathetic nervous system results in:
A- far vision accommodation
B- increased inotropy
C- increased insulin secretion
D- contraction of the urinary sphincter
Answer:
C- increased insulin secretion

Stimulation of the parasympathetic nervous system results in: increased insulin secretion

Insulin secretion is increased by stimulation of the parasympathetic nervous system through the vagus nerves.

pg. 1343
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The formation clinically significant amounts of carbon monoxide has been associated with:

A- the use of a non-rebreathing circuit
B- the use of fresh carbon dioxide absorber
C- the use of desflurane
D- expiratory valve incompetence
The formation clinically significant amounts of carbon monoxide has been associated with:

A- the use of a non-rebreathing circuit
B- the use of fresh carbon dioxide absorber
C- the use of desflurane
D- expiratory valve incompetence

Answer:
C- the use of desflurane
The formation clinically significant amounts of carbon monoxide has been associated with: the use of desflurane

The formation of CO depends on the use of a volatile agent containing a difluoromethoxy moiety (desflurane, isoflurane, enflurane). This moiety can react with desiccated base (baralime or sodalime) to form CO. Fresh absorber has sufficient water to prevent the reaction. Clinically, CO intoxication occurs after a weekend when the flow of dry oxygen in the machine has desiccated the absorber and desflurane is being used.

pp. 471-472
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Anesthesiology. 89(4):929-941, October 1998. Baxter, Pamela J. PhD; Garton, Kyle BS; Kharasch, Evan D. MD, PhD

In the flow-volume loops below, restrictive lung disease is best represented by:
- A
- B
- C
- D
In the flow-volume loops below, restrictive lung disease is best represented by:
– A
– B
– C
– D
Restrictive disease is best represented by flow-volume loop D, which demonstrates reductions in TV, TLC and FRC.

pg. 1034
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Positive end expiratory pressure (PEEP):

A- decreases dead space
B- increases venous return to the heart
C- decreases intrapulmonary shunting
D- decreases extravascular lung water
Positive end expiratory pressure (PEEP):

A- decreases dead space
B- increases venous return to the heart
C- decreases intrapulmonary shunting
D- decreases extravascular lung water

Answer: C
Positive end expiratory pressure (PEEP): decreases intrapulmonary shunting

The major effect of PEEP is to increase FRC and tidal ventilation above the closing capacity. This results in a decrease in intrapulmonary shunting. Neither PEEP or CPAP decrease extravascular lung water. By increasing intrathoracic pressure, PEEP decreases venous return to the heart.

pp. 283, 1595
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

General anesthesia is associated with impaired gas exchange mainly because of increased shunt due to atelectasis in the dependent regions of the lung. Postoperative atelectasis is associated with adverse clinical outcomes in terms of hypoxic respiratory failure requiring endotracheal intubation and pneumonia secondary to impairment of ciliary and lymphatic functions. Prevention of atelectasis and/or airway closure could be a mechanism by which positive end expiratory pressure (PEEP) improves oxygenation. Positive end expiratory pressure has been used intraoperatively as a part of open lung and protective lung ventilation strategies.

The essential component of cardioplegia solutions is:
A- mannitol
B- magnesium
C- potassium
D- corticosteroid
The essential component of cardioplegia solutions is:
A- mannitol
B- magnesium
C- potassium
D- corticosteroid
Answer:
C- potassium

The essential component of cardioplegia solutions is: potassium

High concentrations of potassium (20 – 30 mEq/L) are used in cardioplegia solutions. These solutions result in an increase in extracellular potassium and reduce transmembrane potential. This progressively interferes with the normal sodium currents of depolarization and eventually the sodium channels are completely inactivated.

pg. 519
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

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

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: high-frequency oscillation, high-frequency positive-pressure ventilation

High-frequency oscillation (HFO) creates a to-and-fro gas movement in the airway at rates of 180 – 3000 times/min. High frequency positive-pressure ventilation is delivered at a rate of 60 – 120 breaths/min. Tidal volume is at or below anatomic dead space. High-frequency ventilation techniques may be useful in cases of bronchopleural and tracheoesophageal fistulas.

pg. 1062
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

kg

Answers:
During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
(Enter numerical answer in box below. Click ‘Next’ when completed.) 3.0 – 4.4 kg

Using cricoid yolk studies, the optimum force necessary to effectively occlude the esophagus without obstruction of the trachea is between 30 and 44 Newtons (3.0 – 4.4 kg). It is recommended that 2 kg of force be applied prior to loss of consciousness and that pressure be increased to 4 kg of force after loss of consciousness.

pg. 449
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

During an anterior-posterior spinal fusion, in a 70-kg patient, the laboratory reports an intraoperative hematocrit of 21% with a hemoglobin of 7g/dL. Two units of packed red blood cells are administered over the course of 30 minutes. Upon completion of the transfusion, the anticipated hematocrit will be approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

%

Answer: 25 – 27%

A commonly used rule of thumb states that each unit of PRBCs increases the hemoglobin 1 g/dL and the hematocrit 2% to 3%.

pg. 396
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Blood typing and cross match
Blood typing and cross match

Pulmonary changes associated with Duchenne's muscular dystrophy include:

A- a restrictive ventilatory defect
B- an obstructive ventilatory defect
C- decreased pulmonary artery pressures
D- increased residual volume
Pulmonary changes associated with Duchenne’s muscular dystrophy include:

A- a restrictive ventilatory defect
B- an obstructive ventilatory defect
C- decreased pulmonary artery pressures
D- increased residual volume

Answer:
A- a restrictive ventilatory defect
Pulmonary changes associated with Duchenne’s muscular dystrophy include: a restrictive ventilatory defect

The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilatory defect in patients with Duchenne’s muscular dystrophy. Pulmonary hypertension is also commonly seen.

pg. 753
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 46-year-old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately:

A- 2%
B- 5%
C- 10%
D- 25%

Answer:
C- 10%

Patients with acute hepatitis should have elective surgery postponed until the acute hepatitis has resolved. Studies indicate increased perioperative morbidity (12%) and mortality (10% with laparotomy) during acute hepatitis.

pp. 1315-1316
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

An increase in intraocular pressure has been associated with: (select 3)

- nitrous oxide administration
- succinylcholine administration
- opioid administration
- hyperventilation
- laryngoscopy
- hypoxemia
- sevoflurane administration
An increase in intraocular pressure has been associated with: (select 3)

– nitrous oxide administration
– succinylcholine administration
– opioid administration
– hyperventilation
– laryngoscopy
– hypoxemia
– sevoflurane administration

Answer:
An increase in intraocular pressure has been associated: succinylcholine administration, hypoxemia, laryngoscopy

Succinylcholine increases intraocular pressure by 5 – 10 mm Hg for 5 – 10 minutes after administration. This increase is primarily the result of prolonged contracture of the extraocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetic agents and opioids have been associated with a reduction in intraocular pressure. Hypoxemia, hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation have all been shown to increase IOP.

pp. 760-761
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the pressure-volume loop below, cardiac work is best represented by:

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

A- the area of the curve
B- the slope of the line from points C to D
C- the distance of the line from points C to D
D- the slope of a line from points A to D

Answer:
A- the area of the curve

Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

pg. 250
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case?

A- Check oxygen cylinder supply
B- Check the carbon dioxide absorber
C- Performance of a machine low-pressure leak test
D- Calibration of the oxygen monitor

Answer:
B- Check the carbon dioxide absorber

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case? Check the carbon dioxide absorber

Verification of the adequacy of the carbon dioxide absorber is suggested prior to every case. If the same anesthesia machine is being used by the same provider, E-cylinder pressure checks, machine low-pressure leak testing and calibration of the oxygen sensor need not be repeated after an initial check.

pp. 84-85
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

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

– increased carbon dioxide levels
– increased 2,3-DPG levels
– increased pH
– the presence of fetal hemoglobin
– increased body temperature
– the presence of hemoglobin-S

Answer:
Factors increasing the affinity of hemoglobin for oxygen include: increased pH, presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus.

pp. 603-604
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

In the figure below, inspiratory capacity is best represented by:

- A
- A + tidal volume
- B
- B + tidal volume
In the figure below, inspiratory capacity is best represented by:

– A
– A + tidal volume
– B
– B + tidal volume

In the figure below, inspiratory capacity is best represented by: A + tidal volume

Inspiratory capacity is the sum of the inspiratory reserve volume (A) and the tidal volume. B represents the expiratory reserve volume, C represents the FRC, D represents the residual volume, E represents the vital capacity and F represents the total lung volume.

pp. 278-279
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Laminar flow in the airway occurs in the: (Select 2)

A- trachea
B- main stem bronchi
C- terminal bronchiole
D- 3rd generation bronchus
E- respiratory bronchiole
Laminar flow in the airway occurs in the: (Select 2)

A- trachea
B- main stem bronchi
C- terminal bronchiole
D- 3rd generation bronchus
E- respiratory bronchiole

Laminar flow in the airway occurs mostly in the: terminal bronchiole, respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow.

pp. 498-499
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sickle hemoglobin: (Select 2)

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

– has a lower P50 than hemoglobin A
– releases oxygen less readily than hemoglobin A
– is present in about 30% of African Americans
– readily polymerizes and precipitates in the red cell
– results from a single amino acid substitution on the ?-chain
– has decreased solubility as compared to hemoglobin A

Sickle hemoglobin: readily polymerizes and precipitates in the red cell, has decreased solubility as compared to hemoglobin A

Sickle hemoglobin (HbS) has a lower affinity for oxygen and an elevated P50 (31 mm Hg) as compared to hemoglobin A (27 mm Hg). HbS also has decreased solubility and readily polymerizes and precipitates in the red cell producing the sickled appearance of the cell. HbS results from the substitution of valine for glutamic acid on the ?-chain.

pg. 1177
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is:

A- phenoxybenzamine
B- doxazosin
C- propranolol
D- terazosin

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is: phenoxybenzamine

Phenoxybenzamine is a nonselective ?-antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and terazosin are selective ?1-antagonists. Propranolol is a nonselective ?-antagonist. In the preparation of patients with pheochromocytoma, ?-blockade and intravascular volume replacement must precede ?-blockade, so as to prevent the possibility of unopposed ?-stimulation.

pg. 192
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Nerves blocked with a fascia iliaca block include the:

A- sciatic nerve 
B- femoral nerve 
C- pudendal nerves 
D- anterior tibial nerve
Nerves blocked with a fascia iliaca block include the:

A- sciatic nerve
B- femoral nerve
C- pudendal nerves
D- anterior tibial nerve

Nerves blocked with a fascia iliaca block include the: femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

pp. 1003-1004
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Average blood loss during a vaginal delivery is:

A- 100 – 200 ml
B- 400 – 500 ml
C- 700 – 800 ml
D- 1000 – 1500 ml

Average blood loss during a vaginal delivery is: 400 – 500 ml

At term, blood volume has increased by 1000 – 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 – 500 ml, compared with 800 – 1000 ml for cesarean section.

pg. 827
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Characteristics of omphalocele include: (Select 2)

– location lateral to the umbilicus
– lacks a hernia sac
– results from the failure of midgut migration into the abdomen
– nitrous oxide should be used during the repair to ensure a rapid emergence
– association with trisomy 21
– results from abnormal development of the right omphalomesenteric artery

Characteristics of omphalocele include: association with trisomy 21, results from the failure of midgut migration into the abdomen

Gastroschisis and omphalocele are characterized by defects in the abdominal wall that allow herniation of the viscera. Omphaoceles occur at the base of the umbilicus, have a hernia sac and are commonly associated with other anomalies. In contrast, gastroschisis is usually lateral to the umbilicus, lacks a hernia sac and is usually an isolated finding. Nitrous oxide is best avoided during repair as it may result in bowel distention making closure more difficult.

pg. 901
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Gastrochisis
Gastrochisis

Omphalocele
Omphalocele

Basal metabolic oxygen consumption in a 20-kg patient is approximately:
(Enter numerical answer in box below. Click 'Next' when completed.) 

 mL/min
Basal metabolic oxygen consumption in a 20-kg patient is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mL/min

Basal metabolic oxygen consumption in a 20 kg patient is approximately: 95 ml/min

Basal metabolic oxygen consumption can be estimated using the above formula:

pg. 175
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of:

A- midazolam
B- rocuronium
C- fentanyl
D- succinylcholine

An increase in the plasma concentration and a prolongation of the elimination half-life of etomidate is seen with the concomitant administration of: fentanyl

Fentanyl has been shown to increase the plasma level of etomidate as well as prolong the elimination half-life of the drug.

pg. 185
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Disodium edetate or sodium metabisulfite is added to formulations of propofol to:

A- enhance drug solubility
B- adjust pH
C- inhibit bacterial growth
D- increase drug potency

Disodium edetate or sodium metabisulfite is added to formulations of propofol to: inhibit bacterial growth

Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth.

pg. 186
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:

A- 20 cmH2O 
B- 50 cmH2O 
C- 25 psi 
D- 50 psi
During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of:

A- 20 cmH2O
B- 50 cmH2O
C- 25 psi
D- 50 psi

During emergent transtracheal jet ventilation using a 14 gauge catheter, generation of sufficient gas flow requires a driving pressure of: 50 psi

After proper location of the catheter is confirmed by aspiration air, jet ventilation may be achieved with intermittent pulses of oxygen at 50 psi.

pg. 1237
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

A- internal laryngeal nerve 
B- external laryngeal nerve 
C- recurrent laryngeal nerve 
D- glossopharyngeal nerve
Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

A- internal laryngeal nerve
B- external laryngeal nerve
C- recurrent laryngeal nerve
D- glossopharyngeal nerve

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the: recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea.

pg. 310
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Laryngeal nerve
Laryngeal nerve

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:

A- 20 – 30 mm Hg
B- 35 – 45 mm Hg
C- 50 – 60 mm Hg
D- 90 – 100 mm Hg

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of: 50 – 60 mm Hg

Healthy young individuals tolerate mean arterial pressures as low as 50 – 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 – 30% below baseline.

pg. 262
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Correct statements concerning the use of benzodiazepines in the elderly include:

A- volume of distribution is increased
B- reduced pharmacodynamic sensitivity is observed
C- the elimination half-life of diazepam, but not midazolam, is increased
D- all of the above

Correct statements concerning the use of benzodiazepines in the elderly include: volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased.

pg. 895
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Concerning preoperative informed consent:

A- it should disclose only life-threatening complications
B- charges of assault and battery are possible if it is not obtained
C- oral consent is insufficient
D- it is not necessary if the procedure is done in an office setting

Concerning preoperative informed consent: charges of assault and battery are possible if it is not obtained

Any procedure performed without the patient’s consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.

pp. 29-30
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to:

A- 0.5 ppm
B- 5 ppm
C- 25 ppm
D- 50 ppm

The National Institute for Occupational Safety (NIOSH) recommends limiting the operating room concentration of nitrous oxide to: 25 ppm

NIOSH recommends limiting the room concentration of nitrous oxide to 25 ppm and halogenated agents to 2 ppm (0.5 ppm if nitrous oxide is also being used).

pp. 652-654
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The highest incidence of muscle pain following the use of succinylcholine is seen in:
A- infants 
B- octogenarians 
C- outpatients 
D- pregnant patients
The highest incidence of muscle pain following the use of succinylcholine is seen in:
A- infants
B- octogenarians
C- outpatients
D- pregnant patients
The highest incidence of muscle pain following the use of succinylcholine is seen in: outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

pg. 532
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The cardiovascular effects of pancuronium are caused by: (Select 3)

vagal blockade
stimulation of cardiac muscarinic receptors
ganglionic stimulation
decreased catacholamine reuptake
direct myocardial stimulation
blockade of cardiac slow calcium channels
central thalamic stimulation

The cardiovascular effects of pancuronium are caused by: vagal blockade, ganglionic stimulation, decreased catecholamine reuptake

The cardiovascular effects of pancuronium are caused by the combination of vagal blockade and sympathetic stimulation. The latter is due to a combination of ganglionic stimulation, catecholamine release and decreased catecholamine reuptake.

pg. 537
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

pg. 217
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Anesthetic implications of multiple sclerosis include:

A- exacerbation induced by spinal anesthesia
B- exacerbation induced by epidural anesthesia
C- exacerbation of symptoms secondary to hypothermia
D- the presence of significant peripheral neuropathy causing severe hyperkalemia after succinylcholine administration

Anesthetic implications of multiple sclerosis include: exacerbation induced by spinal anesthesia

Spinal anesthesia has been reported to cause exacerbation of the disease. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia.

pg. 619
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Local anesthetics with the potential to form methemoglobin include: (Select 3)

EMLA topical anesthetic cream
bupivacaine
benzocaine
ropivacaine
prilocaine
mepivacaine

Local anesthetics with the potential to form methemoglobin include: EMLA topical anesthetic cream, prilocaine, benzocaine

EMLA cream contains both lidocaine and prilocaine. The metabolites of prilocaine can convert hemoglobin to methemoglobin. Benzocaine can also cause methemoglobinemia.

pg. 140
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Methemoglobin Risk with Benzocaine Containing Local Anesthetics”
URL: http://www.upstate.edu/uha/pharmacy/newsletters/kidstuff_06/kidstuff_05_06.pdf

Ulnar nerve injury:

A- results in wrist drop and loss of sensation in the web space between the thumb and index finger 
B- occurs more frequently in males 
C- manifests itself in the immediate postoperative period 
D- is most commonly seen in the patient with a BMI of less than 18
Ulnar nerve injury:

A- results in wrist drop and loss of sensation in the web space between the thumb and index finger
B- occurs more frequently in males
C- manifests itself in the immediate postoperative period
D- is most commonly seen in the patient with a BMI of less than 18

Ulnar nerve injury: occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:
1) male sex – various reports suggest that 70 – 90% of patients with postoperative ulnar neuropathy are men
2) high body mass index – BMI > or = 38
3) prolonged postoperative bed rest.
Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury.

pp. 809-810
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The potency of local anesthetics increases as the:

A- lipid solubility increases
B- pKa increases
C- number of double bonds in the anesthetic molecule increases
D- molecular weight decreases

The potency of local anesthetics increases as the: lipid solubility increases

Local anesthetic potency correlates directly with lipid solubility. In general, lipid solubility increases with an increase in the total number of carbon atoms in the molecule and by adding a halogen to the aromatic ring.

pg. 129
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A decrease in cerebral blood flow is seen after the administration of:

isoflurane
propofol
desflurane
ketamine

A decrease in cerebral blood flow is seen after the administration of: propofol

The inhaled anesthetic agents and ketamine all increase cerebral blood flow (CBF). Benzodiazepines, etomidate, propofol and barbiturates all decrease CBF.

pg. 701
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The age group with the highest minimum alveolar concentration (MAC) of desflurane is:

A- 2 – 3 months
B- 1 – 2 years
C- 25 – 30 years
D- greater than 75 years

The age group with the highest minimum alveolar concentration (MAC) of desflurane is: 2 – 3 months

The two-to-three-months-of-age group represents the highest MAC requirement. MAC subsequently decreases with advancing age.

pg. 883
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

%

The loss of ventricular filling as a result of acute atrial fibrillation is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.) 15-25%

Passive flow accounts for about 75 – 85% of ventricular filling. The remaining 15 – 25% occurs as a result of atrial contraction, which is lost during atrial fibrillation.

pg. 249
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Topically applied ophthalmic medications are absorbed:

A- as quickly as intravenous administration
B- more quickly than subcutaneous administration
C- only minutely, with insignificant clinical effect
D- directly into the central nervous system through the optic nerve foramen

Topically applied ophthalmic medications are absorbed: more quickly than subcutaneous administration

Topically applied ophthalmic medications are absorbed at a rate intermediate between intravenous and subcutaneous injection. Children and the elderly are at particular risk for the toxic effects of topically applied medications.

pg. 762
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During pregnancy, the minimum alveolar concentration (MAC):

A- decreases until the 20th week
B- increases until the 20th week
C- decreases throughout the pregnancy
D- increases throughout the pregnancy

During pregnancy, the minimum alveolar concentration (MAC): decreases throughout the pregnancy

The MAC progressively decreases during pregnancy, at term by as much as 40%. MAC returns to normal by the third day after delivery.

pg. 826
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Correct location of the catheter tip of a central venous line is in the:

A- superior vena cava
B- right atrium
C- right ventricle
D- pulmonary artery
Correct location of the catheter tip of a central venous line is in the:

A- superior vena cava
B- right atrium
C- right ventricle
D- pulmonary artery

Correct location of the catheter tip of a central venous line is in the: superior vena cava

The CVP catheter tip should not be allowed to migrate into the heart chamber to avoid arrhythmias and perforation.

pg. 103
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Central line and Port A cath
Central line and Port A cath

Central line placement
Central line placement

Physiologic effects of electroconvulsive therapy (ECT) include an:

A- initial sympathetic response with sustained tachycardia
B- initial sympathetic discharge followed by a sustained parasympathetic response
C- initial parasympathetic discharge followed by a sustained sympathetic response
D- initial parasympathetic response with sustained bradycardia

Physiologic effects of electroconvulsive therapy (ECT) include an: initial parasympathetic discharge followed by a sustained sympathetic response

An initial parasympathetic discharge followed by a sustained sympathetic response is immediately seen after the induction of a seizure. Marked bradycardia with increased secretions can occur, which is then followed by hypertension and tachycardia. Patients scheduled for ECT are routinely given anticholinergic medication preoperatively.

pg. 1277
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The postretrobulbar block apnea syndrome:

A- is likely secondary to intravascular injection
B- most commonly occurs during or immediately after injection
C- is associated with unconsciousness
D- carries a high morbidity and mortality

The postretrobulbar block apnea syndrome: is associated with unconsciousness

The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.

pg. 766
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by:

A- placing the grounding pad near the pacemaker
B- using infrequent bursts of longer duration
C- the use of a bipolar cautery
D- reducing the surface area of the return electrode

A 76-year-old man is scheduled for a hemicolectomy. His past medical history is significant for third degree heart block treated with a permanent pacemaker. Problems with electrocautery use in this patient can be minimized by: the use of a bipolar cautery

Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.

pg. 403
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:

A- T4 - T8
B- T8 - L2
C- L2 - L4
D- L4 - S1
The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from:

A- T4 – T8
B- T8 – L2
C- L2 – L4
D- L4 – S1

The arteria radicularis magna, or artery of Adamkiewicz, most commonly arises from: T8 – L2

A major complication of thoracic aortic surgery is paraplegia, occurring in up to 20% of elective cases, and is secondary to spinal cord ischemia. The arteria radicularis magna supplies blood to the anterior spinal artery. The arteria radicularis magna has a variable origin from aorta, arising between T5 – T8 in 15%, between T9 – T12 in 60% and between L1 – L2 in 25% of individuals.

pg. 480
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The most severe transfusion reactions are due to:

A- ABO incompatibility
B- Rh incompatibility
C- febrile reactions
D- non-ABO hemolytic reactions

The most severe transfusion reactions are due to: ABO incompatibility

The most severe transfusion reactions are due to ABO incompatibility. Naturally acquired antibodies can react against the transfused antigens, activate complement and result in intravascular hemolysis.

pg. 1172
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the figure below, isoflurane is best represented by:
 A 
 B 
 D 
 E
In the figure below, isoflurane is best represented by:
A
B
D
E
On this graph, line B best depicts the change in vapor pressure seen with the change in temperature of isoflurane. Note that at 20o C, the vapor pressure represented by line B is 238 mmHg, corresponding to the saturated vapor pressure of isoflurane at that temperature. Line A corresponds with desflurane, line C with halothane, line D with enflurane and line E with sevoflurane.

pg. 66
Ehrenwerth, J, Eisenkraft, JB, and Berry, JM. Anesthesia Equipment Principles and Applications. St. Louis: Elsevier, 2013.

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above:

A- 5 mm Hg
B- 15 mm Hg
C- 25 mm Hg
D- 30 mm Hg

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above: 15 mm Hg

Intracranial hypertension is defined as a sustained increase in intracranial pressure (ICP) above 15 mm Hg. Uncompensated increases in tissue or fluid within the rigid intracranial vault produce the sustained pressure elevations.

pp. 871-874
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be:

A- between 300 and 400
B- between 200 and 300
C- between 100 and 200
D- less than 100

The rapid shallow breathing index (RSBI) is useful in predicting successful weaning from mechanical ventilation. Prior to extubation this index should be: less than 100

RSBI is frequently used to help predict who can be successfully weaned from mechanical ventilation. With the patient breathing spontaneously, the ventilatory rate is divided by the tidal volume (liters). Successful extubation can be predicted by an RSBI of less than 100.

Crawford, J, Otero, R. “Rapid shallow breathing index a key predictor for noninvasive ventilation.” URL: http://ccforum.com/content/11/S2/P169, March, 2007.

pg. 1297
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The perception of an ordinarily non-noxious stimulus as pain is referred to as:

A- allodynia
B- anesthesia dolorosa
C- dysesthesia
D- hyperalgesia

The perception of an ordinarily non-noxious stimulus as pain is referred to as: allodynia

Allodynia is the perception of non-noxious stimuli as pain. Dysesthesia is an unpleasant sensation without a stimulus. Hyperesthesia is an increased response to a mild stimulus. Anesthesia dolorosa is pain in an area that lacks sensation.

pp. 1649-1650
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013

Ninety percent of congenital diaphragmatic hernias occur:

A- through the left posterolateral foramen
B- through the right posterolateral foramen
C- through the anterior foramen
D- along the inferior vena cava
Ninety percent of congenital diaphragmatic hernias occur:

A- through the left posterolateral foramen
B- through the right posterolateral foramen
C- through the anterior foramen
D- along the inferior vena cava

Ninety percent of congenital diaphragmatic hernias occur: through the left posterolateral foramen

Left-sided herniation through the posterolateral foramen of Bochdalek accounts for 90% of diaphragmatic hernias. Hypoxia, scaphoid abdomen and evidence of bowel in the thorax are the hallmarks of diaphragmatic herniation. Peak airway pressures should not exceed 30 cm H2O to minimize the risk of pneumothorax during surgical correction.

pg. 899
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During fetal monitoring, Type III decelerations are thought to be related to:

A- head compression
B- umbilical cord compression
C- uteroplacental insufficiency
D- placental abruption

During fetal monitoring, Type III decelerations are thought to be related to: umbilical cord compression

Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

pg. 1167
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:

A- hypernatremia
B- hyperglycemia
C- difficulty with intubation and airway management
D- increased blood viscosity due to elevated hematocrit
Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:

A- hypernatremia
B- hyperglycemia
C- difficulty with intubation and airway management
D- increased blood viscosity due to elevated hematocrit

Anesthetic complications associated with hypothyroidism include: difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

pp. 875-876
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Hypothyroidism -Hyperthyroidism
Hypothyroidism -Hyperthyroidism

Hypothyroidism- Hyperthyroidism
Hypothyroidism- Hyperthyroidism

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:

A- genioglossus muscle 
B- longitudinal muscle of the tongue 
C- palatoglossus muscle 
D- styloglossus muscle
Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:

A- genioglossus muscle
B- longitudinal muscle of the tongue
C- palatoglossus muscle
D- styloglossus muscle

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the: genioglossus muscle

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

pg. 314
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The most frequent manifestation of sickle cell disease is:

A- pain 
B- splenic sequestration 
C- aplastic crisis 
D- right upper quadrant syndrome
The most frequent manifestation of sickle cell disease is:

A- pain
B- splenic sequestration
C- aplastic crisis
D- right upper quadrant syndrome

The most frequent manifestation of sickle cell disease is: pain

The most frequent manifestation of sickle cell disease is pain. The pain is thought to be secondary to tissue ischemia and usually affects the back, chest, extremities and abdomen.

pg. 631
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Reactants that are regenerated during the absorption of carbon dioxide by soda lime include:

A- carbonic acid
B- sodium hydroxide
C- calcium hydroxide
D- calcium carbonate

Reactants that are regenerated during the absorption of carbon dioxide by soda lime include: sodium hydroxide

Both water and sodium hydroxide are initially required during the absorption of carbon dioxide by soda lime, but then are regenerated.

pg. 269
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

Sevoflurane can react with soda lime or Baralyme and forms a nephro toxic substance called Compound A. 
 
There are several causes that increase the risk of Compound A forming: 
- Low fresh gas flow. This will increase the temperature and the concentration in the absorber. FDA recommends using higher fresh gas levels than 2 liter per minute to avoid Compound A.
-Use of Baralyme has shown to produce more Compound A than conventional soda lime.
-High concentrations of Sevoflurane increase the risk.
-High temperatures in the soda lime. 
-Dry soda lime
- KOH in the Soda lime.
Sevoflurane can react with soda lime or Baralyme and forms a nephro toxic substance called Compound A.

There are several causes that increase the risk of Compound A forming:
– Low fresh gas flow. This will increase the temperature and the concentration in the absorber. FDA recommends using higher fresh gas levels than 2 liter per minute to avoid Compound A.
-Use of Baralyme has shown to produce more Compound A than conventional soda lime.
-High concentrations of Sevoflurane increase the risk.
-High temperatures in the soda lime.
-Dry soda lime
– KOH in the Soda lime.

Inhaled Anesthetics
Inhaled Anesthetics

During the administration of general anesthesia for a radical prostatectomy, the rhythm strip below is obtained. The most appropriate therapeutic measures at this time would include:

A- initiation of a nitroglycerine infusion
B- administration of metoprolol
C- requesting the use of a bipolar cautery
D- engage the artifact filter on the ECG monitor

During the administration of general anesthesia for a radical prostatectomy, the rhythm strip below is obtained. The most appropriate therapeutic measures at this time would include: requesting the use of a bipolar cautery.
This rhythm strip indicates a paced rhythm with clearly visible pacer spikes. Electrical interference from the electrocautery can be interpreted as myocardial activity and can suppress the pacemaker generator. The use of a bipolar cautery will reduce the electrical interference produced; if that is not possible, then pure cut is better than “blend” or “coag.”

pp. 204-207, 1720
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The effects of barbiturates on ischemic areas of the brain include:

A- vasoconstriction
B- vasodilation
C- redirection of blood flow to the ischemic areas
D- redirection of blood flow away from ischemic areas

The effects of barbiturates on ischemic areas of the brain include: redirection of blood flow to the ischemic areas

Barbiturates cause cerebral vasoconstriction in normal areas. These agents tend to redistribute blood flow to ischemic areas in what is sometimes referred to as a reverse steal phenomenon or Robin Hood effect. Ischemic areas remain maximally dilated and unaffected by the barbiturate.

pg. 485
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Venous irritation associated with the injection of diazepam and lorazepam is secondary to:

A- the high degree of water solubility of these agents
B- the presence of propylene glycol as a solvent
C- the presence of metabisulfite as a preservative
D- the low pH of these agents

Venous irritation associated with the injection of diazepam and lorazepam is secondary to: the presence of propylene glycol as a solvent

The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation.

pg. 488
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In the thromboelastogram below, clot strength is best represented by:

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

A
B
E
F

In the thromboelastogram below, clot strength is best represented by: E
The maximum amplitude (E) is a measure of the strength of the fully formed clot. It reflects primarily platelet number and function although it also requires proper fibrin formation to achieve normal values.

pg. 1519
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include:

A- a nitroglycerine infusion
B- inotropic support
C- afterload reduction
D- maintenance of adequate preload

In patients with a history of hypertrophic cardiomyopathy, intraoperative management should include: maintenance of adequate preload

In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable.

Download CoreNotes

pp. 1083-1084
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Correct statements regarding cerebral metabolism include:

A- the brain can only utilize glucose as an energy source
B- forty percent of brain glucose consumption is anaerobically metabolized
C-hyperglycemia can reduce the damage from focal hypoxic injury
D- the adult brain consumes approximately 50 ml/min of oxygen

Correct statements regarding cerebral metabolism include: the adult brain consumes approximately 50 ml/min of oxygen

The adult brain consumes about 20% of the total body oxygen (50 ml/min). Neuronal cells normally utilize glucose as their energy source, but can also utilize ketone bodies and lactate. Hyperglycemia has been shown to worsen global and focal hypoxic brain injury.

pg. 576
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the graph of cerebral blood flow below, PaO2 would best be represented by curve:

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

A
B
C
D

In the graph of cerebral blood flow below, PaO2 would best be represented by curve: A
Curve A best represents the effects of changing oxygen tensions on cerebral blood flow. Hypoxemia causes a significant increase in CBF to meet the brain’s metabolic demand. Hyperoxia, however, causes little change in CBF.

pg. 999
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of:

A- isoflurane
B- sevoflurane
C- desflurane
D- nitrous oxide

In patients receiving vecuronium, the greatest augmentation of neuromuscular blockade is seen with the use of: desflurane

Volatile agents decrease the nondepolarizer dosage requirements. The degree of the augmentation of blockade depends on the inhalational agent, with desflurane > sevoflurane > isoflurane > nitrous oxide.

pg. 213
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: (Select 3)

– hypotension secondary to cement monomer absorption
– hypoxemia secondary to air embolization
– hypoxemia secondary to fat embolization
– hypocarbia
– decreased pulmonary artery pressure
– increased end-tidal carbon dioxide

During hip replacement surgery, cardiopulmonary changes associated with the application of acrylic bone cement include: hypotension secondary to cement monomer absorption, hypoxemia secondary to air embolization, hypoxemia secondary to fat embolization

During hip replacement surgery, hypotension associated with the use of acrylic bone cement has been attributed to absorption of methyl methacrylate monomer, embolization of air and bone marrow, lysis of red cells and marrow and conversion of methyl methacrylate to methacrylic acid. Hypoxemia is common. Embolic events cause an increase in dead space with a reduction in ETCO2 with an increase in PaCO2.

pg. 1454
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Maternal mortality associated with amniotic fluid embolization is:

A- 10 – 15%
B- 20 – 25%
C- 40 – 45%
D- greater than 50%

Maternal mortality associated with amniotic fluid embolization is: greater than 50%

Amniotic fluid embolism is rare with a occurrence of about 1:20,000. However, it carries a very high mortality; some studies quoting as much as 86%. Mortality within the first hour after onset is about 50%.

pg. 867
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The highest level of protein binding is seen with:

A- procaine
B- lidocaine
C- mepivacaine
D- bupivacaine

The local anesthetic with the highest degree of protein binding is: bupivacaine

The physicochemical property that determines the duration of action of a local anesthetic is lipid solubility, which is directly correlated with plasma protein binding. Bupivacaine and levobupivacaine have the highest degree of protein binding (97%).

pg. 269
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The highest rate of systemic absorption of local anesthetic is seen with:

A- epidural injection
B- intercostal injection
C- caudal injection
D- brachial plexus injection
The highest rate of systemic absorption of local anesthetic is seen with:

A- epidural injection
B- intercostal injection
C- caudal injection
D- brachial plexus injection

The highest rate of systemic absorption of local anesthetic is seen with: intercostal injection

The rate of systemic absorption of local anesthetic is proportionate to the vascularity of the site of injection: intravenous > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > subcutaneous.

pg. 569
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Absolute contraindications to electroconvulsive therapy (ECT) include:

A- congestive heart failure
B- pregnancy
C- myocardial infarction 5 months prior to therapy
D- increased intracranial pressure

Absolute contraindications to electroconvulsive therapy (ECT) include: increased intracranial pressure

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

In the neuromuscular junction, acetylcholine receptor binding sites are found on the:

 ?-subunits
 ?-subunits
 ?-subunits
 ? -subunits
In the neuromuscular junction, acetylcholine receptor binding sites are found on the:

?-subunits
?-subunits
?-subunits
? -subunits

In the neuromuscular junction, acetylcholine receptor binding sites are found on the: ?-subunits

Each acetylcholine (ACh) receptor in the neuromuscular junction consists of 5 protein subunits. Only the ?-subunits are capable of binding ACh molecules. If both binding sites are occupied, the channel briefly opens. The ?-subunits are also the site of action of neuromuscular blockers.

pg. 527
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In the fetus, the percentage of cardiac output directed to the placenta is approximately:

A- 10%
B- 25%
C- 50%
D- 100%
In the fetus, the percentage of cardiac output directed to the placenta is approximately:

A- 10%
B- 25%
C- 50%
D- 100%

In the fetus, the percentage of cardiac output directed to the placenta is approximately: 50%

In the fetus, the lungs receive little blood flow. The placenta receives nearly one-half of the fetal cardiac output and is responsible for respiratory gas exchange.

pg. 836
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The elimination half-life of intravenously administered oxytocin in the parturient is approximately:

A- 30 to 120 seconds
B- 3 to 5 minutes
C- 10 to 15 minutes
D- 20 to 30 minutes

The elimination half-life of intravenously administered oxytocin in the parturient is approximately: 3 to 5 minutes

Both endogenous and intravenously administered oxytocin have short elimination half-lives of about 3 to 5 minutes. As a result, oxytocin must be administered as a continuous infusion for the induction of labor.

pg. 835
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A fresh E-cylinder of oxygen:

A- contains more liters of gas than an E-cylinder of nitrous oxide
B- contains about 90% liquid oxygen and 10% oxygen as a gas
C- contains about 660 liters of oxygen
D- has a lower pressure than the pipeline oxygen supply

A fresh E-cylinder of oxygen: contains about 660 liters of oxygen

A fresh E-cylinder of oxygen contains about 660 liters of oxygen and is pressurized to 1900 psi.

pg. 8
Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.

Pathophysiologic changes associated with liver disease include: (Select 2)

increased cardiac output
increased systemic vascular resistance
increased mean blood pressure
sodium-losing nephropathy
hyperkalemia
arterial hypoxemia

Pathophysiologic changes associated with liver disease include (Select 2): increased cardiac output, arterial hypoxemia

Arterio-venous shunting, resulting from advanced liver disease, results in a decrease in systemic vascular resistance, a decrease in blood pressure and an increase in cardiac output. Arterial hypoxemia is common in patients with advanced liver disease and appears to be the result of ascites, hepatic hydrothorax and widespread pulmonary vasodilation.

pp. 773-774
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

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

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

A
B
C
D

In the graph of cerebral blood flow below, PaCO2 would best be represented by curve: B
Curve B best represents the effects of changing carbon dioxide tensions on cerebral blood flow. Between the ranges of 20 to 80 mm Hg a linear relationship exists between PaCO2 and CBF, such that a change in PaCO2 from 30 to 60 mm Hg will double CBF.

pp. 998-999
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Clinically significant histamine release has been associated with the use of:

A- vecuronium
B- rocuronium
C- cisatracurium
D- atracurium

Clinically significant histamine release has been associated with the use of: atracurium

Atracurium has been associated with histamine release from mast cells and can result in bronchospasm, skin flushing and hypotension.

pg. 535
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pathophysiologic changes associated with metabolic alkalosis include: (Select 2)

compensatory hyperventilaton
hypokalemia
reduced tissue oxygen availability
ionized hypercalcemia
decreased digoxin effect
arterial hypoxemia

Pathophysiologic changes associated with metabolic alkalosis include: (Select 2): hypokalemia, reduced tissue oxygen availability

Metabolic alkalosis is associated with hypokalemia, ionized hypocalcemia, secondary ventricular arrhythmias, increased digoxin toxicity, and compensatory hypoventilation (hypercarbia). Alkalemia may reduce tissue oxygen availability by shifting the oxyhemoglobin dissociation curve to the left and by decreasing cardiac output.

pg. 328
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The purpose of the ductus venosus in fetal circulation is to:

A- allow umbilical vein blood to bypass the liver
B- allow umbilical artery blood to bypass the liver
C- bypass the pulmonary circulation
D- divert portal vein blood to the placenta

The purpose of the ductus venosus in fetal circulation is to: allow umbilical vein blood to bypass the liver

Up to 50% of the umbilical vein blood can pass directly into the inferior vena cava, bypassing the liver, through the ductus venosus. The remainder mixes with blood from the portal vein and passes through the liver prior to returning to the heart.

pg. 1163
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Highly specific preoperative screening tests have a:

A- low incidence of false-positives results
B- low incidence of false-negative results
C- result that is specific for one pathologic process
D- low sensitivity

Highly specific preoperative screening tests have a: low incidence of false-positives results

The usefulness of a screening test depends on its sensitivity and specificity. Sensitive tests have a low rate of false-negative results, whereas specific tests have a low rate of false-positive results.

pp. 139, 299
Polgar, S, Thomas, SA. Introduction to Research in the Health Sciences. Philadelphia: Churchill Livingstone, 2000

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

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

A
B
C
D

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

Obstructive disease is best represented by flow-volume loop A, which demonstrates increased FRC and TLC with decreased expiratory flow.

pg. 611
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

Serotonin has vasodilatory properties in the: (Select 2)

– renal vasculature
– hepatic vasculature
– skeletal muscle vasculature
– pulmonary vasculature
– coronary vasculature

Serotonin has vasodilatory properties in the: skeletal muscle vasculature, coronary vasculature

Serotonin is a vasoconstrictor in most vascular beds, but has vasodilatory properties in the vasculature of the heart and skeletal muscle.

pg. 284
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Drugs that bind to the proton pump of gastric parietal cell and inhibit hydrogen ion secretion include:

A- ranitidine
B- cimetadine
C- famotidine
D- omeprazole

Drugs that bind to the proton pump of gastric parietal cell and inhibit hydrogen ion secretion include: omeprazole

Omeprazole (Prilosec) inhibits the proton pump of the parietal cells of the gastric mucosa, decreases hydrogen ion secretion and increase pH. Cimetidine, ranitidine and famotidine also increase gastric pH, however their mechanism is through blockade of the H2 receptor.

pg. 283
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Drugs that inhibit coagulation through direct inhibition of thrombin include:

A- heparin
B- warfarin
C- bivalirudin
D- aprotonin

Drugs that inhibit coagulation through direct inhibition of thrombin include: bivalirudin

Bivalirudin, hirudin, lepirudin and argatroban are anticoagulants that directly inhibit thrombin. These agents are most commonly used for cardiopulmonary bypass when heparin is contraindicated. No specific reversal agent is available and termination of effect occurs as a result of renal elimination of the drug.

pg. 416
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Enoxaparin:

A- causes less platelet inhibition than heparin
B- is easily reversed with protamine
C- has a half-life that is 35% less than that of heparin
D- effects are monitored using the INR

Enoxaparin: causes less platelet inhibition than heparin

Low molecular weight heparins (LMWH), such as enoxaparin, have greater activity against factor Xa than thrombin. As a result, the INR is not a reliable monitoring tool. The LMWHs cause less platelet inhibition and are associated with a lesser incidence of heparin induced thrombocytopenia.

pg. 400
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK and Stock, MC. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2009

Termination of the effects of succinylcholine at the neuromuscular junction occurs as a result of:

A- succinylcholine hydrolysis by acetylcholinesterase
B- diffusion of succinylcholine away from the receptors
C- succinylchoine hydrolysis by hepatic esterases
D- the competition of succinylcholine with acetylcholine

Termination of the effects of succinylcholine at the neuromuscular junction occurs as a result of: diffusion of succinylcholine away from the receptors

Because depolarizing muscle relaxants are not metabolized by acetylcholinesterase, they diffuse away from the neuromuscular junction and are hydrolyzed in the plasma by pseudocholinesterase.

pp. 203-204
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

An occurrence malpractice insurance policy:

A- offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed
B- offers coverage if the policy is in place at the time the claim is filed
C- is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy
D- is the most common form of malpractice insurance in place today

An occurrence malpractice insurance policy: offers coverage if the policy was in place at the time of the incident, regardless of when the claim is filed

An occurrence policy offers coverage of an incident resulting in a claim, whenever that claim might be filed. The much more common claims-made policy covers claims that are filed only while the insurance is in force. Umbrella coverage is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice policy.

pg. 38
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Signs of cardiac tamponade include: (Select 2)

– distended neck veins
– increased QRS voltage seen on ECG
– decreased central venous pressure
– bradycardia
– systemic vasoconstriction
– an increase in systolic blood pressure during inspiration

Clinical signs of cardiac tamponade include: (Select 2) distended neck veins, systemic vasoconstriction

Cardiac tamponade is indicated by the presence of neck vein distention, hypotension, muffled heart sounds (Beck’s triad) and a greater than 10 mm Hg decline in blood pressure during spontaneous inspiration (pulsus paradoxus). Tachycardia and systemic vasoconstriction are present to maintain blood pressure with the associated decreased stroke volume.

pp. 495-496
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Respiratory parameters that are increased during pregnancy include: (Select 2)

– airway resistance
– tidal volume
– oxygen consumption
– plasma bicarbonate levels
– functional residual capacity
– PaCO2

Respiratory parameters that are increased during pregnancy include: (Select 2) tidal volume, oxygen consumption

Respiratory/ventilatory effects of pregnancy include increased oxygen consumption, decreased airway resistance, decreased FRC, increased tidal volume and rate, increased PaO2, decreased PaCO2 and decreased serum bicarbonate.

pg. 1129
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

Droperidol:

A- has antiarrhytmic activity
B- causes shortening of the QT interval
C- causes peripheral vasoconstriction
D- is effective for blood pressure control in patients with pheochromocytoma

Droperidol: has antiarrhythmic activity

Droperidol has mild alpha-blocking activity and causes vasodilation and has antiarrhythmic properties with prolongation of the QT interval. As a result of the prolongation of the QT interval, droperidol has been associated with torsades de pointes and should not be given to patients with QT intervals measuring more than 440 ms. Patients with pheochromocytoma should not receive droperidol because it can induce catecholamine release.

pp. 190-192
Hemmings, HC, Talmage, DE. Pharmacology and Physiology for Anesthesia. Philadelphia: Elsevier, 2013.

Type I pneumocytes:

A- prevent the passage of albumin into the alveolus 
B- are more numerous than Type II pneumocytes 
C- produce surfactant 
D- are capable of rapid cell division
Type I pneumocytes:

A- prevent the passage of albumin into the alveolus
B- are more numerous than Type II pneumocytes
C- produce surfactant
D- are capable of rapid cell division

Type I pneumocytes: prevent the passage of albumin into the alveolus

Type I pneumocytes are flat and form a tight junction with one another. This prevents the passage of oncotic molecules, such as albumin, into the alveolus. Type II pneumocytes are smaller, but more numerous, and produce surfactant. Unlike Type I pneumocytes, Type II pneumocytes are capable of cell division and can produce Type I pneumocytes when needed.

pg. 490
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Coagulation Cascade
Coagulation Cascade

The phrenic nerves arise from the:

A- nucleus ambiguous 
B- C1 - C2 nerve roots 
C- C3 - C5 nerve roots 
D- C6 - T2 nerve roots
The phrenic nerves arise from the:

A- nucleus ambiguous
B- C1 – C2 nerve roots
C- C3 – C5 nerve roots
D- C6 – T2 nerve roots

The phrenic nerves arise from the: C3 – C5 nerve roots

The phrenic nerves arise from the C3 – C5 nerve roots. Unilateral phrenic nerve palsy only modestly reduces most indices of pulmonary function (about 25%). Bilateral phrenic nerve palsies produce more severe impairment, but accessory muscles may maintain adequate ventilation. Cervical cord injuries above C5 are incompatible with spontaneous ventilation.

pp. 946-947
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pathophysiologic changes associated with ALI/ARDS include: (Select 2)

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

– hypoxemia responsive to oxygen therapy
– increased static compliance of the chest wall
– diffuse alveolar edema
– high dead space fraction
– reduced mean pulmonary artery pressure
– decreased intrapulmonary shunt

Pathophysiologic changes associated with ALI/ARDS include: (Select 2) diffuse alveolar edema, high dead space fraction

ALI and ARDS are syndromes of acute, hypoxemic respiratory failure, with resulting increased lung permeability and diffuse alveolar edema. Clinically, ARDS and ALI are characterized by reduced static thoracic (lung and chest wall) compliance and severe impairment of gas exchange, including high intrapulmonary shunt and dead space fraction with pulmonary hypertension. The high level of intrapulmonary shunt results in hypoxia, which is relatively unresponsive to oxygen therapy.

pp. 1594-1595
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The primary mechanism of intraoperative heat loss resulting in hypothermia is:

A- convection
B- radiation
C- conduction
D- evaporation

The primary mechanism of intraoperative heat loss resulting in hypothermia is: radiation

Radiation accounts for approximately 40% of intraoperative heat loss. Convection is the next most significant mechanism of loss accounting for 32%.

pg. 321
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Sinus arrhythmia:

A- is mediated through sympathetic innervation of the AV node
B- causes an increase in heart rate with inspiration
C- is indicative of SA node ischemia
D- is the primary cause of premature atrial contractions

Sinus arrhythmia: causes an increase in heart rate with inspiration

Sinus arrhythmia is a cyclic variation in heart rate that corresponds to ventilation, increasing with inspiration and decreasing with expiration. Sinus arrhythmia is a normal cardiac rhythm and is due to cyclic changes in vagal tone.

pg. 1717
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Of the following, the block associated with the highest blood level of local anesthetic per volume injected is the:

A- epidural block
B- spinal block
C- intercostal block
D- caudal block

Of the following, the block associated with the highest blood level of local anesthetic per volume injected is the: intercostal block

Blood concentration of local anesthetic is dependent on the total volume and concentration injected. However, with the exception of airway blocks, the intercostal block results in the highest blood levels of local anesthetic per volume injected.

pg. 569
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In addition to providing analgesia, tramadol has been shown to:

A- inhibit the reuptake of serotonin and norepinephrine
B- inhibit cholinesterase
C- significantly delay gastric emptying
D- cause comparable respiratory depression to morphine

In addition to providing analgesia, tramadol has been shown to: inhibit the reuptake of serotonin and norepinephrine

Tramadol is a synthetic opioid that also blocks neuronal reuptake of norepinephrine and serotonin. Tramadol is associated with significantly less respiratory depression and delay in gastric emptying as compared to other narcotics.

pg. 186
Hemmings, HC, Talmage, DE. Pharmacology and Physiology for Anesthesia.. Philadelphia: Elsevier, 2013.

pg. 1058
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Compensatory mechanisms generally present in patients with congestive heart failure include:

A- decreased sympathetic tone
B- decreased plasma renin levels
C- decreased plasma aldosterone levels
D- ventricular hypertrophy

Compensatory mechanisms generally present in patients with congestive heart failure include: ventricular hypertrophy

Major compensatory mechanisms present in patients with CHF include increased preload, increased sympathetic tone, activation of the renin-angiotensin-aldosterone system, release of ADH and ventricular hypertrophy.

pg. 367-368
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The risk of paradoxical air embolism is increased in patients with a patent foramen ovale. The incidence of patent foramen ovale in the adult population is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

%

The risk of paradoxical air embolism is increased in patients with a patent foramen ovale. The incidence of patent foramen ovale in the adult population is approximately: 10 – 25%

The incidence of venous air embolism is highest during sitting crainotomies, with an incidence of 20 – 40%. The risk of paradoxical venous air embolization is increased in patients with patent foramen ovale, which has a reported incidence of 10 – 25% in the adult population.

pg. 792
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Neuromuscular blocking agents that undergo metabolism through the Hofmann elimination include: (Select 2)

– rocuronium
– vecuronium
– atracurium
– doxacurium
– cisatracurium
– succinylcholine

Neuromuscular blocking agents that undergo metabolism through the Hofmann elimination include: (Select 2) atracurium, cisatracurium

Atracurium and cisatracurium are bisquaternary ammonium benzylisoquinoline compounds of intermediate duration of action. They are degraded via two metabolic pathways. One of these pathways is the Hofmann reaction, a nonenzymatic degradation with a rate that increases as temperature and/or pH increases. The second pathway is nonspecific ester hydrolysis.

pp. 535-536
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

34-year-old female is undergoing tumescent liposuction of the abdomen and flanks. Peak serum levels of local anesthetic from the tumescent solution are most commonly seen in:

A- the first 2 hours
B- 4 to 6 hours
C- 7 to 9 hours
D- 12 to 14 hours

A 34-year-old female is undergoing tumescent liposuction of the abdomen and flanks. Peak serum levels of local anesthetic from the tumescent solution are most commonly seen in: 12 – 14 hours

Tumescent liposuction is commonly done with large volumes of tumescent solution consisting of normal saline with 1:1,000,000 epinephrine and 0.025 – 0.1% lidocaine. Peak serum levels of lidocaine occur 12 – 14 hours after injection and decline over the next 6 – 14 hours.

pg. 868
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Opioids currently NOT approved for epidural or intrathecal use include:

A- fentanyl
B- sufentanil
C- morphine
D- remifentanil

Opioids currently NOT approved for epidural or intrathecal use include: remifentanil

Remifentanil is prepared in a solution of glycine, a known inhibitory neurotransmitter. Currently, remifentanil is not approved for epidural or intrathecal use.

pg. 114 – 115
Stoelting, RK. Pharmacology and Physiology in Anesthetic Practice. Philadelphia: Lippincott Williams and Wilkins, 2006.

A 82-year-old female is scheduled for a total hip replacement under spinal anesthesia. She has been receiving enoxaparin for deep vein thrombosis prophylaxis. Current recommendations regarding the dosing of enoxaparin state that the drug be:

A- continued without interruption as scheduled
B- held for 4 – 6 hours prior to the spinal anesthetic
C- held for 10 – 12 hours prior to the spinal anesthetic
D- held for not less than 24 hours prior to the spinal anesthetic

A 82-year-old female is scheduled for a total hip replacement under spinal anesthesia. She has been receiving enoxaparin for deep vein thrombosis prophylaxis. Current recommendations regarding the dosing of enoxaparin state that the drug be: held for 10 – 12 hours prior to the spinal anesthetic

Patients receiving fractionated low-molecular weight heparin are to be considered at increased risk of spinal hematoma. Patients receiving these drugs should have the drug held for 10 – 12 hours preoperatively according to the Consensus Statement from the American Society for Regional Anesthesia and Pain Medicine.

pg. 929
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Safety features that prevent filling of the vaporizer with an incorrect agent include:

A- the pin index safety system
B- agent-specific keyed filling ports
C- the diameter index safety system
D- counter-threading of the bottle attachment

Safety features that prevent filling of the vaporizer with an incorrect agent include: agent-specific keyed filling ports

Modern vaporizers offer agent-specific keyed filling ports to prevent filling with an incorrect agent. The pin-index safety system is found on e-cylinders to prevent incorrect tank placement.

pg. 63
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

person acting as an amicus curiae:

A- is not a party to the litigation
B- gives expert testimony for the defense
C- gives expert testimony for the plaintiff
D- cannot file a written brief

A person acting as an amicus curiae: is not a party to the litigation

Amicus curiae is a phrase that literally means ‘friend of the court’ — someone who is not a party to the litigation, but who believes that the court’s decision may affect its interest. An expert, not associated with either the defendant or plaintiff may, at the court’s discretion, file a brief or give testimony to assist the court in decision making.

“Amicus curiae.” URL: http://en.wikipedia.org/wiki/Amicus_curiae

“Amicus curiae.” URL: http://www.merriam-webster.com/dictionary/amicus%20curiae

The first nurse anesthetist to be appointed to a university medical school faculty was:

A- Alice Maude Hunt
B- Agatha Hodgins
C- Helen Lamb
D- Alice Magaw

The first nurse anesthetist to be appointed to a university medical school faculty was: Alice Maude Hunt

In 1922, Alice Maude Hunt became an instructor in anesthesia at the Yale University School of Medicine and was later promoted to assistant professor. Hunt also pioneered the use of nitrous oxide and oxygen as an anesthetic modality.

pg. 16
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

Re-order the list of inhaled agents below from highest vapor pressure to lowest (Highest vapor pressure agent at top of list):

• Isoflurane
• Sevoflurane
• Nitrous Oxide
• Desflurane

Re-order the list of inhaled agents below from highest vapor pressure to lowest (Highest vapor pressure agent at top of list):
Nitrous Oxide
Desflurane
Isoflurane
Sevoflurane

Vapor Pressure of Agents
At 20o C, the highest vapor pressure of the inhaled agents is possessed by nitrous oxide (38,700 mm Hg), followed by desflurane (669 mm Hg), isoflurane (238 mm Hg) and sevoflurane (157 mm Hg).

pg. 86
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Reduction of heart rate seen with the administration of opiates is mediated through the:

A- sigma receptors
B- delta receptors
C- kappa receptors
D- mu receptors

Reduction of heart rate seen with the administration of opiates is mediated through the: mu receptors

The cardiovascular effects of narcotics appear to be mediated through the mu receptors. In addition, these receptors seem, at least in part, to be responsible for the ventilatory depression associated with narcotic admnistration.

pg. 147
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

The effects of 60-Hz current on a human for 1-second are shown below. By dragging & reordering the selections in yellow, match the current to the physiologic effect.
• Perception Threshold
• Let-Go Current
• Microshock Risk
• V. Fibrillation
• 100 ?Amp
• 200 mAmp
• 1 mAmp
• 15 mAmp
The effects of 60-Hz current on a human for 1-second are shown below. By dragging & reordering the selections in yellow, match the current to the physiologic effect:

1mAmp: Perception Threshold
15mAmp: Let Go current
100 uAmp: Michoshock Rsik
200 mAmp: V. Fibrillation
pg. 624
Ehrenwerth, J, Eisenkraft, JB, and Berry, JM. Anesthesia Equipment Principles and Applications. St. Louis: Elsevier, 2013.

Mortality after liposuction procedures most commonly is the result of:

A- pulmonary embolism
B- bowel perforation
C- fat embolization
D- reactions to anesthetic agents

Mortality after liposuction procedures most commonly is the result of: pulmonary embolism

The mortality rate from liposuction procedures is approximately 0.02%. The most common cause of mortality is pulmonary embolism accounting for 23.1% of the deaths.

pg. 868
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Heart rate:

A- is the sole determinant of cardiac output in the elderly
B- is normally determined by the intrinsic rate of the AV node
C- decreases with increasing age
D- is increased by stimulation of the M2 cholinergic receptors

Heart rate: decreases with increasing age

Cardiac output is the product of stoke volume and heart rate. Heart rate is an intrinsic function of the SA node and decreases with increasing age. Enhanced vagal activity slows the heart via stimulation of the M2 cholinergic receptors.

pg. 351
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Clinical signs of tension pneumothorax include:

A- contralateral absence of breath sounds
B- ipsilateral hyporesonance to percussion
C- neck vein distention
D- all of the above

Your response is correct.

Clinical signs of tension pneumothorax include: neck vein distention

A tension pneumothorax develops from air entering the pleural space through a one-way valve in the lung or chest wall. Clinical signs include ipsilateral absence of breath sounds, hyperresonance to percussion, contralateral tracheal shift and distended neck veins.

pg. 1497
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Portal hypertension leads to the development of portal-systemic venous collateral channels. These collateral sites commonly include the:

A- hemorrhoidal veins 
B- pulmonary veins 
C- hepatic vein 
D- azygous vein
Portal hypertension leads to the development of portal-systemic venous collateral channels. These collateral sites commonly include the:

A- hemorrhoidal veins
B- pulmonary veins
C- hepatic vein
D- azygous vein

Portal hypertension leads to the development of portal-systemic venous collateral channels. These collateral sites commonly include the: hemorrhoidal veins

Chronic portal hypertension leads to the development of portal-systemic collateral channels. Four major collateral sites are commonly recognized: gastroesophageal, hemorrhoidal, periumbilical and retroperitoneal.

pg. 771
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

As compared to hygroscopic heat-moisture exchangers, hydrophobic heat-moisture exchangers:

A- depend on electrostatic properties to retain moisture
B- are more effective filters of pathogens
C- are more efficient devices for retaining heat and moisture
D- are more likely to become saturated and increase resistance to ventilation

As compared to hygroscopic heat-moisture exchangers, hydrophobic heat-moisture exchangers: are more effective filters of pathogens

HMEs may be either hygroscopic or hydrophobic. Hygroscopic HMEs use paper or other fiber barrier, which possess electrostatic properties. They adsorb water in expiration and release it in inspiration and are efficient devices for retaining heat and moisture. Being fiber based, they are more prone to becoming saturated and causing increased resistance to ventilation.
Hydrophobic HMEs are more efficient filters of pathogens, but are unable to deliver the degree of humidification offered by hygroscopic HMEs.

pp. 182-183
Ehrenwerth, J, Eisenkraft, JB, and Berry, JM. Anesthesia Equipment Principles and Applications. St. Louis: Elsevier, 2013.

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is:

A- phenoxybenzamine
B- doxazosin
C- propranolol
D- terazosin

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is: phenoxybenzamine

Phenoxybenzamine is a nonselective ?-antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and terazosin are selective ?1-antagonists. Propranolol is a nonselective ?-antagonist. In the preparation of patients with pheochromocytoma, ?-blockade and intravascular volume replacement must precede ?-blockade, so as to prevent the possibility of unopposed ?-stimulation.

pp. 745-746
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The portion of the nephron responsible for concentration of urine via the countercurrent mechanism is the:

A- glomerulus 
B- loop of Henle 
C- proximal convoluted tubule 
D- distal convoluted tubule
The portion of the nephron responsible for concentration of urine via the countercurrent mechanism is the:

A- glomerulus
B- loop of Henle
C- proximal convoluted tubule
D- distal convoluted tubule

The portion of the nephron responsible for concentration of urine via the countercurrent mechanism is the: loop of Henle

The loop of Henle is responsible for formation of hypertonic fluid in the (renal) medullary interstitium via the countercurrent multiplier system.

pg. 732
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

Postoperative ulnar nerve injury:

A- results in wrist drop and loss of sensation in the web space between the thumb and index finger
B- occurs more frequently in males
C- manifests itself in the immediate postoperative period
D- is most commonly seen in the patient with a BMI of less than 38

Postoperative ulnar nerve injury: occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:
1) male sex – various reports suggest that 70-90% of patients with postoperative ulnar neuropathy are men
2) high body mass index – BMI > or = 38
3) prolonged postoperative bed rest.
Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger is associated with radial nerve injury.

In the figure below, the Carlens tube is best represented by: (Make your selection by clicking on the appropriate part of the figure)
In the figure below, the Carlens tube is best represented by: (Make your selection by clicking on the appropriate part of the figure)
The Carlens double-lumen tubes have a carinal hook to aid in proper placement and minimize tube movement after placement. Potential problems with carinal hooks include increased difficulty with proper placement, trauma to the airway, interference with bronchial closure, and break-off of the hook, which can become lost in the bronchial tree.

pp. 395, 398
Dorsch, JA, Dorsch, SE. A Practical Approach to Anesthesia Equipment. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.

In contrast to patients undergoing on-pump coronary artery bypass grafting (CABG), patients undergoing off-pump CABG:

A- usually require little volume replacement
B- do not require anticoagulation
C- have isolated left coronary of left anterior descending artery disease
D- usually require relatively high mean arterial pressures during distal anastomoses grafting

In contrast to patients undergoing on-pump coronary artery bypass grafting (CABG), patients undergoing off-pump CABG: usually require relatively high mean arterial pressures during distal anastomoses graftine

Off-pump CABG (OPCAB) is done in patients with a variety of coronary artery lesions. Since the patient will not be receiving the volume of the pump-prime, crystalloid and/or colloid solutions are used to correct fluid deficit. Anticoagulation is required, but partial heparinization is often used. During distal anastomoses grafting, CPP is maintained by keeping a relatively high MAP.

pg. 536
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

The single greatest cause of mortality in the patient with sickle cell disease is a result of:

A- acute chest syndrome 
B- sequestration crisis 
C- aplastic crisis
D- vaso-occlusive crisis
The single greatest cause of mortality in the patient with sickle cell disease is a result of:

A- acute chest syndrome
B- sequestration crisis
C- aplastic crisis
D- vaso-occlusive crisis

The single greatest cause of mortality in the patient with sickle cell disease is a result of: acute chest syndrome

ACS represents the single greatest threat to the patient with SCD as the mortality is 1% to 20%. The diagnosis of ACS can be made when there are new lung infiltrates on a chest radiograph in the presence of any of the following: chest pain, cough, dyspnea, wheezing, or hypoxemia. Proposed mechanisms of ACS are thrombosis, embolism (clot and fat), and infection. The frequency of ACS after abdominal surgery is 10% to 20%.

pp. 631-632
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The line isolation monitor:

A- provides a source of ungrounded electrical power 
B- reduces the risk microshock 
C- monitors the integrity of the isolated power system 
D- monitors the integrity of equipment grounding wires
The line isolation monitor:

A- provides a source of ungrounded electrical power
B- reduces the risk microshock
C- monitors the integrity of the isolated power system
D- monitors the integrity of equipment grounding wires

The line isolation monitor: monitors the integrity of the isolated power system

The line isolation monitor continuously monitors the integrity of the isolated power system. The line isolation transformer provides ground isolation. Microshock hazards occur with the delivery of 100 microamps or less of current directly to the endocardium. These small amounts of current are well below the sensing range of the ground isolation monitor. The LIM is unable to detect a faulty grounding connection in the equipment attached to the circuit.

pg. 202
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Parasympathetic preganglionic fibers are found in: (Select 3)

 cranial nerve IV
 cranial nerve VII
 cranial nerve IX
 cranial nerve XI
 thoracic nerve 9
 thoracic nerve 11
 sacral nerve 1
 sacral nerve 2
Parasympathetic preganglionic fibers are found in: (Select 3)

cranial nerve IV
cranial nerve VII
cranial nerve IX
cranial nerve XI
thoracic nerve 9
thoracic nerve 11
sacral nerve 1
sacral nerve 2

Parasympathetic preganglionic fibers are found in: cranial nerve VII, cranial nerve IX, sacral nerve 2

Parasympathetic preganglionic fibers are found in cranial nerves III, VII, IX and X as well as sacral nerves 2, 3 and 4.

pg. 363
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

During intraoperative fluoroscopy, the patient receives 32 mR at a distance of 1 foot from the fluoroscopy tube. The maximum radiation dose possible to the anesthesia provider, standing at a distance of 4 feet from the fluoroscopy tube is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mR

During intraoperative fluoroscopy, the patient receives 32 mR at a distance of 1 foot from the fluoroscopy tube. The maximum radiation dose possible to the anesthesia provider, standing at a distance of 4 feet from the fluoroscopy tube is:
(Enter numerical answer in box below. Click ‘Next’ when completed.) 2 mR

Increasing the distance from the source of radiation is a very effective means of reducing dose. Dose rates increase or decrease according to the inverse square of the distance from the source. Using the inverse square law formula:

I1D12 = I2D22
I = intensity, D = distance

(32 mR)(1 ft)2 = (I2)(4 ft)2; I2 = 2 mR

pp. 880-881
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Electrolyte containing irrigation solutions are avoided during transurethral resection of the prostate because they:

A- interfere with the use of the cautery
B- can precipitate severe hyponatremia
C- can cause hyperglycemia in diabetic patients
D- are associated with elevated ammonia levels postoperatively

Electrolyte containing irrigation solutions are avoided during transurethral resection of the prostate because they: interfere with the use of the cautery

Electrolyte containing solutions conduct electricity and interfere with cautery use during the resection of the prostate. Electrolyte solutions are commonly used in the postop period. Sorbitol solutions have been associated with hyperglycemia, especially in diabetic patients. Glycine solutions have been associated with elevated ammonia levels and transient postoperative visual syndrome. Sorbitol, glycine and distilled water have all been associated with TURP syndrome.

pg. 1428
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The speed in an inhalation induction is slowed by right-to-left shunting. The change in the rate of induction is LEAST pronounced when using:

A- nitrous oxide
B- sevoflurane
C- isoflurane
D- desflurane

The speed in an inhalation induction is slowed by right-to-left shunting. The change in the rate of induction is LEAST pronounced when using: isoflurane

With right-to-left shunting there is slowing of an inhalation induction. This effect is less pronounced with agents with high blood/gas solubilities.

pg. 455
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

MAC-BAR is the:

A- partial pressure of an anesthetic required to abolish movement in 50% of patients
B- partial pressure of an anesthetic at which subjects will open their eyes
C- partial pressure of an anesthetic at which autonomic blockade occurs
D- partial pressure of an anesthetic at which amnesia occurs

MAC-BAR is the: partial pressure of an anesthetic at which autonomic blockade occurs

MAC-BAR is the minimum alveolar concentration that blocks autonomic reflexes. MAC-BAR is considerably greater than MAC, particularly in the absence of opioids. It has been estimated that MAC-BAR is approximately 50% above standard MAC.

pg. 458
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

In a 6-year-old, the appropriate length of an endotracheal tube from distal tip to incisors is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

cm

In a 6-year-old, the appropriate length of an endotracheal tube from distal tip to incisors is: 15 – 16.5 cm

Several formulas exist to estimate the length of ETT insertion in patients aged 2 to 12 years. One of the most frequently used is:

Age/2 +12

pp. 1201-1202
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013

Local anesthetic solutions that are isobaric with the cerebrospinal fluid include: (Select 2)

 tetracaine 0.5% in 5% dextrose 
 bupivacaine 0.75% in normal saline 
 procaine 10% in sterile water 
 lidocaine 2% in normal saline 
 bupivacaine 0.3% in sterile water 
 lidocaine 5% in 7.5% dextrose
Local anesthetic solutions that are isobaric with the cerebrospinal fluid include: (Select 2)

tetracaine 0.5% in 5% dextrose
bupivacaine 0.75% in normal saline
procaine 10% in sterile water
lidocaine 2% in normal saline
bupivacaine 0.3% in sterile water
lidocaine 5% in 7.5% dextrose

Local anesthetic solutions that are isobaric with the cerebrospinal fluid include: bupivacaine 0.75% in normal saline, lidocaine 2% in saline

LA Baricity

pp. 916-917
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

An 82-year-old female arrives to the OR for open reduction of a left intratrochanteric fracture. Significant past medical history includes hypertension, moderate aortic stenosis and dementia. The most appropriate anesthetic technique for this patient is:

opioid-based general anesthesia
spinal anesthesia
volatile-agent-based general anesthesia
epidural anesthesia

opioid-based general anesthesia

In patients with mild to moderate aortic stenosis, a primarily opioid-based technique results in minimal cardiac depression, less tachycardia and suppression of the sympathetic response to surgical stimulation. These are all desired effects as HTN and tachycardia may precipitate ischemia in these patients. Spinal or epidural anesthesia as well as a volatile-agent-based anesthesia can cause a fall in afterload with resulting severe hypotension.

pp. 501-502
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

During the delivery of an inhalation anesthetic using 6.5% desflurane in oxygen, nitrous oxide is introduced into the gas mixture. The effect of the addition of nitrous oxide on the concentration of desflurane delivered is:

to cause an increase in desflurane concentration
to cause a decrease in desflurane concentration
to cause no change in desflurane concentration
variable, depending on the ambient atmospheric pressure

During the administration of an inhalation anesthetic using 6.5% desflurane in oxygen, nitrous oxide is introduced into the gas mixture. The effect of the addition of nitrous oxide on the concentration of desflurane delivered is: to cause a decrease in desflurane concentration

When a carrier gas other than 100% oxygen is used, a clear trend toward reduction in the desflurane vaporizer output is seen. This effect is thought to be secondary to the change in gas viscosity that occurs with the introduction of nitrous oxide and is most pronounced at low-flow rates. A reduction of as much as 20% may be produced.

pg. 669
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The area of myocardium most vulnerable to ischemia is the:

left ventricular epicardium
right ventricular epicardium
left ventricular subendocardium
right ventricular subendocardium

The area of myocardium most vulnerable to ischemia is the: left ventricular subendocardium

The subendocardium of the left ventricle is most vulnerable to ischemia since this is an area of greater systolic shortening. In addition, left ventricular subendocardium perfusion is almost entirely restricted to diastole, in contrast to the subendocardium of the right ventricle that receives most of its perfusion during systole.

pg. 244
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The formation of active metabolites has NOT been associated with the use of:

vecuronium
rocuronium
pancuronium
succinylcholine

The formation of active metabolites has NOT been associated with the use of: rocuronium

The 3-OH metabolites of both vecuronium and pancuronium possess about 50% of the neuromuscular blocking activity of parent compound. Succinylcholine is metabolized to choline, succinic acid and succinylmonocholine. Succinylmonocholine also has some neuromuscular blocking activity. A small amount of rocuronium is metabolized to the 17-OH compound, which lacks activity. Most rocuronium is excreted by the kidneys and liver as intact drug.

pg. 535-538
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The rate of seroconversion after exposure of mucous membranes to HIV-infected blood is approximately:

0.03%
0.09%
0.3%
0.9%

The rate of seroconversion after exposure of mucous membranes to HIV-infected blood is approximately: 0.09%

Percutaneous exposure (needle stick) carries a risk of HIV-seroconversion of approximately 0.3% or about 1:300. Mucous membrane exposure carries a risk of approximately 0.09% or about 1:1100.

pg. 77
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Actuation of the oxygen flush valve delivers 100% oxygen at a rate of:

10 – 20 L/min
20 – 30 L/min
35 – 75 L/min
80 – 100 L/min

Actuation of the oxygen flush valve delivers 100% oxygen at a rate of: 35 – 75 L/min

The oxygen flush valve delivers 100% oxygen at a rate of 35 – 75 L/min with a pressure of 40 – 60 psi.

pg. 64
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The incidence of headache with inadvertent dural puncture during epidural anesthesia is decreased:

with decreasing age
by keeping the patient supine for more than 12 hours following puncture
with the use of fluid, instead of air, for loss of resistance
by inserting the needle with the bevel aligned perpendicular to the long axis of the meninges

The incidence of headache with inadvertent dural puncture during epidural anesthesia is decreased: with the use of fluid, instead of air, for loss of resistance

The use of fluid instead of air has been associated with a significant reduction in the incidence of postdural puncture headache (PDPH). Other factors associated with a reduced incidence of PDPH are: increasing age, insertion of the bevel aligned parallel to the long axis of the meninges and the use of smaller needles. There is no evidence that keeping the patient supine reduces the incidence of PDPH.

pg. 926
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Factors decreasing physiologic dead space include:


 the supine position 
 anticholinergic agents 
 increasing age 
 emphysema
Factors decreasing physiologic dead space include:

the supine position
anticholinergic agents
increasing age
emphysema

Factors decreasing physiologic dead space include: the supine position

Dead space is comprised of gases in non-respiratory airways (anatomic dead space) as well as in alveoli that are not perfused (alveolar dead space). The sum of the two is known as physiologic dead space. Certain factors affect dead space. The supine position is known to decrease dead space, whereas anticholinergics, ?2-sympathomimetics, advancing age and COPD all increase dead space.

pg. 599
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 363
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

As compared with plasma osmolality, hypertonic crystalloid solutions include:

D5W
Ringer’s lactate
D5 0.25NS
D5 0.45 NS

As compared with plasma osmolality, hypertonic crystalloid solutions include: D5 0.45NS

Normal plasma osmolality ranges between 280 – 290 mOsm/L. D5W is hypotonic in relation to plasma, with a tonicity of 253 mOsm/L. Both Ringer’s lactate and D5 0.25NS are isotonic solutions, with tonicities of 273 and 355 mOSm /L respectively. D5 0.45NS is hypertonic with a tonicity of 406 – 432 mOsm/L.

pg. 392
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Selective adrenergic stimulation of the ?2-receptor results in:

increased heart rate
increased insulin secretion
detrusor muscle contraction
pupillary constriction

Selective adrenergic stimulation of the ?2-receptor results in: increased insulin secretion

?2-receptor stimulation results in: increased insulin secretion, bronchodilation, increased salivary gland secretion, decreased upper GI motility, gluconeogenesis, pupillary dilation and detrusor muscle relaxation. Increased heart rate is a result of ?1-receptor stimulation. Pupillary constriction (miosis) is the result of parasympathetic stimulation.

pg. 187
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

Pathophysiologic changes associated with hypercortisolism include: (Select 2)

hyperkalemia
plasma volume depletion
metabolic alkalosis
hypoglycemia
hypotension
osteoporosis
hyponatremia

Signs and symptoms associated with hypercortisolism include: (Select 2): metabolic alkalosis, osteoporosis

The clinical picture of hypercortisolism includes central obesity, hypertension, glucose intolerance, weakness, bruising and osteoporosis. Mineralocorticoid effects include fluid retention and hypokalemic alkalosis.

pg. 865
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The most consistent clinical manifestation of aspiration pneumonitis is:

bronchospasm
arterial hypoxemia
pulmonary vasoconstriction
tachypnea

The most consistent clinical manifestation of aspiration pneumonitis is: arterial hypoxemia

Inhaled gastric fluid is rapidly distributed throughout the lungs, leading to destruction of surfactant-producing cells, damage to the pulmonary capillary endothelium and resultant atelectasis and pulmonary edema. Arterial hypoxemia is the most consistent clinical finding associated with aspiration pneumonitis. Tachypnea, bronchospasm and pulmonary vasoconstriction with secondary pulmonary hypertension may also be present.

pg. 640
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 20

A full-term, 4.2 kg neonate is scheduled for a thoracotomy for resection of congenital lobar emphysema. The infant’s starting hematocrit is 48%. Estimated allowable blood loss to maintain a hematocrit at or above 38% is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mL

A full-term, 4.2 kg neonate is scheduled for a thoracotomy for resection of congenital lobar emphysema. The infant’s starting hematocrit is 48%. Estimated allowable blood loss to maintain a hematocrit at or above 38% is: 70 – 110 mL

The full-term neonate has approximately 85 ml/kg total blood volume. Therefore:
4.2 kg x 85 ml/kg = 357 ml (blood volume)
MABL = Blood Volume x (HCT(starting) – HCT(final)) / HCT(average)
357 ml x (48 – 38) / 43 = 83 mL

Please note that multiple formulas exist for the calculation of allowable blood loss, which may yield varying results.

pp. 1165, 1171
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Hormones released by the neurohypophysis include: (Select 2)

thryotropin
growth hormone
arginine vasopressin
adrenocorticotropic hormone
follicle stimulating hormone
oxytocin
prolactin
luteinizing hormone

Hormones released by the neurohypophysis include (Select 2): oxytocin, arginine vasopressin

The neurohypophysis is another term for the posterior pituitary gland. The hormones of the neurohypophysis, oxytocin and arginine vasopressin (vasopressin, ADH), are synthesized in the hypothalamus and stored in the posterior pituitary. Stimulus for the release of arginine vasopressin arises from osmoreceptors in the hypothalamus that sense an increase in plasma osmolality.

pp. 843, 846-847
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Pancreatic somatostatin producing cells in the Islets of Langerhans are:

alpha cells
beta cells
gamma cells
delta cells

Pancreatic somatostatin producing cells in the Islets of Langerhans are: delta cells

The Islets of Langerhans are comprised of four cell types: alpha cells producing glucagon, beta cells producing insulin, delta cells producing somatostatin and PP cells producing pancreatic polypeptide.

pg. 789
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Pancreas.” URL: http://en.wikipedia.org/wiki/pancreas

Congenital heart diseases associate with right-to-left shunting include: (Select 3)

tricuspid atresia
hypoplastic left heart syndrome
aortopulmonary window
patent ductus arteriosus
tetralogy of Fallot
subvalvular aortic stenosis
ventricular septal defects
atrial septal defects

Congenital heart diseases associate with right-to-left shunting include (Select 3): tricuspid atresia, hypoplastic left heart syndrome, tetralogy of Fallot

Right-to-left shunting (cyanotic) heart disease is associated with: Tetrology of Fallot, pulmonary atresia, triscupid atresia, transposition of the great vessels, truncus arteriosus, single ventricle, double-outlet ventricle, total anomalous pulmonary venous return and hypoplastic left heart.
With tricuspid atresia, blood can flow out of the right atrium only via a patent foramen ovale (PFO). A PDA or VSD is necessary for the blood to flow from the left ventricle to the pulmonary circulation.

pg. 1181
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The recommended maximum leakage current allowed in operating room equipment is:

5 ?A
10 ?A
1 mA
5 mA

The recommended maximum leakage current allowed in operating room equipment is: 10 ?A

10 ?A has been established as the recommended maximum allowable leakage current. This amount of current is below the threshold of perception (1mA) as well as below the threshold for risk of microshock.

pg. 192
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Causes of normal-anion-gap acidosis include:

renal failure
starvation
diarrhea
lactic acidosis

Causes of normal-anion-gap acidosis include: diarrhea

Normal-anion-gap acidosis is also called hyperchloremic acidosis and results from the selective loss of bicarbonate anion or the introduction of large amounts of chloride anion. Common causes include: diarrhea, hypoaldosteronism, renal tubular acidosis and increased intake of chloride containing acids sometimes found in hyperalimentation.

pg. 461
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Hypoxemia during one-lung anesthesia is most effectively treated by:

PEEP applied to the ventilated lung
continuous oxygen insufflation to the collapsed lung
changing tidal volume and rate
periodic inflation of the collapsed lung

Hypoxemia during one-lung anesthesia is most effectively treated by: periodic inflation of the collapsed lung

The application of PEEP to the ventilated lung, changes in the ventilatory parameters and oxygen insufflation to the collapsed lung may offer marginal improvement in oxygenation. However, periodic inflation of the collapsed lung with oxygen, early ligation of the ipsilateral pulmonary artery and CPAP to the collapsed lung offer consistently effective improvement in oxygenation.

pp. 678-679
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

Branches of the femoral nerve anesthetized during an ankle block include the:

deep peroneal nerve
sural nerve
saphenous nerve
posterior tibial nerve

Branches of the femoral nerve anesthetized during an ankle block include the: saphenous nerve

The saphenous nerve is the only branch of the femoral nerve innervating the foot. The four remaining nerves innervating the foot, the deep peroneal nerve, the posterior tibial nerve, the sural nerve and the superficial peroneal nerve, are all branches of the sciatic nerve.

pp. 1123-1124
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:

echinacea
valerian
ginkgo
ephedra

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is: valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

pg. 346t
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 585t
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

A decrease in pseudocholinesterase activity has been associated with the use of: (Select 3)

pancuronium
esmolol
droperidol
vecuronium
metoclopramide
magnesium sulfate
dantrolene
rocuronium

A decrease in pseudocholinesterase activity has been associated with the use of: pancuronium, esmolol, metoclopramide

The following drugs have been associated with a decrease in pseudocholinesterase activity: echothiophate, pyridostigmine, neostigmine, phenelzine, cyclophosphamide, metoclopramide, esmolol, pancuronium and oral contraceptives. Although both dantrolene and magnesium may alter the effects of neuromuscular blockers, neither causes inhibition of pseudocholinesterase.

pg. 207
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

psig ?

During the delivery of an anesthetic in the radiology department, full E-cylinders of nitrous oxide and oxygen are being used. If a 3:2 mixture of nitrous oxide:oxygen is being delivered and the case has been proceeding for 60 minutes, the expected pressure in the nitrous oxide E-cylinder is: 745 – 750 psig

Nitrous oxide has a critical temperature of 37oC. This allow nitrous oxide to exist as a liquid at room temperature. Full E-cylinders of nitrous oxide contain approximately 1590 L at a pressure of 745 psig. A sixty minute delivery of 3 L/min would result in a 180 L consumption, and this would be inadequate to consume all the liquid nitrous oxide in the tank. As a result, there would be no change in tank pressure.

pg. 622
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

The formation of metanephrine is the result of:

catechol-O-methyltransferase metabolism of epinephrine
catechol-O-methyltransferase metabolism of norepinephrine
monamine oxidase metabolism of epinephrine
monamine oxidase metabolism of norepinephrine

The formation of metanephrine is the result of: catechol-O-methyltransferase metabolism of epinephrine

Catechol-O-methyltransferase (COMT) metabolizes epinephrine to metanephrine and norepinephrine to normetanephrine. Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to vanillymandelic acid (VMA).

pg. 868
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

An action potential characterized by a spike followed by a plateau phase is seen in:

peripheral sensory nerve cells
peripheral motor nerve cells
striated skeletal muscle cells
cardiac muscle cells

An action potential characterized by a spike followed by a plateau phase is seen in: cardiac muscle cells

In contrast to the action potentials of nerve and skeletal muscle cells, the action potential of the cardiac myocyte is characterized by a sharp spike followed by a plateau phase (2), which results from the opening of slower calcium channels.

pg. 345
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

During mediastinoscopy the risk of air embolization is greatest:

when the patient is supine
during spontaneous ventilation
immediately after closure of the incision
in the postoperative period

During mediastinoscopy the risk of air embolization is greatest: during spontaneous ventilation

Air embolization is seen with mediastinoscopy as a result of the 30o elevation of the head. This risk is increased if the patient is spontaneously ventilating, secondary to the negative intrathoracic pressures generated during inhalation.

pp. 988-989
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

During placement of a lumbar epidural using a midline approach, the needle passes through the: (Select 3)

interspinous ligament
anterior longitudinal ligament
intervertebral disk
supraspinous ligament
ligamentum flavum
facet joint

During placement of a lumbar epidural using a midline approach, the needle passes through the: supraspinous ligament, interspinous ligament, ligamentum flavum

Passing anteriorly from the skin to the epidural space are the following structures: skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum.

pp. 941-942
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013

Interpleural analgesia can be accomplished by placing local anesthetic:

along the cephalad border of the T6 rib
immediately deep to the parietal pleura
immediately deep to the visceral pleura
superficial to the internal intercostal muscle

Interpleural analgesia can be accomplished by placing local anesthetic: immediately deep to the parietal pleura

Interpleural analgesia is accomplished by placing an catheter between the parietal and visceral pleura. A loss-of-resistance technique is most commonly used at the T6 to T8 intercostal spaces, or the catheter can be placed under direct vision by the surgeon. Pneumothorax is a significant complication if the needle or catheter penetrates the visceral pleura.

pg. 1069
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013

In the CVP trace below, the v wave is caused by:


 atrial contraction 
 ventricular contraction 
 atrial filling 
 opening of the tricuspid valve
In the CVP trace below, the v wave is caused by:

atrial contraction
ventricular contraction
atrial filling
opening of the tricuspid valve

In the CVP trace below, the v wave is caused by: atrial filling

In the normal CVP tracing, the a wave is due to atrial systole. The c wave coincides with ventricular contraction. The v wave is the result of atrial filling prior to the opening of the tricuspid valve. The x descent is thought to be due to the pulling down of the atrium by ventricular contraction. The y descent corresponds to the opening of the tricuspid valve.

pp. 298-300
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The synthesis of acetylcholine from acetylcoenzyme A and choline is catalyzed by:

free acetate anion
choline acetyltransferase
acetyl cholinesterase
pseudocholinesterase

The synthesis of acetylcholine from acetylcoenzyme A and choline is catalyzed by: choline acetyltransferase

The synthesis of acetylcholine occurs in the cholinergic nerve terminal. Acetyl Co-A and choline combine to form acetylcholine. This reaction is catalyzed by the enzyme choline acetyltransferase.

pg. 819
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The primary causative factor in the development of persistent pulmonary hypertension (PPH) in the neonate is:

cystic fibrosis
pregnancy-induced hypertension
hypoxemia
right-to-left shunting through a patent ductus arteriosus

The primary causative factor in the development of persistent pulmonary hypertension (PPH) in the neonate is: hypoxemia

Hypoxia or acidosis during the early neonatal period may predispose the infant to return to fetal circulation. This serious condition, previously known as persistent fetal circulation (PFC), is currently known as persistent pulmonary hypertension (PPH). Hypoxemia and/or acidosis promotes an increase in pulmonary vascular resistance which ultimately causes right to left shunting through the ductus arteriosus, foramen ovale, or both. Shunting causes continued hypoxemia, leading to a continued increase in pulmonary vascular resistance, and a vicious cycle ensues. Primary causes of hypoxemia in the neonate include pneumonia and meconium aspiration.

pp. 1163-1164
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Electrocardiographic changes seen with hypokalemia include:

peaked T waves
increasingly prominent U waves
shortened PR interval with P wave inversion
decreased QRS amplitude

Electrocardiographic changes seen with hypokalemia include: increasingly prominent U waves

Electrocardiographic changes seen with hypokalemia include:

T wave flattening/inversion
ST segment depression
increased P wave amplitude
prolongation of the P-R interval
increasingly prominent U waves

pg. 378, 1712
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

pg. 1125
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Deleterious effects of hypothermia include: (Select 2)

impaired renal function
right shift of the hemoglobin-oxygen saturation curve
irreversible platelet dysfunction
increased incidence of wound infection
increased postoperative protein anabolism

Deleterious effects of hypothermia include: impaired renal function, increased incidence of wound infection

Deleterious effects of hypothermia include:

increased PVR
left shift of the hemoglobin-oxygen saturation curve
reversible platelet dysfunction
postoperative protein catabolism
altered mental status
impaired renal function
decreased drug metabolism
poor wound healing
increased incidence of infection
cardiac arrhythmias
pp. 1235-1236
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Prior to pneumonectomy, split lung function testing is indicated in the patient with:

an FEV1 of 2.2 L
a PaCO2 of 49 mm Hg on room air
a PaO2 of 54 mm Hg on room air
a maximum VO2 of 21 mL/kg/min

Prior to pneumonectomy, split lung function testing is indicated in the patient with: a PaCO2 of 49 mm Hg on room air

Split lung function testing is indicated in patients requiring pneumonectomy, but not meeting the recommended laboratory criteria. Current recommendations for patients requiring pneumonectomy are:

PaCO2 < 45 mm Hg FEV1 > 2 L
Predicted postop FEV1 > 800 mL
Maximum VO2 > 15 mL/kg/min
FEV1/FVC > 50% of predicted
pp. 663-665
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Mechanisms of renal compensation during acidosis include:

decreased reabsorption of filtered bicarbonate
decreased excretion of hydrogen ions
increased production of ammonia
increased elimination of carbon dioxide

Mechanisms of renal compensation during acidosis include: increased production of ammonia

The renal response to acidemia is:

increased reabsorption of bicarbonate anion
increased excretion of hydrogen ion in the form of titratable acids
increased production of ammonia
Although increased carbon dioxide elimination is a compensatory mechanism in acidemia, it is accomplished by increased alveolar ventilation.

pg. 734
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Postintubation croup:

is secondary to inflammation of subglottic structures
is less common when cuffed endotracheal tubes are used
occurs most frequently in infants less than 4 months of age
is most often seen immediately upon extubation

Postintubation croup: is secondary to inflammation of subglottic structures

Postintubation croup usually occurs at the level of the cricoid, since this is the narrowest part of the pediatric airway. Croup is less common with endotracheal tubes that are uncuffed and small enough to allow a gas leak at 10 – 25 cm H2O. Postintubation croup is associated with early childhood (1 – 4 years). Unlike laryngospasm, postintubation croup is seen some time after extubation, usually within 3 hours.

pp. 463-464
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 1231
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Closing capacity is defined as:

closing volume + expiratory reserve volume
functional residual capacity – residual volume
closing volume + residual volume
residual volume + expiratory reserve volume

Closing capacity is defined as: closing volume + residual volume

Closing capacity is the lung volume at which airways begin to close and is defined as the closing volume + residual volume.

pg. 497
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Dantrolene: (Select 2)

depends on an extracellular mechanism to achieve muscle relaxation
inhibits calcium ion release from the sarcoplasmic reticulum
can also be used in the treatment of thyroid storm
therapy should not be repeated after an MH episode has terminated
has a half-life of approximately 12 hours

Dantrolene: inhibits calcium ion release from the sarcoplasmic reticulum, can be used in the treatment of thyroid storm

Dantrolene binds with the Ryr1 receptor and inhibits calcium ion release from the sarcoplasmic reticulum. Dantrolene’s effects are intracellular and may result in muscle weakness and ventilatory insufficiency. The half-life of dantrolene is approximately 6 hours. Dantrolene has also been used to treat neuroleptic malignant syndrome and thyroid storm.

pp. 1188, 1190
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The figure below shows a pulmonary artery catheter with the distal port in several locations. The measurement of the pressure in the distal port would most closely correlate with the left ventricular end-diastolic pressure when the catheter is placed in which position? (Make your selection by clicking on the appropriate part of the figure)
The figure below shows a pulmonary artery catheter with the distal port in several locations. The measurement of the pressure in the distal port would most closely correlate to the left ventricular end-diastolic pressure when the catheter is placed in which position?

D- (last picture)
In the presence of a normal mitral valve, left atrial pressure approaches left ventricular pressure during diastolic filling. The distal lumen of a correctly wedged PAC is isolated from right-sided pressures and correlates with left ventricular end-diastolic pressure.

pg. 413
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Renal effects of nitrous oxide include:

decreased renal blood flow secondary to decreased cardiac output
decreased renal blood flow secondary to increased renal vascular resistance
increased renal blood flow secondary to sympathetic stimulation
increased glomerular filtration with increased reabsorption

Renal effects of nitrous oxide include: decreased renal blood flow secondary to increased renal vascular resistance

Nitrous oxide appears to decrease renal blood flow by increasing renal vascular resistance. This results in decreased glomerular filtration and decreased urine output.

pg. 167
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The elimination half-life of a drug:

is inversely proportional to the clearance
is inversely proportional to the volume of distribution
is directly proportional to clearance
is shortest in drugs that are rapidly redistributed

The elimination half-life of a drug: is inversely proportional to the clearance

The elimination half-life of a drug is proportional to the volume of distribution and inversely proportional to the rate of clearance.

pg. 165
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Effects of lidocaine include:

increased intracranial pressure
increased refractory period of cardiac muscle
decreased fibrinolysis
myonecrosis

Effects of lidocaine include: myonecrosis

Intravenous lidocaine decreases cerebral blood flow unless seizure activity develops. Lidocaine decreases the refractory period of cardiac muscle and decreases platelet aggregation while enhancing fibrinolysis. Local anesthetics have been shown to cause lytic degeneration and necrosis of muscle fibers when directly injected into the muscle (trigger point injections).

pp. 270-274
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Correct statements concerning the use of antidepressants in pain management include:

analgesic effects require a higher dose than that needed for antidepression
analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake
antidepressants are not effective in neuropathic pain
newer SSRIs are more effective analgesics than the older tricyclic antidepressants

Correct statements concerning the use of antidepressants in pain management include: analgesic effects appear to be secondary to the blockade of serotonin and norepinephrine reuptake

Antidepressants demonstrate an analgesic effect at doses lower that those needed for antidepressant effect. Both actions appear secondary to the block of the reuptake of serotonin and norepinephrine. Older tricyclic antidepressants seem more effective analgesics than the newer SSRIs. Antidepressants are most useful in patients with neuropathic pain.

pg. 1055
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Using the figure below, a block of the sural nerve would produce anesthesia of: (Make your selection by clicking on the appropriate part of the figure)
Using the figure below, a block of the sural nerve would produce anesthesia of: (Make your selection by clicking on the appropriate part of the figure)
I. Calcaneal branch (tibial Nerve)
II. Saphenous nerve
III. Medial Plantar nerve
IV. Lateral Plantar nerve
V. Sural nerve

The body mass index (BMI) associated with morbid obesity is:

> 30
> 35
> 40
> 45

The body mass index (BMI) associated with morbid obesity is: > 40

Overweight and obesity are classified using the BMI. Overweight is defined as a BMI > 24, obesity as a BMI > 30, morbid obesity as a BMI > 40, super obesity as a BMI > 50 and super-super obesity as a BMI > 60. BMI is calculated with the following formula:

BMI = Weight (kg) / Height (meters)2

pg. 1050
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Release of aldosterone by the adrenal cortex is stimulated by: (select 3)

angiotensin I
angiotensin II
hypokalemia
pituitary ACTH
congestive heart failure
hypervolemia

Release of aldosterone by the adrenal cortex is stimulated by: angiotensin II, pituitary ACTH, congestive heart failure

Aldosterone release is stimulated by the renin-angiotensin system, but specifically by angiotensin II. Other causes of aldosterone release include hyperkalemia, ACTH release, hypovolemia, hypotension, CHF and the stress response.

pg. 738
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Renal blood flow: (Select 2)

 is largely determined by renal oxygen consumption
 accounts for 20 - 25% of the cardiac output
 is distributed mostly to juxtamedullary nephrons
 can be directed away from cortical nephrons by sympathetic stimulation
 is not autoregulated
Renal blood flow: (Select 2)

is largely determined by renal oxygen consumption
accounts for 20 – 25% of the cardiac output
is distributed mostly to juxtamedullary nephrons
can be directed away from cortical nephrons by sympathetic stimulation
is not autoregulated

Renal blood flow: accounts for 20 – 25% of the cardiac output, can be directed away from cortical nephrons by sympathetic stimulation

The kidneys are the only organ for which oxygen consumption is determined by blood flow; the reverse is true in other organs. The kidneys receive 20 – 25% of the cardiac output with only 10 – 15% going to the juxtamedullary nephrons and 80% going to cortical nephrons. However, blood flow can be redirected to juxtamedullary nephrons by increased levels of catecholamines and angiotensin II. Autoregulation of RBF occurs between mean arterial pressures of 80 – 180 mm Hg.

pp. 639-641
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 36-year-old female is scheduled for an elective cholecystectomy. Her past medical history is significant for depression treated with phenelzine (Nardil). Her anesthetic plan should include: (Select 2)

discontinuation of phenelzine for at least 2 weeks prior to surgery
the avoidance of indirect acting vasopressors
the avoidance of propofol
the avoidance of meperidine
the avoidance of nitrous oxide
the avoidance of volatile anesthetic agents

A 36-year-old female is scheduled for an elective cholecystectomy. Her past medical history is significant for depression treated with phenelzine (Nardil). Her anesthetic plan should include: the avoidance of meperidine, the avoidance of indirect acting vasopressors

Phenelzine is a monamine oxidase (MAO) inhibitor. The practice of discontinuing MAO inhibitors prior to surgery is no longer recommended. The use of meperidine in patients receiving MAO inhibitors has been associated with hypertensive crisis and should be avoided. Additionally, indirect acting vasopressors have also been associated with hypertensive crisis and direct acting vasopressors should be used to treat hypotension.

pg. 625
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Neuroleptic malignant syndrome:

can be precipitated with the use of metoclopramide
carries a mortality of over 80%
can be treated with physostigmine administration
can be diagnosed with muscle biopsy

Neuroleptic malignant syndrome: can be precipitated with the use of metoclopramide

Neuroleptic malignant syndrome is a rare complication of antipsychotic therapy. Meperidine and metoclopramide can also precipitate the disorder which appears to be secondary to dopamine blockade in the basal ganglia. The disease has many characteristics in common with MH including increased temperature, metabolic derangement and hyperthermia. The mortality is 20 – 30%. Treatment with dantrolene and dopamine agonist, bromocripitine, appears effective.

pg. 626
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The most common complication of thoracic paravertebral nerve block is:

hypotension
subarachnoid injection
pneumothorax
intravascular injection

The most common complication of thoracic paravertebral nerve block is: pneumothorax

Pneumothorax is the most common complication of paravertebral block and a chest radiograph is needed upon completion of the block. Other complications include subarachnoid injection, epidural injection, intravascular injection, and hypotension.

pg. 1073
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

In the diagram below, regional anesthesia of the area depicted by #1 can be accomplished with a block of the:

 radial nerve
 median nerve
 ulnar nerve
 coracobrachialis nerve
In the diagram below, regional anesthesia of the area depicted by #1 can be accomplished with a block of the:

radial nerve
median nerve
ulnar nerve
coracobrachialis nerve

In the diagram below, regional anesthesia of the area depicted by #1 can be accomplished with a block of the: median nerve

The median nerve supplies innervation the the area marked as #1, the ulnar nerve to area #3 and the radial nerve to area #2.

pp. 394-397
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

divisions

The number of dichotomous divisions of the tracheobronchial tree from the trachea to the alveolar sacs is approximately: 20 – 25

Dichotomous division, each branch dividing into two smaller branches, of the tracheobronchial tree is estimated to involve 20 – 25 divisions.

pg. 593
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

The largest fraction of carbon dioxide in the blood is in the form of:

carbamino compounds
bicarbonate
dissolved gas
carboxyhemoglobin

The largest fraction of carbon dioxide in the blood is in the form of: bicarbonate

Nearly 90% of carbon dioxide in the blood is in the form of bicarbonate.

pg. 605
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mm Hg, the expected PaCO2 at the end of the apneic period would be:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mm Hg

A 42-year-old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mm Hg, the expected PaCO2 at the end of the apneic period would be: 67 to 74 mm Hg

The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10 – 20 minutes in most patients. Arterial PaCO2 rises 6 mm Hg in the first minute followed by a rise of 3 – 4 mm Hg during each subsequent minute. In this patient this will produce a 27 – 34 mm Hg increase, resulting in a PaCO2 of 67 to 74 mm Hg.

pg. 561
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Stimulation of the parasympathetic nervous system results in:

far vision accommodation
increased inotropy
increased insulin secretion
contraction of the urinary sphincter

Stimulation of the parasympathetic nervous system results in: increased insulin secretion

Insulin secretion is increased by stimulation of the parasympathetic nervous system through the vagus nerves.

pg. 1343
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The formation clinically significant amounts of carbon monoxide has been associated with:

the use of a non-rebreathing circuit
the use of fresh carbon dioxide absorber
the use of desflurane
expiratory valve incompetence

The formation clinically significant amounts of carbon monoxide has been associated with: the use of desflurane

The formation of CO depends on the use of a volatile agent containing a difluoromethoxy moiety (desflurane, isoflurane, enflurane). This moiety can react with desiccated base (baralime or sodalime) to form CO. Fresh absorber has sufficient water to prevent the reaction. Clinically, CO intoxication occurs after a weekend when the flow of dry oxygen in the machine has desiccated the absorber and desflurane is being used.

pp. 471-472
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Anesthesiology. 89(4):929-941, October 1998. Baxter, Pamela J. PhD; Garton, Kyle BS; Kharasch, Evan D. MD, PhD

Positive end expiratory pressure (PEEP):

decreases dead space
increases venous return to the heart
decreases intrapulmonary shunting
decreases extravascular lung water

Positive end expiratory pressure (PEEP): decreases intrapulmonary shunting

The major effect of PEEP is to increase FRC and tidal ventilation above the closing capacity. This results in a decrease in intrapulmonary shunting. Neither PEEP or CPAP decrease extravascular lung water. By increasing intrathoracic pressure, PEEP decreases venous return to the heart.

pp. 283, 1595
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The essential component of cardioplegia solutions is:

mannitol
magnesium
potassium
corticosteroid

The essential component of cardioplegia solutions is: potassium

High concentrations of potassium (20 – 30 mEq/L) are used in cardioplegia solutions. These solutions result in an increase in extracellular potassium and reduce transmembrane potential. This progressively interferes with the normal sodium currents of depolarization and eventually the sodium channels are completely inactivated.

pg. 519
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: (Select 2)

high-frequency oscillation
inverse I:E ratio ventilation
airway pressure release ventilation
differential lung ventilation
high-frequency positive-pressure ventilation
pressure support ventilation

Forms of mechanical ventilation that produce tidal volumes at or below anatomic dead space include: high-frequency oscillation, high-frequency positive-pressure ventilation

High-frequency oscillation (HFO) creates a to-and-fro gas movement in the airway at rates of 180 – 3000 times/min. High frequency positive-pressure ventilation is delivered at a rate of 60 – 120 breaths/min. Tidal volume is at or below anatomic dead space. High-frequency ventilation techniques may be useful in cases of bronchopleural and tracheoesophageal fistulas.

pg. 1062
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

kg

During rapid-sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
(Enter numerical answer in box below. Click ‘Next’ when completed.) 3.0 – 4.4 kg

Using cricoid yolk studies, the optimum force necessary to effectively occlude the esophagus without obstruction of the trachea is between 30 and 44 Newtons (3.0 – 4.4 kg). It is recommended that 2 kg of force be applied prior to loss of consciousness and that pressure be increased to 4 kg of force after loss of consciousness.

pg. 449
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

During an anterior-posterior spinal fusion, in a 70-kg patient, the laboratory reports an intraoperative hematocrit of 21% with a hemoglobin of 7g/dL. Two units of packed red blood cells are administered over the course of 30 minutes. Upon completion of the transfusion, the anticipated hematocrit will be approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

%

During an anterior-posterior spinal fusion, in a 70-kg patient, the laboratory reports an intraoperative hematocrit of 21% with a hemoglobin of 7g/dL. Two units of packed red blood cells are administered over the course of 30 minutes. Upon completion of the transfusion, the anticipated hematocrit will be approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.) 25 – 27%

A commonly used rule of thumb states that each unit of PRBCs increases the hemoglobin 1 g/dL and the hematocrit 2% to 3%.

pg. 396
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Changes found in banked blood include: (Select 2)

increased levels of 2,3-DPG
a left shift of the hemoglobin dissociation curve
decreased levels of potassium
formation of microaggregates
alkalosis secondary to the presence of citrate
increased intracellular ATP stores
thrombocytosis

Changes found in banked blood include: (Select 2) a left shift of the hemoglobin dissociation curve, formation of microaggregates

Changes occurring in banked blood include:

Depletion of 2,3-DPG
Depletion of intracellular ATP
Oxidative damage
Increased adhesion to vascular endothelium
Altered cell morphology
Accumulation of microaggregates
Hyperkalemia (as high as 17.2 mEq/L)
Absence of platelets (after 2 days of storage)
Hemolysis
Accumulation of proinflammatory products
pg. 396
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2013.

Pulmonary changes associated with Duchenne’s muscular dystrophy include:

a restrictive ventilatory defect
an obstructive ventilatory defect
decreased pulmonary artery pressures
increased residual volume

Pulmonary changes associated with Duchenne’s muscular dystrophy include: a restrictive ventilatory defect

The combination of marked kyphoscoliosis and degeneration of the respiratory muscles produces a severe restrictive ventilatory defect in patients with Duchenne’s muscular dystrophy. Pulmonary hypertension is also commonly seen.

pg. 753
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A 46-year-old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately:

2%
5%
10%
25%

A 46-year-old male is scheduled for an emergent laparotomy for small bowel obstruction. His history is complicated by the acute onset of hepatitis B four days earlier and he presents with significant scleral jaundice. The perioperative mortality in this patient is approximately: 10%

Patients with acute hepatitis should have elective surgery postponed until the acute hepatitis has resolved. Studies indicate increased perioperative morbidity (12%) and mortality (10% with laparotomy) during acute hepatitis.

pp. 1315-1316
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

An increase in intraocular pressure has been associated with: (select 3)

nitrous oxide administration
succinylcholine administration
opioid administration
hyperventilation
laryngoscopy
hypoxemia
sevoflurane administration

An increase in intraocular pressure has been associated: succinylcholine administration, hypoxemia, laryngoscopy

Succinylcholine increases intraocular pressure by 5 – 10 mm Hg for 5 – 10 minutes after administration. This increase is primarily the result of prolonged contracture of the extraocular muscles from the depolarizing effects of succinylcholine. Nitrous oxide, volatile anesthetic agents and opioids have been associated with a reduction in intraocular pressure. Hypoxemia, hypercarbia, hypertension, hypervolemia, laryngoscopy and intubation have all been shown to increase IOP.

pp. 760-761
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case?

Check oxygen cylinder supply
Check the carbon dioxide absorber
Performance of a machine low-pressure leak test
Calibration of the oxygen monitor

Current anesthesia apparatus checkout recommendations suggest which of the following prior to every case? Check the carbon dioxide absorber

Verification of the adequacy of the carbon dioxide absorber is suggested prior to every case. If the same anesthesia machine is being used by the same provider, E-cylinder pressure checks, machine low-pressure leak testing and calibration of the oxygen sensor need not be repeated after an initial check.

pp. 84-85
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of:

13 – 15
9 – 12
6 – 9
less than 6

According to the Modified Glasgow Coma Scale, a moderate head injury is associated with a score of: 9 – 12

According to the Modified Glasgow Coma scale, mild head injury is associated with a score of 13 – 15, moderate head injury is associated with a score of 9 – 12, and severe head injury is associated with a score of less than 8.

pg. 923
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The addition of bicarbonate to a local anesthetic solution:

delays the onset of blockade
increases the concentration of the nonionic form of the local anesthetic
causes a fall in the pH of the solution
should only be done when using bupivacaine

The addition of bicarbonate to a local anesthetic solution: increases the concentration of the nonionic form of the local anesthetic

The onset of neural blockade depends on the penetration of the nerve cell membrane by the nonionic form of the anesthetic. Increasing the pH of the anesthetic solution increases the concentration of the nonionic form and thereby hastens the onset of the block. Bicarbonate is usually not added to bupivacaine, since it can cause precipitation if the pH is raised above 6.8.

pg. 963
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Factors increasing the affinity of hemoglobin for oxygen include: (Select 2)

increased carbon dioxide levels
increased 2,3-DPG levels
increased pH
the presence of fetal hemoglobin
increased body temperature
the presence of hemoglobin-S

Factors increasing the affinity of hemoglobin for oxygen include: increased pH, presence of fetal hemoglobin

Factors that increase the affinity of hemoglobin for oxygen would cause a leftward shift of the hemoglobin dissociation curve and a decrease in the P50. These factors include alkalosis, decreased CO2 levels, and decreased 2,3-DPG levels. Hemoglobin-S, found in patients with sickle cell disease, has a decreased affinity for oxygen. Fetal hemoglobin, however, has an increased affinity for oxygen to help in oxygen transfer from the mother to the fetus.

pp. 603-604
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

In the figure below, inspiratory capacity is best represented by:
 A
 A + tidal volume
 B
 B + tidal volume
In the figure below, inspiratory capacity is best represented by:
A
A + tidal volume
B
B + tidal volume
In the figure below, inspiratory capacity is best represented by: A + tidal volume

Inspiratory capacity is the sum of the inspiratory reserve volume (A) and the tidal volume. B represents the expiratory reserve volume, C represents the FRC, D represents the residual volume, E represents the vital capacity and F represents the total lung volume.

pp. 278-279
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Laminar flow in the airway occurs in the: (Select 2)

trachea
main stem bronchi
terminal bronchiole
3rd generation bronchus
respiratory bronchiole

Laminar flow in the airway occurs mostly in the: terminal bronchiole, respiratory bronchiole

Flow in the larger airways is mostly turbulent. Laminar flow normally occurs only distal to small bronchioles (< 1mm). The Reynolds number is used to predict the type of airway flow; a low Reynolds number (< 1000) is associated with laminar flow, whereas a high value (> 1500) is associated with turbulent flow.

pp. 498-499
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is:

phenoxybenzamine
doxazosin
propranolol
terazosin

A nonselective ?-antagonist used in the preoperative preparation of a patient with pheochromocytoma is: phenoxybenzamine

Phenoxybenzamine is a nonselective ?-antagonist used in the preoperative preparation of the patient with pheochromocytoma. Doxazosin and terazosin are selective ?1-antagonists. Propranolol is a nonselective ?-antagonist. In the preparation of patients with pheochromocytoma, ?-blockade and intravascular volume replacement must precede ?-blockade, so as to prevent the possibility of unopposed ?-stimulation.

pg. 192
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Nerves blocked with a fascia iliaca block include the:

sciatic nerve
femoral nerve
pudendal nerves
anterior tibial nerve

Nerves blocked with a fascia iliaca block include the: femoral nerve

The fascia iliaca block utilizes a deposition of local anesthetic in the fascia iliaca compartment to block the femoral, lateral femoral cutaneous, obturator and genitofemoral nerves.

pp. 1003-1004
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Average blood loss during a vaginal delivery is:

100 – 200 ml
400 – 500 ml
700 – 800 ml
1000 – 1500 ml

Average blood loss during a vaginal delivery is: 400 – 500 ml

At term, blood volume has increased by 1000 – 1500 ml in most women allowing them to easily tolerate the blood loss associated with delivery. Average blood loss during vaginal delivery is 400 – 500 ml, compared with 800 – 1000 ml for cesarean section.

pg. 827
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Characteristics of omphalocele include: (Select 2)


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

location lateral to the umbilicus
lacks a hernia sac
results from the failure of midgut migration into the abdomen
nitrous oxide should be used during the repair to ensure a rapid emergence
association with trisomy 21
results from abnormal development of the right omphalomesenteric artery

Characteristics of omphalocele include: association with trisomy 21, results from the failure of midgut migration into the abdomen

Gastroschisis and omphalocele are characterized by defects in the abdominal wall that allow herniation of the viscera. Omphaoceles occur at the base of the umbilicus, have a hernia sac and are commonly associated with other anomalies. In contrast, gastroschisis is usually lateral to the umbilicus, lacks a hernia sac and is usually an isolated finding. Nitrous oxide is best avoided during repair as it may result in bowel distention making closure more difficult.

pg. 901
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Absolute contraindications to the use of epidural anesthesia in the parturient include: (Select 2)

inability of the patient to cooperate
herniated lumbar disc
multiple sclerosis
patient refusal
history of previous cesarean section
aortic regurgitation

Absolute contraindications to the use of epidural anesthesia in the parturient include: inability of the patient to cooperate, patient refusal

Absolute contraindications to epidural anesthesia/analgesia in the parturient include infection over the injection site, coagulopathy, thrombocytopenia, marked hypovolemia, true local anesthetic allergy, patient refusal and inability of the patient to cooperate. Preexisting neurological disease and back disorders are relative contraindications. Patients with aortic regurgitation usually benefit from the reduction in afterload seen after neuraxial anesthesia.

pg. 849
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Physiologic derangements seen in the patient with scleroderma include: (Select 3)

pulmonary hypertension
esophageal dysmotility
excessive oral secretions and salivation
myocardial fibrosis
hypotension
spastic quadraparesis

Physiologic derangements seen in the patient with scleroderma include: pulmonary hypertension, esophageal dysmotility, myocardial fibrosis

Scleroderma is an autoimmune disease with multi-organ involvement. It is characterized by excessive deposition of collagen and subsequent fibrosis of the skin and internal organs. Manifestations are most evident in the skin, but pulmonary, cardiac, vascular and renal involvement may also be present. Patients with scleroderma are frequently difficult intubations and are at high risk for aspiration. Systemic hypertension from renal disease is very common. Xerostomia and decreased lacrimation are a result of exocrine gland involvement.

pg. 636
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Basal metabolic oxygen consumption in a 20-kg patient is approximately:
(Enter numerical answer in box below. Click ‘Next’ when completed.)

mL/min

Basal metabolic oxygen consumption in a 20 kg patient is approximately: 95 ml/min

Basal metabolic oxygen consumption can be estimated using the following formula:

pg. 175
Morgan, GE, Mikhail, MS, and Murray, MJ. Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2006.

Disodium edetate or sodium metabusulfite is added to formulations of propofol:
To enhance drug solubility
adjust the pH
inhibit bacterial growth
increase drug potency
Disodium edetate or sodium metabisulfite is added to formulations of propofol to: inhibit bacterial growth

Current formulations of propofol contain 0.005% disodium edetate or 0.025% sodium metabisulfite to help retard the rate of microorganism growth.

pg. 186
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the:

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

internal laryngeal nerve
external laryngeal nerve
recurrent laryngeal nerve
glossopharyngeal nerve

Sensory innervation of the trachea and larynx below the vocal cords is supplied by the: recurrent laryngeal nerve

The vagus nerve provides sensation to the airway below the epiglottis. The superior laryngeal branch of the vagus divides into an external (motor) and internal (sensory) laryngeal nerve that provide sensory supply to the larynx between the epiglottis and the vocal cords. Another branch of the vagus, the recurrent laryngeal nerve, innervates the larynx below the vocal cords and trachea.

pg. 310
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Larynx and Pharynx innervation

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of:

20 – 30 mm Hg
35 – 45 mm Hg
50 – 60 mm Hg
90 – 100 mm Hg

A 24-year-old female is scheduled for resection of a cerebral aneurysm. She has no other significant past medical history. Acceptable levels of hypotension would include a mean arterial pressure of: 50 – 60 mm Hg

Healthy young individuals tolerate mean arterial pressures as low as 50 – 60 mm Hg without complications. Chronically hypertensive patients have altered autoregulation of cerebral blood flow and may tolerate a mean arterial pressure of no more than 20 – 30% below baseline.

pg. 262
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

Correct statements concerning the use of benzodiazepines in the elderly include:

volume of distribution is increased
reduced pharmacodynamic sensitivity is observed
the elimination half-life of diazepam, but not midazolam, is increased
all of the above

Correct statements concerning the use of benzodiazepines in the elderly include: volume of distribution is increased

Aging increases the volume of distribution for all benzodiazepines, effectively prolonging their elimination half-lives. Enhanced pharmacodynamic sensitivity is also observed. The elimination half-lives of both diazepam and midazolam are increased.

pg. 895
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Concerning preoperative informed consent:

it should disclose only life-threatening complications
charges of assault and battery are possible if it is not obtained
oral consent is insufficient
it is not necessary if the procedure is done in an office setting

Concerning preoperative informed consent: charges of assault and battery are possible if it is not obtained

Any procedure performed without the patient’s consent can constitute assault and battery. Oral consent may be sufficient, but written consent is advisable for medicolegal purposes. It is generally accepted that not all risks need to be detailed, but risks that are realistic and have resulted in complications in similar patients should be disclosed.

pp. 29-30
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014

The highest incidence of muscle pain following the use of succinylcholine is seen in:

infants
octogenarians
outpatients
pregnant patients

The highest incidence of muscle pain following the use of succinylcholine is seen in: outpatients

Myalgia following the use of succinylcholine is most commonly seen in females and outpatients. Pregnancy and extremes of age seem to be protective.

pg. 532
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Anesthetic implications of multiple sclerosis include:

exacerbation induced by spinal anesthesia
exacerbation induced by epidural anesthesia
exacerbation of symptoms secondary to hypothermia
the presence of significant peripheral neuropathy causing severe hyperkalemia after succinylcholine administrati

Anesthetic implications of multiple sclerosis include: exacerbation induced by spinal anesthesia

Spinal anesthesia has been reported to cause exacerbation of the disease. Epidural and other regional techniques appear to have no adverse effect, especially in obstetrics; however a lower concentration of local anesthetic should be used. Demyelinated nerve fibers are extremely sensitive to hyperthermia, but conduction is usually improved by mild hypothermia.

pg. 619
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Local anesthetics with the potential to form methemoglobin include: (Select 3)

EMLA topical anesthetic cream
bupivacaine
benzocaine
ropivacaine
prilocaine
mepivacaine

Local anesthetics with the potential to form methemoglobin include: EMLA topical anesthetic cream, prilocaine, benzocaine

EMLA cream contains both lidocaine and prilocaine. The metabolites of prilocaine can convert hemoglobin to methemoglobin. Benzocaine can also cause methemoglobinemia.

pg. 140
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

“Methemoglobin Risk with Benzocaine Containing Local Anesthetics”
URL: http://www.upstate.edu/uha/pharmacy/newsletters/kidstuff_06/kidstuff_05_06.pdf

Ulnar nerve injury:

results in wrist drop and loss of sensation in the web space between the thumb and index finger
occurs more frequently in males
manifests itself in the immediate postoperative period
is most commonly seen in the patient with a BMI of less than 18

Ulnar nerve injury: occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:
1) male sex – various reports suggest that 70 – 90% of patients with postoperative ulnar neuropathy are men
2) high body mass index – BMI > or = 38
3) prolonged postoperative bed rest.
Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury.

pp. 809-810
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The potency of local anesthetics increases as the:

lipid solubility increases
pKa increases
number of double bonds in the anesthetic molecule increases
molecular weight decreases

The potency of local anesthetics increases as the: lipid solubility increases

Local anesthetic potency correlates directly with lipid solubility. In general, lipid solubility increases with an increase in the total number of carbon atoms in the molecule and by adding a halogen to the aromatic ring.

pg. 129
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

A decrease in cerebral blood flow is seen after the administration of:

isoflurane
propofol
desflurane
ketamine

A decrease in cerebral blood flow is seen after the administration of: propofol

The inhaled anesthetic agents and ketamine all increase cerebral blood flow (CBF). Benzodiazepines, etomidate, propofol and barbiturates all decrease CBF.

pg. 701
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Intracranial HTN is defined as a sustained increased in intracranial pressure (ICP) above:
a- 5 mmHg
b- 15 mmHg
c- 25 mmHg
d-30 mmHg
b- 15 mmHg

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:
A- genioglossus muscle
B- Longitudinal muscle of the tongue
C- palatoglossus muscle
D- styloglossus muscle
A- genioglossus muscle

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

Page 314. BUtterworth, JF, Mackey, DC, and Wasnick.

Venous irritation associated with the injection of diazepam and lorazepam is secondary to:
A- the high degree of water solubility of these agents
B- the presence of propylene glycol as a solvent
C- the presence of metabisulfite as a preservative
D- the low pH of these agents
Answer: B- the presence of propylene glycol as a solvent.

The insolubility of diazepam and lorazepam in water requires that parenteral preparations contain propylene glycol, which has been associated with venous irritation.
Page 488 Barash.

Effects of Lidocaine include:
a- increased intracranial pressure
b- increased refractory period of cardiac muscle
c- decreased fibrinolysis
d- myonecrosis
Effects of Lidocaine include:
a- increased intracranial pressure
b- increased refractory period of cardiac muscle
c- decreased fibrinolysis
d- myonecrosis
d- myonecrosis

Intravenous lidocaine decreases cerebral blood flow unless seizure activity develops. Lidocaine decreases the refractory period of cardiac muscle and decreases platelet aggregation while enhancing fibrinolysis.
Local anesthetics have been shown to cause lytic degeneration and necrosis of muscle fibers when directly injected into the muscle (trigger point injections).

pp 270-274
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgana & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books.

The body mass index (BMI) associated with morbid obesity is:
a- greater or equal to 30
b- greater or equal to 35
c- greater or equal to 40
d- greater or equal to 45
The body mass index (BMI) associated with morbid obesity is:
a- greater or equal to 30
b- greater or equal to 35
c- greater or equal to 40
d- greater or equal to 45
c- greater or equal to 40

Overweight and obesity are classified using the BMI. Overweight is defined as a BMI greater or equal to 24, obesity as a BMI greater or equal to 30, morbid obesity as a BMI greater or equal to 40, super obesity as a BMI greater or equal to 50 and super-super obesity as a BMI greater or equal to 60.
BMI is calculated with the following formula:
BMI= Weight (kg) / height (meters)2

Page 1050 Nagelhout

Renal blood flow: (select 2)
- is largely determined by renal oxygen consumption
- accounts for 20-25% of the cardiac output
- is distributed mostly to juxtamedullary nephrons
- can be directed away from cortical nephrons by sympathetic stimulation
- is not autoregulated
Renal blood flow: (select 2)
– is largely determined by renal oxygen consumption
– accounts for 20-25% of the cardiac output
– is distributed mostly to juxtamedullary nephrons
– can be directed away from cortical nephrons by sympathetic stimulation
– is not autoregulated
– accounts for 20-25% of the cardiac output
– can be directed away from cortical nephrons by sympathetic stimulation

The kidneys are the ONLY organ for which oxygen consumption is determined by blood flow; the reverse is true in other organs.
The kidneys receive 20-25% of the cardiac output with only 10-15% going to the juxtamedullary nephrons and 80% going to cortical nephrons. However, blood flow can be redirected to juxtamedullary nephrons by increased levels of catecholamines and angiotensin II. Auto-regulation of renal blood flow occurs between mean arterial pressure of 80-180 mmHg

pp 639-641 Morgan & Mikhail’s Clinical Anesthesiology

A 36 year old female is scheduled for an elective cholecystectomy. Her past medical hx is significant for depression treated with phenelzine (nardil). Her anesthetic plan should include: (select 2)
-discontinuation of phenylzine for at least 2 weeks prior to surgery
- the avoidance of indirect acting vasopressors
- the avoidance of Propofol
- the avoidance of Mepiridine
- the avoidance of nitrous oxide
A 36 year old female is scheduled for an elective cholecystectomy. Her past medical hx is significant for depression treated with phenelzine (nardil). Her anesthetic plan should include: (select 2)
-discontinuation of phenylzine for at least 2 weeks prior to surgery
– the avoidance of indirect acting vasopressors
– the avoidance of Propofol
– the avoidance of Mepiridine
– the avoidance of nitrous oxide
– the avoidance on indirect acting vasopressors
– the avoidance of Meperidine

Phenelzine is a monoamine oxidase (MAO) inhibitor. The practice of discontinuing MAO inhibitors prior to surgery is no longer recommended. The use of meperidine in patients receiving MAO inhibitors has been associated with hypertensive crisis adn should be avoided.
Additionally, indirect acting vasopressors (Ephedrine, cocaine) have also been associated with hypertensive crisis and direct acting vasopressors (Phenylephrine, Isoproterenol, Dobutamine) should be used to treat hypotension.
Page 625 Morgan & MIkhail’s Clinical Anesthesiology

A 42 year old man is undergoing a thoracoscopy. During the procedure an 8-minute period of apneic oxygenation is required. If the patient’s PaCO2 is 40 mmHg, the expected PaCO2 at the end of the apneic period would be?

mmHg?

Answer: 67 to 74 mm Hg

The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10-20 minutes in most patients. Arterial PaCO2 rises 6mmHg in the first minute followed by a rise of 3-4mmHg during each subsequent minute.
In this patient this will produce a 27-34 mmHg increase, resulting in a PaCO2 of 67 to 74 mmHg.

Page 561 Butterworth, Morgan & Mikhail’s Clinical Anesthesiology

During a rapid sequence induction, cricoid pressure is applied to reduce the incidence of regurgitation. After loss of consciousness, the recommended amount of downward force applied to the cricoid cartilage is:
(enter a numerical answer in box below).
Answer: 3.0 -4.4 kg
Using cricoid yolk studies, the optimum force necessary to effectively occlude the esophagus without obstruction of the trachea is between 30 and 40 Newtons (3.0 – 4.4 kg). It is recommended that 2 kg of force be applied prior to loss of consciousness and that pressure be increased to 4kg of force after loss of consciousness.
Page 449 Nagelhout

During an anterior-posterior spinal fusion, in a 70 kg patient, the laboratory reports an intraoperative hematocrit of 21% with a hemoglobin of 7g/dL. Two units of PRBCs are administered over the course of 30 minutes, Upon completion of the transfusion, the anticipated hematocrit will be approximately:
Answer: 25 to 27%

A commonly used rule of thumb states that each unit of PRBCs increases the hemoglobin 1g/dL and the hematocrit 2% to 3%.
Page 396 Nagelhout and Plaus

Ulnar nerve injury:
-results in wrist drop and loss of sensation in the web space between the thumb and index finger
-occurs more frequently in males
-manifests itself in the immediate postoperative period
-is most commonly seen in the patient with a BMI of less than 18
Answer: occurs more frequently in males

Three attributes which are highly associated with development of postoperative ulnar nerve injury are:
1-male sex- various reports suggest that 70-90% of patients with postoperative ulnar neuropathy are men
2- high body mass index-BMI> or = 38
3- prolonged postoperative bed rest.

Many patients with postoperative ulnar neuropathy have a high frequency of contralateral ulnar nerve dysfunction, suggestive of a pre-existing abnormality. Patients may not develop symptoms of ulnar neuropathy until more than 48 hours postoperatively. Wrist drop and loss of sensation of the web space between the thumb and index finger are associated with radial nerve injury.
PP 809-810 Barash Clinical Anesthesia

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

The postretrobulbar block apnea syndrome is probably due to injection of local anesthetic into the optic nerve sheath, with spread into the CSF. The CNS is exposed to high concentrations of local anesthetic leading to apprehension and unconsciousness. Apnea occurs within 20 minutes and resolves within an hour. Treatment is supportive.

Page 766 Morgan & Mikhails

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

Electrical interference from the electrocautery can be interpreted by the pacemaker as myocardial activity and suppress pacemaker activity. These problems can be minimized by limiting use to short bursts, placing the grounding pad as far from the pacemaker as possible and using a bipolar cautery.

pg. 403
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

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

Allodynia is the perception of non-noxious stimuli as pain. Dysesthesia is an unpleasant sensation without a stimulus. Hyperesthesia is an increased response to a mild stimulus. Anesthesia dolorosa is pain in an area that lacks sensation.

pp. 1649-1650
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Cholinesterase inhibitors that freely cross the blood-brain barrier include:
neostigmine
pyridostigmine
physostigmine
edrophonium
Cholinesterase inhibitors that freely cross the blood-brain barrier include: physostigmine

Physostigmine is a teritary amine and has a carbamate group, but no quaternary ammonium. Therefore, it is lipid soluble and is the only clinically available cholinesterase inhibitor that freely passes the blood-brain barrier.

pg. 383
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

During fetal monitoring, Type III decelerations are thought to be related to:

head compression
umbilical cord compression
uteroplacental insufficiency
placental abruption

During fetal monitoring, Type III decelerations are thought to be related to: umbilical cord compression

Type III, or variable, decelerations are the most common type of decelerations. They are thought to be related to umbilical cord compression and intermittent decreases in umbilical blood flow.

pg. 1167
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Pathophysiologic factors affecting the anesthetic management of patients with hypothyroidism include:
hypernatremia
hyperglycemia
difficulty with intubation and airway management
increased blood viscosity due to elevated hematocrit
Anesthetic complications associated with hypothyroidism include: difficulty with intubation and airway management

Potential problems of hypothyroidism include hypoglycemia, anemia, hyponatremia and difficulty during intubation because of a large tongue or the presence of a goiter. Hypothermia secondary to a low metabolic rate is a common postoperative complication.

pp. 875-876
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Airway obstruction caused by the tongue falling posteriorly against the wall of the pharynx is secondary to relaxation of the:
genioglossus muscle
longitudinal muscle of the tongue
palatoglossus muscle
styloglossus muscle
The genioglossus muscle allows the tongue to be protruded and kept away from the posterior pharynx. It is innervated by the hypoglossal nerve. The palatoglossus muscle elevates the tongue and depresses the soft palate. The styloglossus muscle elevates and retracts the tongue. The superior longitudinal muscle of the tongue is an intrinsic muscle of the tongue that elevates the tip.

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pg. 314
Butterworth, JF, Mackey, DC, and Wasnick, JD. Morgan & Mikhail’s Clinical Anesthesiology. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division, 2013.

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

In patients with outflow obstruction, myocardial depression and maintenance of preload and afterload are desirable.

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pp. 1083-1084
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

The highest rate of systemic absorption of local anesthetic is seen with:
epidural injection
intercostal injection
caudal injection
brachial plexus injection
The highest rate of systemic absorption of local anesthetic is seen with: intercostal injection

The rate of systemic absorption of local anesthetic is proportionate to the vascularity of the site of injection: intravenous > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > subcutaneous.

pg. 569
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

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

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

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

Curve B best represents the effects of changing carbon dioxide tensions on cerebral blood flow. Between the ranges of 20 to 80 mm Hg a linear relationship exists between PaCO2 and CBF, such that a change in PaCO2 from 30 to 60 mm Hg will double CBF.

pp. 998-999
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Sinus arrhythmia:
is mediated through sympathetic innervation of the AV node
causes an increase in heart rate with inspiration
is indicative of SA node ischemia
is the primary cause of premature atrial contractions
Sinus arrhythmia: causes an increase in heart rate with inspiration

Sinus arrhythmia is a cyclic variation in heart rate that corresponds to ventilation, increasing with inspiration and decreasing with expiration. Sinus arrhythmia is a normal cardiac rhythm and is due to cyclic changes in vagal tone.

pg. 1717
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

A 5-day-old male is scheduled for a pyloromyotomy. The patient has experienced two episodes of apnea since birth. Anesthetic management shown to reduce the incidence of postoperative apnea includes:

A- the use of ketamine as the sole anesthetic agent
B- the intravenous administration of caffeine
C- use of desflurane as the sole anesthetic agent
D- the avoidance of nitrous oxide

A 5-day-old male is scheduled for a pyloromyotomy. The patient has experienced two episodes of apnea since birth. Anesthetic management shown to reduce the incidence of postoperative apnea includes: the intravenous administration of caffeine

Both caffeine and theophylline have been shown to reduce the incidence of postoperatitive apnea in infants at increased risk. Caffeine is favored because of its wider therapeutic margin. The recommended loading dose is 10 mg/kg caffeine base.

pg. 1200
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is:
A- echinacea
B- valerian
C- ginkgo
D- ephedra
An anxiolytic herbal medication associated with a decrease in the requirement of inhaled anesthetic agent (MAC) is: valerian

Both valerian and kava have been shown to have a GABA-mediated hypnotic effect and by this mechanism decrease MAC. Acute withdrawal after chronic use may result in an increase in MAC.

pg. 346t
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 585t
Barash, PG, Cullen, BF, Stoelting, RK, Cahalan, MK, Stock, MC, and Ortega, R. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

Prior to pneumonectomy, split lung function testing is indicated in the patient with:

an FEV1 of 2.2 L
a PaCO2 of 49 mm Hg on room air
a PaO2 of 54 mm Hg on room air
a maximum VO2 of 21 mL/kg/min

Prior to pneumonectomy, split lung function testing is indicated in the patient with: a PaCO2 of 49 mm Hg on room air

Split lung function testing is indicated in patients requiring pneumonectomy, but not meeting the recommended laboratory criteria. Current recommendations for patients requiring pneumonectomy are:

PaCO2 < 45 mm Hg FEV1 > 2 L
Predicted postop FEV1 > 800 mL
Maximum VO2 > 15 mL/kg/min
FEV1/FVC > 50% of predicted
pp. 663-665
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

Postintubation croup:
is secondary to inflammation of subglottic structures
is less common when cuffed endotracheal tubes are used
occurs most frequently in infants less than 4 months of age
is most often seen immediately upon extubation
Postintubation croup: is secondary to inflammation of subglottic structures

Postintubation croup usually occurs at the level of the cricoid, since this is the narrowest part of the pediatric airway. Croup is less common with endotracheal tubes that are uncuffed and small enough to allow a gas leak at 10 – 25 cm H2O. Postintubation croup is associated with early childhood (1 – 4 years). Unlike laryngospasm, postintubation croup is seen some time after extubation, usually within 3 hours.

pp. 463-464
Nagelhout, JJ, and Plaus, KL. Nurse Anesthesia. St. Louis: Elsevier, 2014.

pg. 1231
Longnecker, DE, Brown, DL, Newman MF and Zapol, WM. Anesthesiology. New York: McGraw Hill, 2012.

Autonomic hyperreflexia: A. is common with cord lesions below T8 B. can precipitate pulmonary edema C. is not effectively prevented by regional anesthesia D. can be prevented with adequate intraoperative sedation Autonomic hyperreflexia: can precipitate pulmonary edema Autonomic hyperreflexia should …

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The three major parts of the brain are the: A) Midbrain, cerebellum, and spinal cord. B) Cerebrum, cerebellum, and brain stem. C) Brain stem, midbrain, and spinal cord. D) Cerebellum, medulla, and occiput. B) Cerebrum, cerebellum, and brain stem. The …

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