Bonus Questions 2013 Flashcards
Here's a compilation of the q's from the 2014 class.
1
Q
- You are about to place a femoral nerve block. Since you are in Punxsutawney, you are not allowed to use ultrasound guidance—you must rely on your expert knowledge of anatomy. You quickly refresh your memory by knowing:
a. The acronym NAVL (Nerve, Artery, Vein, and Ligament) starts medial and ends lateral
b. The nerve lies about 0.5-1 cm deeper and 1.5 cm lateral to the femoral artery
c. Knowing your anatomy will guarantee that you will achieve a perfect block 100% of the time.
d. After making your local skin wheel you should insert your needle in a cephalad angle (approximately 30 degrees)
e. After making your local skin wheel you should insert your needle in a caudal angle (approximately 30 degrees)
A
a. Answer b and e
i. Rationale: knowing b demonstrates proper order of NAVL anatomy (which runs lateral to medial, not the other way around), and e demonstrates an accurate understanding that angling your needle celphalad increases the likelihood that you will cover the femoral nerve before it bifurcates.
ii. Barash 6th edition, page 988 and 990
2
Q
- While placing a femoral block, you decide to use a nerve stimulator. Accurate understanding of this is demonstrated by knowing:
a. Eliciting a strong knee twitch means you are right where you want to be and should dump your local anesthetic here
b. Immediately after inserting your needle you should start the nerve stimulator at 4 mA
c. After eliciting a strong leg reflex with the nerve stimulator reduced down to 0.3 mA, you should aspirate, if no blood, inject local anesthetic (in 5 ml increments)
d. You notice a strong leg reflex with the nerve stimulator at 0.2 mA, therefore you should insert your needle approximately 2-3 mm closer to the nerve
A
i. Rationale: Answer c demonstrates accurate knowledge of proper reflex (not just knee but total leg reflex), as well as proper understanding of nerve stimulator mechanics and local anesthetic injection technique
ii. Barash 6th edition, page 957
3
Q
- You are working in a remote hospital about to place an interscalene block. The resources in this location are limited. They do, however, have a room designated for block placement. Before you begin to place the block you ensure that you have the following in the room before you start (select 4):
a. Suction
b. Emergency airway supplies
c. Oxygen
d. Sufficient lighting
e. Sedation medications
f. Lipid rescue
g. Difficult airway cart
A
i. Rationale: Answers a-d demonstrates understanding of the proper equipment needed to place a block. Sedation medications are nice, lipid rescue should be nearby, and a difficult airway cart great to have nearby—but none of these are required.
ii. Barash 6th edition, page 956
4
Q
- You place a femoral and popliteal nerve block prior to a total knee arthroplasty using anatomy and nerve stimulator technique. After 10 minutes the patient reports that he can still flex/extend his leg and states that he doesn’t “feel much different” than he did prior to the block. This report means that you should:
a. Try the block again—this time using ultrasound
b. Change your anesthetic plan to a general anesthetic
c. Check the patient again in about 1-2 minutes to see if his block is working then
d. Wait another 10-20 minutes before you rule out the block
A
i. Rationale: Answer D. Blocks can take about 20-30 minutes to set up. Blocking again may be unnecessary plus run the risk of local anesthetic toxicity. Changing the anesthetic plan to a general may be premature. Checking again in 1-2 minutes is still not enough time to fully allow for “soak time.”
ii. Barash 6th edition, page 956
5
Q
- While using a nerve stimulator and ultrasound to place an interscalene block, it is usually helpful to:
a. Mark your site after a scout look with the ultrasound, use sterile gloves, mask, prep with proper cleaning solution, drape, and use ultrasound transducer gel.
b. Same as above except use clean gloves vs sterile gloves since this is only a clean technique.
c. Use an “in-plane” technique when lining up your landmarks and needle (longitudinal)
d. Use an “out-of-plane” technique when lining up your landmarks and needle (transverse)
e. Both a and c
f. Both a and d
A
i. Rationale: Sterile technique minimizes the risk of infection. Although an out-of-plane technique can be utilized for compact areas, it is most helpful to use an in-plane technique when placing a block so you can visualize your needle as it approaches the needle as this technique allows visualization of vital strictures (lungs, major vessels, etc.)
ii. Barash 6th edition, page 958
6
Q
- To adequately prevent pain from an arm tourniquet, which of the following nerve blocks should be performed to augment an axillary brachial plexus block?
a. Musculocutaneous, medial brachial cutaneous, and intercostobrachial nerve blocks
b. Musculocutaneous and medial brachial cutaneous nerve block
c. Musculocutaneous and intercostobrachial nerve blocks
d. Ulnar and Radial nerve blocks
A
Answer A.
These 3 nerves may need to be blocked separately as they exit the brachial
Plexus sheath high in the axilla.
Nagelhout page 1087
7
Q
- All of the following local anesthetics exert a vasodilatory effect except for:
a. Ropivacaine
b. Lidocaine
c. Prilocaine
d. Bupivacaine
A
Answer A
Ropivacaine and cocaine are the only LA’s that produce vasoconstriction.
Morgan and Mikhail Pages 271-274
8
Q
- By inserting a needle 2 cm medial and caudal to the anterior superior iliac spine and injecting 10-15 ml of local anesthetic after the needle penetrates the fascia lata, you would be attempting to block which nerve?
a. Obuturator
b. Lateral femoral cutaneous
c. Musculocutaneous
d. Sciatic
A
Answer B
The lateral femoral cutaneous nerve emerges underneath the inguinal ligament And becomes superficial inside the fascia lata near the anterior superior anterior superior iliac spine
Morgan and Mikhail 346-347
9
Q
- The blood supply to the spinal cord and nerve roots arises from:
a. Paired anterior and paired posterior spinal arteries
b. A single anterior and paired posterior arteries
c. Paired anterior arteries and a single posterior artery
d. A single anterior and a single posterior artery
A
Answer B.
The blood supply to the spinal cord is derived from a single anterior and paired posterior arteries. The anterior spinal artery is formed from the vertebral artery and supplies the anterior 2/3 of the cord while the posterior spinal arteries are derived from the posterior inferior cerebellar arteries and supply the posterior 1/3 of the spinal cord.
Morgan and Mikhail 294-295
10
Q
- A burn patient exhibits signs of inhalation injury and possible carbon monoxide poisoning. All of the following regarding carbon monoxide are true except:
a. It has a greater infinity for hemoglobin than oxygen
b. It can result in metabolic acidosis
c. It impairs mitochondrial function
d. It shift the oxyhemoglobin dissociation curve to the right
A
Answer D
Carbon monoxide has an affinity for hemoglobin that is 200 times greater than that of oxygen, impairs mitochondrial function, uncouples oxidative phosphorylation and reduces ATP production resulting in metabolic acidosis, and shifts the oxyhemoglobin dissociation curve to the left, impairing the unloading of oxygen to the tissues. In addition, it acts as a direct myocardial toxin and can prevent survival in resuscitation efforts during cardiac arrest. Barash Page 909
11
Q
- Superiorly the epidural space extends from the _____ to the ______.
a. Foramen magnum, sacral hiatus
b. Foramen magnum, cauda equina
c. C2, L5
d. C2, sacral hiatus
A
Answer: A. Superiorly, the epidural space extends to the foramen magnum, where dura is fused to the bse of the skull. Caudally it ends at the sacral hiatus.
James Duke – Anesthesia Secrets. Fourth Edition. Page 458.
12
Q
- What is an absolute contraindication to spinal anesthesia?
a. Sepsis
b. Chronic back pain
c. Intracranial hypertension
d. Progressive neurologic disease such as multiple sclerosis
A
Answer: C. Absolute contraindications include local infection at the puncture site, bacteremia, severe hypovolemia, coagulopathy, severe stenotic valvular disease, intracranial hypertension and patient refusal. Relative contraindications include progressive neurologic disease such as multiple sclerosis, low back pain, and sepsis.
James Duke – Anesthesia Secrets. Fourth Edition. Page 454.
13
Q
- What is the leading cause of morbidity and mortality in the burn patient?
a. Hypovolemic shock
b. Cardiogenic shock
c. Renal failure
d. Infection
A
Answer: D. Infection in the burn patient is a leading cause of morbidity and mortality and remains one of the most demanding concerns for the burn team. As burn wound size increases, bloodstream infection increases dramatically secondary to exposure to IV catheters and burn wound manipulation-induced bacteremia.
James Duke – Anesthesia Secrets Fourth Edition. Pg 383.
14
Q
- Electroconvulsive therapy can be used safely in all patients except:
a. Pts with a cardiac pacemaker
b. Pts with an implantable cardiodefibrillator
c. Parturients
d. Recent MI
A
Answer: D. ECT should be used very cautiously if at all when the effects on cerebral blood flow, ICP, HR, and BP may prove problematic to the patient. Pts with unstable cardiac disease and those with cerebral space occupying lesions are at risk of complications. ECT has been used safely in pts with cardiac pacemaker or implantable cardiodefibrillators and during pregnancy. James Duke – Anesthesia Secrets. Fourth Edition. Page 523.
15
Q
- Your patient is presenting for a toe amputation and has a known ester allergy (rash, bronchospasm). An ankle block is the best anesthetic option for him due to severe cardiovascular issues and COPD. What would you do?
a. Tell him that a nerve block is not an option due to his proven ester allergy, and his surgery will be very high risk under general anesthesia.
b. Proceed with injecting an ester because you know that true allergies to local anesthetics are rare and his “allergy” was most likely systemic toxicity.
c. Administer an ankle block using an amide local anesthetic.
d. Tell him that he is not a surgical candidate.
A
Answer: C. There is no cross-sensitivity between classes of local anesthetics. Therefore patients known to be allergic to ester local anesthetics could receive amide local anesthetics. However, caution is still warranted in case the patient is allergic to the preservative that may be common to both classes of drugs.
James Duke – Anesthesia Secrets. Fourth Edition. Page 106.
16
Q
- A patient presents with a fracture to the third metatarsal (middle toe) of the right foot. Which nerve would need to be blocked along with the medial plantar nerve to provide adequate anesthesia to the operative site?
a. Sural Nerve
b. Deep Peroneal Nerve
c. Superficial Peroneal Nerve
d. Saphenous Nerve
A
Answer: C
Rationale: The superficial peroneal nerve provides dorsal coverage of the third forth and fifth metatarsals.
Reference: Miller- Page 293 Figure 18-11, Innervation of the lower extremities.
17
Q
- Hypotension after spinal anesthesia occurs from: (Choose Two)
a. Parasympathetic blockade which increases venous return
b. Sympathetic blockade which decrease venous return
c. Sympathetic blockade which decreases SVR
d. Parasympathetic blockade which increases SVR
A
Answer: B and C
Rationale: Spinal Anesthesia blocks the sympathetic nervous system lowering the patient’s blood pressure by decreasing venous return and decreasing systemic vascular resistance.
Reference: Miller- Page 270
18
Q
- A patient has a lesion of their spine at the level of T1. All of the following nerves could be compromised EXCEPT:
a. Musculocutaneous
b. Axillary
c. Radial
d. Median
e. Ulnar
A
Answer: A
Rationale: The musculocutaneous nerve is innervated from C 5, 6, 7. The remaining options could possibly have some innervation from T1 and could therefore be effected.
Reference: Miller- Page 288 Figure 18-5, The Brachial Plexus.
19
Q
- After epidural catheter placement, your patient experiences bilateral lower extremity motor loss prior to any drug injection. You begin to suspect your needle contacted which anatomic region during placement?
a. Spinal nerve rootlets of the Cauda Equina
b. The Artery of Adamkiewicz
c. The Dura
d. Epidural vein
e. None of the above
A
Answer: B
Rationale: Accidental damage to the Artery of Adamkiewicz during epidural placement can occur. This causes characteristic bilateral lower extremity motor loss (anterior spinal artery syndrome).
Reference: Miller- Page 261
20
Q
- To what dermatome level would the spinal height need to reach for surgery on the appendix or lower abdomen?
a. T 4 (nipple)
b. T 6-7 (xiphoid process)
c. T 10 (umbilicus)
d. L 1-3 (Inguinal ligament)
A
Answer: B
Rationale: T 4 is adequate but higher than necessary for appendix or lower abdominal surgery. T 6-7 is the proper choice for spinal height in this region. T 10 and L 1-3 are not sufficient height to anesthetize the desired surgical site.
Reference: Miller- Page 268, Table 17-2, Sensory Level of Anesthesia Necessary for surgical procedures.
21
Q
- If the oculocardiac reflex is suspected during ophthalmic surgery what is the first step the anesthetist should take to alleviate the symptoms?
a. Administer 1 mg of atropine IV
b. Administer .01 mg/kg epinephrine IV
c. Ask the surgeon to stop the surgical stimulus
d. Prepare for immediate cardioversion
A
Answer C
“If a cardiac dysrhythmia appears, initially the surgeon should be asked to cease operative manipulation. Next, the patient’s anesthetic depth and ventilatory status are evaluated. Commonly, heart rate and rhythm return to baseline within 20 seconds after institution of these measures.”
(Barash 6th Edition pg. 1327)
22
Q
- Bradycardia associated with the oculocardiac reflex is
a. Less likely to occur with repeated stimulation during ophthalmic surgery
b. More likely to occur with repeated stimulation during ophthalmic surgery
c. Not associated with ophthalmic surgery
d. Not clinically significant and can be ignored
A
Answer A
“…with repeated manipulation, bradycardia is less likely to recur, probably secondary to fatigue of the reflex arc at the level of the cardioinhibitory center.”
(Barash 6th Edition pg. 1327)
23
Q
- Gynecoid (peripheral) obesity is associated with (Choose 2)
a. Increased oxygen consumption and increased incidence of cardiovascular disease.
b. Less metabolically active adipose tissue so it is less closely associated with cardiovascular disease.
c. Adipose tissue that is located predominantly in the upper body.
d. Adipose tissue that is located predominantly in the hips, buttocks, and thighs.
A
Answers B and D
“Varying pathophysiologic consequences are associated with the anatomic distribution of body fat. In android (Central) obesity, adipose tissue is located predominantly in the upper body (truncal distribution) and is associated with increased oxygen consumption and increased incidence of cardiovascular disease. Visceral fat is particularly associated with cardiovascular disease and left ventricular dysfunction. In Gynecoid (peripheral) obesity, adipose tissue is located predominantly in the hips, buttocks, and thighs. This fat is less metabolically active so it I less closely associated with cardiovascular disease.
(Barash 6th Edition pg. 1230
24
Q
- Perioperative monitoring during off-site anesthesia must include which of the following:
a. Pulse oximetry, invasive monitoring, EKG, constant blood pressure
b. Intermittent blood pressure monitoring, EKG, end-tidal CO2 invasive monitoring
c. Pulse oximetry, heart rate, intermittent blood pressure monitoring, EKG, end-tidal CO2, Temperature monitoring
d. EKG, Cerebral oxygenation, Temperature monitoring, EKG, pulse oximetry
A
Answer C
“Perioperative monitoring must adhere to the ASA standards for basic anesthetic monitoring. These include continuous monitoring of heart rate and oxygen saturation, intermittent noninvasive blood pressure monitoring, end-tidal CO2 monitoring and the capacity for both temperature monitoring and continuous electrocardiogram.”
(Barash 6th Edition pg. 854)
25
1. Using the “Rule of 9s” calculate the percent burn for a patient with second and third degree burns to his entire anterior torso and a circumferential burns to his right arm.
a. 36%
b. 18%
c. 9%
d. 27%
Answer D
“The size of the burned area as a fraction of the total body surface area (TBSA) is estimated by the “rule of nines.” In an adult, the head contributes to 9%; the upper extremities, 18%; the trunk, 36%; and the lower extremities, 36% of the TBSA.”
(Barash 6th Edition pg. 908-909)
26
1. You plan to give an interscalene block to a 67 y.o. male with CAD, emphysema, severe OA, and BPH, who is undergoing Rt ORIF of the shoulder. Pt has been cleared by his cardiologist, has normal PFTs and states he is able to walk 2 flights of stairs with moderate DOE. You know that the incidence of diaphragmatic dysfunction after performing an interscalene block approaches:
a. 25%
b. 50%
c. 75%
d. 100%
Answer d. 100% (Brock-Utne, 2011, p. 25)
Studies have found phrenic nerve block to occur in 100% of interscalene block. The phrenic nerve innervates the diaphragm.
27
You have been called emergently to give an anesthetic to a 45 yo morbidly obese diabetic undergoing and I & D of his left heel after he stepped on a thumb tack. The pt has a history of difficult airway and severe PONV. After talking with the patient and his family you all agreed that Spinal anesthesia is the best option. You know that the patient is slightly acidotic, with a serum pH of 7.32. You anticipate that this finding has the possibility to affect your Bupivacaine spinal in the following way:
a. Acidic pH decreases the potency of Bupivacaine
b. Acidic pH increases the potency of Bufpivacaine
c. Acidic pH shortens the onset time of Bupivacaine
d. Acidic pH prolongs the onset time of Bupivacaine
Answer d. Acidic pH prolongs the onset time of Bupivacaine (Duke, 2011, p. 107)
The degree of ionization, or the pKa, influences the onset time of local anesthetics. Potency is determined by lipid solubility not pKa. Because local anesthetics are all weak bases, increasing the acidity of the pH would cause more of the local anesthetic to become ionized, thereby prolonging the time of onset.
28
Before performing an intercostal nerve block for pain management for a patient with 3 broken ribs and flail chest, you understand that comparing systemic absorption of local anesthetic between different regional blocks,
a. Intercostal is the most likely to be rapidly systemically absorbed.
b. Intercostal is less likely than paracervical to be rapidly absorbed.
c. Intercostal is only more likely than intravenous in terms of rapid systemic absorption.
d. Intercostal is less likely than brachial plexus blocks in terms of rapid systemic absorption.
Answer a. Intercostal is the most likely to be rapidly systemically absorbed. (Duke, 2011, p. 108)
From fastest to slowest, IV > Tracheal > Intercostal > Caudal > Paracervical > Epidural > Brachial Plexus > Subarachnoid > Subcutaneous. However, in terms of regional anesthetic procedures, the most rapidly absorbed is the intercostal block. We do not typically use IV or transtracheal administration for regional anesthesia. Bier blocks work by transudation of local anesthetic out of the circulation into the third space compartment, and a major concern is the avoidance of rapid systemic absorption.
29
While performing a single-shot axillary block, you find palpation of the axillary artery pulse difficult, so you elect to use a nerve stimulator to ascertain nerve location by motor stimulation. The first stimulation that you see when inserting the needle is flexion of the elbow (or stimulation of the coracobrachialis muscle), you know from this that:
a. You are in the neural sheath and should inject.
b. You are outside the neural sheath and should redirect the needle downward and more superficially.
c. You have directed the needle too inferiorly and are stimulating the radial artery, you should inject and then redirect more superiorly.
d. You should decrease the intensity of the output current, you are in the neural sheath, but stimulation has spread due to the inaccurate settings.
Answer b. You are outside the neural sheath and should redirect the needle downward and more superficially. (Hadzic, 2007, pp. Ch 28, Axillary Brachial Plexus Block exact page unkown)
The rationale for using the single-shot technique is that because of the presence of a neurovascular sheath, containing at the level of the axilla, the median, ulnar, and radial nerves, injection of LA in this sheath should sufficiently spread to anesthetize all three. Stimulation of the coracobrachialis or musculocutaneous nerve results in flexion of the elbow, so that you are too superior to the axillary portion of the neurovascular sheath. Radial artery stimulation would be evidenced by extension of the wrist and hand.
30
You are performing a femoral nerve block with nerve stimulation to aid placement. The initial response to the output current is the stimulation of the Sartorius muscle. You know that this means:
a. The needle tip has stimulated the main trunk of the femoral nerve, so you should accept this and inject your local anesthetic .
b. The needle tip is slightly anterior and medial to the main trunk of the femoral nerve, so you should redirect the needle laterally and advance deeper.
c. The needle is inserted too superficially, so you should push deeper until contacting hip or the superior ramus of the pubic bone, and only then inject.
d. You should not get a muscle twitch with the femoral nerve block, so you should withdraw, palpate for the femoral artery, and insert so as to pass through the artery then inject.
Answer b. The needle tip is slightly anterior and medial to the main trunk of the femoral nerve, so you should redirect the needle laterally and advance deeper. (Hadzic, 2007, pp. Ch 35 Femoral Nerve Block, exact page unkown)
The sartorious and its innervation are superficial and medial to the femoral nerve, what you are looking for is patellar snap. Contacting bone simply means you have gone too deep, and you should not inject here. If there is no muscle twitch, then you are probably far too lateral or medial, follow a more systematic approach to locating the artery and other landmarks.
31
The “snap” felt just before entering the epidural space represents passage through which ligament?
a. Anterior longitudinal ligaments
b. Posterior longitudinal ligaments
c. Ligamentum flavum
d. Supraspinous ligament
Answer C
(Barash, ed 5, pp698-699)
The structures that are traversed by a needle placed in the midline prior to the epidural space are as follows: skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, and ligamentum flavum. The flavum is tough and dense and a change in the resistance to advancing the needle is often perceived and to many feels like a snap.
32
. Severe hypotension associated with high spinal anesthesia is caused by primarily
a. Decreased systemic vascular resistance
b. Decreased cardiac output secondary to bradycardia
c. Decreased cardiac output secondary to decreased preload
d. Decreased cardiac output secondary to decreased myocardial contractility
Answer C
| With a high spinal, the decrease in venous dilation is the predominant cause of hypotension. (Barash, ed 5, pp708-709)
33
Para-aminobenzoic acid is a metabolite of
a. Mepivicaine
b. Ropivicaine
c. Procaine
d. Bupivicaine
e. Prilocaine
Answer C
Paba is an active metabolite of the ester-type local anesthetics. Esters are metabolized by the enzyme psuedocholinesterase. Paba is a metabolite breakdown product of ester anesthetics and is responsible for allergic reactions in some individual. (Stoelting pp180-189)
34
Which of the following local anesthetics undergoes the least hepatic clearance?
a. Lidocaine
b. Bupivicaine
c. Chloroprocaine
d. Prilocaine
```
Answer C
(source is Barash, page 462) Commonly injected local anesthetics are divided chemically into two groups: esters and amides. The esters include procaine, chloroprocaine, and tetracaine. The amides are lidocaine, mepivicaine, prilocaine, buipivicaine, levobupivicaine, etidocaine, and ropivacaine. The esters undergo plasma clearance by cholinesterases and have relatively short half-lives, whereas the amides undergo hepatic clearance and have longer half lives
```
35
A 36-year-old female patient is undergoing a thyroidectomy under a deep cervical plexus nerve block. Which of the following complications would be LEAST likely with this block?
a. Horner’s syndrome
b. Subarachnoid injection
c. Blockade of the spinal accessory nerve
d. Blockade of the recurrent laryngeal nerve
Answer C
Complications of deep cervical plexus block include injection of the local anesthetic into the vertebral artery, subarachnoid space, or epidural space. Other nerves that may be anesthetized include the phrenic nerve (which is why bilateral deep cervical plexus blocks should be performed with caution, if at all), and the recurrent laryngeal nerve. (Barash ed 5 p723)
36
2. When putting traction on the _____________ _______________ muscle it provokes the oculocardiac reflex, which manifests as bradycardia and occasionally cardiac dysrhythmias.
a. Lateral rectus
b. Superior rectus
c. Medial rectus
d. Posterior rectus
Answer: C medial rectus
Reference/ Rationale: Baby Barash pg. 813 Section IV part A. The oculocardiac reflex manifests as bradycardia (and occasionally cardiac dysrhythmias) that is elicited by pressure on the globe and by traction on the extraocular muslces (strabismus surgery), especially the medial rectus.
37
. After providing anesthesia for a tonsillectomy patient, what position should the patient be positioned in postoperatively?
a. Supine with their head extended
b. Lateral with their head slightly up
c. Lateral with their head slightly down
d. Supine with their head turned to the side
Answer: C
Reference/ Rationale: Jaffe pg. 209: They should be placed in the lateral position with their head slightly down to protect the airway from bleeding or gastric aspiration until they are fully awake. This is referred to as the ‘tonsillar’ position.
38
Calculate the ideal body weight of a 30-year-old male who is 5’11’’ and 180 lbs.
IBW (M)= ht in cm – 100 71in X 2.54 cm = 180.34cm
= 180.34 – 100
IBW = 80.34 kg
Answer: 80.34 Kg
Reference/ Rationale: Barash pg. 1231: Male ideal body weight in kg= Height in centimeters – 100. The female ideal body weight in kilograms = height in centimeters – 105.
39
A patient presenting for bariatric surgery had preoperative PFTs performed. What type of breathing pattern would you expect to be reflected in the results?
a. Obstructive breathing pattern
b. Normal breathing pattern
c. Restrictive breathing pattern
d. A & C
Answer: C
Reference/ Rationale: Jaffe pg. 600: A patient presenting for bariatric surgery that had preop PFTs performed would show a restrictive breathing pattern. Jaffe pg. 600: Adipose tissue is metabolically active. Oxygen consumption and CO2 production rise with increasing weight 2* to increased metabolic demands. The work of breathing is increased, while respiratory muscle performance is impaired. Mass loading of the thoracic and abdominal walls causes abnormalities in both lung volume and gas exchange, especially when the patient is supine. The increased total respiratory resistance and decreased compliance associated with extreme obesity result in shallow, rapid breathing.
40
Horner Syndrome is common after interscalene block and consists of:
a. Ptosis
b. Myosis
c. Enophthalmia
d. Anhydrosis
e. All of the above
Answer: E
Reference/ Rationale: Hadzic pg. 414. Claude-Bernard- Horner syndrome is characterized by ptosis, myosis, and enopthalmia due to the diffusion of the local anesthetic solution on the sympathetic cervical ganglion chain (including the stellate ganglion).
41
1. Which Structure of the eye is not apart of the three structures that make up the middle layers of the eye?
A. Choriod
B. Cilliary Body
C. Iris
D. Sclera
Answer:D
Rational:
-Sclera is the outer most layer of the eye
-The three structures that make up the middle layer of the eye are:
-Choroid-Layer of blood vessels.
-Ciliary body-behind iris:produces aqueous humor.
-Iris-Pigmented,Controls light entry.
Reference:(Barash Handbook of Clinical Anesthesia page 810-820)
42
2. During middle ear,mastoid and inner ear procedures which nerve is monitored with the use of the NIM or (Nerve Integration Monitor)?
A. Tibial Nerve
B. Common Peroneal Nerve
C. Sural Nerve
D. Facial Nerve
Answer:D
Rational:
-Monitoring the Facial Nerve ensures that the surgeon does not encounter or damage the facial nerve.
-The main function of the facial nerve is motor control of most of the muscles of facial expression.
-Also, the facial receives taste sensation from the anterior 2/3 of the tongue via the chorda tympani.
Reference:(Barash Handbook of Clinical Anesthesia page 798-809)
43
3. Which of the following was the 1st Amide Local used?
A. Cocaine
B. Procaine
C. Prilocaine
D. Lidocaine
Answer: D
Rational:
-1st Local Anesthetic: Cocaine 1884
-1st Synthetic Local (Ester) Procaine (1905)
-1st Amide Local Lidocaine (1943)
Reference: (Miller-Basics of Anesthesia 6th ed. Page 6)
44
4. When utilizing the Push, Pull, Pinch and Punt method to assess the lower extremity nerves, the practitioner would observe Plantar Flexion or Push of the Foot as a reaction of which nerve.
A. Common Peroneal Nerve
B. Obturator Nerve
C. Femoral Nerve
D. Tibial Nerve
Answer: D (Tibial Nerve)
Rational:
-Common Peroneal Nerve: Dorsal Flexion of the Foot
-Tibial Nerve: Plantar Flexion or push of the foot
-Obturator Nerve: Adduct against Pressure
-Femoral:Punt the Ball
-Lateral Femoral Cutaneous:Pinch of the lateral thigh
Reference:(Levy’s Lower Extremity Lecture)
45
```
5. When evaluating the Adipose tissue distribution of a surgical candidate, the practitioner observes a Gluteal Femoral or Pear Shaped body configuration, which body type would the patient posses?
A. Android
B. Google
C. Apple
D. Gynecoid
```
Answer: D (Gynecoid Shaped)
Rational:
-Android: Central or Abdominal Visceral-Apple Shaped
-Gynecoid:Gluteal Femoral or Peripheral-Pear Shaped
Reference(Barash Handbook of Clinical Anesthesia page. 754-768)
46
```
1. Decrease in respiratory compliance in the obese patient with central obesity leads to:
A. Decrease in FRC
B. Vital capacity
C. Total lung compliance
D. All the above
```
Answer is D all the above
These parameters are lower in individuals with upper body fat distribution. The decrease in FRC is the result of decreased ERV. Reduction in ERV is the result of encroachment of abdominal contents on the diaphragm, decrease in respiratory system compliance by the chest wall fat, and impairment of respiratory muscle strength.
Resource:
David E. Longnecker Anesthesiology (no edition) pg. 375
47
1. All of the following intravenous drug doses for the obese patient are correct except:
A. Dexmedetomidine should be based on total body weight
B. Remifentanil should be based on ideal body weight
C. Midazolam should be based on ideal and total body weight
D. Propofol should be based on ideal body weight
Answer is D.
Dexmedetomidine lacks effect on respiration, should be based on TBW; Remifentanil has similar pharmacokinetics in obese and non obese patients there but has significantly slower clearance in obese patients therefore dose based on IBW.; Midazolam loading dose should be based on TBW because it has a larger volume of distribution needed to achieve sedation , maintenance dose should be based on IBW and Propofol is highly lipophylic should be based on TBW because total clearance and volume of distribution at steady state correlate well with TBW.
Resource:
David E. Longnecker (Anesthesiology) pg. 384
48
1. Your morbidly obese patient arrest and needs defibrillation. You have a monophasic defibrillator and defibrillate at the maximum joules of 400 with no change in rhythm. You:
A. Repeat the defibrillation at a lower joule
B. Abandon defibrillation because the patient is too large
C. Switch to chest compressions due to the patients size
D. Repeat defibrillation at 400J
Answer is D.
The maximum 400J of energy on regular defibrillators is sufficient for the morbidly obese, because their chest wall usually is not much thicker, but the higher transthoracic impedance from the fat may obligate several attempts.
Resource:
David E. Longnecker (Anesthesiology) pg. 391
49
1. The mixture of 3% chloroprocaine and 0.5% Bupivicaine will produce what length of anesthetic duration:
A. Chloroprocaine will produce rapid onset , and Bupivicaine will provide long duration
B. Both local anesthetics are equal in duration
C. Mixing of local anesthetics has no advantages
D. Chloroprocaine will produce a long duration and Bupivicaine a rapid onset.
Answer is C.
Mixture of chloroprocaine and Bupivicaine resulted in a slower onset than chloroprocaine alone and a shorter duration than Bupivicaine alone.
Resource:
David E. Longnecker (Anesthesiology) 962
50
1. All of the following are presenting signs and symptoms of spinal hematoma except:
A. Back pain
B. Motor deficit not explained by the administered anesthetic
C. Sensory deficit not explained by the administered anesthetic
D. Al l the above
Answer D.
The usual presenting symptoms are back pain and motor and sensory deficit that is not explained by the administered anesthetic/analgesic agents. Patients with these symptoms especially patients on anticoagulants, definitive diagnosis should be sought without delay.
Resource:
Longnecker (Anesthesiology) pg. 998
51
An axillary block would be appropriate for procedures done:
a. at or below the elbow
b. shoulder
c. elbow only
d. above the elbow
Answer A
An axillary block will provide anesthesia for any procedure at or below the elbow.
Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 4th ed. Philadelphia, PA: WB Saunders Company; 2010: 10
52
. When using a “three in one”, which nerve is not blocked?
a. lateral femoral cutaneous
b. obturator
c. sciatic
d. femoral
Answer C
A "three-in-one" block anesthetizes the lateral femoral cutaneous, obturator, and femoral nerves and is performed by injecting 20-40 mL of local anesthetic into the neurovascular sheath just lateral to the femoral pulse.Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. New York, NY: McGraw-Hill; 2006: 344-345.
53
A 54 year old male with chronic liver failure presents for a TIPS procedure. During the case, he requires an infusion two units of PRBCs. Given his history of liver disease, what is a the greatest risk of transfusing the blood too rapidly?
a. hypertension
b. hypervolemia
c. Citrate toxity
d. allergic reaction
Answer C
Blood needs to be transfused slowly if possible, to avoid citrate toxicity. In patients with liver disease, their ability to metabolize the citrate in blood products is decreased.
Stoelting, RK, dierdorf SF. Anesthesia and Co-existing Diseases. 5th Edition. New York, NY:
Churchill-Livingston;2008:27
54
An 84 year old female presents for strabismus surgery. The patient suddenly develops bradycardia with a rate of 30. What is the FIRST thing you should do?
a. nothing, this is normal
b. administer atropine
c. ask the surgeon to stop
d. Check ventilation status
Answer C
Prompt removal of instigating surgical stimulus frequently results in rapid recovery. Unrelated tension may cause cardiac arrest.
Miller, R., & Pardo, M., Jr. (2011). Basics of Anesthesia (Sixth ed.). Philadelphia, PA:
Elsevier Saunders. 488.
55
What is an expected side effect of an interscalene block?
a. ringing of the ears
b. ipsilateral phrenic nerve block
c. intraneural injection
d. anesthesia distal to the forearm
Answer B
diaphragmatic paralysis on the same side is expected. This is due to the the phrenic nerve’s close proximity to the middle scalene muscle.
Miller, R., & Pardo, M., Jr. (2011). Basics of Anesthesia (Sixth ed.). Philadelphia, PA:
Elsevier Saunders.288.
56
1. In the obese patient compared to the individual with a normal BMI, all of the following are true except:
a. Chest wall compliance is decreased
b. Lung compliance is normal
c. Functional residual capacity is reduced
d. Lung compliance is increased
Correct answer D.
In the obese individual chest wall compliance is decreased, lung compliance is normal, and Functional residual capacity is reduced (Barash, Clinical Anesthesia, 1997, pg 975
57
During a renal transplant what is the major intraoperative anesthetic consideration? Select 2
a. Systolic pressure >90
b. Systolic pressure >80
c. Mean systolic pressure >60
d. Cvp>5
Correct answers A & C
Major anesthetic consideration with renal transplantation is maintenance of renal blood flow. Typical hemodynamic goals include systolic pressure >90, mean systemic pressure >60 and CVP>10 (Barash, Clinical Anesthesia, 6th 2009 ; pg 1400
58
1. You are going to redose and epidural that had been dosed one hour prior you should do all of the following except:
a. Inject the local anesthetic since you just used the catheter
b. Aspirate and check for return of blood or Cerebral spinal fluid
c. Be sure the solution you inject with is sterile preservative free solution
d. Check the patients vital signs before , during and after bolus injection
Correct answer A
You should aspirate prior to each injection of an epidural catheter to reduce the risk of intravascular or subarachnoid injection. Wong, Spinal and Epidural Anesthesia 2007, pg 51.
59
1. Where is the epidural space between the ligamentum flavum and the dura mater the largest?
a. L2-L3
b. L4-L5
c. S1-S2
d. L1-l2
Correct answer a
The epidural space between the ligamentum flavum and the dura mater is largest at L2-L3, approximately 4-6mm(Barash, Clinical Anesthesia, 2001, P 689
60
1. You placed a labor epidural in a 39 weeks G2P1 patient 12 hours ago. Her temp is now 38 degrees Celsius. What orders should include:
a. Pull the catheter immediately
b. Order a stat MRI past epidural removal
c. No additional interventions needed at this time.
d. Except to proceed with immediate C/section
Correct answer c
An increase in core materal body temperature is associated with labor epidural analgesia and may be influenced by several factors, including duration, ambient temperature, administration of systemic opiods, and the presence of shivering. During the first 5 hours of epidural analgesia, there is no significant increase in body temperature. Temperature increases at a rate of about 0.1 C/hour and may reach 38 degrees Celsius in as many as 15% of women with a labor epidural compared with 1% without an epidural (Miller & Pardo, Basics of Anesthesia, 2007, pg 527)
61
1) You have been called to the emergency to secure the airway of a patient that has suffered from smoke inhalation. The patient has been diagnosed with carbon monoxide poisoning. You know that carbon monoxide has a _______ affinity to hemoglobin compared to oxygen and will shift the oxyhemoglobin dissociation curve to the _______?
a) Lower / Left
b) Lower / Right
c) Greater / Left
d) Greater / Right
Answer C
Rationale: Carbon monoxide has an affinity for hemoglobin that is 200 times greater than that of oxygen, impairs mitchondrial function, uncouples oxidative phosphorylation and reduces ATP production resulting in metabolic acidosis, and shifts the oxyhemoglobin dissociation curve to the left, impairing the unloading of oxygen to the tissues. (Barash. Clinical Anesthesia. Page 909)
62
1) Your patient today has severe chronic pulmonary disease and requires the amputation of a gangrenous toe. You have decided that the best option for the patient is to perform a peripheral nerve block. After placing the block successfully your patient becomes bradycardic and now has a prolonged PR interval. Which of the following factors contributed to this change in your patient’s condition? (select all that apply)
a) Alkalosis
b) Hypoxia
c) Acidosis
d) Hypercarbia
Answers B,C,D
Rationale: Hypoxia, hypercarbia, and acidosis are the three major factors contributing to the negative chronotropic and inotropic effects of local anesthetics. (Nagelhout. Nurse Anesthesia. Page 155)
63
1) You are going to place a subarachnoid block for a patient undergoing a total knee arthroplasty. As you advance your needle you feel a “pop.” Based on this finding you suspect your needle has just penetrated the...
a) Ligamentum Flavum
b) Supraspinous Ligament
c) Interspinous Ligament
d) Who the heck knows… let’s just hope there is CSF when you take out the stylet
Answer A
: The 'pop' could represent the loss of resistance sensation felt as the needle penetrates the ligamentum flavum and enters the subarachnoid space. (Longnecker. Anesthesiology. Page 983).
64
When placing a popliteal block you know that the nerve being blocked is the…
a) Saphenous
b) Femoral
c) Sciatic
d) Obturator
Answer C
Rationale: A popliteal block is performed on the sciatic nerve as it passes through the popliteal fossa. (Nagelhout. Nurse Anesthesia. Page 1099)
65
1) When performing an axillary block you realize that which of the following may need to be blocked separately with an injection into the coracobrachialis muscle?
a) Musculocutaneous
b) Radial
c) Medial
d) Ulnar
Answer A
Rationale: The musculocutaneous and medial brachial cutaneous cutaneous nerves may require individual blockage because they exit the sheath high in the axilla. (Nagelhout. Nurse Anesthesia. Page 1087)
66
```
. Which of the following dermatome levels is improperly matched?
A. T1 : Below clavicle
B. T6 : Xyphoid Process
C. L1 : Umbilical Level
D .T4 : Nipple Line
```
Answer:
C. Umbilical Level.
Rationale: L1 corresponds with Ilio-inguinal level. T10 corresponds with the umbilical level. Figure 37.-5 Human Sensory dermatomes.
Barash Clinical Anesthesia, 2001 p.931
67
```
Which of the following is NOT a side effect of neuraxial opioids?
A. respiratory depression
B. puritis
C. nausea and vomiting
D. decreased GI motility
E. urinary retention
```
Answer: D decreased GI motility
Rationale: The gastrointestinal effects of spinal and epidural anesthesia are largely the result of sympathetic blockade. The abdominal organs derive their sympathetic innervation from T6-L2. Blockade of these fibers results in unopposed parasympathetic activity by way of the vagus nerve. Consequently, secretions increase, sphincters relax, and the bowel becomes constricted.
Barash Clinical Anesthesia, 2001 p. 947
68
```
Common side effects of Total Spinal Anesthesia include: (PICK 2)
A. Bradycardia
B. Hypotension
C. Hypertension
D. Increased Temperature
```
Answer: A and B
Rationale: Total spinal anesthesia occurs when local anesthetic spreads high enough to block the entire spinal cord and occasionally the brainstem during either spinal or epidural anesthesia. Profound hypotension and bradycardia are common secondary to complete sympathetic blockade. Respiratory arrest may occur as a result of respiratory muscle paralysis or dysfunction of brainstems respiratory control centers.
Barash Clinical Anesthesia, 2001 p. 949
69
```
What is the specific gravity of Cerebral Spinal Fluid?
A. 0.900-1.002
B. 1.003-1.008
C. 1.009-1.014
D. 1.015-1.020
```
Answer: B
Rationale: The specific gravity of CSF is 1.003-1.008. If the specific gravity of a solution is less than 1.003 it is hypobaric and if the specific gravity of a solution is more than 1.008 it is hyperbaric.
Morgan and Mikhail Clinical Anesthesiology, 1996, p 169
70
```
When doing a “three in one” block also known as a lumbar plexus block which nerve is not blocked?
A. Femoral
B. Obturator
C. Saphenous
D. Lateral Femoral Cutaneous
```
Answer: C. Saphenous
Rationale: The lumbar plexus block anesthetizes the femoral, obturator, and lateral femoral cutaneous nerves. Used alone, the block is applicable for minor knee surgeries (arthroscopy), and in combination with spinal anesthesia is appropriate for major knee surgery.
Barash Clinical Anesthesia, 2001, p739
71
1. A 4 years old child has had an uneventful tonsillectomy and adenoidectomy at the local ambulatory surgery center. After going home 2 hours post op and taking a nap, child wasn’t feeling well. He was pale, sweaty and restless. What is most likely is the explanation for this?
a. Infection, caused by the surgery
b. Hemorrhage
c. It’s a normal s/s of post op
d. None of the above
Answer B
Rationale: Approximately 75% of postoperative tonsillar hemorrhage occurs within 6 hours of surgery. Suggestive S/S unexplained tachycardia, excessive swallowing, pallor, restlessness, sweating, increased cap refill time. Clinical Anesthesia, Barash 6th edition
72
1. What are the most commonly reported respiratory abnormalities in an obese population? (pick 2)
a. Decrease in FRC due to decrease in ERV
b. Decrease in Closing capacity
c. Decrease in Residual Volume
d. Right-to-left shunting
Answers A and D
Reduction in FRC is primarily a result of reduced expiratory reserve volume (ERV), but the relationship between FRC and closing capacity, the volume at which small airways begin to close, is adversely affected. Reduced FRC (due to decreased ERV) can result in lung volumes below closing capacity in the course of normal tidal ventilation, leading to small airway closure, ventilation-perfusion mismatch, right-to-left shunting, and arterial hypoxemia. Clinical Anesthesia, Barash 6th edition
73
1. These are the most important factors when considering distribution of the neuraxial anesthesia, except?
a. Baricity of the local anesthetic solution
b. Position of the patient during and just after injection
c. Concentration of local anesthetic
d. Dose of the anesthetic injected
Answer C
Baricity plays an important role in determining the spread of local anesthetic in the spinal space and is equal to the density of the local anesthetic divided by the density of the CSF at 37°C. Patient positioning affects the spread of the anesthetic. Dose and volume both play a role in the spread of local anesthetics after spinal injection, although dose has been shown to be more important than volume. Concentration of local anesthetic before injection has no bearing on distribution because after injection, due to the mixing of the CSF and local anesthetic, there is a new concentration. Textbook of Regional Anesthesia and Acute Pain Management, Hadzic 2007
74
1. The most common side effects encountered after interscalene block are? (pick all that apply)
a. Hoarseness
b. Ulnar nerve paralysis
c. Claude-Bernard-Horner syndrome
d. Bezold-Jarisch reflex
Answers a, c, d
The most common side effects encountered after interscalene block are hoarseness (10–20%) due to the blockade of the recurrent laryngeal nerve, which occurs more frequently on the right side. Claude-Bernard-Horner syndrome (40-60%) is characterized by ptosis, myosis, and enopthalmia due to the diffusion of the local anesthetic solution on the sympathetic cervical ganglion chain (including the stellatum ganglion) The reason for this syndrome is the spread of the local anesthetic around the anterior scalene muscle behind the carotid artery and internal jugular vein toward the longus colli muscle. This results in blockade of the cervical ganglion (Horner syndrome) and phrenic nerve, which are located in this area. The occurrence of the paradoxical Bezold-Jarisch reflex, that is, sudden bradycardia and hypotension (15–30%), is favored by the sitting position and can be often prevented by avoiding hypovolemia. Textbook of Regional Anesthesia and Acute Pain Management, Hadzic 2007
75
1. When performing an inguinal block for herniorrhaphy you are trying to block which nerves? (pick all that apply)
a. Iliohypogastric n.
b. Internal oblique n.
c. Ilioinguinal n.
d. Illiaca n.
Answers a, c
Postherniorrhaphy pain is moderate to severe and often poorly controlled with opioids as single modal therapy. Ilioinguinal and iliohypogastric blocks have been shown to significantly reduce pain associated with herniorrhaphy, regardless of whether the blocks are used as the primary anesthetic or for pain control after general or spinal anesthesia. Textbook of Regional Anesthesia and Acute Pain Management, Hadzic 2007
76
1. An interscalene brachial plexus block would be suitable for all the following procedures except?
a. ORIF of metacarpal
b. Shoulder arthroscopy
c. Excision of a lesion of the radial aspect of the forearm
d. Distal biceps tendon repair
Answer A
Resource: A brachial plexus block is usually indicated for procedures of the upper arm, shoulder and forearm. It is usually not sufficient for procedures on the hand; however, the C8 and T1 nerves, which innervate the ulnar aspect of the forearm, are frequently missed as well. (Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia 6th edition. Philadelphia PA, 2009, 971.
77
1. A Caudal anesthetic is used to provide pain relief for which of the following procedures?
a. Lower extremity surgery
b. Labor and delivery
c. Chronic pain
d. All of the above
Answer D
Resource: Caudal anesthesia is used most commonly as an adjunct to general anesthesia in Pediatric surgery. It can also be used for pediatric surgery, urologic surgery, lower extremity orthopedic surgery, labor and delivery, and chronic pain. (Nagelhout JJ, Plaus K. Nurse Anesthesia, 4th edition Philadelpia PA: WB Saunders Company 2010; 1073.)
78
1. In adults the subarachnoid space extends from the foramen magnum to?
a. L1
b. L3
c. S2
d. S5
answer c
Resource: In adults, the subarachnoid space extends from the foramen magnum to S2, and to S3 in children. The spinal cord extends to L1 in adults and L3 in children. (Morgan, Mikhail, Clinical Anesthesiology. 4th edition. New York, NY: McGraw-Hill; 2006: 293
79
1. A popliteal block disrupts neurotransmission in the?
a. Femoral nerve
b. Popliteal nerve
c. Sciatic nerve
d. Saphenous nerve
Answer C
Resource: A popliteal block is preformed on the sciatic nerve as it passes through the popliteal fossa. (Nagelhout, Plaus. Nurse Anesthesia 4th edition. Philadelphia PA: WB Saunders Company; 2010: 1099.
80
1. A postdural puncture headache is generally relieved by assuming a?
a. Sitting position
b. Standing position
c. Lying position
d. None of the above
Answer C
Resource: One of the hallmark signs of a PDPH that it is aggravated by sitting or standing and relieved by lying down. (Morgan Mikhail. Clinical Anesthesiology 4th edition. New York, NY: McGraw-Hill; 2006: 319
81
1) Morbid obesity results in a(an)________________lung disease, characterized by ___________________________.
a) Obstructive/ FRC,ERV,TLC,CC
b) Restrictive/ FRC,ERV, TLC, CC
c) Obstructive/FRC, ERV, TLC, VC, IC
d) Restrictive/ FRC, ERV, TLC, VC, IC
Answer D
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 4th ed. St. Louis, MO; 2010: 1027-8.
Morbid obesity is associated with reductions of FRC, expiratory reserve volume (ERV) and total lung capacity. FRC declines exponentially with BMI…concomitant diminution of vital capacity, total lung capacity, ERV, and inspiratory capacity are demonstrated by rapid, shallow breathing. These ventilation patterns are characteristic of restrictive
82
1) The superior rectus, inferior rectus, medial rectus and inferior oblique orbital muscles are innervated by cranial nerve________________, the lateral rectus orbital muscle is innervated by cranial nerve_______________, and the superior oblique orbital muscle is innervated by cranial nerve______________.
a) III (oculomotor), IV (trochlear), VI (abducens)
b) III (oculomotor), VI (abducens), IV (trochlear)
c) II (optic), VI(abducens),V (trigeminal)
d) II (optic), VI (abducens), IV (trochlear)
Answer B
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 4th ed. St. Louis, MO; 2010: 943-5.
The oculomotor nerve (cranial nerve III) innervates the following muscles of the orbit: the superior rectus muscle, the inferior rectus muscle, the inferior oblique muscle, the medial rectus muscle, and the levator muscle of the upper eyelid.
The trochlear nerve (cranial nerve IV) provides motor fibers for the superior oblique muscle. This nerve enters the orbit through the superior orbital fissure outside the muscle cone. It is the only orbital cranial motor nerve that enters the orbit outside the muscle cone. Once inside the orbit the nerve root moves in a medial direction to innervate the superior oblique muscle.
The abducens nerve (cranial nerve IV) provides motor function to the lateral rectus muscle. The nerve enters through the superior orbital fissure within the muscle cone and continues along the conal surface of the lateral rectus muscle, eventually inserting in the posterior one third of that muscle.
83
1) You are called to the short stay unit to provide anesthesia for elective cardioversion. Upon interviewing the patient, he states that he was not told to fast and stopped for breakfast prior to arriving at the hospital. The cardiologist is about to embark upon a 2-wk vacation and no other provider will be available to perform the cardioversion. What is the best way to proceed with the anesthesia?
a) GETA w/ETT
b) awake
c) cancel the case
d) MAC w/propofol and versed
Answer A
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 4th ed. St. Louis, MO; 2010: 1280
If cardioversion is required in a patient who has not fasted, general anesthesia
Tracheal intubation is necessary to prevent aspiration of gastric contents.
84
1) Local anesthetics bind to receptors in the ______or________state resulting in a ___________or___________block.
a) closed or inactive/phasic or frequency-dependent
b) closed or active/complete or total
c) open or inactive/phasic or frequency-dependent
d) open or resting/complete or total
Answer C
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 4th ed. St. Louis, MO; 2010: 144
Studies indicate that local anesthetics have a greater tendency to bind to receptors in the open or inactive state (phasic or frequency-dependent block). This finding is referred to as the “modulated receptor hypothesis” of local anesthetic action. The open or inactive state may increase the affinity for binding, the physical access of the drug to the receptor, or both. Because of this preference, local anesthetics are more likely to block rapidly firing nerves than nerves in which action potentials are less frequent.
85
1. Interscalene block is typically not suited for surgery on the hand due to poor coverage of what nerve distribution.
a. Ulnar
b. Median
c. Musculocutaneous
d. Radial
Answer A
86
1. Which of the following symptoms consistent with horner’s syndrome. (choose 3)
a. Ptosis
b. Myosis
c. Enophthalmia
d. Bradycardia
e. Blurred vision
Answers A B C
87
1. While performing a spinal anesthetic you contact the pia mater. Your next action should be.
a. Inject your local anesthetic with 10-25% decrease in dose.
b. Insert the needle an additional 1 mm and check for csf.
c. Stop what you a doing and remove the needle.
d. Pull back the needle 1 mm and check for csf.
Answer C
88
1. ____ fibers of the autonomic nervous system have the fastest onset of blockade while ____ fibers have the fastest recovery.
a. B and A- alpha
b. B and A-Beta
c. A-alpha and B
d. C and B
Answer A
89
1. When performing surgery between the 1st and 2nd toe of the which nerve would need to be blocked.
a. Calcaneal nerve
b. Sural nerve
c. Saphenous nerve
d. Superficial peroneal nerve.
Hadzic chapter 39
