c4. ADVANCED PRInciples A (1-76)

Question 0

2. Of the following chemotherapy agents, which can cause pulmonary fibrosis in 5-10% of patients?
   a. vincristind
   b. bleomycin
   c. doxorubicin
   d. cisplatin

Answer 0

-b. bleomycin
Five to 10% of patients treated with bleomycin develop pulmonary toxicity. One to 2% of all patients die of this complication. It is recommended that concentrations of oxygen of 30% and colloids rather than crystalloids be administered.

Question 1

1. A patient has just experienced masseter muscle rigidity from succinlycholine. What laboratory value may confirm the diagnosis of malignant hyperthermia?
   a. muscle biopsy
   b. elevation of CPK (creatnint phsophokinase) level gratere than 20,000 IU/L
   c. caffiene-contracture test
   d. elevation in serum lactic dehydrogenase (LDH) level greater than 200 IU/L

Answer 1

-b. CPK level greater than 20, 000 IU/L
Vreatnine phosphokinase levels should be checked at 6,12 and 24 hours after an episode of massetere muscle rigidity. If CPK lefels are still grossly elevated at 12 hours, additional samples should be obtained until the levels return to normal. Studies have shown that with a level greater than 20,000, in the preioperative period a cocomimtant myopathy myopathy is not present. The diagnosis of malignant hyperthermia can be made with certainty.

Question 2

3. Preoperative assessment of the patient with pheochromocytoma should include:
   a. evidence of digitalis effect on ECG
   b. ACTH levels
   c. exercise tolerance
   d. adequacy of adrenergic blockade

Answer 2

-d. adequacy of adrenergic blockade
before surgery is scheduled it is important to establish alpha blockade first, followed by beta blockade. Alpha blockade should be instituted first to ensure adequate vasodilation before beta blocker induced cardiac depression

Question 3

4. Drugs to be avoided in the anesthetic management of the patient with pheochromocytoma would not include:
   a. vagolytic agents
   b. histhamine-releasing drugs
   c. adrenergic antagonists
   d. beta agonists

Answer 3

-c.adrenergic antagonists
Alpha and beta blockers are essential for cardiovascular control owing to the increased catecholamine levels secreted by the tumors. The other agents would stimulate cardiovascular activity and are thus contraindicated.

Question 4

5. What should be done first if a patient’s pacemaker fails intraoperatively?
   a. place a transvenous pacer as soon as possible
   b. administer atropine for bradycardia
   c. increase the patient’s inspired oxygen to 100%
   d. immediately start cardiopulmonary resuscitation

Answer 4

-c. increase patient’s inspired o2 to 100%
If a pacemaker fails:
1. Inspired O2 concentration should be increased to 100% immediately.
2. Check connectors and generator battery light.
3. Set pacemaker into the asynchronous mode while reasons for the failure are assessed

Question 5

6. When should the delivery of shock waves occur during extracorporeal shock wave lithotripsy for patients with a history of arrhythmias or pacemaker use?
   a. timed with the start of the P wave
   b. timed with the beginning of the R wave
   c. timed at 20 msec after the R wave
   d. timed at 30 msec after the T wave

Answer 5

-c. timed at 20 miliseconds after the R wave
Synchronization of the shock waves to the R waves of the ECG decrease the incidence of arrhythmias. They are usualy found to be 20 msec after the R wave to correspond to the ventricular refractory period

Question 6

7. Which of the following would not be considered an indication for prerioperative temporary pacing?
   a. a new bundle branch or heart block
   b. symptomatic bradyarrhythmia
   c. refractory SVT
   d. asymptomatic bigeminal rhythm

Answer 6

-d. asymptomatic bigeminal rhythm
Indications for a pacemaker include:
-a new symptomatic bradyarrhythmia
-a new bundle branch block
-new second or third degree heart block associated with MI
-refractory SVT

Question 7

8. The following are keys to anesthetic management for patient’s with carcinoid syndrome except:
   a. avoid histhamine releasing drugs
   b. avoid catecholamine administration
   c. maintain moderate hypercapnia
   d. avoid hypertension

Answer 7

-c. maintain moderate hypercapnia
The key to anesthetic management for patients with carcinoid syndrome is avoiding agents or techniques that cause the tumor to release vasoactive substances. These include:
-hypotension
-histhamine releasing drugs (morphine, atricurium, ? sux)
-surgical manipulation of the tumor
-catecholamine releasing drugs (ketamine)

Octreotide and steroids may be indicated

Question 8

9. How is adenosine administered?
   a. orally with food
   b. intramuscularly
   c. by rapid intravenous bolus
   d. sublingually

Answer 8

-c. by rapid intravenous bolus
Adenosine is administered rapidly by intravenous push. It should be given in a central line if possible and followed by a saline flush to ensure adequate cardiac levels. Adenosine is rapidly taken up into cells with a half life measured in seconds

Question 9

10. How is adenosine metabolized?
    a. pseudocholinesterase
    b. Hoffman elimination
    c. cytochrome P-450
    d. adenosine deaminase

Answer 9

-d. adenosine deaminase

Adenosine is metabolized by adenosine deaminase and xanthine oxidase into uric acid

Question 10

11. How fast is adenosine metabolized?
    a. less than 1 minute
    b. 5 to 10 minutes
    c. approximately 20 minutes
    d. about 1 hour

Answer 10

-a. less than 1 minute
adenosine is rapidly taken into cells and converted to uric acid. This process takes less than 1 minute, which accounts for the very short duration of action of the drug.

Question 11

12. What is the indication of adenosine?
    a. rapid atrial fib or flutter
    b. re-entrant atrioventricular tachycardias
    c. bradyarrhythmias
    d. wolff-parkinson-white syndrome

Answer 11

-b. re-entrant atrioventricular and supraventricular tachyarrhythmias will respond to adenosine therapy. If the arrhythmia involves the AV node in its patheway, adenosine can terminate by producing the atrioventricular block.

Question 12

13. All of the following are anesthetic goals for the patient with sickle cell anemia, except:
    a. avoid hypotension and hypovolemia
    b. maintain hematocrit less than 32%
    c. avoid hypothermia and hyperthermia
    d. maintain FIO2 greater than 0.50

Answer 12

-b. maintain hct less than 32%
Conditions that might promote hemoglobin desaturation or low flow rates should be avoided. These include hypothermia or hyperthermia, acidosis, hypoxia, hypotension and hypovolemia.

Question 13

14. When is sickling of the red blood cell most likely to occur?
    a. under extreme hypoxemia or low flow states
    b. when the hematocrit is greater than 35%
    c. with infection
    d. can occur at any time

Answer 13

-a. under extreme hypoxemia or low flow states

hypo and hyper thermia as well as hypoxia and hypovolemia can incite sickling

Question 14

15. Which of the following would be the most appropriate therapy for an adult diabetic patient with a blood sugar level of 300 mg/dL?
    a. NPH insulin IV
    b. regular insulin SQ
    c. Lente insulin SQ
    d. regular insulin IV

Answer 14

-d. regular insulin IV
regular insulin is the only form of preparationthat should be used intravenously. The intravenous route circumvents the unpredictable absorption of SQ insulin, which can be aggravated by changes in blood pressure and cuteneous blood flow that occur during anesthesia.

Question 15

16. What ECG leads best detect myocardial ischemia or infarct if the right atrium, sinus node, atrioventricular node and right ventricles are involved?
    a. II,III, aVF
    b. V1, V5
    c. I, aVL
    d. would be difficult to determine

Answer 15

-a. II,III, aVF
leads II, III, aVF monitor the right side of the heart supplied by the RCA. Leads V3 to V5 monitor the anterolateral aspects of the left ventricle. Leads I and aVL monitor the lateral aspects of the left ventricle.

Question 16

17. What ECG leads best detect myocardial ischemia or infarction in the anterolateral aspect of the left ventricle is involved?
    a. II,III, aVF
    b. unable to determine
    c. V3 to V5
    d. I, aVL (V6)

Answer 16

-c. V3 to V5

leads V3-V5 monitor the anterior portion of the left heart

Question 17

18. What ECG leads best detect myocardial infarct or ischemia in the lateral aspects of the left ventricle?
    a. no way to determine
    b. I, aVL
    c. II,III, aVF
    d. V3 to V5

Answer 17

-d. I, aVL (& V6)

lateral parts of the heart are monitored by I, aVL and also V6

Question 18

19. What site should be avoided when placing a pulmonary catheter?
    a. right internal jugular vein
    b. left or right femoral vein
    c. left internal jugular vein
    d. right external jugular vein

Answer 18

-c. left internal jugular vein
left internal jugular cannulationis undesirable because of potential for:
-damaging the thoracic duct
-difficult manuvering the catheter
-potential for puncture of the left carotid artery
-pulmonary embolism

Question 19

20. Which of the following is not considered a serious complication of interscalene block?
    a. pneumothorax
    b. grand mal seizure after vertebral artery injection
    c. stellate ganglion block
    d. central nervous system excitation phenomena after intravenous injection

Answer 19

-c. stellate ganglion block
stellate ganglion block may occur with the interscalene approach to the brachial plexus. Stellate ganglion block results in Horner’s syndrome, which includes miosis, ptosis, and hydrosis. This occurs in 30% to 50% of interscalene blocks.

Question 20

21. Which diagnosis must be considered in patients after coronary artery bypass graft surgery presenting with unexplained low cardiac output?
    a. cardiac tamponade
    b. myocardial infarction
    c. hypovolemia
    d. superior vena cava syndrome

Answer 20

-a. cardiac tamponade
cardiac tamponade must always be considered postoperatively when cardiac output is minimal. Stroke volume, due to the tamponade is limited and fixed and cardiac output and blood pressure become dependent on heart rate.

Question 21

22. Explain why the ventircle may fill during cardiopulmonary bypass:
    a. blood draining from the left atrium
    b. leak in the cardiopulmonary bypass system
    c. blood flow from the thebesian and bronchial veins
    d. blood returning from the superior vena cava

Answer 21

-c. blood flow from the thebesian and bronchial veins
When the heart is not open, as in cornary bypass graft procedures, it may be necessary to insert a catheter that acts as a vent to prevent distention from blood returning through the thebesian or bronchial veins

Question 22

23. What is the most frequent complication of a retrobulbar block?
    a. ineffective anesthesia
    b. complete loss of vision
    c. hemorrhage
    d. seizures

Answer 22

-c. hemorrhage
The most comomon complication of retrobulbar block is retrobulbar hemorrhage. Be careful not to perform this technique on patients with bleeding disorders or on patients that are on anticoagulants

Question 23

24. Which factor does not decrease uterine blood flow?
    a. uterine contractions
    b. maternal hyperventilation
    c. maternal hypotension
    d. vasoconstriction of uterine vasculature

Answer 23

-b. maternal hyperventilation
Uterine blood flow is not significantly afected by respiratory gas exchange except in extreme hypocarbia (paco2 less than 20 mmHg), which can reduce urinary blood flow.

Question 24

25. Which of the following is not a complication of cricothyroidotomy?
    a. pneumothorax
    b. bleeding
    c. esophageal puncture
    d. respiratory alkalosis

Answer 24

-d. respiratory alkalosis
The acute complications of cricothyroidotomy are:
-pneumothorax
-SQ emphysema
-mediastinal emphysema
-bleeding
-esophageal puncture
-aspiration
-respiratory acidosis

Question 25

26. Perioperative management of gastroschisis and omphalocele centres around prevention of which of the following?
    a. hypothermia, dehydration and infection
    b. hyperthermia, hypocapnia and oliguria
    c. hyperthermia, overhydration and infection
    d. hypothermia, hypercapnia and anuria

Answer 25

-a. hypothermia, dehydration and infection
Gastroschisis and omphalocele are disorders characterized by defect in the abdominal wall allowing herniation of viscera. Perioperative management centes around avoiding hypotheremia, dehydration and infection. These problems usually are more serious in gastroschisis because the protective hernial sac is absent.

Question 26

27. Which of the following complaints would distinguish local anesthetic toxicity from hyponatremia in a patient undergoing a transurethral prostatic resection?
    a. leg cramps and diaphoressis
    b. tinnitus and slurred speech
    c. confusion and dyspnea
    d. nausea and vomiting

Answer 26

-b. tinnitus and slurred speech
Tinnitus and slurred speech would be indicative of a high central nervous system (CNS) level of local anesthetic and would be premonitory signs of CNS excitation.

Question 27

28. What is the maximum amount of hetastarch that should be given to a patient?
    a. 1 ml/kg
    b. 50 ml/kg
    c. 25 ml/kg
    d. 20 ml/kg

Answer 27

-d. 20 ml/kg
hetastarch is used to expand intravascular fluid volume for the treatment of hypovolemia due to burns or hemorrhage. The ususal total daily iv dose is 20ml/kg/day.

Question 28

29. Postoperative problems after carotid endarterectomy include all except:
    a. MI
    b. CVI
    c. hyperkalemia
    d. hematoma formation at the operative site

Answer 28

-c. hyperkalemia
postoperative problems of the carotid endarterectomy common include liability of systolic BP, airway compression d/t hematoma, loss of carotid body function, MI, and CVI

Question 29

30. what is the most serious complication of a supraclavicular block?
    a. hemorrhage
    b. pneumothorax
    c. local anesthetic toxicity
    d. nerve injury

Answer 29

-b. pneumothorax
pneumothorax and hemothorax are the most common complications of this block. Incidence of pneumothorax can be as high as 6%

Question 30

31. What is the most common cause of heparin resistance?
    a. repeated doses of heparin
    b. diabetic history
    c. pseudocholinesterase breakdown
    d. antithrombin III deficiency

Answer 30

-d. antithrombin III deficiency
Occasional heparin resistance results from an antithrombin III deficiency. This is the serine protease that is enhanced by heparin.

Question 31

32. What is thetreatment for heparin resistance?
    a. simply increase the dose
    b. transfuse 1 unit of prbcs
    c. transfuse 2 units of ffp
    d. wait 24 hours before giving the next dose

Answer 31

-c. 2 units of fresh frozen plasma
Patients with antithrombin III deficiency will achieve adequate anticoagulation after admnistration of ffp, antithrombin III concentrate or synthetic antithrombin III.

Question 32

33. During a Beir block, what is the minimum amount of time the tourniquet needs to be inflated?
    a. 40 minutes
    b. 1 hour
    c. 20 minutes
    d. no minimum time

Answer 32

-c. 20 minutes
The minimum time the tourniquet needs to be inflated is 20 minutes to avoid sudden absorption of anesthetic into the systemic circulation. Between 20-40 minutes, cyclic deflation is recommended. Beyond 40 minutes, deflation can be done in a single manuver.

Question 33

34. When do signs of hypocalcemia after thyroidectomy appear?
    a. this rarely occurs after thyroidectomy
    b. typically after 1 week postopertaively
    c. immediately
    d. most often 24 to 72 hours postoperatively

Answer 33

• d. 24-72 hours
  hypoparathyroidism from unintentional removal of the parathyroid glands during thyroidectomy will cause acute hypocalcemia within 24-72 hours postoperatively.

Question 34

35. What anesthetic technique is relatively contraindicated for patients with multiple sclerosis?
    a. general endotracheal
    b. regional anesthesia
    c. “hypotensive” technique
    d. local sedation

Answer 34

-b. regional anesthesia
Some reports indicate that symptoms of MS are exacerbated by some types of anesthesia, particularly regional anesthesia. A relapse postoperatively is not uncommon.

Question 35

36. Which of the following should be avoided when managing a patient with cystic fibrosis?
    a. use higher FIO2 intraoperatively
    b. adequately hydrate
    c. hymidify gasses
    d. pretreat with atropine

Answer 35

-d. pre treat with atropine
treatment of patients with cystic fibrosis is primarily dedicated to clearing respiratory secretions from the respiratory system. Atropine’s drying effect would work against this priority, therefore, it should be avoided.

Question 36

37. Which factor is least likely the cause of intraoperative bronchospasm?
    a. light anesthesia
    b. mechanical obstruction
    c. endobronchial intubation
    d. acute bronchial asthma

Answer 36

-d. acute bronchial asthma
Intraoperative bronchospasm is usually due to factors other than acute exacerbation of bronchial asthma. More likely causes are mechanical obstruction or light anesthesia.

Question 37

38. An epidural anesthetic is administered; what typically is the first sign it is working?
    a. loss of motor ability of the lower extremities
    b. peripheral vasodilation
    c. sensory analgesia
    d. increased heart rate

Answer 37

-c. sensory analgesia
Sympathetic or motor blockade would occur after a change in heart rate from a test dose of epinephrine and sensory block from the local anesthetic.

Question 38

39. Which of the following would most likely cause oozing at the surgical site in a patient who was transfused with 12 units of PRBCs?
    a. hemolytic transfusion reaction
    b. low platelet count
    c. dilutional thrombocytopenia
    d. citrate toxicity

Answer 38

-c. dilutional thrombocytopenia
Transfusion of 10-15 units of PRBCs in adults could result in a platelet count of 100,000 or less. This dilutional thrombocytopenia is treated with infusion of platelet concentrates.
(although citrate toxicity could interfere with calcium which is a clotting factor)

Question 39

40. A patient with a history of cancer and currently being treated with bleomycin is at risk for what?
    a. cardiac dysrhythmias
    b. hypotension
    c. pulmonary toxicity
    d. nausea and vomiting

Answer 39

-c. pulmonary toxicity

pulmonary toxicity after bleomycin occurs in 10-15% of cases

Question 40

41. When the abdominal aorta is cross-clamped, what effect does it have on heart volumes and pressures?
    a. both afterload and peripheral vascular resistance increase
    b. only afterload increases and peripheral vascular resistance decreases
    c. peripheral vascular resistance increases but afterload decreases
    d. no physiologic change

Answer 40

-a. both afterload and periphreal (systemic) vascular resistance increase
Occlusion of the aorta causes hypertension in the proximal segment and hypotension in the distal segment. Cross clamping produces an increase in afterload and peripheral vascular resistance in proportion to the level of the occlusion. Similarly, myocardial stress varies with the level of the occlusion.

Question 41

42. Fetal hemoglobin (HbF) circulates in the blood until about the age of 6 months; what is the P50 of HgF?
    a. 21 mmHg
    b. 26 mmHg
    c. 19 mmHg
    d. 32 mmHg
    42b. explain p50; (low and high are called____ shifts respectively?)

Answer 41

-c. 19 mmHg
Fetal hemoglobin has a P50 of 19 mmHg compared with adult hgb which has a P50 of 26.6 mmhg.
42b. p50 is the pressure it takes to hold onto oxygen
(lower p50 =shift to left; oxygen stays on better at a lower pressure)
(higher p50 =shift to right; oxygen is released easier; needs a higher pressure to stay on)

Question 42

43. In the anesthetic management for a neonate with a diagnosed diaphragmatic hernia, before an awake intubation, what should be done?
    a. start an arterial line
    b. topicalize the oral pharynx
    c. insert an oro/nasogastric tube to decompress the stomach
    d. can sedate the child with low doses of benzodiazepine

Answer 42

-c. insert an oro/nasogastric tube to decompress the stomach
a diaphragmatic hernia in a neonate is an emergency procedure. It requires awake intubation of an orogastric tube and may possibly include insertion of an arterial line to determine blood gasses and pH

Question 43

44. Signs and symptoms of diaphragmatic hernia include all of the following except:
    a. scaphoid abdomen
    b. pectus excavatum
    c. bowel sounds ascultated in the chest
    d. arterial hypoxemia

Answer 43

-b. pectus excavatum
the signs and symptoms of diaphragmatic hernia evidence soon after birth and include scaphoid abdomen, barrell chest (? pectus carinatum), bowel sounds in the chest and profound hypoxia (due to intrusion into lung capacity).

Question 44

45. The two most important aspects in the anesthetic management of omphalocele and gastroschisis would include:
    a. monitor urinary output and arterial pressures
    b. watch for cardiac arrhythmias and metabolic acidosis
    c. peroxygenation and verifying tube placement via fiberoptic scope
    d. maintaining body temp and fluid replacement

Answer 44

-d. maintaining body temp and fluid replacement
Important aspects in the surgical management include maintenance of body temperature and continuation of fluid replacement because hypovolemia is almost always an issue. postoperative ventilation and parenteral nutrition have increased survival to approximately 75%.

Question 45

46. The hypertension caused from autonomic hyperreflexia should be treated with any of the following except:
    a. calcium channel blockers
    b. sodium nitroprusside
    c. ganglion-blocking drugs
    d. alpha adrenergic antagonists

46b. what is a ganglion blocker?

Answer 45

-a. calcium channel blockers
calcium channel blockers are hypertensive in action, but are least likely to be used in this disorder. The doses to treat this would be too high and could result in heart block or undesirable muscle effects (remember this is a T5 or higher paraplegic that gets this disorder)

46b. ganglion blockers are used in the treatment of autonomic dysreflexia; examples are pentamine & benzohexonium

Question 46

47. An 80 year old alcoholic undergoes open gallbladder surgery (3 days after admission) under general endotracheal anesthesia. Emergence was without difficulty, and spontaneous respirations were adequate. Twenty minutes after admittance to the postanesthesia care unit the patient becomes combative, confused, and restless. The most likely cause is:
    a. delirium
    b. hypoxia
    c. cerebral ischemia
    d. hypocarbia

Answer 46

-a. delirium
Although hypoxia must be ruled out, the more likely cause is emergence delirium. A small number of patients may awaken in an agitated state requiring restraints or re-sedation.

Question 47

48. The following are all true in the geriatric patient except:
    a. decreased PAO2
    b. increased A-ado2
    c. decreased static lung compliance
    d. decreased breathing capacity

Answer 47

-a. decreased PAO2
With age, chest wall compliance decreases. In the elderly, small airways may even close during tidal breathing. this widens the alveolar/arterial gradient for oxygen. PO2, however is relatively unaffected.

Question 48

49. Activated clotting time (ACT)assesses:
    a. intrinsic and common pathways
    b. intrinsic pathway
    c. common pathway
    d. extrinsic and common pathways

Answer 48

-a. intrinsic and common
Activated clotting time is a test of the intrinsic system and final common pathways. It is widely used to monitor heparin therapy especially in the operating room. Normal values are usually in the range of 90-120 seconds.

Question 49

50. Generally accepted indications for permanent pacemaker insertion include all except:
    a. second-degree heart block
    b. sick sinus syndrome
    c. complete heart block
    d. trifasicular block

Answer 49

-a. second degree heart block
Indications for insertion of a permanent pacemaker include sinus node dysfunction, complete heart block, symptomatic atrioventricular block, and trifascicular heart block

Question 50

51. Regarding patients with an automatic cardiovertor-defibrillator (AICD):
    a. The pulse generator should be deactivated if electrocautery is planned
    b. magnetic resonance imaging is not contraindicated
    c. lithotripsy may be performed safely
    d. a simple magnet is not strong enough to deactivate the device

Answer 50

-a. the pulse generator should be deactivated if electrocautery is planned
Patients with aicd should have it deactivated with a magnet before electrocautery, MRI, and lithotripsy. A simple magnet device will easily deactivate and reactivate the pacemaker.

Question 51

52. In patients with idiopathic hypertrophic subaortic stenosis (IHSS), all of the following will make obstruction to outflow worse except:
    a. increased left ventricular volume
    b. decreased atrial pressure
    c. decreased intraventricular volume
    d. increased contractility

Answer 51

-a. increased left ventricular volume
IHSS resluts from asymetrical hypertrophy of the interventricular septum, leading to outflow obstruction. Factors that worsen outlow obstruction include hypotension, decreased intraventricular volume, and increased contractility

Question 52

53. In the patient with aortic stenosis, all are important except:
    a. pulmonary capillary wedge pressure should be monitored to estimate left ventricular end diastolic pressure
    b. maintenance of sinus rhythm
    c. maintenance of preload
    d. bradycardia is not tolerated

Answer 52

-a. pulmonary capillary wedge pressure should be monitored to estimate left ventricular end diastolic pressure.
In aortic stenosis it is important to maintain sinus rhythm and adequate preload. Hypotension should be aggressively treated. Tachycardia and bradycardia are poorly tolerated. Wedge pressure will underestimate the left end diastolic pressure, therefore it may not be useful
(wedge is a good estimate of LVEDP in normal aortic and mitral valve function only).

Question 53

54. In anesthetizing the patient with aortic stenosis all are true except:
    a. avoid bradycardia
    b. maintain adequate intravascular volume
    c. maintain sinus rhythm
    d. maintain decreased afterload

Answer 53

-d. maintain decreased afterload
reduction in the afterload leads to a reduction in blood pressure and coronary perfusion because cardiac output is relatively fixed by the stenotic valve

Question 54

55. With regard to the pathophysiology of aortic stenosis:
    a. angina infrequently occurs
    b. concentric hypertrophy develops
    c. chamber size is increased
    d. ventricular compliance is increased

Answer 54

-b. concentric hypertrophy develops
aortic stenosis is a fixed outlet obstruction to ventiricular ejection. Ventricular compliance decreases and end diastolic pressure increases

Question 55

56. In formulating an anesthesia plan for the patient with aortic insufficiency, all are needed except:
    a. increased afterload
    b. modest tachycardia
    c. judicious fluid administration
    d. decrease systemic vascular resistance

Answer 55

-a. increase afterload
Full, fast, forward is the phrase to remember managing these patients. Afterload reduction augments forward flow. Volume replacement is necessary to maintain preload, and tachycardia reduces ventricular volumes

Question 56

57. The anesthetic considerations for the patient with mitral stenosis include all except:
    a. hypercarbia will increase pulmonary vascular resistance
    b. avoid hypoxemia
    c. maintain increased pulmonary vascular resistance
    d. maintain slow/normal heart rate

Answer 56

-c. maintain increased pulmonary vascular resistance
Increases in pulmonary vascular resistance exacerbate right ventricular failure. Therefore, it is important to avoid vasoconstrictor drugs, hypoxia, hypercarbia and acidosis, which all may increase pulmonary vascular resistance.

Question 57

58. Hemodynamic goals for the patient with mitral regurgitation include all except:
    a. hypercarbia should be avoided
    b. maintain intravascular volume
    c. avoid increased pulmonary vascular resistance
    d. maintain slow to normal heart rate

Answer 57

-d. maintain slow to normal heart rate

Slightly elevated heart rate helps to decrease ventricular volume and thus reduces regurgitation.

Question 58

59. All of the following are common electrocardiographic findings of mitral regurgitation except:
    a. atrial fibrillation
    b. left bundle branch block
    c. atrial and ventricular premature beats
    d. P mitrale

Answer 58

-b. left bundle branch block
Incomplete right bundle branch block is seen in 5% of the patients. Left bundle branch block is uncommon and may indicate ventricular disease. Atrial arrhythmias develop over time, and P mitrale may be seen in click murmur syndrome.

Question 59

60. which of the following produces a pansystolic murmur?
    a. aortic insufficiency
    b. aortic stenosis
    c. mitral stenosis
    d. mitral insufficiency

Answer 59

• d. mitral insufficiency
• -Mitral insufficiency produces a pansystolic murmur.
• -Mitral stenosis produces presystolic murmur.
• -Aortic insufficiency produces an immediate diastolic murmur
• -Aortic stenosis produces a systloic ejection murmur
• -floppy valve syndrome produces a late systolic murmur

Question 60

61. According to the New York Heart association classification of heart disease, which of the following are characteristic of Class II?
    a. marked limitation of physical activity
    b. slight limitation of physical activity
    c. unable to carry out physical activity without discomfort
    d. no limitations of physical activity

Answer 60

-b. slight limitation of physical activity
New york heart association clasification states:
Class I: no limitations of activity
Class II: slight limitation of activity
Class III: marked limitation of activity
Class IV: unable to carry out any physical activity without discomfort

Question 61

62. Click murmur syndrome is associated with which heart valve?
    a. mitral
    b. pulmonic
    c. aortic
    d. tricuspid

Answer 61

-a. mitral
Click murmur syndrome is associated with disease of the mitral valve. It is a common finding in patients with P mitrale.

Question 62

63. What is the muscle relaxant of choice in patients with mitral regurgitation?
    a. atracurium
    b. vecuronium
    c. pancuronium
    d. mivacurium

Answer 62

-c. pancuronium
A muscle relaxant that maintains or increases heart rate is preferred. Pancuronium produces slight tachycardia due to a vagolytic and sympathomimetic action.

Question 63

64. The first letter of the five letter pacemaker identification codes represents:
    a. chamber(s) sensed
    b. chamber(s) paced
    c. programmable functions
    d. mode of response

Answer 63

-a. chambers paced
Five letter pacemaker code is as follows:
1st letter= chamber paced
2nd letter= chamber sensed
3rd letter= mode of response
4th letter=programmable functions
5th letter= special functions

Question 64

65. All of the following promote hypokalemia by shifting potassium into the cells except:
    a. insulin
    b. alkaloids
    c. beta-adrenergic stimulation
    d. beta blockers

Answer 64

d. beta blockers
Beta stimulation causes a release of epinephrine, which shifts potassium intracellularly. Therefore beta receptor blockers would minimize this effect.

Question 65

66. All of the following promote hyperkalemia except:
    a. diuretics
    b. acidosis
    c. alpha adrenergic stimulation
    d. rapid increase in plasma osmolarity

Answer 65

-a. diuretics

diuretics can cause blockade of potassium reabsorption and therefore commonly produce hypokalemia

Question 66

67. In an acute aginal attack, intravenous administration of nitrates works to relieve angina by:
    a. direct arterial vasodilation
    b. dilating the coronary arteries
    c. decreasing preload
    d. decreasing heart rate

Answer 66

-c. decreasing preload
Nitrates are primarily the venous dilators; therefore, reducing preload and cardiac demand is the mechanism by which they relieve angina. They may or may not produce benificial coronary artery dilation

Question 67

68. All of the following are true of the geriatric patient except:
    a. impairment of hepatic microsomal enzymes is not age related
    b. they are pharmocodynamically more sensitive to benzodiazepines
    c. minimal alveolar concentration of inhalation agents decreases with age
    d. the elimination half life for opioids is increased

Answer 67

-a. impairment of hepatic microsomal enzymes is not age related
changes in microsomal enzymes may occur at any age and are probably not the reason for dose requirement changes in the eledrly with acutely administered drugs. It would be more likely that changes in these enzymes would affect chronically administered medications.

Question 68

69. All of the following are true of the geriatric patient except:
    a. they have difficulty with glucose load
    b. the number of effective renal glumeruli decreases with age
    c. they have increased serum albumin levels resulting in greater protein binding of drugs.
    d. they have a declining skeletal muscle mass and blood volume with age.

Answer 68

-c. they have increased serum albumin levels resulting in greater protein binding of drugs
Serum protein levels decrease with age. In persons older than age 50, serum albumin levels fall from approximately 4g/dL to 3.5 g/dL

Question 69

70. All of the following are safe for the patient with a latex allergy except:
    a. polyvinyl chloride endotracheal tube
    b. paper tape
    c. tegaderm
    d. tourniquets
    70b. what other often missed latex item cannot be used?

Answer 69

-d. tourniquets
some tourniquets contain latex (old days), and thererfore should not be used in patients with a latex allergy. If necessary, use tourniquets over gown or clothing to prevent contact with skin.
70b. standard foley catheter (get a latex free foley).

Question 70

71. All of the following are early manifestations of malignant hyperthermia except:
    a. unexplained tachycardia
    b. high temperature
    c. increased end-tidal CO2
    d. masseter muscle spasm

Answer 70

-b. high temperature
Unexplained tachycardia, increase in end tidal CO2, and masseter muscle spasms are early warning signs of MH. The high temperature that is the hallmark of the disease may be a late developing sign.

Question 71

72. Neonatal retrolental fibroplasia is a result of oxygen toxicity above what percent of oxygen?
    a. 40%
    b. 30%
    c. 50%
    d. 70%

Answer 71

-a. 40%
Oxygen therapy in neonates with immature retinas can lead to a detachment, fibrosis, and disorganized vascular proliferation. Neonates younger than 36 weeks gestation are at greatest risk and inthose up to 44 weeks gestation, there is still some risk present. Arterial oxygen concentrations are better correlates than alveolar oxygen concentrations. Arterial oxygen tensions less than 140 mmhg are considered safe.

Question 72

73. All of the following have been shown to increase the incidence of postoperative nausea and vomiting except:
    a. eye surgery
    b. narcotics
    c. isoflorane
    d. tonsillectomy

Answer 72

-c. isoflorane

The inhalation anesthetics except for nitrous oxide do not increase the incidence of PONV

Question 73

74. Which of the following is an absolute contraindication to spinal anesthesia?
    a. chronic back pain
    b. sepsis
    c. uncooperative patient
    d. prior lumbar spine surgery

Answer 73

-b. sepsis
Sepsis is an absolute contraindication to spinal anesthesia. Introducing infection into the CSF by injecting a spinal anesthetic during sepsis must be avoided. The others, although representing some difficulty, are NOT absolute contraindications.

Question 74

75. During spinal anesthesia, the local anesthetic is administered between which two meningeal layers?
    a. pia and arachnoid
    b. dura and pia
    c. dura and arachniod
    d. dura and epidura

Answer 74

-a. pia and arachniod
the spinal needle punctures the dura and arachnoid layers into the subarachnoid space. Therefore, the local anesthetics are injected between the arachnid and pia meningeal layers.

Question 75

76. When performing subarachnoid block, the first ligament penetrated is:
    a. interspinous
    b. ligamentum flavum
    c. supraspinous
    d. posterior longitudinal ligament

Answer 75

-c. supraspinous
The spinal needle punctures the:
1st. supraspinous ligament
2nd. interspinous ligament
3rd. ligamentum flavum
4th. meningeal layers