Exam #1

Question 1

Succinylcholine should only be used in children during emergencies because of the experience with hyperkalemia in:

Answer 1

Duchene’s muscular dystrophy

Question 2

Which one of the following muscle relaxants would exhibit the least variability in its kinetic profile in a patient with hepatic and renal failure?

Answer 2

cistracurium

Question 3

Which one of the following is classified as a long acting muscle relaxant?

Answer 3

pancuronium

Question 4

Which two of the following relaxants exhibit NO cardiovascular side effects?

Answer 4

rocuronium, vercuronium

Question 5

Which of the listed muscle relaxants would have a prolonged effect in a patient with hepatic and/or renal disease?

Answer 5

pancuronium, rocuronium, vecuronium

Question 6

Immediately following surgery that involved the use of sugamadex (Bridion) as a reversal agent, the patient had to be anesthetized because of a complication that developed. In this case which of the following neuromuscular blockers are most likely to be effective?

Answer 6

cisatracurium, succinylcholine

Question 7

Select the two muscle relaxants that are most likely to be associated with histamine release.

Answer 7

atracurium, succinylcholine

Question 8

The muscle relaxant effects of atracurium and cisatracurium dissipate due to which two of the following processes?

Answer 8

Hoffman elimination, non-specific ester hydrolysis

Question 9

Which one of the following is least likely to produce satisfactory results when reversing a deeply blocked (100%) patient?

Answer 9

edrophonium

Question 10

A patient is using daily a cholinesterase inhibitor such as donepezil (Aricept) to slow developing Alzheimers condition. Theoretically, which of the neuromuscular blockers is most likely to have a prolonged duration of action?

Answer 10

succinylcholine

Question 11

The response you would expect when checking the tetanus in a patient approximately 50% blocked with rocuronium is:

Answer 11

fade with post-tetanic facilitation

Question 12

Stimulation of the ____________ probably best tracks RECOVERY of a neuromuscular blocking agent?

Answer 12

ulnar nerve

Question 13

Masseter muscle spasm is an unexpected effect possibly a prodromal sign related to malignant hyperthermia which is associated with which one of the following relaxants?

Answer 13

succinylcholine

Question 14

The most appropriate treatment for a patient with atypical pseudocholinesterase following succinylcholine administration is:

Answer 14

intubation, sedation, controlled ventilation

Question 15

Pretreatment with glycopyrrolate (Robinul) prior to administration of an anticholinesterase agent will block ____________ side effects?

Answer 15

muscarinic

Question 16

A patient receiving aminoglycoside antibiotics for surgical prophylaxis does not adequately reverse the administered muscle relaxant at theend of the procedure. Your next treatment would be?

Answer 16

intubation, sedation, controlled ventilation

Question 17

Cisatracurium is a steroisomer of atracurium. Cisatracurium possesses all of the characteristics of atracurium except for:

Answer 17

histamine release

Question 18

Normal pseudocholinesterase:

Answer 18

is inhibited by acetylcholinesterase inhibitors

Question 19

Being able to lift the head and hold it up for 5 seconds is a pretty good estimate of normal clinical function following use of neuromuscular blocking agents. Approximately what percentage of receptors are occupied by the blockers when patients can perform this test successfully?

Answer 19

about 50% are unoccupied

Question 20

Atracurium would be expected to produce which of the following cardiac side effects?

Answer 20

hypotension and tachycardia

Question 21

Succinycholine would be expected to produce which of the following cardiac side effects?

Answer 21

slight tachycardia followed by occasional severe bradycardia with repeat doses in adults or any dose in children

Question 22

Which one of the following is generally considered the fastest acting non-depolarizing muscle relaxant in usual doses?

Answer 22

rocuronium

Question 23

In an average patient, the transient hyperkalemia produced by succinylcholine results in an increase potassium levels of approximately:

Answer 23

0.5 mEq/L

Question 24

Which one of the following would indicate the greatest degree of muscle relaxant reversal?

Answer 24

sustained head lift for 5 seconds

Question 25

The cardiac side effects pancuronium is most likely to produce include:

Answer 25

tachycardia

Question 26

Which of the following would you expect to prolong the effects of cisatracurium and atracurium?

Answer 26

none of the above would prolong the effects of cisatracurium and atracurium

Question 27

Match each of the drugs below with the appropriate hydrolytic enzymes which are responsible for catalyzing their metabolism. neostigmine succinylcholine vecuronium edrophonium rocuronium cisatracurium

Answer 27

plasma cholinesterase plasma cholinesterase not significantly metabolized by hydrolytic enzymes plasma cholinesterase not significantly metabolized by hydrolytic enzyme non-specific esterases and Hoffman reaction

Question 28

Match each of the described characteristics of neuromuscular blockade with either a depolarizing (phase I) or non-depolarizing (phase II) block.

Reversal with anti cholinesterase drugs

muscle fasiculation precedes the onset of neuromuscular blockade

train of four (TOF) and double burst fade

sustained response to tetanic stimulation

lack of fade to train-of four (TOF)or double burst stimulation

absence of post-tetanic potentiation, stimulation, or facilitation

block potentiated by anticholinesterase drugs

Answer 28

Phase II Phase I Phase II Phase I Phase I Phase I Phase I

Question 29

Match each of the described characteristics of neuromuscular blockade with either a depolarizing (phase I) or non-depolarizing (phase II) block. Reversal with anti cholinesterase drugs muscle fasiculation precedes the onset of neuromuscular blockade train of four (TOF) and double burst fade sustained response to tetanic stimulation lack of fade to train-of four (TOF)or double burst stimulation absence of post-tetanic potentiation, stimulation, or facilitation block potentiated by anticholinesterase drugs

Answer 29

Phase II Phase I Phase II Phase I Phase I Phase I Phase I

Question 30

For each of the neuromuscular blocking agents in the following questions, select the described elimination characteristics listed below. Characteristics may be used one time or more than once. vecuronium pancuronium succinylcholine cisatracurium

Answer 30

the drug undergoes SIGNIFICANT hepatic and/or renal elimination the drug undergoes PRIMARILY (>80%) renal elimination the drug is hydrolyzed with cholinesterase as the catalyst drug elimination is NEITHER renal or hepatic dependent

Question 31

In the following questions, match the responses to train of four stimulation with the appropriate estimates of degree of blockade. loss of all four twitch responses indicates _____ blockade train of four ratio (TOFR) of > 0.90 equals ______ blockade loss of two twitches equals ________ blockade presence of only one twitch equals ________ block train of four ratio (TOFR) of 0.60 equals _______ blockade loss of one twitches equals _______ blockade post-tetanic count of 1 equals __________ blockade

Answer 31

100% block 70% blockade or less 80 - 85% block 90 - 95% block 70 - 75% block 75 - 80% block 100% block

Question 32

Match each of the skeletal muscle groups in the sequence of being affected during the ONSET when administering a skeletal muscle relaxant. diaphragm extremities ocular muscles (eye lid) intercostals

Answer 32

last second first third

Question 33

One of your patients has a prolonged apnea following succinylcholine administration. A patient history is not available. You order a dibucaine inhibition test and also obtain information about pseudocholinesterase activity. In this patient the dibucaine number = 77 and the pseudocholinesterase activity is 17%. The diagnosis in this case is most likely:

Answer 33

normal cholinesterase, low levels

Question 34

Select the correct statement regarding the onset of action of the anticholinesterase agents.

Answer 34

Edrophonium has the fastest onset of action

Question 35

Pharmacological factors that may prolong duration of neuromuscular block paralysis include:

Answer 35

aminoglycoside antibiotics, corticosteroids, dantrolene

Question 36

Contraindications to the use of succinylcholine include:

Answer 36

all of the above are contraindications to succinylcholine use

Question 37

Indicate all of the neuromuscular blocking agents that have a steroid-like chemical structure.

Answer 37

rocuronium, vecuronium

Question 38

Sugammadex is a selective relaxant binding agent (SRBA) which has its best reversing effect on:

Answer 38

rocuronium

Question 39

Sugammadex is a selective relaxant binding agent (SRBA) which has its best reversing effect on:

Answer 39

rocuronium

Question 40

Neostigmine reverses the neuromuscular blockade of non-depolarizing agents primarily by:

Answer 40

inhibiting cholinesterase enzymes to elevate acetylcholine levels in the end-plate region

Question 41

Which of the following statements about sugammadex is incorrect?

Answer 41

Use of sugammadex prevents benzoisoquinoline neuromuscular blocking agents from working.

Question 42

All neuromuscular blocking agents resemble acetylcholine by containing:

Answer 42

one or more positively charged quaternary ammonia groups

Question 43

In planning your anesthetic for the day, you (the student CRNA) decide you want to use pancuronium because it is so cheap (and will make you appear cost-conscious). However, your patient presents with ____ and ____ so you choose another neuromuscular blocking agent, knowing that the patient’s conditions contraindicates the use of pancuronium.

Answer 43

chronic renal insufficency; baseline tachycardia

Question 44

Which one of the following physiological and pharmacological factors is least likely to prolong the duration of neuromuscular blocking agents?

Answer 44

burn injury

Question 45

The surgery is ending. Your CRNA asks you what reversal agents you plan to use. You respond, ‘Glycopyrrolate and edrophonium, sir (or ma’am).’ Your CRNA instantly realizes you had a lousy instructor for the muscle relaxant section of Pharmacology, and responds, ‘OK, but be prepared to treat ____.’

Answer 45

initial bradycardia

Question 46

Which one of the following is most likely to produce CNS effects?

Answer 46

atropine

Question 47

Considering perioperative anaphylaxis, which one of the following has been shown to be the leading cause?

Answer 47

neuromuscular blocking agents

Question 48

Match the neuromuscular term with the most appropriate colored lettered section on the graph above. Clinical duration of NMB Onset of neuromuscular block

Answer 48

Section D Section A

Question 49

The ‘priming technique’

Answer 49

may produce respiratory distress (difficulty swallowing) in some patients,

Question 50

Which of the following statements is true?

Answer 50

Generally, only one twitch in response to TOF stimuli is the level of neuromuscular block to be at during surgery. , A rapid and successful reversal usually can be accomplished if initiated when TOF stimulation gives 4 twitches.