COMP Exam 1

Question 1

1. Risk factors for deep vein thrombosis include all of the following except

A. a BMI greater than 60
B. obesity hypoventilation syndrome
C. venous stasis
D. Factor VIII deficiency

Answer 1

D. Factor VIII deficiency

A BMI of 60 or more, evidence of venous stasis, central obesity, and obesity hypoventilation syndrome or obstructive sleep apnea are significant risk factors for deep vein thrombosis.

Question 2

2. During the first phase of the injury of a major trauma patient, a core body temperature below 35 degrees Celsius is often associated with: (select two)

A. hypotension
B. coagulopathy
C. alkalosis
D. hypoxia

Answer 2

A. hypotension
B. coagulopathy

A core body temperature below 35 degrees Celsius is often associated with acidosis, hypotension, and coagulopathy during the early phase of injury for the major trauma patient.

Question 3

3. What would constitute a significant change in a somatosensory evoked potential?

A. A 10 percent decrease in amplitude
B. A 10 percent increase in amplitude
C. A 10 percent increase in latency
D. A 10 percent decrease in latency

Answer 3

C. A 10 percent increase in latency

A decrease in amplitude by 50 percent or an increase in latency by 10 percent commonly define a significant change in SSEPs.

Question 4

4. Within the first hour of the neohepatic period, the patient exhibits a decrease in cardiac output and an increase in systemic vascular resistance. What does this change indicate?

A. The patient is rejecting the liver
B. It is likely that the patient is bleeding internally
C. Calcium and fresh frozen plasma should be administered
D. The graft is functioning well

Answer 4

D. The graft is functioning well

A decrease in cardiac output and an increase in the SVR indicates that the graft is functioning correctly and the new liver is beginning to metabolize the vasoactive substances that produce the characteristic low SVR and high cardiac output in patients with end stage liver disease. Other signs that the graft is functioning correctly include: calcium is no longer needed even when large volumes of FFP are infused as the new liver is able to metabolize the citrate preservative and the base deficit normalizes.

Question 5

5. What condition would produce the flow-volume loop shaded in pink?

A. Unilateral vocal cord paralysis
B. Chronic obstructive pulmonary disease
C. Tracheomalacia
D. Tracheal stenosis

Answer 5

D. Tracheal stenosis

A fixed airway obstruction can be caused by a foreign body in the airway, a lesion like tracheal stenosis, or anatomical compression by a tumor or goiter. In a fixed obstruction, the flow-volume loop exhibits decreased flow during both inspiration and expiration. It looks as if the top and bottom of the loop are chopped off.

Question 6

6. A hormone response that initiates signals which amplify the release of the same hormone is referred to as a

A. positive feedback mechanism
B. negative feedback mechanism
C. target-control amplifier
D. circadian rhythm

Answer 6

A. positive feedback mechanism

A positive feedback mechanism is a hormone-regulating system in which the release of a hormone triggers changes which amplify the release of the same hormone.

Question 7

7. Which opioid has the fastest onset?

A. Alfentanil
B. Sufentanil
C. Fentanyl
D. Morphine

Answer 7

A. Alfentanil

Alfentanil has an almost immediate onset when administered. Alfentanil has a small volume of distribution, and 90 percent of the drug is in the nonionized form at physiologic pH, leading to an increased amount of drug being available for binding.

Question 8

8. Why is a single-shot spinal anesthetic not used for primiparous laboring mothers?

A. It produces severe hypotension
B. It results in fetal bradycardia
C. It does not provide a sufficient duration of analgesia
D. The risk of epidural bleeding is too high

Answer 8

C. It does not provide a sufficient duration of analgesia

A single-shot spinal anesthetic will not deliver the duration of analgesia necessary for most laboring patients. In the primiparous patient, multiple injections would be necessary. Even in the multiparous patient, the potential for emergency cesarean section would require a new anesthetic for performance of the procedure.

Question 9

9. According to the AANA code of ethics, which of the following is NOT a requirement in the maintenance of a competent level of practice?

A. Achieving and maintaining a doctoral degree
B. Engaging in continuous quality improvement activities
C. Maintaining registered nursing licensure
D. Fulfilling all advanced practice requirements

Answer 9

A. Achieving and maintaining a doctoral degree

According to the AANA code of ethics, a CRNA has a duty to maintain practice competency by engaging in continuous quality improvement activities, engaging in lifelong educational activities related to the profession, maintaining a state nursing licensure, and fulfilling any and all advanced practice requirements.

Question 10

10. You suspect that a colleague about to induce anesthesia on a patient is chemically impaired. Which initial intervention would be appropriate?

A. Delay the case until another CRNA is available
B. Allow the case to proceed but notify administration
C. Allow the case to proceed but notify the AANA
D. Perform the first 5-10 minutes of the case with the CRNA

Answer 10

A. Delay the case until another CRNA is available

According to the AANA code of ethics, the CRNA has a duty to take appropriate action to protect patients from healthcare providers who may subject the patient to situations that may cause harm, whether due to incompetence, impairment, illegality, or unethical practices. In this case, the CRNA should not allow the case to proceed until another anesthesia provider is available. Then, actions can be initiated to determine the nature of the impairment.

Question 11

11. A nurse anesthetist administered a drug by physician’s order that was found to be an erroneous dose that caused harm to the patient. Which of the following would relieve the anesthetist of the burden of ethical responsibility?

A. the physician’s order was erroneous
B. the institution had no policy indicating the dose was too large
C. the patient did not have an allergy to the drug
D. none of these relieve the burden of responsibility

Answer 11

D. none of these relieve the burden of responsibility

According to the AANA code of ethics, the CRNA is responsible and accountable for decisions and actions made in the course of his or her professional practice. Physician orders and institutional policies do not relieve the burden of responsibility of the CRNA.

Question 12

12. Which demographic is most likely to experience a type I hypersensitivity reaction under anesthesia?

A. Adult female
B. Adult male
C. Adolescent female
D. Adolescent male

Answer 12

A. Adult female

Adult females are three times more likely to experience a type I hypersensitivity reaction. There is no gender difference in adolescence, which suggests that sex hormones may play a role in the incidence of reactions.

Question 13

13. When should chest compressions be initiated in the neonate?

A. Heart rate < 60 bpm
B. Heart rate < 100 bpm
C. If apnea is present
D. If gasping is present

Answer 13

A. Heart rate < 60 bpm

After ventilation with oxygen for 30 seconds, chest compressions should be initiated in the neonate when the heart rate is less than 60 bpm.

Question 14

14. Alfentanil has a faster clearance in children because of their _____.

A. increased pulmonary uptake
B. smaller volume of distribution
C. increased hepatic blood flow
D. faster renal elimination

Answer 14

B. smaller volume of distribution

Alfentanil has a faster clearance in children because of their smaller volume of distribution for the drug.

Question 15

15. A patient with chronic renal failure exhibits life-threatening hyperkalemia and dialysis is not immediately available. Select two agents administered together to treat hyperkalemia.

A. Hypoventilation
B. Glucose administration
C. Insulin administration
D. Heparin administration

Answer 15

B. Glucose administration
C. Insulin administration

Although dialysis would be the definitive treatment for this patient, other treatments include: glucose, insulin, bicarbonate, and hyperventilation.

Question 16

16. A patient with a Bivona tracheostomy tube is about to undergo an MRI. You know that

A. you should replace the Bivona tube with a Shiley tube
B. the Bivona tube is MRI-safe
C. the presence of a tracheostomy is a contraindication to an MRI
D. vibrations from the MRI will often dislodge the Bivona tube

Answer 16

A. you should replace the Bivona tube with a Shiley tube

Although it is not mentioned in the product packaging, a Bivona tracheostomy tube contains ferrous material and should be replaced with a Shiley tube before the scan.

Question 17

What are the most common anatomical sites for invasive arterial monitoring line placement? (select two)

A. radial
B. brachial
C. femoral
D. dorsalis pedis

Answer 17

A. radial
C. femoral

Although many arterial sites can be used (including brachial, axillary, and dorsalis pedis), the most commonly used are the radial and femoral sites.

Question 18

18. The most common congenital abnormality that can result in aortic dissection is

A. Marfan syndrome
B. Bicuspid aortic valve
C. Ehlers-Danlos syndrome
D. Takayasu’s arteritis

Answer 18

B. Bicuspid aortic valve

Although Marfan syndrome and Ehlers-Danlos syndrome are associated with an increased risk for aortic aneurysm and dissection, bicuspid aortic valve is far more common, occurring in 1% of the population. Takayasu’s arteritis is associated with peripheral vascular disease.

Question 19

19. You are consulted by the emergency department for a patient exhibiting inspiratory stridor, drooling, sore throat, dysphagia, tachycardia, fever, and prefers a sitting, sniffing position to breathe easier. You suspect that this patient suffers from

A. Inflammation of the subglottic airway structures
B. Inflammation of the epiglottis
C. Inflammation of the supraglottic airway structures
D. Unilateral vocal cord paralysis

Answer 19

C. Inflammation of the supraglottic airway structures

Although this patient exhibits symptoms associated with epiglottitis, the diagnosis is a misnomer. The patient with epiglottitis actually suffers from generalized irritation and severe edema of all of the supraglottic structures. Some academics have even suggested renaming the condition supraglottitis to more accurately reflect the pathology.

Question 20

20. A patient has a pH of 7.3. You administer three acidic drugs to this patient that have three different pKa values. Match the degree of ionization you would expect to see in this patient with the pKa value of the drug.

pKa = 8.1            < 50% ionized     
pKa = 4.5            > 50% ionized      
pKa = 7.3             50% ionized

Answer 20

pKa = 8.1                > 50% ionized
pKa = 4.5                 50% ionized
pKa = 7.3 	        <50% ionized

An acidic drug with a pKa of 4.5 will be more than 50% ionized in a pH of 7.3. An acidic drug with a pKa of 7.3 will be exactly 50% ionized at a pH of 7.3. An acidic drug with a pKa of 8.1 will be less than 50% ionized at a pH of 7.3. Refer to the pKa workbook and video in this program for a detailed explanation of how to discern this information quickly.

Question 21

21. Which hormone is produced in the hypothalamus, released from the neurohyphosis, and targets the collecting ducts in the distal nephron?

A. Aldosterone
B. Antidiuretic hormone
C. Angiotensin
D. Atrial natriuretic factor

Answer 21

B. Antidiuretic hormone

Antidiuretic hormone (ADH) is a hormone produced in the hypothalamus, released from the neurohypophysis (posterior pituitary) and targets the distal nephron. ADH increases tubular permeability causing the reabsorption of water. In the absence of ADH, the collecting ducts and distal tubule are almost impermeable to water.

Question 22

22. Which anti-epileptic drug is least likely to produce aplastic anemia?

A. Valproate
B. Gabapentin
C. Phenytoin
D. Carbamazepine

Answer 22

B. Gabapentin

Antiepileptic drugs are associated with anemias. The symptoms are typically mild, but can occasionally produce aplastic anemia. They are most commonly seen with valproate, carbamazepine, and phenytoin.

Question 23

23. Factors that decrease the amount of prolapse in patients with mitral valve prolapse include (select four)

A. Drug-induced myocardial depression
B. Pulmonary hypertension
C. Increased preload
D. Hypertension
E. Decreased systemic vascular resistance
F. Tachycardia
G. Atrial fibrillation
H. Vasoconstriction

Answer 23

A. Drug-induced myocardial depression
C. Increased preload
D. Hypertension
H. Vasoconstriction

Any factor that maintains a larger ventricular volume will decrease the degree of prolapse. Hypertension, vasoconstriction, drug-induced myocardial depression, and increased preload will decrease the degree of prolapse.

Question 24

24. An attempt to touch a person without their consent, even if no harm is caused, is referred to as

A. wrongful contact
B. battery
C. felony touching
D. assault

Answer 24

D. assault

Assault is the attempt to touch another person. Battery is the actual touching of a person without their consent. Harm does not have to be caused in cases of assault or battery.

Question 25

25. What determines the duration of action of an irreversible antagonist? A. Hepatic blood flow B. Receptor regeneration C. Renal clearance of the drug D. The ED50 of the drug

Answer 25

B. Receptor regeneration Because the drug binds irreversibly with the receptor, the duration of action of the drug is not as closely related to its metabolism as it is to the speed at which new receptors can be produced.

Question 26

26. Which lung function test involves the inhalation of a gas mixture containing carbon monoxide? A. Diffusion capacity B. Body plethysmography C. Inhalation challenge test D. FEF 25-75

Answer 26

A. Diffusion capacity Because the oxygen level in the pulmonary capillaries varies as it moves through the lungs, oxygen cannot be used to measure the ability of gas to diffuse across the alveolar capillary membrane. Instead, a gas mixture containing carbon monoxide is used to determine diffusion capacity because carbon monoxide has a negligent partial pressure in the blood and binds to hemoglobin over 200 times more powerfully than oxygen.

Question 27

27. The pharmacokinetics of which neuromuscular blocking agent would be least affected by liver failure? A. Cisatracurium B. Pancuronium C. Rocuronium D. Vecuronium

Answer 27

A. Cisatracurium Because they rely on Hofmann elimination, the duration of action of atracurium and cisatracurium is not affected by hepatic disease. Repeat doses or continuous infusions of agents that rely on hepatic metabolism such as vecuronium, rocuronium, and pancuronium, however, are another story. As these drugs accumulate, the decreased ability of the liver to metabolize the drug can result in a prolonged duration of action. They also have active metabolites which contribute to the prolonged duration of action.

Question 28

28. Which statement helps explain why the duration of action of midazolam is prolonged in patients with renal disease? A. Midazolam is not a highly protein bound drug B. Renal insufficiency increases the plasma clearance of midazolam C. A large portion of midazolam is excreted as active metabolites D. The termination of midazolam's effect is primarily due to redistribution

Answer 28

C. A large portion of midazolam is excreted as active metabolites Benzodiazepines are extensively protein bound. The reduced protein binding in patients with renal disease results in an increased free fraction of the drug. Also, 60-80% of midazolam is excreted as an active metabolite. In renal disease, this metabolite accumulates and can result in prolonged sedation.

Question 29

29. Beta-adrenergic blockers administered to a parturient A. do not cross the placenta B. can produce reflex tachycardia in the newborn C. can result in hypoglycemia in the newborn D. are associated with fetal respiratory depression

Answer 29

C. can result in hypoglycemia in the newborn Beta-adrenergic blockers administered to a parturient cross the placenta and can produce bradycardia, hypoglycemia, and hypotension in the newborn. Beta-blockers are also likely to pass into breast milk.

Question 30

30. Bradycardia is associated with repeat doses of _____ in pediatric patients. A. glycopyrrolate B. ketamine C. propofol D. succinylcholine

Answer 30

D. succinylcholine Bradycardia and potentially asystole are potential side effects of succinylcholine re-administration, particular in children.

Question 31

31. Following a carotid endarterectomy, a patient in the recovery area exhibits significant headache and slurred speech followed by the onset of seizures. This would be consistent with A. myocardial infarction B. cerebellar dysfunction C. cerebral hyperperfusion syndrome D. ruptured abdominal aortic aneurysm

Answer 31

C. cerebral hyperperfusion syndrome Cerebral hyperperfusion syndrome can occur following a carotid endarterectomy and produce symptoms such as headache, seizures, cerebral edema, and intracerebral hemorrhage. It occurs due to the sudden relief of a high-grade stenosis combined with impaired cerebral autoregulation. It can be devastating, but complete recovery is possible if recognized and treated early. The primary goals are the treatment of hypertension and control of cerebral perfusion.

Question 32

32. Compared to standard video-assisted thoracoscopic surgery (VATS), robotic video-assisted thoracic surgery (RVATS) is associated with A. Decreased risk of chylothorax B. Increased risk of recurrent laryngeal nerve injury C. Decreased risk of perioperative morbidity D. Longer duration of hospital stay

Answer 32

B. Increased risk of recurrent laryngeal nerve injury Compared to a VATS, the RVATS procedure has similar lengths of hospital stay and risk of perioperative morbidity. The risks of chylothorax and recurrent laryngeal nerve injury are actually increased with an RVATS.

Question 33

33. Which of the following agents produces irreversible inhibition of platelet function by preventing the synthesis of thromboxane A2? A. Phosphodiesterase inhibitors B. ADP receptor antagonists C. Acetylsalicylic acid D. Glycoprotein Iib/IIIa receptor antagonists

Answer 33

C. Acetylsalicylic acid Cyclooxygenase inhibitors such as aspirin cause irreversible inhibition of platelet cyclooxygenase which prevents synthesis of thromboxane A2. ADP receptor antagonists such as ticlopidine and clopidogrel block the ADP receptor non-competitively and irreversibly inhibit IIb/IIIa platelet aggregation. Phosphodiesterase inhibitors such as dipyridamole act by inhibiting phosphodiesterase which results in an increase in cyclic AMP which is an inhibitor of platelet aggregation. Glycoprotein Iib/IIIa receptor antagonists such as abciximab reversibly block the Iib/IIIa site by which fibrinogen crosslinks platelets together.

Question 34

34. Which gas law states that the total pressure of a system is the additive pressure of each individual gas in a mixture? A. Boyle's B. Charles' C. Dalton's D. Gay-Lussac's

Answer 34

C. Dalton's Dalton's law states that the total pressure of a mixture of gases is equal to the sum of the pressures each individual gas in the mixture exerts.

Question 35

35. Which of the following is not a potential side effect of dexmedetomidine? A. delayed recovery B. hypotension C. bradycardia D. respiratory depression

Answer 35

D. respiratory depression Dexmedetomidine does not produce significant respiratory depression. Hypotension, bradycardia, oversedation, and delayed recovery are potential side effects of the drug.

Question 36

36. During the initial recovery period, which agent has been associated with a high incidence of altered short-term memory and cognition, hallucinations, and nightmares? A. Propofol B. Midazolam C. Ketamine D. Diazepam

Answer 36

C. Ketamine During the initial recovery period, ketamine has been associated with a high incidence of psychomimetic reactions. These include altered short-term memory and cognition, hallucinations, and nightmares.

Question 37

37. Which type of visual evoked potential is performed on an awake patient? A. Patterned VEPs B. Unpatterned VEPs C. Stochastic VEPs D. Constant simulus VEPs

Answer 37

A. Patterned VEPs During Visual Evoked Potentials (VEPs), the patient is presented a visual stimulus for a select number of times, then the cerebral responses are dispayed after being amplified and averaged on a computer. There are two types of VEPs: patterned and unpatterned. Patterned tests are used on awake patients.

Question 38

38. Which of the following statements regarding metabolic function in the elderly is true? A. Maximal oxygen consumption increases with age B. Circulating catecholamine levels decrease with age C. Insulin resistance decreases with age D. Elderly patients have a decreased response to beta-adrenergic agents

Answer 38

D. Elderly patients have a decreased response to beta-adrenergic agents Elderly patients have a decreased response to beta-adrenergic agents and an increase in circulating catecholamine levels. Maximal oxygen consumption decreases with age and insulin resistance increases, resulting in a decreased ability to handle glucose loads.

Question 39

39. What is the pH indicator added to soda lime to help assess the functional integrity of the absorbent? A. Ethyl violet B. Water C. Potassium hydroxide D. Sodium hydroxide

Answer 39

A. Ethyl violet Ethyl violet is a pH indicator that is added to soda lime to help determine when the absorbent is exhausted. When the pH of the absorbent decreases, the ethyl violet changes from colorless to purple.

Question 40

40. Heat that is lost as body moisture converts from the liquid phase to gas phase is referred to as A. radiant heat loss B. convective heat loss C. conductive heat loss D. evaporative heat loss

Answer 40

D. evaporative heat loss Evaporative heat loss occurs when moisture from the skin, exposed organs, and the respiratory tract turns from the liquid to gas phase. This process requires energy and the majority of the energy comes from our bodies. As a result of the loss of energy, our body loses heat as well.

Question 41

41. Which of the following is not associated with an increased risk for postoperative blindness in patients undergoing surgery in the prone position? A. bradycardia B. anemia C. prolonged surgical duration D. hypotension

Answer 41

A. bradycardia Factors associated with a higher risk for developing postoperative blindness following prone procedures include prolonged surgical duration, anemia or massive blood loss, and hypotension. Some studies have also implicated the knee-chest position and the use of a horseshoe headrest as possible contributing agents.

Question 42

42. Which factor decreases ETCO2 during anesthesia? A. Hypothermia B. Shivering C. Malignant hyperthermia D. Sepsis

Answer 42

A. Hypothermia Factors that will decrease ETCO2 include hypothermia and hypothyroidism.

Question 43

43. In the image below, place and X on the innominate artery.

Answer 43

From the patient's right to left, the three major vessels leaving the superior aspect of the aorta are: the innominate artery (also known as the brachiocephalic trunk), the left common carotid artery, and the left subclavian artery.

Question 44

``` 44. Your anesthetic plan for a patient includes spinal anesthesia. The patient takes several herbal medications. Which herbal agent would disrupt platelet aggregation for the longest period of time after discontinuation? A. Ginseng B. Garlic C. St. John's Wort D. Ginkgo ```

Answer 44

B. Garlic Garlic can disrupt platelet aggregation for up to 7 days after discontinuation. Ginkgo and ginseng both impair coagulation for about 36 hours after discontinuation.

Question 45

45. How do poorly-soluble substances such as glucose typically cross cell membranes? A. Passive transport B. Osmosis C. Facilitated diffusion D. Pinocytosis

Answer 45

C. Facilitated diffusion Glucose crosses cell membranes by a variety of methods, but it occurs primarily via facilitated diffusion, which is mediated by a carrier. Some cell sites also employ active transport.

Question 46

46. Which of the following statements regarding hemophilia is false? A. Hemophilia A is a sex-linked disorder B. Hemophilia B is also known as Christmas disease C. Patients with hemophilia A are deficient in factor VIII D. Factor VIII is known as Christmas factor

Answer 46

D. Factor VIII is known as Christmas factor Hemophilia A is a sex-linked deficiency of factor VIII that is carried on the X chromosome. Hemophilia B results from a decreased level of factor IX, also known as Christmas factor.

Question 47

47. Which of the following statements regarding hemophilia A are true? (select two) A. Hemophilia A is sex-linked and only affects males B. Patients with hemophilia A have a decrease in Factor VIII C. The PTT is prolonged in patients with hemophilia A D. Hemophilia A is also known as Christmas disease

Answer 47

B. Patients with hemophilia A have a decrease in Factor VIII C. The PTT is prolonged in patients with hemophilia A Hemophilia A is sex-linked recessive disorder but affects both males and females (males are just much more likely to have the disease). It is associated with a decrease in Factor VIII levels. Patients with hemophilia A will exhibit a prolonged PTT. Hemophilia B is also known as Christmas disease because Factor IX, which is deficient in patients with hemophilia B, is also known as Christmas factor.

Question 48

48. Which form of hepatitis is not transmitted by the percutaneous route? A. Type A B. Type B C. Type C D. Type D

Answer 48

A. Type A Hepatitis B, C, and D are all transmitted by the percutaneous route. Additionally, hepatitis B can be transmitted sexually. Hepatitis A, however, is transmitted via the fecal-oral route or by sewage-contaminated shellfish.

Question 49

49. You should be cautious in administering a high neuraxial block to a patient with chronic hepatic disease because the block can result in A. an increase in portal pressure B. a reduction in hepatic blood flow C. an decrease in circulating coagulation factors D. elevated ALT levels

Answer 49

B. a reduction in hepatic blood flow High (T5) neuraxial blocks are associated with a decrease in hepatic blood flow that may not be reversed with the administration of catecholamines.

Question 50

50. Which of the following statements regarding respiratory gas tension and cerebral blood flow (CBF) is true? A. CBF decreases in response to hypocapnia B. CBF is not related to carbon dioxide tension C. CBF is directly proportional to PaO2 between tensions of 50 and 100 mmHg D. PaO2 tension has no effect on CBF

Answer 50

A. CBF decreases in response to hypocapnia Hypocapnia decreases cerebral blood flow. This effect usually lasts for about 4-6 hours. PaO2 has little effect on CBF until it reaches a tension of 50 mmHg at which point it dramatically increases CBF.

Question 51

51. Which scoring system is useful for classifying the severity of cirrhosis as well as providing a 3-month mortality risk? A. Child-Pugh B. MELD C. APACHE D. CRAMS

Answer 51

B. MELD In the past, the Child-Pugh scoring system has been utilized in classifying the severity of cirrhosis; however, the MELD score is being used more often as it is also a reliable tool in measuring 3-month mortality risk.

Question 52

52. In which West lung zones would the pulmonary arterial pressure be greater than the alveolar pressure? A. Zones 1 and 2 B. Zones 1 and 3 C. Zones 2 and 3 D. Zones 1, 2, and 3

Answer 52

C. Zones 2 and 3 In West zone 1, the pulmonary alveolar pressure is greater than both the arterial and venous pressures (PA>Pa>Pv). In West zone 2 (Pa>PA>Pv) and West zone 3 (Pa>Pv>PA), the arterial pressure is greater than both the alveolar pressure and the venous pressure.

Question 53

53. You are performing a combined spinal/epidural anesthetic. You have already administered the spinal anesthetic and are preparing to inject local anesthetic through the epidural catheter. How will this affect the spinal block? A. It will increase the height of the spinal block B. It will decrease the height of the spinal block C. It will shorten the duration of the spinal block D. The epidural injection has no effect on the spinal block

Answer 53

A. It will increase the height of the spinal block Injection of solution through the epidural catheter is known to increase the spread of the spinal anesthetic. It is believed that the increased volume injected into the epidural space compresses the subarachnoid space, resulting in an increase in pressure that 'pushes' the local anesthetic in the subarachnoid space higher. Another cause is the leakage of local anesthetic from the epidural space into the subarachnoid space via the dural puncture made for the spinal anesthetic.

Question 54

54. Which of the following actions would be acceptable for helping to maintain the inspired humidity in a ventilated patient undergoing anesthesia? (select two) A. Rinsing the inside of the breathing bag with water prior to using it B. Connecting two HME's in a series in the breathing circuit C. Increasing the patient's tidal volume when using an HME D. Using a two-limbed circuit rather than a single limbed circuit

Answer 54

A. Rinsing the inside of the breathing bag with water prior to using it B. Connecting two HME's in a series in the breathing circuit Introducing water into the circuit by rinsing the inside of the breathing bag with water prior to using it is an acceptable way to increase inspired humidity. Using two HME's in a series can improve humidification, but care must be taken to monitor for the effects of increased deadspace or work of breathing. Increasing the patient's tidal volume will result in greater gas flow through the HME and will reduce its effectiveness. A single-limbed circuit will improve humidification to a slightly greater degree than a two-limbed circuit.

Question 55

55. Which antihypertensive exhibits both alpha-1 adrenergic and beta-adrenergic blockade? A. Verapamil B. Labetolol C. Metoprolol D. Esmolol

Answer 55

B. Labetolol Labetolol is unique in that it has selective alpha-1 receptor blocking properties as well as nonselective beta-1 and beta-2 adrenergic blocking properties.

Question 56

56. Levothyroxine is A. synthetic T3 B. synthetic T4 C. synthetic triiodothyronine D. propylthiouracil

Answer 56

B. synthetic T4 Levothyroxine is a synthetic form of thyroxine, or T4. In the tissues, it is deiodinated into triiodothyronine (T3). Propylthiouracil is an antithyroid medication.

Question 57

57. Which of the following devices would not be recommended for use in a magnetic resonance imaging suite? A. wall oxygen flowmeters B. ETCO2 sampling line extension C. supraglottic airway device D. anode endotracheal tube

Answer 57

D. anode endotracheal tube Loops in the monitor leads can cause thermal injury during the MRI. The magnetic field can induce the flow of current in coiled leads or tubing, causing them to become hot enough to burn the patient. For this reason, flexible LMAs and anode endotracheal tubes that contain wire winding should not be used. Even tissue loops, such as the curve caused by the patient's hand touching his/her hip can induce current flow and result in injury. All of the standard equipment necessary to deliver anesthesia in any other environment is still mandatory for delivery of an anesthetic in an MRI suite, including all monitoring and emergency equipment. An oxygen supply is necessary, but is usually provided by a non-ferrous wall oxygen flowmeter.

Question 58

58. What is the most rapidly growing tumor of the anterior mediastinum in children? A. Lymphoblastic T cell lymphoma B. Mediastinal teratoma C. Thymoma D. Thyroid cancer

Answer 58

A. Lymphoblastic T cell lymphoma Lymphoblastic T cell lymphoma is the most rapidly growing tumor in the mediastinum in children.

Question 59

59. At what age does the MAC value start to decrease? A. 30 B. 40 C. 50 D. 60

Answer 59

B. 40 MAC decreases by about 6% percent per decade after the age of 40.

Question 60

60. Neonates may exhibit an increased free fraction of sufentanil primarily because they have A. decreased levels of alpha-1 acid glycoprotein B. increased albumin levels C. decreased total body water D. decreased muscle mass

Answer 60

A. decreased levels of alpha-1 acid glycoprotein Neonates have decreased levels of alpha-1 acid glycoprotein. As a result, they may require lower doses proportionally because of the increased free fraction of the drug.

Question 61

61. Which of the following drugs would not be safe for use in the anesthetic management of a patient with acute porphyria? A. Nitrous oxide B. Neostigmine C. Morphine D. Ketorolac

Answer 61

D. Ketorolac Nitrous oxide, neostigmine, morphine, fentanyl, succinylcholine, pancuronium, and propofol are considered safe for use in patients with porphyria. Ketorolac, thiopental, thiamylal, etomidate, pentazocine, methohexital, and nifedipine should all be avoided.

Question 62

62. Which chemical is responsible for mediating nonshivering thermogenesis in the newborn? A. Norepinephrine B. Epinephrine C. Serotonin D. Histamine

Answer 62

A. Norepinephrine Nonshivering thermogenesis is a norepinephrine-mediated mechanism of heat production that involves uncoupling of oxidative phosphorylation within the mitochondria-rich brown fat cells found over the neck, back, viscera, and great vessels. Nonshivering thermogenesis occurs in premature infants and full-term newborns, but does not occur in adults.

Question 63

63. The absorption and distribution of a drug would fall under the study of A. pharmacokinetics B. pharmacodynamics C. pharmacogenomics D. distributive science

Answer 63

A. pharmacokinetics Pharmacokinetics, or what the body does to the drug can be remembered with the ADME mnemonic, which stands for absorption, distribution, metabolism, and excretion of the drug. Understanding how a drug is affected by these processes can help you predict what changes would occur if a patient has an alteration in one of them.

Question 64

64. Select two nonselective alpha-antagonist agents used to manage pheochromocytoma. A. Doxazosin B. Terazosin C. Phentolamine D. Phenoxybenzamine

Answer 64

C. Phentolamine D. Phenoxybenzamine Phenoxybenzamine is the most commonly used alpha-blocker in the treatment of pheochromocytoma, but phentolamine is also used.

Question 65

65. The use of desflurane and isoflurane with a dessicated CO2 absorbent can result in the production of A. compound A B. carbon monoxide C. free oxygen radicals D. increased serum fluoride levels in the patient

Answer 65

B. carbon monoxide Prolonged exposure of desflurane or isoflurane to dessicated CO2 absorbent can result in the degradation of the anesthetic with the resulting production of carbon monoxide. Increased temperature and higher doses of anesthetic agent both increase the amount of carbon monoxide produced.

Question 66

66. A patient with hemophilia B is about to undergo orthopedic surgery. Which agent is most appropriate for decreasing the bleeding tendency of this patient? A. factor IX-prothrombin complexes B. packed red blood cells C. purified factor IX D. albumin

Answer 66

C. purified factor IX Recombinant factor IX, purified factor IX, or factor IX-prothrombin complex can be used for preoperative prophylaxis or to treat bleeding episodes. One caution in the use of factor IX-prothrombin complexes is that sufficient doses to elevate the factor IX quantities above 50% are associated with an increased risk of thromboembolic phenomena, especially in patients undergoing orthopedic procedures. In these cases, it is important to use purified or recombinant factor IX.

Question 67

67. Compared to resection of another portion of the liver, a right hepatic lobectomy places the patient at risk for an increased incidence of A. postoperative pain B. hypertensive crisis C. disseminated intravascular coagulation D. air embolism

Answer 67

D. air embolism Resection of a large part of the liver (such as a right lobectomy) or resection of a tumor near the vena cava or portal vessels increases the risk for air embolism.

Question 68

68. Which of the following devices offers the most resistance to breathing? A. A 7.5 mm endotracheal tube B. A size 4 LMA C. The y-piece on a dual-limb anesthesia circuit D. The corrugated tubing of an anesthesia circuit

Answer 68

A. A 7.5 mm endotracheal tube Resistance to gas flow is a function of the length of the tube and its diameter. The shorter the length and the larger the diameter, the less resistance it offers. Of these items, the endotracheal tube offers the greatest amount of resistance to gas flow.

Question 69

69. Resistive heating devices utilize what method of heat transfer? A. Conduction B. Convection C. Radiation D. Evaporation

Answer 69

A. Conduction Resistive heat devices such as a heating blanket transfer heat via conduction.

Question 70

70. Which of the following agents is a long-acting beta-2 agonist? A. albuterol B. epinephrine C. salmeterol D. terbutaline

Answer 70

C. salmeterol Salmeterol, formoterol, and arformoterol are long-acting beta-2 agonists used in the treatment of asthma. Albuterol, terbutaline, and epinephrine are short-acting beta-2 agonists.

Question 71

71. What is the most common cause of secondary hypertension? A. Obesity B. Hyperlipidemia C. Renal artery stenosis D. Hyperaldosteronism

Answer 71

C. Renal artery stenosis Secondary hypertension is an increase in blood pressure due to a cause that can be identified and cured such as pheochromocytoma, renal artery stenosis, coarctation of the aorta, Conn's syndrome, or Cushing's disease. Renal artery stenosis is the most common cause of secondary hypertension.

Question 72

72. Sevoflurane may need to be used with caution or possibly avoided in patients with A. epilepsy B. liver failure C. disseminated intravascular coagulation D. Down syndrome

Answer 72

A. epilepsy Sevoflurane can enhance seizure activity and needs to be used with caution in patients with a history of epilepsy.

Question 73

73. Which local anesthetic exists as a pure S enantiomer? A. Bupivacaine B. Ropivacaine C. Tetracaine D. Benzocaine

Answer 73

B. Ropivacaine Some local anesthetics such as mepivacaine, bupivacaine, and ropivacaine are known as chiral drugs because they have a carbon atom with an asymmetrical position. As a result, these drugs can have a left-handed configuration known as an S-enantiomer or a right-handed configuration known as an R-enantiomer. Most commercially available preparations of mepivacaine and bupivacaine are racemic preparations, meaning that they are equal parts S and R enantiomers. Ropivacaine and levobupivacaine, however, are developed as pure S enantiomers which are considered to be less neurotoxic and cardiotoxic.

Question 74

74. Select two hemodynamic changes that result from carotid and aortic body stimulation. A. Decreases in adrenal secretion B. Bradycardia C. Hypertension D. Decreases in bronchiolar tone

Answer 74

B. Bradycardia C. Hypertension Stimulation of carotid and aortic bodies produces hypertension, bradycardia, an increase in adrenal secretions, and an increase in bronchiolar tone.

Question 75

75. A patient has a BMI of 51 and is presenting for gastric bypass surgery. What would be the most appropriate method of airway management? A. Insertion of a combitube B. Intubation through an intubating LMA C. Awake fiberoptic intubation D. Cricothyrotomy

Answer 75

C. Awake fiberoptic intubation Studies differ with respect to whether all obese patients are at risk for pulmonary aspiration. It is generally accepted, however, that patients above a BMI of 50 should undergo awake intubation or intubation with propofol alone and no muscle relaxation.

Question 76

76. Which of the following is a potential side effect of the addition of clonidine to an epidural used for postoperative pain management? A. Bradycardia B. Hypertension C. Hypokalemia D. Hyperventilation

Answer 76

A. Bradycardia

Question 77

77. Which antibiotic class is associated with aggravation of muscle weakness in patients with myasthenia gravis? A. Carbapenems B. Cephalosporins C. Macrolides D. Aminoglycosides

Answer 77

D. Aminoglycosides The administration of aminoglycoside antibiotics is associated with aggravation of muscle weakness in myathenic patients.

Question 78

78. Afferent fibers from peripheral nociceptors enter the spinal cord through the A. ventral root B. dorsal root C. laminae D. brain stem

Answer 78

B. dorsal root The afferent fibers from peripheral nociceptors enter the spinal cord through the dorsal root. They may ascend or descend the tract of Lissauer and then synapse with dorsal horn neurons.

Question 79

79. What is the primary blood supply to the thoracolumbar spinal cord? A. Posterior spinal arteries B. Artery of Adamkiewicz C. Costocervical trunk D. Anterior intercostal artery

Answer 79

B. Artery of Adamkiewicz The artery of Adamkiewicz is an aortic radicular artery that supplies most of the blood flow to the anterior spinal artery.

Question 80

80. 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

Answer 80

B. a single anterior and paired posterior arteries 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.

Question 81

81. Which of the following statements regarding the hematology studies of a full-term parturient is correct? A. The total blood volume decreases B. The average platelet count is about 50,000 C. A relative polycythemia is present during pregnancy D. The red blood cell mass increases

Answer 81

D. The red blood cell mass increases The blood volume increases as pregnancy progresses. The total increase is about 25-40% over normal values at term. Because the red blood cell mass only increases by about 20%, there is a relative anemia present.

Question 82

82. The pulse oximeter alarms that the patient is tachycardic. What initial actions are appropriate? (Select two) A. Palpate the pulse B. Administer esmolol C. Verify the rate with the ECG D. Notify the surgeon

Answer 82

A. Palpate the pulse C. Verify the rate with the ECG The first actions to be taken in response to this alarm would be to verify with the ECG and palpate the pulse. False triggers of this alarm could be electrocautery interference or double counting of the P or T waves.

Question 83

83. Rapid sequence induction, cricoid pressure, and a cuffed endotracheal tube are recommended for pregnant women receiving general anesthesia from ____ weeks on even if no symptoms of reflux are present. A. 12 B. 15 C. 18 D. 20

Answer 83

D. 20 The general recommendation is to utilize a rapid sequence induction of general anesthesia for patients at or past the 20th week of gestation due to the increased risk of aspiration.

Question 84

84. Which values represent the normal Hemoglobin A1C range? A. 1-3% B. 4-6% C. 7-8% D. 10% or greater

Answer 84

B. 4-6% The hemoglobin A1C test is considered a more informative measurement of glucose tolerance because it is a measurement of long-term glucose control. The normal hemoglobin A1C level is between 4 and 6 percent.

Question 85

85. What is the minimum time to wait after an epidural steroid injection before attempting a second injection? A. 2 days B. 2 weeks C. 2 months D. 6 months

Answer 85

B. 2 weeks The injection should be given at least 2-3 weeks to allow time for the corticosteroid to exert its effects.

Question 86

86. What method can help prevent lens fogging when using a flexible fiberoptic laryngoscope? A. Soaking the scope in cold water B. Soaking the scope in warm water C. Cleaning the lens with ethyl alcohol D. Cleaning the lens with bleach

Answer 86

B. Soaking the scope in warm water The lens of the scope can become fogged, making visualization difficult. This is more common if the scope is cold, so soaking it in warm saline prior to the procedure helps prevent fogging. The fiberoptic strands in the scope are fragile and can become broken easily. As strands break, visualization can become limited. Care must be taken to protect the instrument from damage, and it should be stored in a safe, secure location. Secretions and blood can obstruct the view of the scope. It contains a suction channel that runs the length of the scope that can be irrigated with normal saline to wash secretions out of the viewing area.

Question 87

87. The most common indication for liver transplantation is cirrhosis due to A. alcohol abuse B. hepatitis B C. hepatitis C D. primary sclerosing cholangitis

Answer 87

C. hepatitis C The most common indication for liver transplantation is cirrhosis due to hepatitis C virus (HCV), however there are many other vast causes ranging from other forms of hepatitis, congenital abnormalities such as cystic fibrosis, malignancies like hepatocellular carcinoma, chronic liver disorders like primary sclerosing cholangitis, and alcoholic cirrhosis, to name a few.

Question 88

88. The nitrous oxide shutoff device on an anesthesia machine A. prevents barotrauma due to pressing the oxygen flush valve B. alarms when the inspired oxygen concentration falls below 21% C. triggers an alarm when the ventilator fails to function D. turns off the nitrous oxide supply when the oxygen pressure drops

Answer 88

D. turns off the nitrous oxide supply when the oxygen pressure drops The nitrous oxide shutoff device (also known as the fail safe device) triggers an alarm and closes the supply of nitrous oxide and other gases when the oxygen pressure falls below 30 psi.

Question 89

89. An increased BUN:creatinine ratio is consistent with A. increased creatinine production B. volume expansion C. decreased urea input D. decreased blood volume

Answer 89

D. decreased blood volume The normal serum ratio of urea nitrogen to creatinine is 10:1. Decreased ratios are associated with increased creatinine production, volume expansion, and decreased urea input. Increased ratios are associated with decreased blood volume, obstructive uropathy, and increased urea input. An increase in BUN with a normal serum creatinine concentration is indicative of a nonrenal cause in elevation.

Question 90

90. Which is the only safety device that evaluates the integrity of the low-pressure circuit in an ongoing fashion? A. Fail-safe valve B. Oxygen supply failure C. Oxygen analyzer D. Proportioning system

Answer 90

C. Oxygen analyzer The oxygen analyzer is the only machine safety device that evaluates the integrity of the low-pressure circuit in an ongoing fashion. It is the only machine monitor that can detect problems downstream from the flow control valves.

Question 91

91. A patient exhibits hypokalemia, but the issue is not emergent. Over what minimum amount of time should you administer 20 mEq of potassium intravenously? A. 5 minutes B. 15 minutes C. 30 minutes D. 60 minutes

Answer 91

D. 60 minutes The presence of paralysis or cardiac dysrhythmias indicates a hypokalemia severe enough to warrant intravenous administration of potassium at rates as high as 20 mEq over 30 minutes. Because the rapid administration of potassium can also produce dysrhythmias, the patient should undergo ECG monitoring during rapid potassium replacement. Nonemergent hypokalemia is preferably treated with enteral potassium supplementation. If intravenous administration is selected for a nonemergent hypokalemia, the rate of administration should not exceed 20 mEq/hour.

Question 92

92. Which of the following would most likely be a cause of hypovolemic hyponatremia? A. Diuretic use B. Cirrhosis C. Nephrotic syndrome D. SIADH

Answer 92

A. Diuretic use The three major categories of hyponatremia are hypervolemic, euvolemic, and hypovolemic. Hypervolemic hyponatremia may be caused by renal failure, congestive heart failure, cirrhosis, or nephrotic syndrome. Euvolemic hyponatremia is suggestive of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Hypovolemic hyponatremia results from free water loss from the kidneys. This can result from diuretic use, mineralocorticoid deficiency, third spacing, gastrointestinal water losses, or nephropathy. The treatment of hyponatremia varies with the volume status of the patient. Hypovolemic hyponatremia is typically treated by volume resuscitation with normal saline. Euvolemic and hypervolemic hyponatremia are treated with water restriction and the use of loop diuretics. Saline administration may be required if symptoms are severe. Acute symptomatic hyponatremia must be treated with hypertonic saline and loop diuretics to promote renal excretion of water.

Question 93

93. In which area of the adrenal gland is cortisol produced? A. Zona glomerulosa B. Zona fasciculata C. Zona reticularis D. Zona denticulata

Answer 93

B. Zona fasciculata The three zones of the adrenal gland from outermost to innermost are the zona glomerulosa (produces mineralocorticoids such as aldosterone), the zona fasciculata (produces glucocorticoids such as cortisol), and the zona reticularis (which produces sex steroids such as androgens). The zona denticulata does not exist.

Question 94

94. What would be the most appropriate intervention for a patient with hyperparathyroidism who has a serum calcium level of 11 mg/dL? A. Calcium gluconate B. Magnesium infusion C. 500 mL intravenous bolus of Lactated Ringer's D. Saline infusion and loop diuretics

Answer 94

D. Saline infusion and loop diuretics The treatment for mild hypercalcemia that is mild (less than 12 mg/dL) is saline infusion and loop diuretics. Other agents that may be used are calcitonin or biphosphonates such as pamidronate which will inhibit the resorption of bone by osteoclasts.

Question 95

95. Basic Principles of Anesthesia: Positioning Select two interventions to prevent ischemic optic neuropathy during spinal fusion surgery. A. Use of crystalloids only B. Maintaining the level of the head above the heart C. Lubricating the eyes D. Reducing venous congestion

Answer 95

B. Maintaining the level of the head above the heart D. Reducing venous congestion The use of crystalloids and colloids to maintain intravascular volume and reduction of intra-abdominal pressure to prevent venous congestion (such as with a Wilson frame) are factors that may help prevent optic ischemia. Limiting the duration of the surgery will also decrease the risk. Although lubricating the eyes may help reduce the risk of a corneal abrasion, it would not affect venous congestion in the eyes.

Question 96

96. Which of the following drugs used in the treatment of rheumatoid arthritis can prolong the duration of succinylcholine? A. Etanercept B. Adlimumab C. Cyclophosphamide D. Corticosteroids

Answer 96

C. Cyclophosphamide The use of cyclophosphamide can inhibit plasma cholinesterase and prolong the duration of action of succinylcholine. Etanercept and adlimumab are anticytokine agents used in the treatment of rheumatoid arthritis.

Question 97

97. Which of the following agents decreases hepatic glucose production? A. Pioglitazone B. Repaglinide C. Glipizide D. Metformin

Answer 97

D. Metformin Thiazolinediones (pioglitazone) and metformin (a biguanide) enhance tissue sensitivity to insulin. Metformin also decreases hepatic glucose production. Meglitinides such as repaglinide increase insulin secretion. Sulfonylureas such as glipizide increase insulin secretion.

Question 98

98. A patient exhibits a sodium level of 130 mEq/L and a serum osmolarity of 315 mOsm/L. Previous administration of which of the following would most likely explain these findings? A. Furosemide B. Spironolactone C. Large volume normal saline boluses D. Mannitol

Answer 98

D. Mannitol This patient has a low serum sodium concentration but a high serum osmolarity. Hyponatremia with a normal or high serum osmolarity results from the presence of non-sodium solutes such as glucose or mannitol.

Question 99

99. Clinically, one of the first signs of vitamin B12 deficiency is A. leukocytosis B. blurred vision C. megaloblastic anemia D. cardiomegaly

Answer 99

C. megaloblastic anemia Vitamin B12 deficiency can produce symptoms such as peripheral neuropathy, myelopathy, and encephalopathy, but the first clinical presentation is typically megaloblastic anemia (also known as pernicious anemia). Megaloblastic anemia is also the most common presentation of folic acid deficiency.

Question 100

100. Which action is most prudent in the intraoperative care of a patient underoing an awake craniotomy? A. Use a laryngeal mask airway B. Ensure the patient's face is always visible C. Avoid propofol D. Avoid remifentanil

Answer 100

B. Ensure the patient's face is always visible When an intracranial lesion is near a center of the brain that controls speech, motor function, or sensory function, it may be advantageous to perform the craniotomy awake, meaning under monitored anesthesia care. This allows for real-time mapping of the cortex and helps reduce the risk of causing neurologic dysfunction. The surgical drape should be positioned so that the patient's face is directly and constantly accessible. It is important to prevent hypoventilation and hypercapnia that could affect surgical exposure. Also, oversedation that results in apnea could be extremely difficult to manage once the patient is positioned in Mayfield tongs.