CPAN Flashcards
(88 cards)
A 64-year-old man presents for elective laparoscopic cholecystectomy under general anesthesia. The patient has a two-year history of Parkinson’s disease and is taking levodopa/carbidopa. Which of the following is the most appropriate prophylactic antiemetic for this patient?
- Metoclopramide
- Ondansetron
- Prochlorperazine
- Droperidol
The correct answer is:
- Ondansetron
Patients taking levodopa/carbidopa show a high incidence of postoperative nausea and vomiting. This is related to the direct activation of dopamine (D2) receptors by the levodopa in the chemoreceptor trigger zone.
Ondansetron has neither anti-dopaminergic activity nor any agonist action at acetylcholine receptors. It blocks the action of serotonin at 5-HT3 receptors to produce antiemesis.
Ondansetron is an ideal agent for postoperative nausea prophylaxis as it has no sedative potential.
Ondansetron efficacy is higher than metoclopramide for nausea prophylaxis.
A 52-year-old man is to undergo a routine open inguinal hernia repair. He has no past medical history and takes no regular medications. In the anesthetic room, he is given propofol, fentanyl, and succinylcholine intravenously. Absence of which of the following enzymes could prolong the neuromuscular blockade effects induced by one of the anesthetic drugs?
- Glucose-6-phosphate dehydrogenase
- Plasma cholinesterase
- Dopamine beta-hydroxyl add
- Cytochrome P450 oxidase
The correct answer is :
- Plasma cholinesterase
Succinylcholine chloride is a short acting depolarizing neuromuscular blockade that is approved by the United States food and drug administration (FDA) as a provision to other sedatives or hypnotics. It is a correlate acetylcholine (ACh); hence, it disrupts all cholinergic receptors of the parasympathetic and sympathetic nervous system.
Decreased levels of plasma cholinesterase are seen in patients with genetic defects, pregnancy malignancy, severe liver disease, chronic renal failure burns infections, anemia, myxedema, and peptic ulcer disease.
This can lead to prolonged effects of succinylcholine, including complete skeletal muscle paralysis. Hyperkalemia can also occur.
The activity of plasma cholinesterase can be decreased by the use of oral contraceptives, corticosteroids, MAO inhibitors, or organophosphate insecticides.
A 16-year-old male student presents to the emergency department after being assaulted by a drug dealer. The patient is conscious and gives a history of being stabbed in the abdomen. The primary survey reveals a 3cm linear deep wound in his epigastric region. His vitals are taken that show a heart rate of 118 beats/minute, a blood pressure of 85/55 mmHg, and a respiratory rate of 20/minute. The patient is resuscitated and shifted to operation room for urgent exploratory laparotomy. During the laparotomy, an anterior gastric perforation is visualized, which is then repaired using the Modified Graham patch repair technique. What is the method of choice for managing postoperative pain in this patient?
- As needed pain medications on demand
- Patient-controlled analgesia
- Epidural anesthesia
- Spinal anesthesia
The correct answer is:
- Patient-Control Analgesia (PCA)
In the hospital, patient-controlled analgesia (PCA) is the best way to deliver pain medication post-operatively.
An infusion pump delivers an intravenous analgesic to the patient when the patient pushes a button.
PCA reduces the wait-time to receive pain medication, reduces nursing work, and reduces the chance of medication errors.
PCA is useful for patients who have good mentation and are physically able to push the button.
1
A clinician is trying to reposition the endotracheal tube and is having some difficulty doing so; he asks for an instrument to aid in this task. Which of the following instruments is likely to be most helpfulin this scenario?
Bayonet forceps
Transfer forceps
Bozeman forceps
Magill forceps
The correct answer is:
- Magill forceps
Endotracheal intubation is an essential skill performed by multiple medical specialists to secure a patient’s airway and provide oxygenation and ventilation.
Magill forceps are angled forceps.
It guides a tracheal tube into the larynx or can also guide the nasogastric tube into the esophagus under direct vision.
These forceps can also be used to remove foreign bodies.
A 45-year-old female patient had to undergo a total abdominal hysterectomy because of menorrhagia non-responsive to pharmacological therapy. Her vital signs are stable, and the preoperative assessment revealed her to be an ideal candidate for general anesthesia. What would be the optimum time for the clinician to administer preoperative antibiotics to this patient so that she has proper antibiotic cover during the operation and does not develop a postoperative infection?
12 hours prior to the incision
60 minutes after the incision
Within 30 to 60 minutes prior to incision
Immediately after the completion of the surgery
The correct answer is:
Within 30 to 60 minutes prior to incision
The first dose is recommended to be timed to occur within 30 to 60 minutes before the surgical incision is made. If a fluoroquinolone or vancomycin is chosen for prophylaxis, the first dose should be administered within 120 minutes of the start of surgery.
The literature supports at least 30 minutes, but no greater than 60 minutes before the skin incision is made as to the optimal timing for the preoperative administration of most commonly used antibiotics. Special consideration is given for ideal preoperative timing when using a tourniquet, as the administration is least effective when the antibiotic is given after the application of a tourniquet.
Weight-based dosing should be followed per standardized protocol, and administration should occur within 1 hour of skin incision and continue for 24 hours postoperatively. Furthermore, surgical durations of greater than 4 hours or estimated blood loss over 1,500 mL necessitates repeat intraoperative dosing of antibiotics. Weight-based guidelines include A. cefazolin 2 g (3 g for weight >120 kg) as a standard adult surgical prophylaxis guideline and B. vancomycin 15 mg/kg.
Unless there is a known infection, prophylactic antibiotics should be discontinued within 24 hours. There remains controversy regarding the duration of therapy to 48 hours postoperatively following cardiothoracic surgery.
In a post-open-heart surgery patient, excessive morphine has been administered. What is the most sensitive indicator of opioid-induced respiratory depression?
- Respiratory rate
- Level of consciousness
- Confusion
- Arterial CO2
The correct answer is:
- Level of consciousness
Drowsiness after opioid is often a marker for respiratory depression.
Before the respiratory rate slows down, most people with opioid toxicity develop drowsiness or a decreased level of consciousness.
Several drugs have been developed which can block respiratory depression completely without affecting analgesia.
Once drowsiness occurs, apnea quickly follows. Naloxone can reverse this stage immediately.
Which of the following is the best method to determine if a patient has a patent airway in an emergency?
- Physical examination of the airway
- Ask the patient to speak
- The jaw thrust maneuver
- The head tilt-chin lift maneuver
The correct answer is:
- Ask the patient to speak
The best method to determine if a patient has a Peyton airway is to ask the patient to speak .
Clear speech indicates a patent airway .
Abnormal speech or the inability to speak, may indicate an obstructed airway .
The jaw thrust and head tilt-chin lift maneuvers are used to open the airway while using bag-valve-mask ventilation .
A 40-year-old patient is scheduled for laparoscopic cholecystectomy. She states that her aunt had a severe reaction to anesthesia and was in the ICU for 1 week. What is the neuromuscular-blocking agent associated with the underlying cause?
- Succinylcholine
- Vecuronium
- Rocuronium
- Atracurium
The correct answer is:
- Succinylcholine
Succinylcholine, along with halogenated inhaled volatile anesthetics, can cause malignant hyperthermia.
Malignant hyperthermia is associated with a hypermetabolic state. It is also associated with hypercarbia, acidosis, fever, circulatory collapse, and muscle rigidity.
Malignant hyperthermia is an autosomal dominant disorder that, if untreated, may cause death.
Dantrolene is the gold standard treatment for malignant hyperthermia in a dose of 2.5 mg/kg that may be repeated to a maximum of 10 mg/kg. Rarely, if symptoms persist, higher doses may be required.
A 27-year-old gravida 2 para 1 presented to the hospital in labor 6 hours ago. She is at 38 weeks gestation. She initially did not want any medication’s for analgesia, but she is now requesting an epidural for her labor pain. The on-call anesthetist explains to her that the epidural catheter will inject her epidural space with medications and will be connected to patient-controlled analgesia (PCA) pump. She is initially uncomfortable with this care plan because she is afraid of overdosing. Which of the following is the most appropriate response for her concern?
- The medications used for PCA do not have any severe or fatal side effects, so the use of more of these medications is not a concern for patient safety.
- A maximum dosage per every 24-hours will be programmed into the machine so it will be impossible for her to overdose.
- PCA has been found to reduce the length of a hospital stay when compared to traditional nurse administered scheduled dosing.
- PCA has been found to have no significant difference between opioid-related side effects compared to traditional nurse-administered schedule dosing.
The correct answer is:
- PCA has been found to have no significant difference between opioid-related side effects compared to traditional nurse-administered schedule dosing.
When PCA was compared to traditional dosing, it was documented to result and higher opioid consumption. However, those same studies also found no significant difference between opioid-related side effects, potentially indicating that the amount of opioid consumption is irrelevant.
The goal of PCA is to provide the patient with adequate pain, relief and minimize undesired outcomes. While PCA therapy has been found to consume more opioid medication, it does not increase opioid related side effects. This indicates that the goal of PCA is maintained within that data.
PCA allows patients to be in more control over their pain and helps them shift toward a more internal locus of control over their care. This explains why it has been found to increase patient satisfaction when it comes to pain control. The increased consumption of opioids without an increased side effects is worth it for the increased patient satisfaction.
Opioid medication’s can have severe and fatal side effects; extreme care needs to be taken when these medication’s are utilized. Patient CA has been found to be less cost-effective than traditional dosing and has no effect on the average length of hospital stay. PCA can be an effective way to administer analgesia and improve patient and nurse satisfaction. However, a multimodal cost-benefit analysis of the treatment plan should be performed before PCA is initiated to avoid undesired outcomes.
A 15-year old male presents with a full-thickness laceration to the right first digit. The provider effectively sutures the laceration closed. However, several hours later, the area surrounding the laceration becomes painful, dusky, and later necrotic. Which of the following is the most likely cause for this event?
- He is on calcium channel blocker for a tachyarrhythmia
- Bupivacaine
- Bupivacaine mixed with epinephrine
- Lidocaine
The correct answer is:
- Bupivacaine mixed with epinephrine
Epinephrine causes vasoconstriction. If used in the digits, nose or penis, this causes vasoconstriction that can lead to ischemia and necrosis.
Bupivacaine or lidocaine without epinephrine is indicated for local anesthetic in these circumstances.
Accidental firing of Epinephrine-pens into the thumb is a frequent cause of similar events.
Calcium channel blockers would cause vasodilation.
What type of electrolyte abnormality is expected in patients who have had a transurethral resection of the prostrate?
- Hypocalcemia
- Hypokalemia
- Hypernatremia
- Hyponatremia
The correct answer is:
- Hyponatremia
Significant absorption of non-electrolyte irrigation solutions such of as glycine, mannitol or sorbitol causes hyponatremia.
Symptoms are usually seen with drops in serum sodium exceeding 10 mEq/L.
Confusion, diminished reflexes, convulsions, stupor, or coma may occur.
The serum osmolal gap can be used to estimate the concentration of the absorbed irritant and its non-ionized metabolites.
A 42 year-old male patient is brought to the emergency department after having been thrown off his motorbike after which his lower extremities were crushed by a passing semi-truck. His vital signs are stable although the patient is unconscious and has significant crush injuries to his bilateral lower extremities below the knees. It is decided to intubate the patient to protect his airway. Which is contraindicated in this scenario?
- Cisatracurium
- Succinylcholine
- Atracurium
- Rocuronium
The correct answer is:
- Succinylcholine
Cisatracurium is a nondepolarizing paralytic and may be used in this patient. Cisatracurium causes histamine release which can cause hypotension, flushing, and broncospasm. In this patient, the depolararizing agent succinylcholine should be avoided since it may cause dangerously high levels of potassium and patients with crush injuries.
Succinylcholine should be avoided and patients with massive tissue damage, such as burns or after crush injuries. As a depolarizing agent, it can cause massive potassium effluent in these conditions leading to arrhythmias and even cardiac arrest.
Atracurium is a nondepolarizing paralytic and may be used in this patient. Atracurium is also associated with histamine release and can cause hypotension, flushing, and bronchospasm. In this patient, the depolarizing agent succinylcholine should be avoided since it may cause dangerously high levels of potassium in patients with crush injuries.
Rocuronium is a nondepolarizing paralytic and may be used in this patient. Rocuronium is metabolized by the liver, and there is a relative contraindication to this drug in patients with liver disease. In this patient, the depolarizing agent succinylcholine should be avoided since it may cause dangerously high levels of potassium in patients with crush injuries.
A 75 year-old female with a past medical history of chronic obstructive, pulmonary disease and hypertension is undergoing a femoral-popliteal bypass. After completion of the bypass, the vascular surgeon ask to reverse the heparin with 70 milligrams (mg) of protamine. The 70 mg of protamine is mistakenly injected as a single intravenous push dose. Which of the following adverse effects is most likely to have occurred as they result?
- Hypertension
- Hypotension
- Fever
- Muscle rigidity
The correct answer is:
- Hypotension
Protamine reverses the anticoagulant effects of heparin .
Protamine is derived from fish sperm and is high in arginine content.
The positively charged protein, particles and protein interact with the negatively charged heparin.
Adverse effects of protamine, including flushing, broncoconstruction, hypersensitivity, and hypotension. It is essential to give protamine a slow infusion because the hypotension can be severe.
A 17 year-old male is brought to the hospital after a fall. He is being treated with chemotherapy for leukemia. His vital signs are within normal limits. His physical exam shows a 0.5 cm linear laceration on the dorsal aspect of his left arm, which is repaired with 2-octyl cyanoacrylate. Which of the following best describes the homecare instructions for this patient?
- Apply over-the-counter topical antibiotic ointment to the area twice a day.
- Gently wash away an any crusted blood from the area.
- Allow extended bathing.
- Return to the emergency department immediately if there is redness, swelling, or drainage from the area.
The correct answer is:
- Return to the emergency department immediately if there is redness, swelling, or drainage from the area.
Two octyl cyanoacrylate has inherent antibiotic properties, and topical antibiotics may even damage the integrity of 2 octyl cyanoacrylate.
While reaching maximum bonding strength quickly , friction, such as scrubbing, can damage the 2-octyl cyanoacrylate and is not recommended.
Showering or nons sustained water exposure is not a contraindication for 2-octyl cyanoacrylate; however, prolonged exposure, such as swimming is not recommended.
While there have been studies that show no difference in infection rates between suture closure, and 2-octyl cyanoacrylate, signs of infection, such as redness, swelling, or pustular drainage should prompt presentation to medical attention.
A patient with a chest tube has bubbling in the water seal drainage during expiration. What does this indicate?
- Pneumothorax
- Emphysema.
- Lung expansion
- Air leak
The correct answer is:
- Air leak
Bubbling in the water seal chamber during expiration indicates that an air leak exists. The larger the leak the more bubbling that will occur.
A water seal chest tube drainage system will allow for air to leave the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on exhalation. Sterile water is normally instilled up to the 2 cm line in a water seal chamber. The chest tube drainage system must be kept upright at all times and the water seal chamber monitored for evaporation of the fluid in the water seal chamber.
Valves are built into most systems to allow for high negative pressure and maintaining the water seal. High negative pressure situations can include patients with vigorous coughing, respiratory distress, milking of the tube, aggressively or disconnected/decreased suction.
Normally wall suction is set on 80 to 100 mmHg to provide a gentle bubbling in the suction control chamber. Otherwise, aggressive bubbling causes evaporation of the water in the suction control chamber, and ultimately decreases the suction pressure. Dry suction drainage systems have no bubbling and no evaporation of water and decrease suction risks. A regulator is used to control the amount of suction by turning a knob or dial to the appropriate level. A red stripe will appear in the window near the prescribed suction level. The dry drainage system comes preset at -20 cm for ease of use and can be adjusted. The wall section will usually need to be set at 80 to 100 mmHg. An orange float will appear in the indicator window. Enough suction must be applied for the float to work. Drainage systems have built-in positive pressure valves as well to protect against positive pressure complications. If a chest tube is clamped, a tension pneumothorax can result.
A 65 year-old woman is undergoing a two level decompression and fusion of the lumbar spine. Neostigmine was administered for the reversal of a non-depolarizing blocking agent. Which of the following describes the potential side effects of the administration of the cholinergic drug?
- Bradycardia
- Decreased secretions
- Mydriasis
- Tachycardia
The correct answer is:
- Bradycardia
One of the cardiac muscarinic effects of neostigmine is bradycardia.
Neostigmine causes cholinergic side effects, including increased secretions.
A cholinergic side effect of Neostigmine is miosis.
Neostigmine causes bradycardia as a resource cholinergic stimulation, not tachycardia.
A 12 year-old obese male with a past medical history of sleep apnea, recurrent strip pharyngitis and recurrent otitis media presents in the pre operative bay as he is scheduled to undergo a tonsillectomy with adenoidectomy. Which of the following is a potential complication of inadequate, postoperative pain control associated with his procedure?
- Dehydration
- Fatigue
- Hoarseness
- Dyspnea
The correct answer is:
- Dehydration
Inadequate postoperative pain can manifest with a variety of adverse somatic symptoms. Symptoms of hypertension, diaphoresis, nausea, vomiting, tachycardia, and anxiety are common among most cases of inadequate pain control in the particular case of tonsillectomy dehydration is a common adverse effect that occurs from inadequate pain relief during swallowing .
When assessing for adequate pain control it is not sufficient to evaluate the patient’s pain level only at rest . A patient’s pain level with activity is an important thing to consider, as well. Uncontrolled pain with activity may impair a patient’s ability to perform activities of daily living or participate in rehab exercises.
Questions to ask during a thorough postoperative pain assessment should aim to determine pain onset, location, quality of the pain, intensity, alleviating and aggravating factors, and the effect of current treatment modalities being used. Patients should also be assessed for any factors that may influence their ability to reliably report their level of pain, such as with the presence of cognitive or communication barriers.
A validated pain assessment tool such as the visual analog scale or faces pain scale should be used to track postoperative pain, treatment effectiveness .
A 58 year- old man is about to undergo elective surgery. He works in a bank and has no significant past medical history. During the preoperative assessment before the procedure, the healthcare provider notes that the heart rate is 45/min. Which of the following is the most appropriate initial step in the management of this client?
- Check troponin levels.
- Give atropine.
- Postpone the surgery.
- Insert a temporary intravenous pacemaker.
The correct answer is:
- Postpone the surgery
Sinus bradycardia is a cardiac rhythm with appropriate cardiac muscular depolarization initiating from the sinus node generating less than 60/min.
If a client is found to have a low heart rate during an elective surgical procedure, the surgery should be canceled .
Sinus bradycardia, like any of the other bradyarrhythmias, is caused by a multitude of intrinsic and extrinsic factors that may compromise the intergovernmental the sinus node. These factors can cause the failure of the impulse formation at the sinus node, impulse conduction at the atrioventricular node, or bundle of His-Purkinje fibers.
The best step would be to postpone the procedure and refer him to a cardiologist for further up .
A 63 year-old is about to undergo an elective laparoscopic cholecystectomy. In the preoperative area, it is determined that the patient’s blood pressure is high because she did not know that she could take her blood pressure medications with sips of water. The anesthesiologist agrees to go ahead with the surgery. What anesthetic will he preferably avoid in this patient?
- Halothane
- Enflurane
- Ketamine
- Succinylcholine
The correct answer is:
- Ketamine
Ketamine is an agent for induction and maintenance of Anesthesia .
It is a good analgesic agent that is also used in the intensive care unit .
During induction, the drug can cause an elevation and blood pressure and muscle tremors .
It is a useful agent when inducing patients who have low blood pressure.
A 57 year-old male is brought to the emergency department with a burn injury over more than 50% of the body surface area. The client is developing signs of respiratory failure the providers plan to intubate the client. What neuromuscular agent is contraindicated in the client?
- Rocuronium
- Atracurium
- Norcurium
- Succinylcholine
The correct answer is:
- Succinylcholine
Succinylcholine is used for rapid sequence intubation, as is very short-acting. It is a depolarizing, skeletal muscle relaxant. It bonds with motor endplate cholinergic receptors producing depolarization.
The neuromuscular block causes flaccid paralysis after initial fasciculations. Succinylcholine can worsen the effects of hyperkalemia.
It must be used with caution and clients with burns traumatic wounds, crush injuries, or hyperkalemia. It also may cause problems with those receiving dioxin or quinidine, arrhythmias or cardiac arrest are possible.
Caution should be employed when using it on clients with renal, pulmonary, cardiovascular, hepatic or cardiac disease.
A patient is brought to the emergency department with shortness of breath. The attending clinician notes that the oxygen saturation of the patient is dropping along with the blood pressure. The attending clinician decides to secure the airway by intubating the patient. He believes the patient may require an endotracheal tube for an extended period of time and may become obstructed. What built-in anatomical mechanism of the endotracheal tube is meant to overcome distal obstruction?
- Bevel
- Murphy’s eye
- Distal balloon
- Distal airway safety mechanism
The correct answer is:
- Murphy’s eye
The Murphy’s eye is a safety mechanism built into the endotracheal tube. If the distal end of the endotracheal tube should become obstructed by the wall of the trachea, gas flow can still occur via Murphy’s eye, positioned in the lateral wall of the tube. This prevents complete obstruction of the tube.
The bevel is meant to facilitate placement into the trachea without injuring the vocal cords.
A cuff is an inflatable balloon at the distal end of the endotracheal tube. The inflated cuff forms a seal against the tracheal wall. This prevents gastric contents from entering the trachea and facilitates the execution of positive pressure ventilation, however, it does not prevent obstruction of the tube.
The “distal airway safety mechanism” is a fictional name for a portion of the tube than does not exist.
A 65 year-old man is undergoing surgery for a right knee replacement, and he is receiving isoflurane general anesthesia. The anesthesiologist notices excessive saliva formation during the surgery. Which of the following medications is most appropriate for this side effect in this patient?
- Diphenhydramine
- Atropine
- Dexamethasone
- Neostigmine
The correct answer is:
- Atropine
Atropine is widely used with anesthesia to decrease oral secretions.
Atropine is administered via intravenous injections and works immediately.
Atropine increases heart rate, dilates pup, causes dry skin, and anesthetizes the nerve endings in the skin.
Atropine also relaxes smooth muscle and suppresses gland and mucous secretions. In the past, it was used to treat peptic ulcers by reducing the production of stomach acid.
A 25-year-old intoxicated man is brought to the emergency department after a knife fight. He has no significant past medical history. He has multiple lacerations to his face, including his eyebrow, forehead, peri-auricular region, and jaw. Bilateral supraorbital and supratrochlear nerve blocks are performed, and multiple other facial lacerations are repaired after local infiltration with bupivacaine. The patient is getting prepared for discharge when he suffers a seizure. He is given intramuscular lorazepam, and the seizure activity abates. Which of the following is the next best step in the management of this patient?
- IV lipid emulsion
- IV lorazepam infusion
- IV hypertonic saline
- IV vitamin B6
The correct answer is:
- IV lipid emulsion
This patient had a total of four nerve blocks as well as a large amount of local infiltration. He is likely suffering from local anesthetic systemic toxicity.
The treatment of local anesthetic systemic toxicity is intravenous lipid emulsion.
Local anesthetic systemic toxicity symptoms can include central nervous system changes, arrhythmias, seizures, respiratory arrest, and coma.
Benzodiazepine can increase seizure threshold but does not affect the other actions of local anesthetic systemic toxicity. Hypertonic saline is used for seizures caused by hyponatremia. Vitamin B6 is used for seizures caused by isoniazid toxicity. This patient does not have any medical history, and thus the most likely cause of his seizure is local anesthetic systemic toxicity.
A 65-year-old male presents to the emergency department with acute onset generalized abdominal pain, nausea, and vomiting. On examination, there is marked abdominal rigidity and guarding. No bowel sounds are audible. After a detailed evaluation, he was diagnosed with intestinal perforation. He is being prepped for surgery, and the nurse administers an intravenous antibiotic before the procedure. What is the role of administering this antibiotic?
- Treat underlinfection
- Maintain the serum antibiotic level until the surgery is over
- Decrease the risk of infection after surgery
- Protect the patient in the event of an aseptic lapse
The correct answer is:
- Decrease the risk of infection after surgery
Preoperative antibiotic prophylaxis is defined as administering antibiotics prior to performing surgery to help decrease the risk of postoperative infections.
The routine administration of prophylactic antibiotics is standard in surgeries in which extensive dissections and higher amounts of anticipated blood loss are expected.
In most surgeries, the intent is to ensure the bactericidal concentration has been reached in the blood and tissues before incision. In this case, the patient already has bacterial contamination of the peritoneum due to the perforation.
Cephalosporins are most commonly used. Other commonly used antibiotics include vancomycin, metronidazole, aminoglycosides, and clindamycin.