Principle of Anesthesia (2025 Summer) Test 1

Question 1

Which of the following is a high-risk cardiac condition requiring elective surgery delay until further evaluation or treatment is completed?
A. Stable angina
B. Stage 1 hypertension
C. Recent myocardial infarction within 30 days
D. Controlled atrial fibrillation

Answer 1

C. Recent myocardial infarction within 30 days
Rationale: A recent MI (within 30 days) is a major risk factor for perioperative reinfarction and mortality. Elective surgery should be postponed until at least 60 days post-MI to minimize risk.
Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 353). Elsevier.

Question 2

Which lab test should be checked within 6-8 hours before surgery to prevent cardiac risks in a patient with chronic kidney disease?
A) Blood urea nitrogen (BUN)
B) Serum creatinine
C) Serum potassium
D) Complete blood count (CBC)

Answer 2

C) Serum potassium
Rationale: Preoperative measurement of serum potassium concentration is recommended within 6 to 8 hours of surgery to avoid unexpected hyperkalemia with adverse cardiac effects. If serum potassium level exceeds 5.5 mEq/L and congestive heart failure is evident, surgery should be delayed until after dialysis.
Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed.). Elsevier.

Question 3

What is the recommended perioperative dose of hydrocortisone for a patient with known or suspected adrenal insufficiency undergoing total joint replacement surgery?

A. Preoperative corticosteroid dose + 25 mg
B. Preoperative corticosteroid dose + 150 mg
C. Preoperative corticosteroid dose + 40 mg
D. Preoperative corticosteroid dose + 75 mg

Answer 3

D. Preoperative corticosteroid dose + 50 - 75 mg hydrocortisone

Rationale: The recommended dose for moderate surgery (e.g., total joint replacement) is their preoperative corticosteroid dose plus 50 - 75 mg of hydrocortisone. If the total dose exceeds 100 mg per day, a steroid like methylprednisolone should be considered.

1 mg of Dexamethasone
= 5 mg of methylprednisone
= 25 mg of Hydrocortisone

Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 347). Elsevier.

Question 4

Which of the following are signs of upper respiratory tract infection in pediatric patients in the preoperative period? Select two.

A. Rhinorrhea
B. Auscultation of rales
C. Pulmonary congestion evidenced on a chest radiograph
D. Bulging and tender eardrums

Answer 4

A & D

Rationale: Signs and symptoms of upper respiratory tract infections include rhinorrhea and bulging or tender eardrums. Lower respiratory infections show signs associated with lower airway anatomy.

Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., pp. 360-361). Elsevier.

Question 5

Which strategies are effective in preventing pulmonary complications in a patient with chronic bronchitis?
Select all apply

A. Weight reduction
B. Prophylactic antibiotics to sterilize sputum
C. Chest physiotherapy
D. Expectorants

Answer 5

A, C, D

Rationale: Strategies include weight reduction, chest physiotherapy, and expectorants. Prophylactic antibiotics can worsen resistance issues.

Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 359). Elsevier.

Question 6

What should be done next for a patient with COPD presenting for elective non-cardiac surgery with a PaCO₂ of 50 mm Hg and PaO₂ of 57 mm Hg?
A. Cancel surgery and consult pulmonary rehab
B. Proceed with surgery; findings are not contraindications
C. Intubate preoperatively and admit to ICU
D. Postpone surgery until PaCO₂ normalizes

Answer 6

B. Proceed with surgery; findings are not contraindications
Rationale: Hypoxemia and hypercarbia increase perioperative risk but are not absolute contraindications for non-cardiac surgery. Patients should be optimized preoperatively, not necessarily delayed or canceled.
Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 359). Elsevier.

Question 7

Which patients are at increased risk of awareness during surgery? Select 3
A) Female
B) Elderly
C) Smoker
D) Obese
E) Obstetric

Answer 7

A, D, & E
Rationale: Risk factors for awareness during anesthesia include female sex, obesity, type of surgery (obstetric, cardiac), and clinician experience.
Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 1351). Elsevier.

Question 8

Which patient is most likely to experience postoperative nausea and vomiting?
A. 85 year-old female with osteoporosis
B. 30 year-old male with a history of tobacco abuse
C. 28 year-old female with vertigo
D. 76 year-old male with coronary artery disease

Answer 8

C. 28 year-old female with vertigo
Rationale: Risk factors for PONV include female gender, age

Question 9

Which is not considered an acceptable clear liquid that can be consumed up to 2 hours before a surgical procedure?
A. Beef Broth
B. Popsicle
C. Clear Jell-O
D. Fat Free Milk

Answer 9

D. Fat Free Milk
Rationale: Clear liquids exclude milk. Accepted clear liquids include water, apple juice, black coffee, and clear Jell-O. Milk must be stopped 6 hours prior to surgery.
Reference: Elisha, S., Nagelhout, J. J., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., pp. 372-373). Elsevier Inc.

Question 10

What characterizes the ‘surgical stress response’? Select all that apply
A) Temporary increase in liver enzymes
B) Induction of a catabolic state
C) Decreased peripheral glucose uptake
D) Uncontrolled postoperative pain
E) Increased endogenous glucose production

Answer 10

B) Induction of a catabolic state, C) Decreased peripheral glucose uptake, E) Increased endogenous glucose production
Rationale: The surgical stress response includes catabolic states, insulin resistance resulting in decreased glucose uptake, and increased glucose production. Minimized by normothermia, reduced invasiveness, and neural blockade.
Reference: Butterworth, 2022.

Question 11

Which anesthetic agent is most commonly associated with increased emergence delirium in pediatric patients?
A. Midazolam
B. Dexmedetomidine
C. Sevoflurane
D. Propofol

Answer 11

C. Sevoflurane
Rationale: Emergence delirium in pediatric cases can reach 50-80%. Sevoflurane is strongly linked to this phenomenon compared to other agents.
Reference: Elisha, S., Nagelhout, J. J., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 1281). Elsevier Inc.

Question 12

What urine amount in the bladder immediately after spinal anesthesia predicts postoperative urinary retention (POUR) for diabetic patients?
A. Greater than 400 to 500 mL
B. Greater than 600 to 700 mL
C. Greater than 800 to 1000 mL
D. Greater than 200 to 300 mL

Answer 12

A. Greater than 400 to 500 mL
Rationale: More than 400 to 500 mL post spinal anesthesia in diabetic patients indicates risk for POUR, due to decreased sensation and contractility of the bladder.
Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 1290). Elsevier.

Question 13

What contributes to approximately 20% of intraoperative anaphylactic reactions?
A. Latex
B. Antibiotics
C. Opioids
D. Propofol

Answer 13

A. Latex
Rationale: Despite improved awareness and prevention measures, latex sensitivity still accounts for a significant number of intraoperative anaphylactic reactions.
Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 339). Elsevier.

Question 14

Which finding indicates the highest risk for perioperative myocardial infarction (MI)?
A. Substernal discomfort brought on by exertion
B. Blood pressure of 130/80
C. Angina relieved by nitroglycerin in less than 15 minutes
D. Newly developed angina within the past 2 months

Answer 14

D. Newly developed angina within the past 2 months
Rationale: Unstable angina, indicated by newly developed angina in the past 2 months, poses the highest risk for perioperative MI compared to stable angina.
Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 353). Elsevier.

Question 15

Which patient has the highest risk for postoperative nausea and vomiting (PONV)?
A. 65-year-old male with a history of smoking
B. 45-year-old nonsmoker female with a history of motion sickness
C. 30-year-old male with no history of motion sickness
D. 70-year-old female undergoing local anesthesia

Answer 15

B. 45-year-old nonsmoker female with a history of motion sickness
Rationale: Risk factors include female gender, history of PONV, motion sickness, and use of volatile anesthetics, making this patient the highest risk.
Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 1287). Elsevier.

Question 16

What finding indicates poor ventricular function?
A) Cardiac index > 2.5 L/min/m², left ventricular end-diastolic pressure 50%.
B) Cardiac index 18 mm Hg, and ejection fraction (EF)

Answer 16

Answer:
B) Cardiac index 18 mm Hg, and ejection fraction (EF)

Question 17

In a patient with a recent history of illicit drug use, abstinence syndrome typically exhibits as:
A) An increase in sympathetic response
B) An increase in parasympathetic response
C) A decrease in parasympathetic response
D) An increase in both sympathetic and parasympathetic response.

Answer 17

Correct Answer: D) Increased in both sympathetic and parasympathetic response
Abstinence syndrome typically exhibits increased sympathetic and parasympathetic responses resulting in hypertension, tachycardia, abdominal cramping and diarrhea, tremors, anxiety, irritability, lacrimation, mydriasis, algid sweat, and yawning.
Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 342). Elsevier

Question 18

Which of the following is a high-risk cardiac condition requiring elective surgery delay until further evaluation or treatment is completed?
A. Stage 1 hypertension
B. Stable angina
C. Recent myocardial infarction within 30 days
D. Controlled atrial fibrillation

Answer 18

Answer: C. Recent myocardial infarction within 30 days
Explanation: A recent MI (within 30 days) greatly increases the risk for perioperative reinfarction and mortality. Elective surgery should be delayed until at least 60 days post-MI.

Question 19

In which of the following scenarios would routine preoperative 12-lead ECG be MOST clearly indicated?
A. A 55-year-old patient with known coronary heart disease undergoing laparoscopic cholecystectomy
B. An asymptomatic 70-year-old patient scheduled for a minor dermatological procedure
C. A healthy 45-year-old patient undergoing elective cataract surgery
D. A 30-year-old pregnant patient with no known medical conditions scheduled for elective C-section

Answer 19

Answer: A
Explanation: Routine ECG is only recommended for patients with known coronary or structural heart disease, not for healthy or low-risk patients.

Question 20

What is the most common cause of airway obstruction in the immediate postoperative phase?
A. Laryngeal obstruction due to laryngospasm
B. The tongue falling back and occluding the pharynx
C. Swelling secondary to surgical manipulation or edema
D. Loss of pharyngeal muscle tone in a sedated or obtunded patient

Answer 20

Answer: D
Explanation: Sedation or obtundation causes pharyngeal muscle tone to drop, leading to posterior displacement of the tongue and airway obstruction.

Question 21

Which of the following findings on questioning would indicate the HIGHEST risk for problematic alcohol consumption based on the CAGE mnemonic?
A. The patient reports feeling guilty about forgetting appointments
B. The patient admits to sometimes having a drink first thing in the morning
C. The patient feels they should reduce their intake of sugary drinks
D. The patient’s spouse has expressed concern about their driving

Answer 21

Answer: B
Explanation: “Eye-opener” (morning drink) is one of the most predictive questions in the CAGE mnemonic.
➡ 2 or more “yes” answers = high risk for alcohol use disorder.

Question 22

What is the PRIMARY perioperative concern associated with St. John’s Wort, and what is the recommended discontinuation time before surgery?
A. Risk of myocardial ischemia and stroke; no specific discontinuation data provided
B. Inhibition of neurotransmitter reuptake; discontinue at least 7 days before surgery
C. Potential to increase sedative effect of anesthetics; no specific discontinuation data provided
D. Increased risk of bleeding; discontinue at least 36 hours before surgery

Answer 22

Answer: B
Explanation:
St. John’s Wort inhibits reuptake of serotonin, dopamine, and norepinephrine → potential drug interactions.
➡ Discontinue ≥7 days before surgery.

Question 23

Which of the following findings indicate poor ventricular function?
A. Cardiac index 18 mm Hg, EF 2.5 L/min/m², LVEDP 50%
C. Cardiac index 50%
D. Pulmonary wedge pressure waveform is not influenced by ischemia-induced papillary muscle dysfunction

Answer 23

Answer: A
Explanation: A cardiac index 18 mmHg, and EF

Question 24

When treating laryngospasm, and jaw thrust with CPAP is ineffective, what is the next pharmacologic intervention?
A. Rocuronium induction dose intramuscularly
B. Intravenous Lidocaine
C. A subparalytic dose of intravenous Succinylcholine
D. Propofol bolus

Answer 24

Answer: C
Explanation: If non-pharmacologic methods fail, give IV succinylcholine 0.1–1 mg/kg or IM 4 mg/kg to relieve spasm.

Question 25

What is the most common cause of postoperative arterial hypoxemia? A. Pulmonary edema B. Aspiration C. Atelectasis D. Forgetting to turn on the oxygen

Answer 25

Answer: C. Atelectasis Explanation: Atelectasis is the leading cause of hypoxemia post-op due to alveolar collapse, especially after general anesthesia.

Question 26

Which assessment finding is MOST indicative of inadequate reversal of neuromuscular blockade in PACU? A. The patient is shivering and feels cold despite room temperature B. HR 55 bpm and BP 90/60 C. The patient can lift their head and move limbs but has shallow respirations D. HR 105 bpm and BP 142/78

Answer 26

Answer: C Explanation: Shallow respirations with weakness indicate residual blockade. Use TOF ratio

Question 27

According to surveys, what was associated with a lack of disclosure from healthcare providers after a critical incident? A. Perception that providers were effectively managing B. Increased patient satisfaction C. Decreased likelihood of legal action D. Lower patient satisfaction, less trust, and stronger negative emotional responses

Answer 27

Answer: D Explanation: Lack of transparency = lower trust, poor satisfaction, more emotional harm for patients.

Question 28

What is a consequence of venous air embolism (VAE), and how is it identified? A. VAE will decrease dead space, causing an ABG to show alkalosis. B. VAE will result in increased perfusion, causing increased EtCO2. C. VAE increases dead space, causing EtCO2 to decrease. D. VAE decreases dead space, causing EtCO2 to decrease.

Answer 28

Answer: C - VAE increases dead space and causes EtCO2 to decrease. Rationale: VAE increases dead space and contains nitrogen. Therefore, capnography will show a drop in EtCO2 and the presence of end tidal nitrogen. The other answers are either partially correct or completely incorrect. A - VAE would cause respiratory acidosis since EtCO2 decreases. B - VAE results in decreased perfusion, not increased. D- VAE causes an increase in dead space, not a decrease. References: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 421). Elsevier.

Question 29

Which of the following statements best describes how the lithotomy position can affect blood pressure during surgery? A. It causes blood pooling in the lower extremities, falsely lowering the blood pressure. B. Tilting the head down increases venous return, leading to consistently elevated blood pressure. C. Leg elevation above the trunk increases central blood volume, potentially leading to falsely elevated blood pressure. D. Blood pressure readings are not affected because the legs are at the same level as the heart.

Answer 29

Answer: C. Leg elevation above the trunk increases central blood volume, potentially leading to falsely elevated blood pressure. Rationale: In the lithotomy position, the legs are elevated above the trunk of the body. Due to central redistribution of blood volume and autotransfusion, blood pressure can appear falsely normal or high. References: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 411). Elsevier.

Question 30

Which of the following factors are associated with to nerve injuries in the operating room? (SATA) A) Extremes of body habitus such as obesity or malnutrition. B) Preexisting conditions like hypertension, diabetes mellitus, peripheral vascular disease and alcoholism. C) Orthopedic surgical cases, specifically joint replacements D) Prolonged surgical times. E) Anesthetic techniques that include hypotension with poor perfusion, neuromuscular blockade with allows extremes in stretching that can cause harm, and positioning devices used incorrectly.

Answer 30

Correct Answers: A, B, D, E Rationale: Prolonged surgical times, improper use of positioning devices, and anesthetic techniques like those listed above are factors that contribute to nerve injuries. Patient-related factors such as extremes in body habitus and preexisting health conditions like those listed above are aspects related to the specific patient that can contribute to nerve injuries. There is no information in the text that orthopedic cases have a higher risk for nerve injury. Elisha, S., Heiner, J., & Nagelhout, J. J. (Eds.). (2023). Nurse anesthesia (7th edition.). Elsevier.

Question 31

What type of nerve injury occurs when the nerve is pulled across immovable structures? A) Compression injury B) Transection injury C) Traction injury D) Crush injury

Answer 31

Answer: C) Traction injury Rational: Traction injuries can occur when a peripheral nerve is pulled over or under immovable structures. Compression can happen when a nerve is forced against a bony prominence or a hard surface. Stretch injuries occur where nerves such as the sciatic nerve or brachial plexus have a long course across many structures. Transection can occur as a result of surgical maneuvers or by trauma. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed.). Elsevier.

Question 32

What surgical position carries the highest risk for compartment syndrome in lower extremities? A) Prone B) Supine C) Lateral decubitus D) Lithotomy

Answer 32

Correct Answer: D) Rationale: Long surgical duration with the patient in lithotomy position is the distinguishing characteristic of surgeries where patients develop lower extremity compartment syndrome. Compartment pressures increase over time in the lithotomy position, and the legs should be periodically lowered to the level of the body if the procedure lasts beyond 2-3 hours. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p 420). Elsevier.

Question 33

Which nerve is most at risk from compression at the fibular head in the lithotomy position? A. Sciatic nerve B. Femoral nerve C. Peroneal nerve D. Obturator nerve

Answer 33

Correct Answer: C. Peroneal nerve Rationale: The peroneal nerve runs close to the fibular head and is vulnerable to compression from stirrups in the lithotomy position, potentially leading to foot drop. Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 424). Elsevier.

Question 34

What is the most common metabolic disease associated with spontaneous isolated femoral neuropathy? A) Hypertension B) Diabetes C) Peripheral vascular disease D) History of smoking within 5 months

Answer 34

Correct Answer: B) Diabetes Preexisting conditions appear to be associated with an increased risk of developing postoperative position-related injuries. Hypertension, diabetes mellitus, peripheral vascular disease, peripheral neuropathies, and alcoholism can exacerbate the physiologic effects of various positions. Nerve injury and preexisting neuropathies are more common in patients with diabetes, and diabetes is the most common metabolic cause of spontaneous isolated femoral neuropathy. Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 414). Elsevier.

Question 35

How much does the Mean Arterial Pressure (MAP) increase or decrease by per inch change in height between the heart and a body region? A) 1 mmHg B) 2 mmHg C) 3 mmHg D) 4 mmHg

Answer 35

Answer: B) 2 mmHg Rationale: Mean arterial pressure increases or decreases by approximately 2mmHg per inch for each change in height between the heart and a body region. Therefore regions elevated above the heart in the head-up, sitting, and lithotomy positions may be at risk for hypoperfusion and ischemia, particularly if hypotension occurs. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p 411). Elsevier.

Question 36

Which of the following is typically the responsibility of the anesthesia provider in the event of an intra-operative fire? A. alcohol-based solutions, drapes, adhesive removers, and towels B. electrocautery, drills, lasers, burrs, and light-sources C. oxygen and nitrous oxide concentrations D. None of the above

Answer 36

Answer: C Rationale: The fire triad is composed of fuel, oxidizers, and ignition. Different members of the surgical team are typically responsible for a given part of the triad. Surgical techs control fuels, the surgical team controls ignition sources, and anesthesia controls the oxidizer (Butterworth, et al., 2022). References: Butterworth, J. F., Mackey, D.C., & Wasnick, J. D. (2022). Morgan & Mikhail's clinical anesthesiology (7th ed.). McGraw-Hill LLC.

Question 37

Which of the following nerves in the leg is most susceptible to injury from OR table straps that are placed too tightly? A. Lateral femoral cutaneous nerve B. Radial nerve C. Saphenous nerve D. Deep peroneal nerve

Answer 37

Answer: A: Lateral femoral cutaneous nerve Rationale: Straps are commonly used in the operating room to secure patients to the operating room table, to ensure that they do not fall off during the operation. Straps that are too tight are a common reason for nerve injury related to equipment. The lateral femoral cutaneous nerve, which provides sensory information to the lateral thigh, is particularly susceptible to injury from table straps that are placed too tightly around the hip, or thigh region. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse anesthesia (7th ed., p 414). Elsevier.

Question 38

Which of the following statements best describes the cardiovascular response to Trendelenburg positioning in hypotensive patients? A. It consistently increases mean arterial pressure (MAP) and cardiac index (CI) B. It leads to predictable improvements in stroke volume and venous return C. It may increase central venous pressure (CVP) but not necessarily improve cardiac output or MAP D. It effectively treats hypovolemia by redistributing blood volume

Answer 38

C. It may increase central venous pressure (CVP) but not necessarily improve cardiac output or MAP Rationale: Although Trendelenburg positioning can increase CVP, PAP, and pulmonary artery occlusion pressure, these changes do not reliably correlate with improved MAP or cardiac output in hypotensive individuals. In fact, some patients may experience no improvement or even a decrease in cardiac index, and hypovolemia may be masked while the patient is in this position. Therefore, it should not be relied upon as a definitive treatment for hypotension. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p 412). Elsevier.

Question 39

When a patient is placed in a steep Trendelenburg position, what happens to the endotracheal tube, which is a complication of the patient's airway? A. Inadvertently right mainstem movement of the endotracheal tube B. inadvertently left mainstem movement of the endotracheal tube C. No movement of the endotracheal tube happens D. The endotracheal tube may become obstructed by gastric contents due to increased aspiration risk

Answer 39

Answer: A. Right mainstem movement of the endotracheal tube placement Rationale: When neck flexion occurs, the endotracheal tube moves downward and may inadvertently enter the right mainstem bronchus. In the Trendelenburg position, pressure of the abdominal contents forces the diaphragm cephalad (move towards the head or anterior), and causes inadvertent right mainstem bronchial endotracheal tube movement. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p 422). Elsevier.

Question 40

Which of the following statements best describes how the lithotomy position can affect blood pressure during surgery? A. It causes blood pooling in the lower extremities, falsely lowering the blood pressure. B. Tilting the head down increases venous return, leading to consistently elevated blood pressure. C. Leg elevation above the trunk increases central blood volume, potentially leading to falsely elevated blood pressure. D. Blood pressure readings are not affected because the legs are at the same level as the heart.

Answer 40

C. Leg elevation above the trunk increases central blood volume, potentially leading to falsely elevated blood pressure. Rationale: In lithotomy, blood volume shifts due to leg elevation can create misleadingly high blood readings, emphasizing proper monitoring techniques. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 411). Elsevier.

Question 41

What type of nerve injury occurs when the nerve is pulled across immovable structures? A) Compression injury B) Transection injury C) Traction injury D) Crush injury

Answer 41

C) Traction injury Rationale: Traction injuries occur from excessive pulling over fixed structures, potentially leading to nerve damage. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia.

Question 42

What is the most sensitive noninvasive device to identify a venous air embolism (VAE)? A. Transesophageal echocardiogram (TEE) B. Precordial Doppler C. End-Tidal CO2 (EtCO2) D. Transcranial Doppler

Answer 42

Answer: B. Precordial Doppler Rationale: According to the text, TEE is the gold standard to identify a VAE. However, this requires special training and takes time to perform, it is invasive, and has undesired risks to the patient. Instead, a noninvasive device such as the precordial doppler can be used and is most sensitive. Transcranial Doppler is an alternative, noninvasive device that has great diagnostic capabilities but is not the most sensitive noninvasive device to identify a VAE. EtCO2 will decrease from a VAE, but other pathologies can cause a decrease in EtCO2 as well and is not a specific diagnostic. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 421). Elsevier.

Question 43

While the fibrillation threshold is 100 mA even small electrical shocks can cause ventricular fibrillation if the shock occurs at which point on an ecg? A. On the P wave B. On the R wave C. Just after the S wave D. On the T wave

Answer 43

Answer: D Rationale: It is difficult to determine the exact minimum voltage at which an electrical shock would lead to v-fib. Timing, not just voltage, plays an important role in causing v-fib. It has been shown that leak currents measuring as low as 100 microamperes (μA) can cause v-fib if the shock bypasses the resistance of the skin during the T wave phase (ventricular repolarization). References: Butterworth, J. F., Mackey, D.C., & Wasnick, J. D. (2022). Morgan & Mikhail's clinical anesthesiology (7th ed.). McGraw-Hill LLC.

Question 44

Which of the following is the most likely clinical consequence of ulnar neuropathy resulting from improper surgical positioning? A. Inability to extend the wrist and loss of sensation to the lateral forearm B. Diminished grip strength and inability to flex the elbow C. Inability to oppose the fifth finger and sensory loss in the fourth and fifth digits D. Numbness over the posterior upper arm and medial forearm

Answer 44

Correct Answer: C. Inability to oppose the fifth finger and sensory loss in the fourth and fifth digits Rationale: Damage to the ulnar nerve results in the inability to oppose the fifth finger and diminished sensation to the fourth and fifth finger and, if prolonged, can result in atrophy of the intrinsic muscles of the hand, creating a clawlike contracture. (Nagelhout, Elisha, & Heiner, 2023, p. 415) Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 415). Elsevier.

Question 45

Ch 24 Airway mgmt What is one difference between the DAS and ASA guidelines for difficult airways/intubation? Select all apply A. Awakening of the patient following failed intubation, and successful bag-mask ventilation B. Surgical Cricothyrotomy as the last emergent intervention in both guidelines C. Initial use of a supraglottic airway following failed intubation in both guidelines D. Emphasis of proficient planning and airway assessment to prepare for a difficult airway

Answer 45

Correct Answer: B & C Rationale The Difficult Airway Society (DAS) and the American Society of Anesthesiologists (ASA) two guidelines provide many similarities in their framework to guide anesthesia providers during a difficult airway. The DAS indicate within their framework that the initial step to be taken towards ventilating a patient after a failed intubation is to attempt to place a supraglottic airway device such as an LMA (Elisha et al., 2023, p.449). This differs from the ASA model because the initial step in that framework is to initiate bag mask ventilation (Elisha et al., 2023). An additional difference to these two guidelines is that the DAS specifies that with failure to oxygenate and ventilate with all previous attempts and devices, a surgical cricothyrotomy should be performed. Within the ASA guidelines a direct promotion of the surgical cricothyrotomy approach is not shown (Elisha et al., 2023). Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse anesthesia (7th ed.). Saunders.

Question 46

Which intrinsic muscles in the larynx are innervated by the recurrent laryngeal nerve? (Select all that apply) A. Cricothyroid B. lateral cricoarytenoid C. Posterior cricoarytenoid D. Thyroarytenoid

Answer 46

Answer = B, C, D Rationale: All of the intrinsic muscles of the larynx are controlled by the recurrent laryngeal nerve except the cricothyroid. The superior laryngeal nerve innervates the cricothyroid. Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 434). Elsevier Inc.

Question 47

Which of the following is NOT a component of the 3-3-2 rule for airway assessment? A. Mouth opening should be at least 3 fingerbreadths. B. Thyromental distance should be at least 3 fingerbreadths. C. Sternomental distance should be at least 2 fingerbreadths. D. Thyroid notch to hyoid bone distance should be at least 2 fingerbreadths.

Answer 47

Answer: C. Sternomental distance should be at least 2 fingerbreadths Rationale: The 3-3-2 rule assesses airway geometry for predicting difficult intubation. The correct parameters are interincisor distance of 3 fingerbreadths, a thyromental distance of 3 fingerbreadths, and a thyroid notch to hyoid bone distance of at least 2 fingerbreadths. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 434). Elsevier Inc.

Question 48

A patient with suspected cervical spine injury requires intubation. The safest technique is: A) Direct laryngoscopy with head extension B) Fiberoptic intubation C) Nasotracheal intubation D) Blind intubation

Answer 48

Correct Answer: B) Fiberoptic intubation Rationale: Fiberoptic intubation allows for airway control with minimal neck movement, making it the safest choice for cervical spine injuries. Trauma to the airway and limited mouth opening are other indications. References: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 463). Elsevier Inc.

Question 49

Which of the following is correct regarding the function of the superior laryngeal nerve (SLN)? A) The internal branch of the SLN provides motor function to the cricothyroid muscle. B) The external branch of the SLN provides sensory input to the hypopharynx above the vocal cords. C) The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords, including the base of the tongue and epiglottis. D) The SLN provides motor function to all muscles of the larynx except the cricothyroid muscle.

Answer 49

Correct Answer: C) Rational: The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords, including the base of the tongue, epiglottis, aryepiglottic folds, and arytenoids. The external branch provides motor function to the cricothyroid muscle of the larynx. The recurrent laryngeal nerve provides motor function to all the muscles of the larynx except the cricothyroid muscle. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 430). Elsevier Inc

Question 50

Which of the following statements accurately differentiates cricoid pressure from the BURP maneuver during laryngoscopy? A) Cricoid pressure is applied to improve glottic visualization, while BURP is used to prevent passive regurgitation of gastric contents. B) Cricoid pressure is applied to occlude the esophagus and prevent aspiration, while BURP is applied to optimize vocal cord visualization during laryngoscopy. C) Both cricoid pressure and BURP serve the same purpose and are used interchangeably during intubation. D) BURP is applied to compress the esophagus, while cricoid pressure is used to manipulate the thyroid cartilage for better visualization.

Answer 50

Correct Answer: B) Cricoid pressure is applied to occlude the esophagus and prevent aspiration, while BURP is applied to optimize vocal cord visualization during laryngoscopy. As such, cricoid pressure, which is also known as the Sellick maneuver, has remained a mainstay of anesthetic practice, particularly in patients at risk for aspiration who receive rapid-sequence induction for general anesthesia. Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 455). Elsevier. The technique backwards-upwards-rightwards-pressure (BURP) has been demonstrated to improve visualization of the vocal cords and can be achieved by the clinician manipulating the larynx at the neck with the right hand during laryngoscopy. Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 443). Elsevier.

Question 51

When is the safest time to extubate a patient after surgery? A. During deep anesthesia only B. During deep anesthesia or when the patient awakens C. During light anesthesia D. Only when the patient awakens

Answer 51

Answer: B Rationale: Extubation can safely occur either while the patient is deeply anesthetized (shown by the lack of reaction to pharyngeal suctioning) or awake (patient exhibits eye opening and purposeful movements). Attempts to extubate the patient during a light plane of anesthesia increases the risk for laryngospasm (Butterworth, 2022). Butterworth, J. F. (with Mackey, D. C., & Wasnick, J. D.). (2022).Morgan & mikhail’s clinical anesthesiology (seventh edition). McGraw-Hill LLC.

Question 52

Which of the following statements describes the effects of unilateral recurrent laryngeal nerve (RNL) injury? A. Airway obstruction and respiratory distress B. Loss of sensory innervation above the vocal cords C. Unilateral damage results in hoarseness but is unlikely to cause respiratory distress D. Paralysis of the cricothyroid muscle

Answer 52

Answer: C Rationale: The internal branch of the superior laryngeal nerve (SLN) provides sensory input above the vocal cords. The external branch of the SLN provides motor function to the cricothyroid muscle. The RNL nerve provides sensory innervation below the vocal cords and to all muscles of the larynx bedsides the cricothyroid muscle. References: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 430). Elsevier Inc.

Question 53

A CRNA provides general anesthesia for a patient who is having surgery. Despite performing airway risk assessments, when intubation is attempted, attempts are unsuccessful. What next step should the provider take after successfully placing a laryngeal mask airway? A. Wake the patient up B. Intubate trachea via the supraglottic airway device (SAD) C. Proceed without intubating the trachea (ventilate using LMA) D. Perform a tracheostomy or cricothyroidotomy E. All of these answers are possible correct actions

Answer 53

Answer: E. Each one of these actions can be the correct answer. Many SADs allow for tracheal intubations (TI) through the SAD, but if the SAD does not have this feature, the surgeon and CRNA must discuss the risks and benefits of performing the surgery with an LMA or whether invasive airway access (tracheostomy/cricothyroidotomy) is necessary. If neither provider is satisfied with these solutions and the procedure can be postponed, the CRNA should awaken and re-evaluate the procedure. These difficult airway guidelines were provided by the Difficult Airway Society (DAS) (Nagelhout et al., 2023, pp. 446-449). References: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., pp. 429-430). Elsevier Inc.

Question 54

A forceful, involuntary spasm of the laryngeal musculature (laryngospasm) has developed in your freshly extubated patient. What is the most likely cause of the laryngospasm, and how can it be effectively managed? A. Laryngospasm is caused by sensory stimulation of the recurrent laryngeal nerve and can be effectively treated with deep tracheal suctioning and administration of a bronchodilator. B. Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve and requires immediate re-intubation as the primary intervention. C. Laryngospasm is caused by sensory stimulation of the recurrent laryngeal nerve and can be effectively treated by manual massage of the trachea to relieve the spasm D. Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve and can be effectively treated with gentle positive pressure ventilation and intravenous lidocaine.

Answer 54

Correct Answer: D Rationale: “Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve. Triggering stimuli include pharyngeal secretions or passing an ETT through the larunx during extubation. Laryngospasm is usually prevented by extubating patients either deeply asleep or fully awake, but it can occur – albeit rarely – in an awake patient. Treatment of laryngospasm includes providing gentle positive pressure ventilation with an anesthesia bag and mask using 100% oxygen or administering intravenous lidocaine (1-1.5mg/kg). If laryngospasm persists and hypoxia develops, small doses of succinylcholine (0.25-0.5mg/kg) may be required (perhaps in combination with small doses of propofol or another anesthetic) to relax the laryngeal muscles and allow controlled ventilation (Butterworth, 2022).”

Question 55

Which anatomical structure separates the upper airway from the lower airway? A. Hyoid bone B. Cricoid cartilage C. Bronchioles D. Epiglottis

Answer 55

Answer: B) Cricoid cartilage Rationale: The cricoid cartilage is a ring-shaped cartilage located at the base of the larynx. It serves as a landmark to separate the upper and lower airways. The larynx extends from the epiglottis to the cricoid cartilage, and then the trachea begins. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., pp. 429-430). Elsevier Inc.

Question 56

While Mallampati classification would correlate to only being able to visualize the soft and hard palate? A. Class I B. Class II C. Class III D. Class IV

Answer 56

Answer: C) Class III Rationale: Class I Mallampati correlates to a full view of the palatal arch including both pillars, uvula, soft and hard palates. Class II Mallampati correlates to the upper part of the pillars, most of the uvula, and the soft and hard palate. Class III correlates to only the soft and hard palate being visible. Lastly, Class IV correlates to only the hard palate being seen. Reference: Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2022). Morgan & Mikhail’s Clinical Anesthesiology (7th ed. pp. 309-311). McGraw Hill LLC.

Question 57

What is a way to prevent gastric aspiration for a patient who received rapid-sequence induction and intubation? The patient ate 4 hours ago and needs an emergent laparoscopic cholecystectomy. A. Cricoid pressure B. Glossopharyngeal nerve block C. Superior laryngeal nerve block D. Does not need to do anything because enough time has passed for food to be digested, and the patient will not vomit

Answer 57

Answer: A. Cricoid Pressure Rationale: Cricoid pressure, also known as the Sellick Maneuver, is used in anesthesia for patients at risk for aspiration who receive rapid-sequence induction for general anesthesia. The application of pressure during rapid-sequence induction has decreased upper and lower esophageal sphincter tone. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 455). Elsevier.

Question 58

What are some advantages of laryngeal mask airways (LMAs) when compared with tracheal intubation? (Pick 2) A. Less dental trauma B. Decreased risk of gastrointestinal aspiration C. Does not require neck mobility D. Decreased risk of gas leak and pollution

Answer 58

Answer: A and C Rationale: Unlike endotracheal tubes, LMAs do not require the use of a rigid laryngoscope blade, which is a primary cause of dental trauma during intubation. LMAs can also be inserted with minimal head and neck movement, making them useful in cases with limited neck mobility. Tracheal intubation, on the other hand, often requires head extension and direct visualization of the vocal cords, which may not be possible in patients with limited neck mobility. B is incorrect because a LMA does not seal off the trachea like a cuffed ETT, which means there is a increased risk of aspiration. D is incorrect because LMAs generally have an increased risk of gas leak compared to ETTs, especially at higher ventilation pressures. Reference: Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2022). Morgan & Mikhail’s clinical anesthesiology (7th ed., p. 325-328). McGraw Hill LLC.

Question 59

Which of the following is the most reliable predictor of a difficult airway? A. Thyromental distance less than 6 cm B. Mallampati Class greater than II C. History of previous difficult intubation D. Prescence of facial hair

Answer 59

Answer: C. History of previous difficult intubation Rationale: A prior history of a difficult airway is one of the strongest predictors of future difficulties in airway management. While anatomical features like a short thyromental distance and high Mallampati class may indicate difficulty, history is the most reliable factor. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 433). Elsevier Inc.

Question 60

What is the most reliable indicator that the endotracheal tube has not inadvertently been placed in the esophagus? A. Bilateral breath sounds B. Persistent end-tidal carbon dioxide C. Equal chest excursion (rise) D. Condensation in the endotracheal tube

Answer 60

Answer: B Rationale: It is important to recognize that other traditional methods of confirming ETT placement, such as equal bilateral breath sounds, symmetric chest wall movement, epigastric auscultation, and observation of tube condensation, lack specificity and can be misleading. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia (7th ed., p. 475). Elsevier.

Question 61

Which of the following clinical signs can provide clues to the diagnosis of bronchial intubation? A) Bilateral breath sounds, stable oxygen saturation, normal peak inspiratory pressures, and easy ventilation with a compliant breathing bag B) Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures C) Decreased peak inspiratory pressures, normal bag compliance, symmetrical chest expansion, and no changes in oxygen saturation D) Easy palpation of the endotracheal tube (ETT) cuff in the sternal notch, equal air entry bilaterally, normal breathing-bag compliance, and no increase in peak inspiratory pressures

Answer 61

Answer: B) Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures Rationale: Clues to the diagnosis of bronchial intubation include: unilateral breath sounds, unexpected hypoxia with pulse oximetry (unreliable with high inspired oxygen concentration), inability to palpate the ETT cuff in the sternal notch during cuff inflation, and decreased breathing-bag compliance due to increased peak inspiratory pressures (Butterworth et al., 2022, p. 337). Other options describe normal findings, which do not indicate bronchial intubation. Reference: Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2022). Morgan & Mikhail’s clinical anesthesiology (7th ed., p. 337). McGraw Hill LLC.

Question 62

Which cartilages of the larynx are paired? (Pick 3) A. Thyroid B. Arytenoid C. Cricoid D. Corniculate E. Cuneiform F. Epiglottic

Answer 62

Answer: B, D, & E Rationale: The larynx is a cartilaginous skeleton held together by ligaments and muscle. The larynx is composed of nine cartilages: thyroid, cricoid, epiglottic, and (in pairs) arytenoid, corniculate, and cuneiform. Reference: Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2022). Morgan & Mikhail’s clinical anesthesiology (7th ed., p. 308). McGraw Hill LLC.

Question 63

Which anatomical structure separates the upper airway from the lower airway? A. Hyoid bone B. Cricoid cartilage C. Bronchioles D. Epiglottis

Answer 63

B. Cricoid cartilage Rationale: The cricoid cartilage is pivotal in delineating the boundary between the upper and lower airways and indicates the start of the trachea. Reference: Nagelhout, J. J., Elisha, S., & Heiner, J. S. (2023). Nurse Anesthesia.

Question 64

Which of the following patients is at an increased risk for awareness during surgery? A) Female B) Elderly C) Smoker D) Obese E) Obstetric

Answer 64

A, D, & E Rationale: Increased risk factors for awareness during anesthesia include being female, having obesity, and undergoing certain types of surgeries such as obstetric or cardiac procedures. Reference: Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed., p. 1351). Elsevier.

Question 65

Your first case of the day is a 38-year-old-woman who presents for a ventral hernia repair. When asked about previous surgeries and complications with them, she reports that she was told she had an “allergic reaction to anesthesia.” Upon further investigation, you discover she was told that she experienced muscle rigidity, tachycardia, and increased temperature. Based upon this information, what differential diagnosis would describe this “allergic reaction to anesthesia”: A) Autonomic Hyperreflexia B) Malignant Hyperthermia C) Porphyria D) None of the above, it was a true allergic reaction

Answer 65

B) Malignant Hyperthermia Nagelhout, p. 842

Question 66

Which inhaled anesthetic would be appropriate to use for this patient's surgery? A) Sevoflurane B) Isoflurane C) Desflurane D) Any of the above E) None of the above

Answer 66

E) None of the above Nagelhout, p. 842

Question 67

The patient in question #1 is asked if she (38 y/o) smokes and she replies, "Yes". You then ask how long she's been a smoker and how much does she smoke? She replies, "about a pack per day, since I was 14 years old." What is her number of pack years? A) 10 pack per year B) 14 pack per year C) 24 pack per year D) 48 pack per year

Answer 67

C) 24 pack per year Pack Years = (Number of packs per day) × (Number of years smoked) = 1 pack per day × 24 years = 24 pack years

Question 68

When assessing the patient's airway in question #1, you note that you can visualize the soft palate and base of the uvula. You give her a Mallampati score of: A) Mallampati I B) Mallampati II C) Mallampati III D) Mallampati IV

Answer 68

C) Mallampati III

Question 69

For the patient in question #1, you decide to proceed with the case as a TIVA and perform a standard SHCRSI endotracheal intubation. Once the ETT is secured, you note the patient’s ETCO2 increases, HR increases, and RR increases (tachypnea). What could be the cause of these symptoms? A) Succinylcholine B) Propofol C) Lidocaine D) Fentanyl

Answer 69

A) Succinylcholine Succinylcholine can trigger malignant hyperthermia, leading to increased ETCO₂, heart rate, and respiratory rate. These signs indicate a hypermetabolic crisis that must be addressed immediately. Nagelhout, p. 842

Question 70

Please match the suggested number of hours a patient should be NPO with the following food/liquid(s) provided. Full meal Clear liquids Breast milk Formula 2 hr 4 hr 6 hr 8 hr

Answer 70

Full meal = 8 hr Clear liquids = 2 hr Breast milk = 4 hr Formula = 6 hr

Question 71

Which of the following is one of the most important determinants of perioperative risk and the need for further testing and perioperative invasive monitoring? A) History of congestive heart failure B) Insulin-dependent diabetes with an A1C >10% C) Exercise tolerance D) Anemia

Answer 71

C) Exercise tolerance ChatGPT: Exercise tolerance is one of the most important determinants of perioperative cardiac risk and plays a crucial role in deciding whether additional testing or invasive monitoring is necessary.

Question 72

Which anesthetic gas vaporizer is heated to 39C? A) Isoflurane B) Desflurane C) Nitrous oxide D) Sevoflurane

Answer 72

B) Desflurane Nagelhout, p. 262

Question 73

Suspicion of acute substance abuse should be followed up with a urine screen for drug identification. True or False?

Answer 73

True Nagelhout, p. 342

Question 74

An objective scoring system frequently used by researchers and clinicians used to describe laryngoscopic difficulty is known as the:

Answer 74

Cormack & Lehane Grading System

Question 75

Match the airway examination component with its airway difficulty indication. Thyromental distance Length of neck ROM of head & neck Length of upper incisions Interincisor distance Relatively long < 3 cm Short Less than 3 fingerbreadths Can't touch tip of chin to chest

Answer 75

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