Quiz 7 Flashcards
(18 cards)
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
Correct Answer: 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.
A patient with chronic kidney disease is scheduled for surgery. Which lab test should be checked within 6-8 hours before surgery to prevent cardiac risks?
A) Blood urea nitrogen (BUN)
B) Serum creatinine
C) Serum potassium
D) Complete blood count (CBC)
Answer: C) Serum potassium
Rational: Preoperative measurement of serum potassium concentration is recommended within 6 to 8 hours of surgery regardless of whether dialysis is performed, because unexpected hyperkalemia with its adverse cardiac effects is known to occur rapidly. If serum potassium level exceeds 5.5 mEq/L and congestive heart failure is apparent, elective surgery should be delayed until after dialysis. If postponement is not an option due to emergency surgery, measures to reduce the serum potassium concentration should be initiated.
For a patient with suspected or known adrenal insufficiency undergoing total joint replacement surgery, what is the recommended perioperative dose of hydrocortisone?
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: D
Rationale:
The recommended dose of hydrocortisone for a patient with known or suspected adrenal insufficiency undergoing moderate surgery (lower extremity revascularization, total joint replacement) is their preoperative corticosteroid dose + 50 - 75 mg of hydrocortisone. The dose for minor surgeries (inguinal hernia repair) is their preoperative corticosteroid dose + 25 mg hydrocortisone. The dose for major surgery (cardiac surgery, aortic aneurysm repair) is their preoperative corticosteroid dose + 100 - 150 mg of hydrocortisone every 8 hours for 48-72 hours. However, if the total dose per day exceeds 100 mg, a steroid such as methylprednisolone should be considered instead. 4 mg of methylprednisolone = 20 mg hydrocortisone.
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
Correct Answer: A & D
Rationale
Signs and symptoms associated with upper respiratory tract infections include sore throat, reddened pharyngeal and oropharyngeal mucus membranes, increased secretions, fever, sneezing, rhinorrhea, and bulging or tender eardrums (Elisha et al., 2023). Conversely, lower respiratory tract infections present signs and symptoms more precisely associated with the lower airway anatomy, such as pulmonary congestion on a chest radiograph and the auscultation of rales in the lung fields (Elisha et al., 2023).
Which of of the following are effective preoperative strategies to prevent pulmonary complications in a patient with chronic bronchitis? (SATP)
a. Weight reduction
b. Prophylactic antibiotics to sterilize sputum
c. chest physiotherapy
d. Expectorants
Answer: a., c., d.
Rationale: Tactics to decrease pulmonary complications in chronic bronchitis populations include respiratory maneuvers, smoking cessation, treatment of pulmonary infections with antibiotics, expectorants, chest physiotherapy, good nutrition, and weight reduction. It is not recommended to administer prophylactic antibiotics to “sterilize” the sputum as this may initiate growth of a resistant bacterial strain that would further complicate respiratory management (Elisha, et al., 2023).
A patient with chronic obstructive pulmonary disease (COPD) presents for elective non-cardiac surgery. His arterial blood gas shows PaCO₂ of 50 mm Hg, PaO₂ of 57 mm Hg, and SpO₂ of 89%. Which of the following is the most appropriate next step?
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: B. Proceed with surgery; findings are not contraindications
Rationale: While hypoxemia (PaO₂ <60), SpO₂ of less than 90%, and hypercarbia (PaCO₂ >45) increase perioperative risk, they are not absolute contraindications for non-cardiac surgery. These values are expected in many patients with moderate to severe COPD. The key is to optimize the patient preoperatively, not necessarily delay or cancel.
Which of the following patients is at increased risk of awareness during surgery? Select 3
A) Female
B) Elderly
C) Smoker
D) Obese
E) Obstetric
Answer: A, D, & E
Rationale: Risk factors for awareness include: female sex, age (younger adults but not children), obesity, clinician experience, previous awareness, after normal hours operation, emergency procedure, type of surgery (obstetric, cardiac, thoracic), and use of nondepolarizing relaxants.
Which patient would be 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: C
Rationale: Risk factors associated with an increased risk of PONV include female gender, age <50 years, history of PONV, history of motion sickness, and a nonsmoker.
Which of the following 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: D. Fat Free Milk
Rationale: Clear liquids can be consumed up to 2 hours before a procedure. Examples of clear liquids include: water, apple juice, black coffee, black tea, clear juice drinks, clear Jell-O, clear broth, ice, popsicles, and Pedialyte. Fat free milk is not a clear liquid and must be stopped 6 hours prior to a surgical procedure.
What is the “surgical stress response” characterized by? (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
Correct answer: B) Induction of a catabolic state, C) Decreased peripheral glucose uptake E) Increased endogenous glucose production
Rationale: “The surgical stress respoinse is characterized by neuro-endocrine, metabolic, inflammatory, and immunological changes initiated by the physiological trespass of the surgical incision and subsequent invasive procedures. The stress response can adversely affect organ function and perioperative outcomes and may include induction of a catabolic state as well as a transient, but reversible, state of insulin resistance, characterized by decreased peripheral glucose uptake and increased endogenous glucose production” (Butterworth, 2022).
During a critical healthcare-related incident where the patient is harmed, who would be considered the second victim?
A. The family of the patient
B. The hospital shareholders
C. The healthcare provider caring for the patient
D. The local community
Answer: C, Healthcare provider caring for the patient.
Rationale: No one desires to harm patients when caring for them. After a critical incident harms a patient, the healthcare professionals involved have often demonstrated PTSD symptoms. These symptoms can result in personal distress, burnout, loss of empathy, and an increased risk of making another error. Processing the incident using six steps is imperative to continue thriving and functioning: chaos/accident response, intrusive reflections, restoring personal integrity, enduring inquisition, obtaining emotional first aid, and moving onward.
Which of the following anesthetic agents is most commonly associated with elevated incidences of emergence delirium in pediatric patients?
A. Midazolam
B. Dexmedetomidine
C. Sevoflurane
D. Propofol
Answer: C - Sevoflurane
Rationale: The incidence of postoperative emergence delirium has been reported to be as high as 50-80% in pediatric cases. There are many factors associated with increased risk of emergence delirium, such as pain, separation anxiety, endotracheal tube presence, and choice of anesthetic agent . In children, sevoflurane-anesthesia has been strongly linked to high levels of emergence delirium, whereas in the adults, benzodiazepine administration has been more related to its incidence (Elisha et al., 2023).
Urinary output and voiding are essential monitoring assessments for post-spinal and epidural anesthesia. Diabetic patients can develop postoperative urinary retention (POUR). What is the amount in the bladder immediately after spinal anesthesia that indicates a predictor of POUR?
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: A. 400 to 500 mL
Rationale: Diabetes can decrease sensation and contractility in the bladder and increase bladder capacity, which increases the development of postoperative urinary retention (POUR). A predictor of POUR is the presence of greater than 400 to 500 mL of urine in the bladder immediately after spinal anesthesia. Opioids, ketamine, general anesthetics, and NSAIDs can increase the risk of POUR.
Which of the following has been attributed to approximately 20% of intraoperative anaphylactic reactions?
A. Latex
B. Antibiotics
C. Opioids
D. Propofol
Answer: Latex
Rationale: The incidence of intraoperative latex reactions has decreased due to increased awareness, preventive measures, and the availability of nonlatex medical supplies. However, latex sensitivity still accounts for up to 20% of intraoperative anaphylactic reactions. Preoperative assessments should include screening for latex allergies and sensitivities to prevent reactions.
Which of the following is associated with the highest risk for perioperative 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: D. Newly developed angina within the past 2 months
Rationale: Stable angina is defined as substernal discomfort brought on by exertion and relieved by rest, nitroglycerin, or both within 15 minutes. Stable angina is unlikely to significantly increase the risk of perioperative MI compared to those with an absence of anginal symptoms. Unstable angina, which can be characterized as newly developed angina occuring within the past 2 months, is associated with the highest risk of perioperative MI.
Which of the following patients is at the highest risk for postoperative nausea and vomiting (PONV)?
A. A 65-year-old male with a history of smoking undergoing bowel resection and has an NG tube
B. A 45-year-old nonsmoker female with a history of motion sickness undergoing breast surgery
C. A 30-year-old male with no history of motion sickness undergoing knee arthroscopy
D. A 70-year-old female undergoing cataract surgery under local anesthesia and mild sedation
Answer: B. A 45-year-old nonsmoker female with a history of motion sickness undergoing breast surgery
Rationale: Risk factors for PONV include female gender, history of PONV or motion sickness, nonsmoking status, use of volatile anesthetics, age less than 50, and opioid administration. The answer is B since this female in question has more risk factors than the 70-year-old female. Females experience PONV two to three times more often than males. Anxiety, obesity, use of a nasogastric tube, history of migraines, and supplemental oxygen are not risk factors of PONV and have been disproven or are not clinically relevant as predictors of PONV.
Which of the following findings indicate poor ventricular function?
A) Cardiac index > 2.5 L/min/m², left ventricular end-diastolic pressure < 12 mm Hg, and ejection fraction (EF) > 50%.
B) Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
C) Presence of ischemia-induced hypokinesis, which always indicates nonviable myocardium.
D) Pulmonary wedge pressure waveform is not influenced by ischemia-induced papillary muscle dysfunction.
Answer: B) Cardiac index < 2.2 L/min/m², left ventricular end-diastolic pressure > 18 mm Hg, and ejection fraction (EF) < 40%.
Rationale: Three readily identifiable findings that indicate poor ventricular function are a cardiac index of less than 2.2 L/m2, a left ventricular end-diastolic pressure of greater than 18 mm Hg, and an EF of less than 40%. Taking note of ischemia-induced dysfunction of the papillary muscles can help in avoiding later confusion about the configuration of the pulmonary wedge pressure waveform and the significance of intraoperative changes in wedge pressure. Wall motion abnormalities should be noted. Areas of akinesis (no movement during systole) usually represent nonviable regions of myocardium and are relatively fixed deficits.
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.
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.
