Week 4 Handout Flipped ALL Flashcards
(96 cards)
1
Q
What does ECG measure?
A
ECG measures electrical heart activity; essential for detecting arrhythmias and ischemia.
2
Q
Why is ECG monitoring vital during anesthesia?
A
It assesses cardiac function in real-time.
3
Q
What are the clinical indications for continuous ECG during anesthesia?
A
Continuous ECG is required during anesthesia; no contraindications (ASA standards).
4
Q
What is Lead II used for in ECG?
A
Lead II is used for standard rhythm analysis.
5
Q
What is Lead V5 used for in ECG?
A
Lead V5 is used for ischemia detection, especially anterior.
6
Q
What is a 3-lead ECG?
A
A 3-lead ECG is basic rhythm monitoring.
7
Q
What is a 5-lead ECG?
A
A 5-lead ECG provides more detailed monitoring and is used in OR/ICU.
8
Q
What is a 12-lead ECG?
A
A 12-lead ECG offers the most comprehensive view and is used for diagnostic purposes.
9
Q
What electrodes are used in a 3-lead ECG?
A
Electrodes are placed on the right arm, left arm, and left leg.
10
Q
What does the P wave represent in ECG interpretation?
A
The P wave represents atrial depolarization, initiating contraction of the atria.
11
Q
What does the QRS complex represent in ECG interpretation?
A
The QRS complex represents ventricular depolarization, contracting the ventricles to pump blood.
12
Q
What does the T wave represent in ECG interpretation?
A
The T wave represents ventricular repolarization, where ventricles return to a resting state before the next heartbeat.
13
Q
What indicates high likelihood of myocardial ischemia on an ECG?
A
ST depression (>1 mm, 80 msec after J-point) indicates high likelihood of myocardial ischemia.
14
Q
What indicates suspicion of acute myocardial infarction on an ECG?
A
ST elevation (>1 mm, 80 msec after J-point) indicates suspicion of acute myocardial infarction (STEMI).
15
Q
What causes artifacts in ECG monitoring?
A
Causes include movement, lead displacement, electrocautery, and 60-Hz interference.
16
Q
What are best practices for ECG monitoring?
A
Monitor Lead II + V5, ensure proper placement, and use conductive gel for signal quality.
17
Q
What is the frequency of blood pressure monitoring during anesthesia?
A
Blood pressure should be monitored every 5 minutes during anesthesia (ASA Standard).
18
Q
What is the purpose of NIBP monitoring?
A
NIBP monitoring is an indicator for organ perfusion and anesthesia decisions.
19
Q
What is the palpation method for NIBP?
A
Palpation involves occluding an artery with a cuff and palpating for the return of pulsations.
20
Q
What is the auscultation method for NIBP?
A
Auscultation uses Korotkoff sounds to determine SBP and DBP.
21
Q
What is oscillometry in NIBP monitoring?
A
Oscillometry is the most common method, using algorithms to estimate SBP, DBP, and MAP.
22
Q
What is tonometry in NIBP monitoring?
A
Tonometry measures arterial blood pressure by sensing the pressure required to occlude a superficial artery.
23
Q
What is the preferred cuff placement for NIBP?
A
The bladder must encircle ≥50% of the limb, with a width of ~40% of limb diameter.
24
Q
What complications can arise from NIBP monitoring?
A
Complications include discomfort, ischemia, nerve damage, and compartment syndrome.
25
What are contraindications for NIBP monitoring?
Contraindications include AV fistulas, PICC lines, open wounds, fractures, and lymph node dissections.
26
What is the purpose of precordial and esophageal stethoscopes?
They monitor heart/lung sounds and can provide additional data like temperature and ECG.
27
What is the benefit of using an esophageal stethoscope?
It provides high-quality heart/lung sounds and can monitor temperature.
28
What are the risks associated with esophageal stethoscopes?
Risks include misplacement into the trachea and avoidance in varices/strictures.
29
What does capnography monitor?
Capnography monitors EtCO₂ levels.
30
What is the normal range for EtCO₂ in adults?
The normal range for EtCO₂ in adults is 35-45 mmHg.
31
What does an increased EtCO₂ indicate?
Increased EtCO₂ can indicate increased CO₂ delivery/production or hypoventilation.
32
What does a decreased EtCO₂ indicate?
Decreased EtCO₂ can indicate decreased CO₂ delivery/production or hyperventilation.
33
What is the significance of the EtCO₂ waveform phases?
Phase I indicates dead space, Phase II indicates a mix of dead space and alveolar gas, and Phase III indicates the alveolar plateau.
34
What does pulse oximetry measure?
Pulse oximetry measures pulse rate and O2 saturation of hemoglobin (SpO₂).
35
What is the accuracy range of modern pulse oximeters?
Modern pulse oximeters have an accuracy of within 2% - 3% at 70% - 100% saturation.
36
What is the Beer-Lambert Law?
It states that the absorption of light is proportional to the concentration of the absorbing substance and the path length.
37
What are the limitations of pulse oximetry?
Limitations include poor indicator of adequate ventilation and false readings due to nail polish or low perfusion.
38
What is the significance of the oxyhemoglobin dissociation curve?
It shows the relationship between partial pressure of oxygen (PaO₂) and oxygen saturation (SpO₂) of hemoglobin.
39
What is normothermia?
Normothermia is approximately 37°C.
40
What is malignant hyperthermia?
Malignant hyperthermia is a genetic hypermetabolic muscle disease triggered by certain anesthetics.
41
What is the immediate action plan for malignant hyperthermia?
Stop triggering agents, call for help, administer dantrolene, sodium bicarbonate, cold IV fluids, and monitor core temperature.
42
What are the monitoring sites for temperature?
Noninvasive sites include temporal, axillary, and oral; tympanic is most accurate when awake.
43
What does 'Stiff' refer to?
Muscle rigidity
## Footnote
FATAL if not treated.
44
What does 'F' stand for in the context of Stiff?
↑ CO₂
45
What does 'A' represent in the Stiff acronym?
Acidosis (metabolic + respiratory)
46
What does 'T' indicate in the Stiff acronym?
Tachycardia
47
What does the second 'A' refer to in the Stiff acronym?
Arrhythmias
48
What does 'L' signify in the Stiff acronym?
Labs (↑ CK, ↑ K⁺, myoglobinuria)
49
What are the noninvasive monitoring sites?
Temporal, axillary, oral—safe, quick, less accurate.
50
What is the most accurate noninvasive monitoring site?
Tympanic (most accurate awake)
## Footnote
Most ideal site with the aural probe because of close proximity to brain, reflecting brain temperature.
51
What monitoring site is more useful in intubated patients?
Nasopharynx
52
What is the most definitive reflection of core temperature?
Bladder and PA catheter (invasive, accurate)
53
What should the operating room temperature be maintained at?
Between 68°F (20°C) and 75°F (24°C)
54
What is a recommended preoperative action?
Prewarm with blankets.
55
Which patients are more vulnerable to temperature fluctuations?
Patients with specific comorbidities (e.g., hypothyroidism, burns) or pediatric patients.
56
What intraoperative measures can be taken to maintain temperature?
Bear hugger, warm IVs/gases.
57
What is a postoperative treatment for shivering?
Meperidine 12.5–25 mg IV, warming devices.
58
What are complications of hypothermia?
Coag issues, shivering, drug metabolism.
59
What are complications of hyperthermia?
Neuro injury, arrhythmias.
60
Which of the following statements about ECG lead selection are correct? (Select all that apply)
A. Lead II is commonly used for arrhythmia detection.
B. Lead V5 is optimal for detecting ischemia in the anterior and lateral walls.
C. A modified V5 lead can be achieved using a 3-lead system.
D. The standard 3-lead system provides the most comprehensive ischemia monitoring.
E. The best ECG lead for ischemia detection is always Lead I.
Correct Answers:
● A,B,C
Rationales:
● Lead II aligns with the heart’s electrical axis, providing the best P-wave visibility, making
it ideal for detecting arrhythmias.
● Lead V5 is positioned over the 5th intercostal space at the anterior axillary line, making it
highly sensitive for ischemia detection in the anterior and lateral walls of the heart.
● In a 3-lead system, the LA electrode can be repositioned to the V5 location to provide
better ischemia monitoring (CS5 configuration).
● The 3-lead system is primarily used for basic arrhythmia detection, while 5-lead ECG
provides better ischemia monitoring due to additional precordial lead placement.
● Lead I is not the most sensitive for ischemia. Instead, Lead V4 and V5 are more effective
for detecting ischemic changes.
61
What are common causes of ECG artifacts? (Select all that apply)
A. Patient movement
B. Electrocautery interference
C. Faulty electrodes
D. Low heart rate
E. 60-Hz electrical interference
Correct Answers:
• A,B,C,E
Rationales:
● Patient movement can create motion artifacts, leading to false readings on the ECG.
● Electrical signals from surgical cautery can disrupt ECG signals, creating artifacts.
● Poor electrode contact, dried gel, or disconnected leads can cause erratic readings.
● Alternating current (AC) devices operating at 60 Hz (in the U.S.) or 50 Hz (in other
regions) can cause interference in ECG readings.
62
How can ECG signal quality be improved? (Select all that apply)
A. Ensuring proper electrode placement
B. Using conductive gel to lower skin resistance
C. Positioning lead wires parallel to power cords
D. Selecting an appropriate filter setting for motion artifacts
E. Avoiding the use of a precordial lead
Correct Answers:
• A,B,D
Rationales:
● Correct placement prevents signal distortion and improves lead accuracy.
● Conductive gel enhances electrical conduction between the skin and electrode, reducing
impedance.
● Lead wires should be positioned perpendicularly to power cords to minimize 60-Hz
interference.
● Using low-pass or notch filters can help reduce motion artifacts while preserving key
ECG features.
● Precordial leads (e.g., V4, V5) enhance ischemia detection, so avoiding them would
reduce diagnostic accuracy.
63
Which ECG lead combination provides the highest sensitivity for detecting myocardial
ischemia?
A. Lead I and Lead II
B. Lead II and Lead III
C. Lead II and Lead V5
D. Lead V1 and Lead V4
Correct Answer
• C
Rationales:
● Lead II is best for arrhythmia detection, while Lead V5 is most sensitive for anterior and
lateral wall ischemia. • Studies show that monitoring Lead II + V5 can detect up to 85%
of ischemic episodes.
64
What is the primary function of the 3-lead ECG system in anesthesia?
A. Continuous ischemia monitoring
B. Basic arrhythmia detection
C. Comprehensive cardiac assessment
D. Diagnosing complex conduction abnormalities
Correct Answer:
• B
Rationales:
• 3-lead ECG is mainly used for basic rhythm monitoring (arrhythmia detection).
• 5-lead or 12-lead ECG is needed for more detailed ischemia or conduction abnormality
analysis.
• Comprehensive cardiac assessment requires a full 12-lead ECG.
65
A 62-year-old male with a history of hypertension and diabetes is scheduled for an elective
laparoscopic cholecystectomy. During preoperative evaluation, he reports experiencing
exertional chest discomfort over the past few weeks. A preoperative ECG shows 1.5 mm ST-
segment depression in leads V4 and V5, recorded 80 msec after the J-point.
What is the most likely cause of this ECG finding, and what should be the next step in
management?
A. Normal variant, proceed with surgery without further testing
B. Myocardial ischemia, consider further cardiac evaluation
C. Electrolyte imbalance, check potassium and calcium levels
D. Pericarditis, look for PR segment depression
Correct Answer:
• B
Rationales:
● ST-segment depression (>1 mm, 80 msec after J-point) is a strong indicator of myocardial
ischemia, especially when seen in leads V4-V5 (which reflect the anterior/lateral walls).
● Patients with exertional chest discomfort and risk factors (HTN, DM) should be further
evaluated before proceeding with elective surger
66
As a general principle, the comfort of operating room personnel must be balanced with patient
care. For adult patients, what is the recommended ambient room temperature range in the
operating room?
A) 68°F to 75°F (20°C to 24°C)
B) 60°F to 65°F (15°C to 18°C)
C) 75°F to 80°F (24°C to 27°C)
D) 80°F to 85°F (27°C to 29°C)
Correct Answer:
A) 68°F to 75°F (20°C to 24°C)
Rationale:
Maintaining an appropriate operating room temperature is essential for both patient safety and
the comfort of the surgical team. The recommended temperature range of 68°F to 75°F (20°C to
24°C) helps prevent patient hypothermia while ensuring a suitable working environment for
personnel. Too low of a temperature increases the risk of perioperative hypothermia in patients,
leading to complications such as increased infection rates, delayed wound healing, and
coagulopathy. Conversely, excessively high temperatures can cause discomfort for the surgical
team, impairing performance. (Butterworth et al., 2022)
67
Which of the following statements about hypothermia in the operating room is correct? ( Select 3
choose)
A) Hypothermia is defined as a core body temperature of less than 36°C.
B) General and regional anesthesia is a potential cause of intraoperative hypothermia.
C) Conductive heat loss is the primary mechanism of heat loss in the operating room.
D) Radiant heat loss is considered the greatest source of heat loss in preoperative and operative
settings.
Correct Answers:
A) Hypothermia is defined as a core body temperature of less than 36°C.
B) Epidural anesthesia is a potential cause of intraoperative hypothermia.
D) Radiant heat loss is considered the greatest source of heat loss in preoperative and operative
settings.
Rationale:
Hypothermia is a common issue in the operating room and is defined as a core body temperature
below 36°C (Elisha et al., 2023). General and regional anesthesia contributes to hypothermia by
causing vasodilation and impairing thermoregulation (Elisha et al., 2023). Radiant heat loss, the
transfer of body heat to a cooler environment, is identified as the greatest contributor to heat loss
in perioperative settings (Elisha et al., 2023). Option C is incorrect because conductive heat
loss in is not the primary mechanism in the operating room; it is, radiant heat loss dominates.
Elisha, S., Heiner, J. S., & Nagelhout, J. J. (2023). Nurse Anesthesia (7th ed. p. 321). Elsevier.
68
Which of the following statements about malignant hyperthermia is correct?
A) Hyperthermia is always the first sign of malignant hyperthermia.
B) When hyperthermia occurs in malignant hyperthermia, core temperature can increase by 1°C
every 5 minutes.
C) Malignant hyperthermia typically develops slowly over several hours.
D) Core temperature changes in malignant hyperthermia are minor and rarely significant.
Correct Answer:
B) When hyperthermia occurs in malignant hyperthermia, core temperature can increase by 1°C
every 5 minutes.
Rationale:
Malignant hyperthermia is a life-threatening condition triggered by certain anesthetic agents,
causing a rapid and extreme metabolic reaction. Hyperthermia is an early symptom, not the first
sign (Butterworth et al., 2022. Early signs may include tachycardia, muscle rigidity, and
increased CO2 production. When hyperthermia does manifest, core temperature can rise quickly,
as much as 1°C every 5 minutes, emphasizing the urgency of immediate intervention
(Butterworth et al., 2022). Malignant hyperthermia is a rapidly progressing condition, not a slow-
developing making option C is incorrect. Core temperature changes are severe, not
minor making option D incorrect.
69
Which of the following statements about preoperative warming is correct?
A) Prewarming the patient for 30 minutes with convective, forced-air warming blankets helps
reduce the initial drop in core temperature.
B) Preoperative warming is ineffective in preventing perioperative hypothermia.
C) Prewarming works by increasing metabolic heat production.
D) The central-peripheral temperature gradient increases after prewarming.
Correct answer
A) Prewarming the patient for 30 minutes with convective, forced-air warming blankets helps
reduce the initial drop in core temperature.
Rationale:
Preoperative forced-air warming is an effective strategy to reduce the phase one decline in core
temperature by minimizing the central-peripheral temperature gradient before anesthesia is
induced (Butterworth et al., 2022). This process helps prevent redistribution hypothermia, a
common cause of perioperative hypothermia (Butterworth et al., 2022). Option B is
incorrect because prewarming is an effective measure in preventing temperature drops. Option C
is incorrect because prewarming does not significantly increase metabolic heat production;
rather, it helps maintain existing heat distribution. Option D is incorrect because the central-
peripheral temperature gradient actually decreases, not increases, after prewarming.
Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2022). Morgan and Mikhail’s Cli
70
What part of our brain is impaired during anesthesia that allows heat loss due to altered
perception of temperature in the anesthetized dermatomes?
A. Pons
B. Hypothalamus
C. Frontal lobe
D. Occipital lobe
Correct answer:
B) Hypothalamus
Rationale:
The thermoregulatory impairment caused by conduction anesthesia results in continued heat
loss due to the altered perception of temperature by the hypothalamus in the anesthetized
dermatomes.
71
Which of the following temperature monitoring techniques are not recommended for patients
that are getting open heart surgery?
A) Pulmonary artery and esophageal probe
B) Tympanic temperature monitoring
C) Oral temperature monitoring
D) Temporal temperature monitoring
Correct answer:
A) Pulmonary artery and esophageal probe
Rationale:
Esophageal and pulmonary artery temperature monitoring is less accurate and less reflective to
core temperature during open heart surgery (Elisha et al., 2023). Tympanic membranes are
considered an ideal site of core temperature because it reflects brain temperature (Elisha et al.,
2023). Oral and temporal temperature monitoring is considered noninvasive and does not reflect
core body temperature (Elisha et al., 2023)
72
What are the uses of precordial and esophageal stethoscopes (Select all that apply)
a. To confirm placement of endotracheal intubation
b. To identify ventilator circuit disconnections
c. To gain visuals of the pharynx
d. To auscultate heart and lung sounds
Answer: A, B, D
Rationale: The three main uses of precordial and esophageal stethoscopes are confirming placement
of endotracheal intubation, identifying ventilator circuit disconnections, and auscultating heart and
lung sounds. While the esophageal stethoscope can be used as a carrier for various devices, a camera
for pharynx visualization is not one of them.
73
In what scenario is the esophageal stethoscope superior to a regular binaural external
stethoscope
a. Anesthesia provider would like to know the quality of breath sounds in an intubated patient with
COPD, but auscultation proves difficult through external stethoscope due to elevated BMI
b. Anesthesia provider is unsure if the endotracheal tube entered the right mainstem bronchus
c. The anesthesia provider wants a clearer auscultation of a heart murmur on a non-intubated patient.
d. Provider needs to assess for return of bowel sounds after surgery
Answer: A
Rationale: An esophageal stethoscope can provide clearer auscultation of breath sound quality,
especially for patients with elevated BMI. These devices are centrally located and, therefore, cannot
determine bilateral breath sounds. They can only be used on intubated patients and are unable to
assess bowel sounds from their position.
74
Which patient is a candidate for placement of an esophageal stethoscope
a. 45-year-old male with esophageal varices
b. 78-year-old female receiving general anesthesia for an ex-lap
c. 63-year-old female with a history of esophageal stricture
d. 15-year-old male receiving conscious sedation for a re-alignment of a dislocated shoulder
Answer: B
Rationale: The 78-year-old female can receive an esophageal stethoscope as she has no stated
contraindications and will be intubated for surgery. The 15-year-old male will not be intubated.
Placement of an esophageal probe in those with a history of strictures or esophageal varices may result
in perforation and/or bleeding.
75
What are the steps included in placing a precordial stethoscope (Select all that apply)
a. Place metallic bell onto the patient’s chest at the sternal notch
b. Ensure the adhesive side is facing away from the patient so that it does not adhere to skin
c. Place earpiece in ear
d. Cleanse device between uses
Answer: A, C, D
Rationale: The adhesive side of the metallic bell on a precordial stethoscope must be applied to the
patient's skin to prevent the device from moving
76
What are the steps included in placing an esophageal stethoscope?
a. Wash hands and apply gloves
b. Apply lubricant to the balloon tip of the esophageal stethoscope catheter
c. slide catheter through the pharynx and into the esophagus
d. Clean thoroughly before applying to next patient
Answer: A, B, C
Rationale: Esophageal stethoscopes are disposable and are only used on one patient per stethoscope
to prevent hospital-acquired infections.
77
With what devices can the esophageal stethoscope pair?
a. Electrodes
b. temperature probes
c. Atrial pacemaker electrodes
d. Endoscopes
Answer: A, B, C
Rationale: The esophageal stethoscope can pair with various devices such as electrodes, temperature
probes, atrial pacemaker electrodes, and ultrasound probes
78
As a general principle, the comfort of operating room personnel must be balanced with patient
care. For adult patients, what is the recommended ambient room temperature range in the
operating room?
A) 68°F to 75°F (20°C to 24°C)
B) 60°F to 65°F (15°C to 18°C)
C) 75°F to 80°F (24°C to 27°C)
D) 80°F to 85°F (27°C to 29°C)
Correct Answer:
A) 68°F to 75°F (20°C to 24°C)
Rationale:
Maintaining an appropriate operating room temperature is essential for both patient safety and
the comfort of the surgical team. The recommended temperature range of 68°F to 75°F (20°C to
24°C) helps prevent patient hypothermia while ensuring a suitable working environment for
personnel. Too low of a temperature increases the risk of perioperative hypothermia in patients,
leading to complications such as increased infection rates, delayed wound healing, and
coagulopathy. Conversely, excessively high temperatures can cause discomfort for the surgical
team, impairing performance.
79
Why is pulse oximetry not a reliable indicator of ventilation adequacy?
A. It is affected by ambient light.
B. It detects oxygen saturation but not carbon dioxide levels.
C. It does not work during apnea.
D. It cannot detect low perfusion states.
Correct Answer: B. It detects oxygen saturation but not carbon dioxide levels.
Rationale: Pulse oximeters only measure oxygen saturation (SpO₂) and do not assess ventilation
or CO₂ levels, making them unreliable for detecting hypercapnia or hypoventilation
80
Which strategy minimizes pulse oximetry inaccuracies in low perfusion states?
A. Increase the oxygen flow rate.
B. Use a central monitoring site (e.g., forehead, nose, ear).
C. Change to a different wavelength.
D. Remove ambient light sources in the operating room.
Correct Answer: B. Use a central monitoring site (e.g., forehead, nose, ear).
Rationale: Low perfusion affects central sites less than peripheral sites like fingers or toes,
ensuring more reliable readings (Nagelhout et al., 2023. p. 320).
81
Which of the following wavelengths is absorbed more by deoxygenated hemoglobin?
A. 940 nm
B. 660 nm
C. 800 nm
D. 500 nm
Correct Answer: B. 660 nm
Rationale: Deoxygenated hemoglobin absorbs more red light (660 nm), whereas oxygenated
hemoglobin absorbs more infrared light (940 nm), as per the Beer-Lambert Law (Bar
82
At what PaO₂ does the oxygen dissociation curve plateau, indicating minimal
changes in SpO₂?
A. 20 mmHg
B. 40 mmHg
C. 60 mmHg
D. 75 mmHg
Correct Answer: D. 75 mmHg
Rationale: The oxygen dissociation curve flattens at a PaO₂ of around 75 mmHg, where further
increases in oxygen tension have minimal impact on hemoglobin saturation (SpO₂). This means
the pulse oximetry no longer reflects the partial pressures of arterial oxygen at pressures higher
than 75 mmHg (Barash et al., 2024. p. 669).
83
What happens to the SpO2 when the oxyhemoglobin dissociation curve has a
rightward shift?
A. Hemoglobin binds oxygen more tightly, increasing SpO2
B. Hemoglobin releases oxygen more readily, decreasing SpO2
C. Oxygen saturation increases for a given PaO₂.
D. The curve flattens significantly at all PaO₂ levels.
Correct Answer: B. Hemoglobin releases oxygen more readily.
Rationale: A rightward shift (e.g., due to acidosis, hypercapnia, or increased temperature)
facilitates oxygen release to tissues, reducing hemoglobin’s oxygen affinity. This shows a
decrease in pulse oximetry saturation on the displayed monitor (
84
What effect does methylene blue have on pulse oximetry readings?
A. Causes falsely high SpO₂ readings.
B. Causes falsely low SpO₂ readings.
C. Does not affect SpO₂ readings.
D. Stops the device from functioning.
Correct Answer: B. Causes falsely low SpO₂ readings.
Rationale: Methylene blue absorbs light in the red and infrared wavelengths, interfering with
pulse oximetry and causing transiently low SpO₂ readings (Nagelhout et
85
Select the true statement regarding capnography:
A. Capnography is inaccurate and not a reliable source of CO2 monitoring
B. Capnography is not necessary when a pulse oximetry probe is in place
C. Capnography is accurate and only 2-5 tor lower than PaCO2
D. Capnography is moderately accurate and regular arterial blood gases must be compared
to ensure EtCO2 accuracy
Answer: C, Capnography is a highly accurate method of measuring a patient’s carbon dioxide
levels. EtCO2 is only lower than PaCO2 by 2-5 tor which allows anesthesia providers to use
capnography to monitor their patients’ ventilation status
86
An anesthesia provider hears a pressure alarm, and notes increased inhaled CO2 levels with an
abnormally long downstroke on the capnogram. What should the provider first check?
A. Check the inspiratory valve on the circle circuit
B. Check the expiratory valve on the circle circuit
C. Trouble shoot the scrubber on the circle circuit
D. Check the Y-piece for disconnection
Answer: A, When a unidirectional valve in a circle system is compromised, exhaled CO2 can
build up causing increased inhalation of CO2. With the failure of an expiratory valve, the
capnography demonstrates an elevated CO2 level, but the waveform remains unchanged. Failure
of an inspiratory valve can lead to not only increased CO2 levels, but also an increased
downstroke on the capnograph (
87
All can increase EtCO2 except:
A. Incompetent expiratory valve
B. Incompetent inspiratory valve
C. Increasing fresh gas flow
D. Malignant hyperthermia
Answer: C, increasing fresh gas flow will decrease CO2 levels. Incompetent expiratory and
inspiratory valves can result in rebreathing CO2. Malignant hyperthermia results in the increased
production of CO2 which can result in elevated EtCO2 levels
88
You note an increase in CO2 and upon further inspection, the cannister color has changed. What
is the best course of action?
A. Increase fresh gas flow rate and wait until after the procedure to change CO2 absorber
cannister
B. Change CO2 absorber cannister immediately
C. Monitor for arrhythmias and change absorber cannister after the case
D. Disconnect patient circuit and use the Ambubag to ventilate the patient
Answer: A, Carbon dioxide absorbers are critical components of an anesthesia machine.
However, it is dangerous to change an absorber mid case. Instead, the anesthesia provider should
increase fresh gas flows to limit the amount of CO2 inspired and finish the case. After, the
cannister can be safely changed.
89
While administering general anesthesia, the provider notes a waveform depression during phase
III on the EtCO2 monitor. What should the provider’s next action be?
A. The patient is experiencing a bronchospasm. Deepen sedation and administer albuterol.
B. There is a blockage in the breathing circuit. Switch to ambubag and manually ventilate.
C. The circuit is disconnected. Confirm y-piece is in place.
D. The patient is attempting spontaneous breathing. Deepen sedation.
Answer: D, When there is a slight depression during phase III of a capnogram, it could indicate
that the patient is trying to breath spontaneously. This could indicate that the provider needs to
increase sedation (Butterworth et a
90
What is not a feature of the diverting (side stream) EtCO2 monitor.
A. It measures concentrations of CO2 and anesthetic gases
B. It scavenges gas and transports it to the monitor
C. The sensor directly rests in an adapter between the circuit and mouth piece
D. It creates minimal dead space
Answer: C, In diverting (side stream) EtCO2 monitors, the exhaled gas from the patient is
scavenged and transported to the monitor where the gas is analyzed. This reduces weight to the
circuit, reduces the amount of dead space, and allows the monitor to analyze the concentration of
other anesthetic gases, not just CO2 (
91
Which of the following are the advantages of noninvasive blood pressure monitoring over
invasive techniques? Select all that apply (select 2).
A. Measurement of blood pressure with reduced infectious risks
B. Provides a direct measurement of arterial blood pressure
C. Achievable blood pressure measurement without potential risk for nerve damage
D. Continuous blood pressure measurement within some applications
Correct Answer: A & D
Rationale
Noninvasive blood pressure monitoring is performed with a reduced infectious risk due to
the absence of direct arterial cannulation (Butterworth et al., 2022, p. 83). Continuity of blood
pressure measurement can be achieved via some noninvasive methods due to innovations in
techniques such as the ClearSight finger cuff system, which allows for continuous beat-to-beat
arterial blood pressure monitoring
92
Which factors contribute more substantially to the accuracy of noninvasive blood pressure cuffs
in the operating room? Select all that apply (select 2).
A. Moderate peripheral vasoconstriction
B. Suitably sized blood pressure cuff
C. Extremity that the cuff is placed
D. The cuff position in relation to the patient’s heart
Correct Answer: B & D
Rationale
The proper sizing and positioning of the patient’s blood pressure cuff are directly related
to the validity of the measurements that the anesthesia provider will achieve (Butterworth et al.,
2022, p. 80). The cuff's position in relation to the patient's heart can gravely affect the
measurement results. Elevating a patient's extremity with the cuff can falsely decrease readings
while decreasing elevation can cause falsely high readings (
93
Which of the following statements is true regarding properly sizing a patient's blood pressure
cuff?
A. The width of the cuff should extend 40% of the length of the patient's extremity
B. A cuff’s bladder that encompasses 50% of the circumference of the extremity is
appropriate
C. Too narrow of a cuff will require less pressure to occlude an artery for pressure
determination
D. Falsely high measurements are achieved when the cuff is too large for a patient
Correct Answer: B
Rationale
The proper sizing of a blood pressure cuff is determined by a bladder that encompasses at
least 50% of the circumference of a patient’s extremity and a width that is approximately 40%
greater than the extremity's diameter (Butterworth et al., 2022, p. 80). Cuff sizes that are too
large for patients can achieve falsely low measurements. Too narrow of a cuff will require greater
pressure to occlude an artery for measurement (
94
Which of the following patients would noninvasive blood pressure monitoring be considered
inappropriate?
A. An 87-year-old male undergoing a scheduled cholecystectomy
B. A 75-year-old female undergoing a cataract removal
C. A 54-year-old male with full-thickness burns to upper and lower extremities
D. A 29-year-old male receiving a blood transfusion preoperatively
Correct Answer: C
Rationale
Patients with open injuries to multiple sites where noninvasive blood pressure monitoring
is achieved should be reconsidered for alternative monitoring due to the risk of further harm
from repetitive blood pressure cuff inflation. Accessibility of measurement sites is a determinant
of noninvasive monitoring usage
95
Why is the upper arm the most desirable position for a blood pressure cuff in pediatric patients?
A. Decreased potential for nerve palsies
B. For the preservation of forearms/wrists for peripheral IV sites
C. Produces less discomfort in children
D. It is a closer indicator of cerebral perfusion pressure
Correct Answer: D
Rationale
Nerve palsies can occur in patients undergoing repetitive noninvasive cuff measurement
if the cuff is not routinely repositioned (Butterworth et al., 2022, p. 80). However, this is not the
reason for desirability in pediatrics. Upper extremity positioning is preferred in pediatric patients
as it has been shown to have the most significant clinical correlation to cerebral perfusion
pressure
96
Which patients would prove to be ineffective for blood pressure monitoring via oscillometry?
Select TWO.
A. 75-year-old female undergoing cardiopulmonary bypass
B. 56-year-old male scheduled for an exploratory laparotomy
C. 66-year-old male with severe arteriosclerosis undergoing an angioplasty
D. 45-year-old female scheduled for a colectomy
Correct Answer: A & C
Rationale
The noninvasive blood pressure techniques of palpation, auscultation, and oscillometry
require pulsatile blood flow to achieve effective measurement. Cardiopulmonary bypass and
highly sclerotic arterial disease can cause decreased to minimal pulsatile flow, which is necessary
for oscillometry to achieve an effective reading (
