Pharmacology

Questions

DIRECTIONS (Questions 366-523): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

366. A 72-year-old female with a past medical history of osteoporosis underwent open reduction and internal fixation of her left hip. She was previously diagnosed with heparin induced thrombocytopenia type II and has a platelet count of 56,000. Which one of the following agents can be administered for immediate postoperative prophylaxis of deep vein thrombosis?

(A) low-molecular-weight heparin

(B) warfarin

(D) unfractionated heparin

(E) fondaparinux

367. Drug elimination from the body

(A) is most efficient for substances with high lipid solubility

(B) may occur by metabolism

(D) is usually not modifiable with pharmacologic interventions

(E) is independent of drug binding to blood and tissues

368. Sevoflurane

(A) can cause hepatotoxicity

(B) is flammable at a concentration of 6%

(D) undergoes hepatic metabolism

(E) causes myocardial irritability

369. In an 80-kg patient with severe pain, administration of thiopental 80 mg will

(A) produce sleep

(B) will have analgesic effects

(D) will sedate the patient but not induce sleep

(E) will blunt the hemodynamic response to painful stimuli

370. Administration of ketamine causes

(A) decreased heart rate

(B) increased heart rate

(D) no change in cardiac output

(E) no change in heart rate

371. Atracurium 0.5 mg/kg is administered for induction of paralysis in a hemodynamically stable, anesthetized patient as an intravenous bolus. Shortly after drug administration, the patient becomes hypotensive. This is most likely due to

(A) adrenoceptor mediated effects

(B) ganglionic blockade

(D) negative inotropic effects

(E) hemodynamic effects of laudanosine

372. Rocuronium

(A) is a ganglionic blocker

(B) at 4 × ED95 causes significant histamine release

(D) is eliminated by the kidney

(E) is not suitable for continuous infusion

373. With regard to drug metabolism reactions

(A) the phase I reactions usually involve conjugation

(B) the phase II reactions generally result in the loss of pharmacological activity

(D) they usually result in an increase in the duration of action of the drug

(E) they can be differentiated into three distinct phases

374. Transdermal scopolamine

(A) will not produce behavioral side effects

(B) is safe for emesis prophylaxis in children

(D) does not cross the blood–brain barrier

(E) can prevent postoperative nausea in adult patients

375. A drug that is a pure opioid antagonist is

(A) butorphanol

(B) levallorphan

(D) neostigmine

(E) edrophonium

376. Milrinone

(A) decreases cyclic-AMP levels

(B) is metabolized by monoamine oxidase

(D) is a β-adrenergic agonist

(E) increases peripheral vascular resistance

377. Bupivacaine

(A) is an ester local anesthetic with a short duration

(B) should be used in a concentration of 0.75% for epidural anesthesia during labor

(D) toxicity is not a problem unless it is injected intravenously

(E) cardiotoxicity is noted by the onset of tachycardia

378. A 23-year-old male is scheduled to undergo repair of an elbow fracture under ultrasound guided brachial plexus blockade. With regard to choice of local anesthetic, which one of the following statements is most accurate?

(A) Tetracaine is less cardiotoxic than chloroprocaine.

(B) The extent of blockade of cardiac sodium channels by bupivacaine is predicted by its local anesthetic potency.

(D) The maximum recommended local anesthetic dosage for ropivacaine is 3 mg/kg.

(E) Lidocaine has a longer duration of action as compared to mepivacaine.

379. Etomidate

(A) has anticonvulsant activity

(B) releases histamine

(D) has an antiemetic effect

(E) increases intraocular pressure

380. Glucuronide metabolites of medications will be excreted in the urine more rapidly than the parent compounds by which one of the following processes?

(A) tubular secretion

(B) glomerular filtration

(D) passive nonionic diffusion

(E) tubular reabsorption

381. The correct ranking of the potencies of the volatile anesthetics, from most potent to least potent, is

(A) sevoflurane > desflurane > isoflurane > halothane

(B) desflurane > sevoflurane > isoflurane > halothane

(D) halothane > isoflurane > sevoflurane > desflurane

(E) halothane > sevoflurane > desflurane > isoflurane

DIRECTIONS: Use the following figure to answer Questions 382-383:

382. If A and B are two different medications producing the same effect, then the figure shows that

(A) A has higher efficacy than B

(B) A has lower efficacy than B

(D) A is more potent than B

(E) A has a higher ED₅₀ than B

383. If A depicts the dose-response relationship of drug X acting alone, and B depicts the dose-response relationship of drug X in the presence of drug Y, then it can be said that drug Y

(A) is a competitive antagonist of drug X

(B) is a noncompetitive antagonist of drug X

(D) increases the efficacy of drug X

(E) decreases the potency of drug X

384. A 63-kg patient with a history of glaucoma who suffered a second degree burn of 10% of the total body surface area in a motor vehicle accident is undergoing surgery for intramedullary nailing of an open tibia fracture 18 h after the accident under general endotracheal anesthesia. Induction of anesthesia was accomplished by administration of fentanyl 2 mcg/kg, propofol 2.5 mg/kg, and succinylcholine 1 mg/kg intravenously. Antibiotic prophylaxis consisted of gentamicin 5 mg/kg intravenously prior to incision. Prolonged duration of neuromuscular blockade after succinylcholine in this patient would be most likely due to

(A) potentiation of the neuromuscular blocking effects by gentamicin

(B) the burn suffered in the motor vehicle crash

(D) prolonged immobilization

385. Desflurane

(A) is highly lipid soluble

(B) has a MAC of 6% when administered with O₂

(D) is not irritating to the airway

(E) metabolism releases significant quantities of fluoride ion

386. A patient scheduled for an emergency procedure gives a history of heroin abuse. A problem that must be anticipated in the perioperative period is

(A) delayed gastric emptying

(B) presence of left ventricular hypertrophy

(D) decreased need for anesthetics

(E) increased sensitivity to catecholamines

387. Local anesthetics have their effect at the

(A) presynaptic nerve terminal

(B) postsynaptic nerve terminal

(D) membrane

(E) calcium channel

388. The action of propofol after injection is terminated by

(A) its elimination unchanged by the kidneys

(B) its biotransformation by the liver

(D) its redistribution

(E) being taken up in fatty tissues

389. Methohexital

(A) is metabolized to a greater extent than thiopental

(B) is converted to active metabolites

(D) causes histamine release from mast cells

(E) is contraindicated in asthma

390. The first-pass effect refers to

(A) the biotransformation of a drug in its vehicle of administration

(B) the change of a drug by enzymes in muscle

(D) the drug lost by urinary excretion

(E) the drug lost by fecal excretion

391. An expected cardiovascular change after ketamine administration is

(A) elevated diastolic pressure, normal systolic pressure

(B) elevated diastolic and systolic pressure

(D) decreased diastolic pressure, increased systolic pressure

(E) no change in blood pressure

392. A small dose of a nondepolarizing muscle relaxant given 3 min before an intubating dose of succinylcholine

(A) increases the dose of succinylcholine required

(B) will not prevent the rise in intracranial pressure

(D) doubles the time to recovery from neuromuscular blockade

(E) permits faster intubation

393. A drug is administered by bolus intravenous injection. Approximately what percentage of the drug remains after four half-lives have elapsed?

(A) 1%

(B) 4%

(D) 10%

(E) 12%

394. Flecainide is

(A) an antiarrhythmic drug in Class IC

(B) a lidocaine analog

(D) the drug of choice for local anesthesia reactions

(E) administered only orally

395. The Administration of anticholinesterase drugs will

(A) prolong all neuromuscular blockade

(B) always reverse nondepolarizing agents

(D) reverse nondepolarizing agents if the plasma concentration of the drug is low enough

(E) reverse the action of a depolarizing agent if only partial paralysis is present

396. A patient is admitted for emergency orthopedic surgery. Preliminary data show a BUN value of 85 mg/dL and serum potassium of 6.0 mEq/L. The least desirable drug for intubation would be

(A) rocuronium

(B) vecuronium

(D) mivacurium

(E) pancuronium

397. The most sensitive test to determine adequate recovery from neuromuscular blockade is

(A) five-second head lift

(B) five-second hand grip

(D) tactile response to double-burst stimulation

(E) tactile response to train-of-four

398. A patient who had been given vecuronium received neostigmine, 3 mg, at the termination of the surgical procedure. Six minutes later, a large amount of white, frothy secretions was noted in the endotracheal tube. Vigorous suctioning was required to remove these secretions in order to ventilate the patient. The treatment of choice for such secretions is

(A) atropine

(B) digoxin

(D) readministration of vecuronium

(E) use of a ventilator

399. Heparin inhibits blood coagulation

(A) by binding calcium ions

(B) through interactions with protamine

(D) by activating plasmin

(E) by activating von Willebrand factor

400. The patient with myasthenia gravis

(A) has normal reactions to muscle relaxants

(B) reacts abnormally to relaxants only when the condition is not well controlled

(D) has an increased sensitivity to nondepolarizing relaxants

(E) has an increased sensitivity to depolarizing relaxants

401. Labetalol

(A) is a nonselective α-adrenergic receptor blocker

(B) has intrinsic sympathomimetic activity at β₂-adrenergic receptors

(D) has a potency ratio of β– to α–adrenergic blockade of approximately 10:1

(E) is a short acting, selective β₁-adrenergic receptor blocker

402. Physostigmine

(A) may be used for the treatment of central anticholinergic syndrome

(B) does not cross the blood–brain barrier

(D) is the drug of choice for reversal of the sedative effect of benzodiazepines

(E) often produces an uncomfortably dry mouth

DIRECTIONS: Use the following scenario to answer Questions 403-408. Many patients are unaware of the reasons for which they are taking their medications. When provided with a list of medications by a patient, an anesthesiologist must be able to recognize the medications and know the likely pathological states for which the medications are indicated. For Questions 403-408, a medication is followed by five diseases or pathological states. Choose the ONE disease for which the medication may be indicated.

403. Lisinopril

(A) panic disorder

(B) hypertension

(D) premature ventricular contractions

(E) hyperthyroidism

404. Amiodarone

(A) Wolff-Parkinson-White syndrome

(B) hyperthyroidism

(D) pulseless electrical activity

(E) ventricular tachycardia

405. Fexofenadine

(A) hay fever

(B) insomnia

(D) chronic pain

(E) inflammatory bowel disease

406. Budesonide

(A) deep venous thrombosis

(B) control of asthma

(D) angina pectoris

(E) atrial fibrillation

407. Dofetilide

(A) muscle spasticity

(B) trigeminal neuralgia

(D) peripheral edema

(E) insomnia

408. Allopurinol

(A) systemic lupus erythematosus

(B) gout

(D) rheumatoid arthritis

(E) psoriatic arthritis

409. A 42-year-old female with a BMI of 32 and a history of severe postoperative nausea and vomiting (PONV) is scheduled for a laparoscopic cholecystectomy for symptomatic cholelithiasis. Your anesthetic plan includes the administration of a 5-HT₃ receptor antagonist and droperidol for the prevention of PONV. If you were to add a third agent, the most useful drug would be

(A) metoclopramide

(B) prochlorperazine

(D) dexamethasone

(E) ephedrine

DIRECTIONS: Use the following figure to answer Questions 410-411:

410. The train-of-four stimulus is depicted in the figure. Stimulation is at 2 Hz. The response in A is normal. By looking at B, you know that

(A) a depolarizing block is present

(B) the patient is partially paralyzed

(D) the train-of-four ratio is 50%

(E) the patient could sustain a head lift

411. The train-of-four ratio for a depolarizing block is

(A) variable

(B) 50%

(D) 75%

(E) 100%

412. Propofol as compared to thiopental

(A) is less likely to provoke bronchospasm

(B) if administered in equipotent doses for induction of anesthesia causes less reduction in systemic blood pressure

(D) has no effect on cerebral metabolic rate

(E) does not cause excitatory motor activity

413. Verapamil

(A) increases myocardial contractility

(B) is a β-adrenergic antagonist

(D) may produce AV-block when combined with volatile anesthetics

(E) belongs to the class of dihydropyridines

414. Lepirudin and argatroban exert their anticoagulant effect by

(A) vitamin K antagonism

(B) inhibition of platelet aggregation

(D) increasing the rate of the thrombin-antithrombin reaction

(E) direct thrombin inhibition

415. If a patient is taking a monoamine oxidase (MAO) inhibitor, which one of the following should be avoided?

(A) local anesthetics

(B) halothane

(D) meperidine

(E) aspirin

416. The most common electrolyte alteration caused by the thiazide diuretics is

(A) hypokalemia

(B) hypoglycemia

(D) hypernatremia

(E) hyperuricemia

417. Nifedipine

(A) is quite effective in supraventricular tachycardia

(B) is used for the treatment of ischemic heart disease

(D) is a peripheral vasoconstrictor

(E) is an effective drug for ventricular tachycardia

418. The interaction of protamine and heparin to terminate anticoagulation is of

(A) competition for binding sites

(B) a chemical interaction leading to an inactive compound

(D) a conformational change

(E) platelet stimulation

419. Epinephrine causes a prolongation of activity of local anesthetics by

(A) chemical interaction

(B) decreasing absorption

(D) competition for binding sites

(E) altered metabolism

420. The combination of nitrous oxide at 0.5 MAC plus isoflurane 0.5 MAC is one of

(A) antagonism

(B) potentiation

(D) synergism

(E) no effect

421. Glycopyrrolate

(A) is a quaternary amine

(B) crosses the blood–brain barrier with ease

(D) is a cholinergic agonist

(E) is a naturally occurring belladonna alkaloid

422. Lidocaine

(A) is eliminated chiefly by the liver

(B) is effective orally

(D) toxicity is noted by the appearance of hematuria

(E) is useful in supraventricular tachycardia

423. The interaction of phenobarbital and phenytoin can be described as one of

(A) chemical interaction

(B) interaction at site of absorption

(D) competition for binding sites

(E) altered metabolism

424. Midazolam

(A) is contraindicated in the child

(B) is shorter-acting than thiopental

(D) suppresses adrenal cortical function

(E) has a high incidence of histamine release

425. The patient who has recently abused cocaine

(A) will be calm and sedated

(B) may be treated with propranolol

(D) will have bradycardia

(E) will have hypotension

426. The methylxanthine group of drugs

(A) includes caffeine

(B) have a strong β₁-adrenergic mimetic effect

(D) causes bronchoconstriction

(E) leads to a decrease in cyclic AMP

427. Sublingual drug administration

(A) leads to lower drug levels compared to oral administration

(B) is more effective for ionized drugs

(D) leads to rapid liver breakdown of the drug

(E) requires a much larger dose for effectiveness

428. Metoclopramide

(A) is a dopaminergic agonist

(B) decreases gastric acid secretion

(D) may lead to vomiting

(E) leads to an ileus and increased small intestinal transit time

429. A patient is scheduled for surgery who is a Jehovah’s Witness. She adamantly refuses to receive blood products. The procedure may require volume replacement. A product that may be used is

(A) 5% albumin

(B) washed red cells

(D) hetastarch

(E) platelets to decrease bleeding, thus making transfusion unnecessary

430. A 21-year-old female is emergently taken to the operating room for exploratory laparotomy after sustaining multiple injuries including a grade 4 splenic rupture in a high-speed motor vehicle accident. Upon transfer to the operating room table, the patient is noted to have pulseless ventricular fibrillation, and cardiopulmonary resuscitation according to ACLS guidelines is initiated. Despite resuscitation according to protocol including the administration of epinephrine intravenously, the patient remains in ventricular fibrillation. Which one of the following drugs or procedures is recommended as an alternative to epinephrine in this setting?

(A) phenylephrine 80 mcg IV push

(B) adenosine 6-12 mg IV push

(D) sodium bicarbonate 50 mEq IV push

(E) overdrive pacing with isoproterenol

431. Edrophonium, in a dose of 1 mg/kg

(A) has a slower onset time than neostigmine

(B) has a much shorter duration than neostigmine

(D) has a faster onset and decreased duration than neostigmine

(E) should be preceded by atropine

432. Sodium nitroprusside is to be used for treatment of intraoperative hypertension. This drug

(A) causes venous dilatation only

(B) will be needed in increased doses if the patient has been previously treated with propranolol

(C) may cause cyanide toxicity in high doses, evidenced by alkalosis and increasing drug dosage needed to achieve the same result

(D) may cause acidosis as a sign of toxicity

(E) may cause a toxicity that is evidenced by an acidosis that is responsive to sodium bicarbonate

433. Postoperative pain control with methadone

(A) is limited by its short half-life

(B) is more effective with oral administration

(D) may take 48 h to obtain a stable effect

(E) does not depress respiration

434. Dopamine

(A) is a transmitter confined to the central nervous system

(B) stimulates dopaminergic receptors only at an infusion rate of 10 mcg/kg/min

(D) increases cardiac output by stimulating β₁-adrenergic receptors

(E) decreases pulmonary artery pressure

435. A patient has undergone a laparotomy for a bowel obstruction. A rapid sequence induction was performed using succinylcholine for muscle relaxation, and pancuronium was subsequently given. Neuromuscular blockade was reversed with neostigmine. A few minutes after extubation, the surgical dressing is stained with blood and the surgeon decides that the wound must be reexplored. If another rapid sequence induction is to be performed,

(A) succinylcholine will be ineffective

(B) succinylcholine will lead to severe hyperkalemia

(D) succinylcholine will be effective, however its duration will be prolonged

(E) succinylcholine will behave as it did during the first rapid sequence induction in this patient

436. Drug clearance

(A) is solely a function of volume of distribution

(B) is a function of age

(D) is dependent on drug concentration

(E) may be due to elimination of an unchanged drug

437. Pharmacotherapy with cimetidine may impair the metabolism of which one of the following drugs?

(A) atracurium

(B) dopamine

(D) lidocaine

(E) succinylcholine

438. Glucagon produces all of the following effects EXCEPT

(A) increased insulin secretion

(B) inotropic cardiac effects

(D) increased hepatic gluconeogenesis

(E) increased lipolysis in adipose tissue

439. Which one of the following statements regarding injectable benzodiazepines is most accurate?

(A) They significantly induce the synthesis of hepatic CYP isozymes.

(B) Administration of benzodiazepines is safe in patients with acute intermittent porphyria.

(D) They exert their therapeutic effect by increasing chloride conductance and hyperpolarizing membranes.

(E) Excessive sedation following IV administration of benzodiazepines should be antagonized with IV naloxone.

DIRECTIONS: Use the following figure to answer Questions 440-442:

440. The figure shows the blood concentration of a drug as a function of time after an intravenous bolus of 400 mg. The volume of distribution of this medication in the central compartment is

(A) 5 L

(B) 8 L

(D) 12 L

(E) 15 L

441. The redistribution half-life for this drug is

(A) 5 min

(B) 10 min

(D) 20 min

(E) 30 min

442. The terminal half-life for this drug is

(A) 1 h

(B) 2 h

(D) 4 h

(E) 5 h

443. A patient who has had surgical ablation of the pituitary gland is scheduled for surgery. She is on desmopressin twice daily. The drug

(A) may be given intravenously during the procedure

(B) may lead to hypotension

(D) is equally effective in nephrogenic diabetes insipidus

(E) may increase blood loss at the time of surgery

444. Hydralazine

(A) is a vasodilator due to its catecholamine inhibitor properties

(B) may cause bradycardia

(D) leads to diuresis and sodium loss

(E) has beneficial effects in patients with angina

445. An age-related difference in drug response in the elderly is

(A) increase in MAC

(B) decreased rate of hepatic glucuronidation of morphine

(D) shorter recovery time to normal ventilatory response after fentanyl

(E) lower intubating dose of vecuronium

446. Nonparticulate antacid administration

(A) should be given 3 h before surgery

(B) decreases gastric volume

(D) has a lag time of 1 hour for effectiveness

(E) is aimed at raising the pH to at least 2.5

447. A drug that is a mixed opioid agonist–antagonist is

(A) butorphanol

(B) naloxone

(D) methohexital

(E) midazolam

448. Patients with alcohol abuse

(A) will have increased anesthetic requirements in the acute state of intoxication

(B) will have reduced anesthetic requirements in the chronic abuse state

(D) will develop tolerance to its respiratory effects with chronic usage

(E) are more resistant to the toxic effects of local anesthetics

449. A 24-year-old patient is undergoing brachial plexus blockade for open reduction and internal fixation of a forearm fracture. After injection of 30 mL of local anesthetic, blood is aspirated through the injection needle. Assuming significant inadvertent intravascular injection, which one of the following agents is least likely to cause Local Anesthetic Systemic Toxicity (LAST)?

(A) tetracaine

(B) chloroprocaine

(D) lidocaine

(E) mepivacaine

450. The pKa of mepivacaine is 7.6. At physiologic pH (7.4), what percentage of mepivacaine molecules are in the uncharged form?

(A) 3.9%

(B) 6.1%

(D) 61%

(E) 100%

451. If a patient presenting for emergent craniotomy has increased intracranial pressure, which one of the following techniques is most likely to result in a net decrease in intracranial pressure by virtue of reducing cerebral blood flow?

(A) A combination of halogenated inhalational anesthetics with nitrous oxide

(B) Hyperventilation combined with a balanced anesthetic technique including the use of opioids

(D) Administration of a dobutamine

(E) Administration of phenylephrine

452. In the distribution phase of an intravenous drug,

(A) the delivery of the drug to tissues is independent of blood flow

(B) highly charged, lipid-insoluble drugs distribute to the vessel-rich group of tissues because of poor uptake by fat

(D) the interstitial concentration of the drug is affected by the pH of the interstitial fluid

453. The loading dose of a drug

(A) is calculated based on the central volume of distribution (Vc)

(B) is designed to achieve immediate steady-state plasma concentration

(D) may lead to undesirable effects

454. Which one of the following statements about amiodarone is true?

(A) It is the drug of choice for the treatment of Wolff-Parkinson-White (WPW) syndrome.

(B) It is considered the most effective of the antiarrhythmic drugs for the prevention of recurrences of atrial fibrillation.

(D) It should be avoided in the patient with refractory ventricular fibrillation and tachycardia.

(E) Drug toxicity during oral loading regimes is common, and mostly affects the kidneys.

455. A 78-year-old patient with past medical history of chronic renal insufficiency and congestive heart failure is admitted to the intensive care unit with symptoms of nausea, visual disturbances, confusion, and sinus bradycardia. The patient is unable to give a reliable history including medication regimen. Based on the patients’ presentation, the drug most likely to cause these symptoms is

(A) amiodarone

(B) quinidine

(D) carvedilol

(E) digoxin

456. The decrease in cerebral metabolic rate caused by inhaled anesthetics is

(A) more pronounced with isoflurane as compared to sevoflurane

(B) independent of dose

(D) present during seizure activity

(E) due to vasoconstriction and resulting decreased cerebral blood flow

457. A patient has been on oral steroid therapy for a dermatologic problem for two years. She is to undergo a cholecystectomy. In order to prevent secondary adrenal insufficiency, the most appropriate approach to perioperative steroid coverage would include which one of the following?

(A) hydrocortisone 100 mg PO at the time of oral benzodiazepine premedication

(B) 50-75 mg hydrocortisone IV at the time of induction

(D) 25 mg hydrocortisone IV at the time of induction

(E) 100-150 mg hydrocortisone IV at the time of induction, followed by a rapid taper back to the usual dose

458. A 78-kg, 36-year-old patient is undergoing saphenous vein stripping of her left lower extremity. After uneventful induction of general anesthesia with placement of LMA, cefazolin 2 gm IV is being administered, when there is a sudden increase in airway pressure, wheezing, tachycardia, and decreased blood pressure. In addition to stopping infusion of cefazolin, an IV fluid bolus, and administration of 100% oxygen, which one of the following actions is most appropriate?

(A) administration of IV glucocorticoid and phenylephrine

(B) administration of subcutaneous epinephrine and IV glucocorticoid

(D) administration of IV epinephrine and IV glucocorticoid

(E) administration of IV dopamine and IV glucocorticoid

459. A 37-year-old patient with a history of chronic alcohol abuse is admitted to the hospital for palpitations. On examination, the patient appears weak and malnourished, and is complaining about muscle cramps. An ECG obtained is significant for polymorphic ventricular tachycardia with QT prolongation. An electrolyte panel obtained from a venous blood draw will most likely show which one of the following electrolyte abnormalities?

(A) hypochloremia

(B) hypocalcemia

(D) hyperkalemia

(E) hypomagnesemia

460. Opioid agonists produce

(A) dilated pupils

(B) nausea and vomiting mediated through the gastrointestinal tract

(D) unconsciousness at high doses

461. A drug suitable for the patient with hyperthyroidism is

(A) amiodarone

(B) propranolol

(D) aspirin

462. Inhalational anesthetic-mediated coronary “steal”

(A) results in a higher incidence of perioperative ischemia when isoflurane is used in patients with coronary artery disease

(B) involves the diversion of blood flow away from areas of fixed stenotic lesions

(D) is associated with increased postoperative mortality

(E) is a common problem under sevoflurane anesthesia

463. Corticosteroids given for the treatment of asthma

(A) have an immediate onset of action

(B) are best given by the inhalation route to decrease onset time

(D) should involve only those drugs with little mineralocorticoid effect

(E) are less effective in controlling inflammation as compared to inhaled β₂-agonists

464. An anesthetic agent with a prolonged duration of action in patients with renal failure is

(A) pancuronium for intubation

(B) fentanyl for analgesia

(D) propofol for induction

(E) etomidate for induction

465. Ionization of a drug

(A) is affected by volume of distribution

(B) is independent of the pKa of the drug

(D) does not affect the ability of the drug to cross membranes

(E) is a function of pH of the fluid in which it is dissolved

466. A pharmacologic difference in the obese patient as compared to the lean patient is a(n)

(A) decreased degree of metabolism of isoflurane

(B) decreased terminal half-life of thiopental

(D) prolonged duration of action of succinylcholine

(E) increased volume of distribution of digoxin

467. Granisetron exerts its therapeutic effect via which one of the following mechanisms?

(A) blockade of 5-HT₃ receptors in the chemoreceptor trigger zone

(B) histamine H₂-receptor antagonism

(D) histamine H₁-receptor antagonism

(E) neurokinin receptor antagonism

468. A patient with acute intermittent porphyria

(A) voids urine containing uroporphyrins that are pathognomonic for the disease

(B) will likely suffer a cardiac arrest if administered thiopental for induction of anesthesia

(D) may be given morphine safely

469. A patient who has been treated in the past with high doses of cisplatin may have which one of the following permanent problems?

(A) pulmonary fibrosis

(B) chronic pancreatitis

(D) congestive heart failure

(E) hepatic cirrhosis

470. A comparison of dissociative and inhalational anesthesia shows that

(A) the relaxed, nonresponding state is present in each

(B) there is decreased muscle tone in each

(D) the eyes may remain open during dissociative anesthesia

(E) complete unconsciousness is a hallmark feature of dissociative anesthesia

471. A patient is suspected to have had an allergic reaction to an injection of lidocaine obtained from a multiple dose vial. Which one of the following statements is most accurate?

(A) The patient will probably have a reaction if a second injection is made with lidocaine from a fresh, single-dose vial.

(B) The patient may be exhibiting a reaction to methylparaben.

(D) The patient is probably reacting to a bacterial contaminant previously introduced into the vial.

(E) The reaction may be avoided by addition of a vasoconstrictor.

472. Captopril

(A) activates angiotensin-converting enzyme

(B) increases levels of angiotensin II

(D) decreases arteriolar resistance

(E) increases cardiac contractility

473. Drug antagonism

(A) may occur when two drugs chemically combine in the body

(B) occurs when two drugs affect a physiologic system in a similar way

(C) is considered competitive when a drug with affinity for a receptor, and intrinsic efficacy competes with the agonist for the primary binding site

(D) may occur when two drugs displace the dose-response curve in the same direction

(E) when competitive, will decrease the maximal response of the agonist on the dose-response curve

DIRECTIONS: Use the following scenario to answer Questions 474-476: A 46-year-old, 63-kg woman enters the hospital for correction of strabismus. She has been using echothiophate iodide drops for 2 years. She undergoes induction of anesthesia with propofol 2.5 mg/kg and succinylcholine 1 mg/kg is given to facilitate intubation. Anesthesia is maintained with 70% N₂O in O₂ and fentanyl 1 mcg/kg. During the procedure she is mechanically ventilated, and no untoward effects occur during the case. At the end of the surgery, the patient does not awaken and does not move or breathe.

474. The most likely cause of the apparent prolonged anesthesia is

(A) fentanyl overdose

(B) prior use of echothiophate iodide

(D) effect of nitrous oxide

(E) propofol overdose

475. A maneuver that can be done to ascertain the cause of the prolongation is

(A) use of a nerve stimulator

(B) inhalation of carbon dioxide

(D) administration of another dose of succinylcholine

476. Application of a nerve stimulator reveals that the patient has no twitch or tetanic response to nerve stimulation. Opioid antagonism with naloxone is attempted without response. The appropriate intervention is

(A) administration of pralidoxime

(B) administration of a stimulant (e.g., epinephrine)

(D) continued ventilation

(E) administration of physostigmine

477. Intramuscular injection

(A) into the gluteus maximus permits a more rapid onset than if the drug were injected into the deltoid muscle

(B) permits a more rapid onset than after subcutaneous injection

(D) cannot be used for nonaqueous solutions

(E) avoids first-pass elimination in the lung prior to distribution to the rest of the body

478. When reversing nondepolarizing neuromuscular blockade,

(A) atropine should be given at the same time as neostigmine

(B) glycopyrrolate should be given at the same time as edrophonium

(D) lack of fade during double-burst stimulation is a good indicator of sufficient muscular function to permit endotracheal extubation

(E) a TOF ratio = 0.7 indicates complete recovery of pharyngeal function

479. A 24-year-old female, G1 P0, with a history of CHF is presenting for cesarean section at 36 weeks gestation. Rapid sequence intubation facilitated by fentanyl, propofol, and succinylcholine is performed. Shortly after successful intubation of the trachea, the patient suffers cardiac arrest. The underlying disease most likely implied as the cause of the cardiac arrest is

(A) myasthenia gravis

(B) Duchenne muscular dystrophy

(D) Charcot-Marie-Tooth disease

(E) myotonic dystrophy

480. The neuroleptic state is characterized by

(A) amnesia

(B) increased motor activity

(D) analgesia

(E) loss of consciousness

481. Which one of the following agents has the highest propensity for producing carbon monoxide during inhalational anesthesia?

(A) isoflurane

(B) halothane

(D) desflurane

(E) enflurane

482. Two drugs are said to have an additive effect when

(A) one drug will accelerate the speed of onset of the other

(B) one drug will prolong the action of the other

(D) the combined effect of the two drugs is the algebraic sum of the individual actions

(E) the combined effect of the two drugs exceeds the sum of each drug given alone

DIRECTIONS: Use the following figure to answer Question 483:

483. The figure shows the ratio of the concentrations of sevoflurane in alveolar gas to inspired gas as a function of time. A factor that will increase the initial slope is

(A) presence of nitrous oxide in inspired gas

(B) decreased inspired sevoflurane concentration

(D) increased cardiac output

(E) pulmonary right-to-left shunting

484. Eaton–Lambert syndrome is characterized by

(A) decreased production of acetylcholine by the nerve cell

(B) decreased release of acetylcholine at the neuromuscular junction

(D) decreased sensitivity to depolarizing muscle relaxants

(E) increased susceptibility to malignant hyperthermia

485. A patient is infected with Clostridium perfringens and has gas gangrene. Which one of the following drug regimens is considered first line for the treatment of this organism?

(A) parenteral penicillin G and parenteral clindamycin

(B) parenteral cefoxitin and parenteral imipenem

(D) parenteral gentamicin and parenteral vancomycin

(E) oral penicillin V and parenteral amikacin

486. A 56-year-old, 85-kg patient with a history of gastroduodenal ulcers is presenting for elective resection of the sigmoid colon for chronic diverticulitis. The patient is premedicated with 10 mg diazepam orally, and undergoes placement of an epidural catheter in the midthoracic area for postoperative pain control. Induction of anesthesia is performed with propofol 2 mg/kg, fentanyl 2 mcg/kg, and rocuronium 0.6 mg/kg. Anesthesia is maintained with desflurane in nitrous oxide and oxygen. At the conclusion of an uncomplicated case, the patient is noted to have prolonged emergence from anesthesia, and appears oversedated after tracheal extubation, despite full recovery from neuromuscular blockade. Which one of the following is the most likely cause?

(A) administration of desflurane

(B) chronic therapy with cimetidine

(D) fentanyl overdose

(E) diazepam overdose

487. The metabolism of nitrous oxide in humans

(A) yields nitric oxide as the main product

(B) occurs in the liver

(D) is increased by phenobarbital pretreatment

(E) occurs in the lungs

488. When methylmethacrylate (MMA) cement is used to secure the femoral component of a hip prosthesis in the femoral canal,

(A) hypertension is a common occurrence

(B) acute vasodilation and cardiac collapse can occur due to hypersensitivity reaction to MMA

(C) cardiovascular collapse and bronchoconstriction may occur due to embolization of fat particles and debris from the intramedullary canal

(D) the patient should have a central venous catheter for the removal of an air embolus

(E) the technique of venting the canal can reliably prevent cardiovascular compromise during the procedure

489. Ondansetron

(A) facilitates gastric emptying

(B) decreases gastroesophageal reflux

(D) has antiemetic effects

(E) acts on dopaminergic receptors in the area postrema

DIRECTIONS: Use the following figure to answer Question 490:

490. The figure depicts the relative effect of propofol in three physiologic states. From this we can say that

(A) the potency of propofol in the anxious patient is increased

(B) the anxious patient will require a larger dose

(D) the bleeding patient has a faster decrease in brain concentration as a result of the propofol being lost with the blood

(E) the anxious patient will have loss of consciousness sooner after IV bolus, as compared to the bleeding patient

491. A recommended single-agent perioperative prophylaxis regimen against a surgical site infection for patient populations with low incidence of methicillin-resistant Staphylococcus aureus (MRSA) is

(A) penicillin G

(B) vancomycin

(D) ampicillin

(E) levofloxacin

492. Carbon monoxide

(A) when bound to hemoglobin can be differentiated from oxyhemoglobin by standard pulse oximetry

(B) causes oxygen to be released less efficiently from hemoglobin in tissues

(D) combines and dissociates from hemoglobin at a rate equal to that of oxygen

(E) leads to a right-shift of the oxygen-hemoglobin dissociation curve

493. An active transmembrane transport mechanism is

(A) transport via filtration

(B) channel mediated diffusion

(D) transport of solute by carrier protein down an electrochemical gradient

(E) saturable

494. An active metabolite of heroin is

(A) thebaine

(B) morphine

(D) codeine

(E) apomorphine

495. Low-molecular-weight heparins

(A) are pentasaccharides

(B) cause a lower incidence of heparin-induced thrombocytopenia than unfractionated heparin

(D) all have equivalent antithrombotic effects

(E) are able to bridge antithrombin to thrombin to the same extent as unfractionated heparin

496. A 42-year-old female is admitted to the hospital approximately 18 h after supposedly ingesting a large quantity of an unknown drug in tablet form. The patient appears confused, tachypneic, complains about nausea and tinnitus, and is febrile at 39°C. Pupils are equal bilaterally at 3 mm and reactive. Shortly after arrival, the patient starts to vomit. Blood gas analysis is significant for a mixed picture consisting of respiratory alkalosis and metabolic acidosis. The patients’ symptoms are most consistent with drug overdose from

(A) acetaminophen

(B) aspirin

(D) diphenhydramine

(E) lithium

497. Of the following metabolic reactions, which one is most likely to be catalyzed by cytochrome P450?

(A) acetylation of hydralazine

(B) demethylation of ketamine

(D) oxidative deamination of norepinephrine

(E) conjugation of acetaminophen to sulfate

498. In a patient who is physically dependent on morphine, which one of the following is a symptom of the abstinence syndrome that begins within 12 h of the last dose of morphine?

(A) bradycardia

(B) lacrimation

(D) pilomotor activity (“gooseflesh”)

(E) coma

499. A 72-year-old man with a history of congestive heart failure presents for evaluation of acute renal insufficiency. On evaluation, the patient also complains about a loss of sense of taste and a chronic cough. Urinalysis is significant for proteinuria. He was started on a new antihypertensive medication a few months ago. The drug most likely implied in his symptoms is

(A) carvedilol

(B) hydralazine

(D) nifedipine

(E) captopril

500. The rapidly perfused (vessel-rich) tissues

(A) include the kidneys

(B) receive an increasing proportion of cardiac output with increasing age

(D) include muscle

(E) account for 30% of total body weight in adults

501. Ketorolac 60 mg and morphine 10 mg produce approximately equivalent magnitudes of which one of the following effects after intramuscular injection?

(A) nausea

(B) sedation

(D) analgesia

(E) abdominal pain

502. The CNS response to an induction dose of propofol would be most altered by which one of the following conditions?

(A) obesity

(B) hypoalbuminemia

(D) renal failure

(E) hypovolemia due to blood loss

503. Which one of the following statements regarding the CNS effects of halogenated volatile anesthetics is most accurate?

(A) Isoflurane, in contrast to halothane, abolishes autoregulation

(B) Halothane can produce an isoelectric EEG at clinically relevant doses

(D) Isoflurane decreases cerebral blood flow

(E) Sevoflurane decreases epileptic brain activity

504. Lamotrigine

(A) is an atypical antipsychotic drug

(B) has a prolonged half-life when pentobarbital, carbamazepine, or phenytoin are administered concomitantly

(D) is effective against a broader spectrum of seizures than phenytoin and carbamazepine

(E) is not metabolized in humans

505. A 42-year-old patient with alcohol induced liver cirrhosis, Child-Pugh class B, underwent operative repair of a femur fracture sustained in a motor vehicle accident under general anesthesia. There were no other associated injuries. Induction of anesthesia was performed with propofol, fentanyl, and cisatracurium, and the anesthesia was maintained with sevoflurane in oxygen and nitrous oxide. After uneventful postoperative extubation and recovery, the patient is transferred to the floor. Three days later, the orthopedics team consults you to evaluate the patient for jaundice, lethargy, and signs of encephalopathy. The patient most likely suffered intraoperative hepatocellular injury due to

(A) immune reaction associated with sevoflurane administration

(B) sevoflurane-mediated decreased hepatic blood flow

(D) hepatotoxic effects of nitrous oxide

(E) hepatotoxic effects of sevoflurane

506. A drugs that may suppress the symptoms of opioid withdrawal is

(A) butorphanol

(B) chlorpromazine

(D) clonidine

(E) flumazenil

507. Emergence sequelae with ketamine include delirium and dreaming that

(A) are always of an unpleasant nature

(B) are caused by GABA_A antagonism of ketamine

(D) can be minimized by giving a benzodiazepine

(E) occur equally across all age groups

508. Omeprazole

(A) in typical doses diminishes the daily acid production by approximately 70%

(B) inhibits the metabolism of some medications by cytochrome P450

(D) decreases the volume of gastric juice

(E) is a histamine H₂-receptor antagonist

509. A 42-year-old schoolteacher underwent transabdominal hysterectomy for endometrial carcinoma. Her past medical history is significant for vitamin B₁₂ deficiency diagnosed three years ago and is otherwise unremarkable. According to the patient, she is in excellent health because of her strictly vegan diet. The case was conducted under general anesthesia with propofol, fentanyl, and vecuronium for induction, followed by isoflurane, nitrous oxide, and oxygen for maintenance of anesthesia. After four hours of surgery, the patient was extubated and transferred to the PACU. On the third postoperative day, you are called to evaluate the patient on the floor because she has developed signs of lower extremity paresthesias and has an unsteady gait. Which one of the anesthetics used for induction and/or maintenance of anesthesia could have a role in this patient’s symptoms?

(A) propofol

(B) isoflurane

(D) nitrous oxide

(E) fentanyl

510. Histamine H₂ antagonists administered in the immediate preoperative period

(A) facilitate gastric emptying

(B) should be used in all patients

(D) protect against aspiration of gastric juice

(E) do not change the need for a cuffed tube

511. Which one of the following drugs is considered unsafe for the patient known to be susceptible to malignant hyperthermia?

(A) nitrous oxide

(B) succinylcholine

(D) ketamine

(E) atracurium

512. An antihypertensive that interacts with the renin-angiotensin system is

(A) losartan

(B) prazosin

(D) minoxidil

(E) hydralazine

DIRECTIONS: Use the following figure to answer Questions 513-514:

513. The position on the ventricular function (Frank-Starling) curve for a patient with systolic heart failure is depicted as point A in the figure. Administration of nicardipine would move the patient’s ventricular function

(A) from A to C

(B) from A to B

(D) from A to D

(E) from A to E

514. Administration of which one of the following drugs, or drug combinations, is most likely to move this patient’s ventricular function from point A to point F?

(A) dobutamine

(B) dobutamine and furosemide

(D) dobutamine and losartan

(E) dobutamine, losartan, and furosemide

515. Fospropofol

(A) has a rapid onset of action after IV administration

(B) is a prodrug

(D) is associated with pain on injection

(E) is administered as a bolus of 2 mg/kg for procedural sedation

516. Which one of the following agents will lead to a decrease in pulmonary vascular resistance through interaction with the endothelin-A receptor (ET_A) on vascular smooth muscle?

(A) inhaled nitric oxide

(B) epoprostenol

(D) treprostinil

(E) bosentan

DIRECTIONS (Questions 517-520): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it and fill in the circle containing the corresponding letter on the answer sheet. Each lettered heading or component may be selected once, more than once, or not at all.

(A) α₁-adrenoceptor

(B) α₂-adrenoceptor

(D) β₂-adrenoceptor

(E) Na,K-ATPase

(F) PDE3

(G) PDE4

(H) PDE5

(I) AT₁

(J) AT₂

(K) V₁

For each medication, select the receptor or enzyme most responsible for its pharmacological effect.

517. antidiuretic hormone

518. inamrinone

519. sildenafil

520. valsartan

DIRECTIONS (Questions 521-523): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it and fill in the circle containing the corresponding letter on the answer sheet. Each lettered heading or component may be selected once, more than once, or not at all.

(A) glomerulus

(B) proximal tubule

(D) thin ascending limb of loop of Henle

(E) thick ascending limb of loop of Henle

(F) distal convoluted tubule

(G) collecting duct

For each diuretic, select the portion of the nephron most responsible for its pharmacological effect.

521. spironolactone

522. acetazolamide

523. furosemide

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