Sheri Berg and Edward Bittner
1. The most common cause of postanesthesia care unit (PACU)–related malpractice claims is
A. Undertreated pain
B. Critical respiratory incidents
C. Nerve injury from regional blocks
D. Cardiovascular events
2. Which of the statements regarding the American Society of Anesthesiologists (ASA) Standards for Postanesthesia Care is true?
A. A physician is responsible for the discharge of a patient from the postanesthesia care unit (PACU)
B. Medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist
C. Use of a PACU scoring system is recommended
D. All of the above
3. The most common cause of postoperative airway obstruction is
A. Loss of pharyngeal tone in a sedated patient
B. Weak diaphragmatic contraction
C. Redundant pharyngeal tissue
D. Laryngeal edema
4. A 36-year-old man who underwent a laparoscopic cholecystectomy develops upper airway obstruction in the PACU. You suspect that residual neuromuscular blockade is a major contributing factor. Which of the following would exclude the presence of residual neuromuscular blockade?
A. Oxygen saturation of 98% on 2-L nasal cannula
B. Normal tidal volumes while spontaneously breathing
C. Normal end-tidal carbon dioxide concentration while spontaneously breathing
D. None of the above
5. After reversal of neuromuscular blockade, pharyngeal function returns to baseline when the adductor pollicis train-of-four (TOF) ratio is greater than
A. 0.9
B. 0.7
C. 0.5
D. 0.4
6. Which of the following is considered the “gold standard” when using clinical assessment to evaluate for residual neuromuscular blockade?
A. Tongue protrusion
B. Ability to lift the head off the bed for 5 seconds
C. Ability to lift the legs off the bed for 5 seconds
D. Hand-grip strength
7. Which of the following metabolic states can contribute to residual neuromuscular blockade?
A. Hypocalcemia
B. Hypomagnesemia
C. Hyperthermia
D. Alkalosis
8. You are called to evaluate a 14-year-old girl in the postanesthesia care unit (PACU) with decreased oxygen saturation. The nurse tells you her anesthesia team “extubated her deep.” You determine that she is in laryngospasm. Which of the following would be the most appropriate first step in her management?
A. Wait for 5 minutes, watch her, and reassess
B. Administer 2 mg/kg of propofol
C. Provide a jaw thrust and apply continuous positive airway pressure (CPAP)
D. Administer 0.5 mg/kg of succinylcholine
9. A 40-year-old woman undergoes an 8-hour spine surgery and is left intubated for concern of airway edema. Which of the following statements regarding the assessment of airway edema is correct?
A. The absence of facial edema excludes the presence of airway edema
B. The presence of air movement around the endotracheal tube with the cuff deflated excludes the presence of airway edema
C. The absence of scleral edema excludes the presence of airway edema
D. The cuff-leak test cannot exclude the presence of airway edema
10. Strategies to reduce the risk of airway obstruction in patients with obstructive sleep apnea (OSA) include all of the following, except
A. Administration of benzodiazepines in place of opioids to reduce anxiety
B. Application of postoperative continuous positive airway pressure (CPAP)
C. Use of continuous regional anesthetic techniques
D. Preoperative screening to identify patients at high risk
11. You are called to evaluate a 65-year-old man in the postanesthesia care unit who underwent a left-carotid endarterectomy earlier in the day. He is having difficulty breathing, and you notice that the left side of his neck appears swollen. As you examine him, he becomes agitated and his oxygen saturation decreases to 92%. You ask for the surgeon be called “stat” and attempt bag mask ventilation. The next step to take is
A. Wait for the surgeon to arrive
B. Release the sutures and evacuate the hematoma
D. Administer naloxone
E. Apply noninvasive ventilation
12. The most common cause of transient postoperative hypoxemia in the postanesthesia care unit (PACU) is
A. Microaspiration
B. Pneumothorax
C. Alveolar hypoventilation
D. Pulmonary embolus
13. For every 1-mm Hg increase in arterial PaCO2, minute ventilation increases by
A. 0.5 L/min
B. 1 L/min
C. 2 L/min
D. 4 L/min
14. Which of the following is not a cause of arterial hypoxemia in the postanesthesia care unit?
A. Decreased alveolar partial pressure of oxygen
B. Ventilation-to-perfusion mismatch
C. Shunt
D. Decreased venous admixture
15. A healthy 21-year-old college football player is admitted to the postanesthesia care unit with hypoxemia after undergoing an Achilles tendon repair. The patient developed laryngospasm after extubation in the operating room, which resolved after application of positive pressure. What is the likely cause of his pulmonary edema?
A. Cardiovascular dysfunction
B. Aspiration
C. Postobstructive pulmonary edema
D. Volume overload
16. Administration of 5 L/min of oxygen by nasal cannula results in an FIO2 delivery of
A. 0.45
B. 0.41
C. 0.34
D. 0.28
17. Which of the following postoperative hemodynamic abnormalities is the most predictive of unplanned ICU admission and mortality
A. Tachycardia
B. Bradycardia
C. Hypotension
D. Hypertension
18. The most common cause of systemic hypotension in the postanesthesia care unit (PACU) is
A. Intravascular volume depletion
B. Myocardial ischemia
C. Residual anesthetic effects
D. Vasodilation
19. A sympathetic block above which level can result in bradycardia and hypotension?
A. T4
B. T6
C. T8
D. T10
20. Which of the following statements regarding a perioperative anaphylactic reaction is most correct?
A. Vasopressin is the drug of choice to treat anaphylaxis
B. The absence of bronchospasm and rash excludes the diagnosis of anaphylaxis
C. Low serum tryptase concentrations can differentiate between anaphylactic and anaphylactoid reactions
D. Neuromuscular-blocking drugs are the most common causes of anaphylactic reactions in the perioperative setting
21. You are called to the bedside to evaluate new ST-segment depressions on a routine postoperative EKG of a 42-year-old woman who underwent a partial colectomy. She is asymptomatic. Her heart rate is 80 to 90 bpm, and her blood pressure is 135/60. Your next step in the management includes
A. Wait and monitor her
B. Send off one set of troponins
C. Administer metoprolol for HR control
D. Call a cardiology consult
22. Which of the following patients warrants a routine postoperative EKG?
A. An 85-year-old male with hypothyroidism who underwent a cystoscopy and ureteral stent placement
B. A 72-year-old male with coronary artery disease (CAD) and hypertension who underwent an ankle fusion
C. A 52-year-old male with hypertension, hyperlipidemia, and diabetes who underwent a radical prostatectomy
D. A 50-year-old male with rheumatoid arthritis who underwent bilateral knee replacements
23. You are called to evaluate a 68-year-old woman who underwent a right upper lobectomy for lung cancer. She is complaining of chest pain and palpitations and explains to you that she has never had this problem before. Her EKG demonstrates atrial fibrillation with a rate of 152. Her blood pressure is currently 65/40. Which of the following is the most appropriate first step in managing her?
A. Repeat EKG in 15 minutes
B. Administer 150 mg IV amiodarone
C. Administer 5 mg IV metoprolol
D. Electrical cardioversion
24. Postoperative premature ventricular contractions (PVCs) most commonly are a result of
A. QT prolongation
B. Excessive β-blocker administration
C. Increased sympathetic system stimulation
D. Residual volatile anesthetics
25. Which of the following could result in bradydysrhythmias in the postoperative period?
A. Opioid administration
B. Bowel distention
C. Increased intraocular pressure
D. All of the above
26. What percentage of patients over the age of 50 who undergo elective surgery will experience postoperative delirium within the first 5 days following their surgical procedure?
A. <1%
B. 5%
C. 10%
D. 25%
27. Which of the following intraoperative factors is predictive of postoperative delirium?
A. Blood loss
B. Anesthetic technique
C. Intraoperative hypotension
D. Intraoperative hypertension
28. Each of the following increases the risk of postoperative delirium, except
A. Advanced age
B. Preexisting cognitive impairment
C. Alcohol abuse
D. Chronic pain
29. Which of the following statements regarding emergence excitement is most correct?
A. It is most common in children aged 6 to 8 years
B. Less than 5% of children experience emergence excitement
C. It is associated with long-term cognitive sequelae
D. Preoperative midazolam administration is associated with an increased incidence
30. Oliguria is defined as urine output less than
A. 0.2 mL/kg/hr
B. 0.5 mL/kg/hr
C. 0.7 mL/kg/hr
D. 1.0 mL/kg/hr
31. Postoperative urinary retention (POUR) is the inability to void despite a bladder volume of
A. 100 to 200 mL
B. 300 to 400 mL
C. 500 to 600 mL
D. 700 to 800 mL
32. The most common cause of oliguria in the immediate postoperative period is
A. Low cardiac output
B. Acute tubular necrosis
C. Renal vascular obstruction
D. Hypovolemia
33. An intra-abdominal pressure higher than which of the following is required to impede renal perfusion?
A. 10 cm H2O
B. 15 cm H2O
C. 20 cm H2O
D. 30 cm H2O
34. A 42-year-old morbidly obese male undergoes a laparoscopic gastric bypass. The surgical procedure lasts 8 hours. Estimated blood loss is 200 mL, and he receives 4.5 L of crystalloid. In the postanesthesia care unit, his urine output is 5 to 10 mL/hr despite an additional 1 L of crystalloid. The most likely etiology of his oliguria is
A. Contrast-induced nephropathy
B. Rhabdomyolysis
C. Hypovolemia
D. Surgical injury of ureters
35. All of the following are consequences of moderate hypothermia (33–35°C), except
A. Inhibition of platelet function
B. Prolongation of neuromuscular blockade
C. Inhibition of drug metabolism
D. Increases coagulation-factor activity
36. The most accurate measurement of core body temperature is obtained via
A. Axillary
B. Tympanic membrane
C. Rectal
D. Nasopharyngeal
37. The most effective treatment for abolishing postoperative shivering is
A. Clonidine
B. Doxapram
C. Meperidine
D. Fentanyl
38. A 22-year-old nonsmoking woman with no previous anesthetic history undergoes a laparoscopic ovarian cystectomy. Her risk of postoperative nausea and vomiting (PONV) is most closely approximated by
A. 5%
B. 10%
C. 20%
D. 40%
39. A 30-year-old woman who underwent a knee arthroscopy has postoperative nausea and vomiting (PONV) in the postanesthesia care unit (PACU). Per report, she received ondansetron 4 mg IV 30 minutes prior to the conclusion of her procedure. Which of the following treatments is most appropriate for managing her PONV in the PACU?
A. Scopolamine patch
B. Dexamethasone
C. Ondansetron
D. Promethazine
40. Which of the following is the most frequent cause of delayed awakening in the postanesthesia care unit (PACU)?
A. Hypothermia
B. Hypoglycemia
C. Residual effects of sedatives
D. Hypercarbia
41. Which of the following general principles regarding discharge from the postanesthesia care unit (PACU) is correct?
A. A mandatory minimum stay in the PACU is not required
B. Patients should not be discharged until they are pain-free
C. Patients need to void prior to PACU discharge
D. Patients need to demonstrate the ability to drink and retain clear fluids prior to PACU discharge
42. According to the ASA Standards for Postanesthesia Care, which of the following statements is correct?
A. A patient is to be transported to the postanesthesia care unit (PACU) by at least one physician
B. A patient must be monitored by continuous pulse oximetry during transport to the PACU
C. A patient who solely received regional anesthesia may routinely bypass the PACU
D. A patient must be discharged from the PACU by a physician
43. An otherwise-healthy adult male breathing room air receives a large dose of opioid that depresses his ventilation to the point that his alveolar PaCO2 is 80 mm Hg. What is his predicted alveolar PaO2?
A. 40 mm Hg
B. 50 mm Hg
C. 70 mm Hg
D. 90 mm Hg
44. If the patient described in the previous question is administered 2 L of oxygen by nasal cannula, then his alveolar PaO2 increases to what amount?
A. 60 mm Hg
B. 80 mm Hg
C. 100 mm Hg
D. 120 mm Hg
45. A 42-year-old woman complains of pain and inability to dorsiflex the first toe. The nerve most likely to be involved is the
A. Sciatic
B. Femoral
C. Tibial
D. Peroneal
46. Which of the following clinical criteria is associated with transfusion-related acute lung injury (TRALI) as compared to transfusion-associated circulatory overload (TACO)?
A. Pulmonary edema
B. Hypoxemia
C. Leukopenia
D. Leukocytosis
47. Which of the following statements regarding postoperative shivering is most correct?
A. Occurs with general anesthesia but not epidural anesthesia
B. Is always associated with a decrease in body temperature
C. In normothermic patients is related to a hypothalamic depressant effects of opioids
D. In normothermic patients results from uninhibited spinal reflexes
48. A 49-year-old woman with nephrolithiasis develops tachycardia, low-grade fever, and hypotension after a ureteral stent placement. Urine output is 5 to 10 mL/hr. All of the following can be used to treat the patient, except
A. Antibiotics
B. Fluids
C. Diuretics
D. Vasopressors
49. All of the following are advantages of high-flow nasal cannula delivery systems, except
A. Humidification of the gas
B. Gas delivery up to 6 L/min
C. Deliver of gas throughout the respiratory cycle
D. Ability to deliver warm gas (37°C)
50. Which of the following procedures is most likely to be associated with postoperative hypertension?
A. Craniotomy
B. Colectomy
C. Gastric bypass
D. Hip arthroplasty
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