Practice Test

Questions

DIRECTIONS (Questions 1-150): 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.

1. The interaction of rocuronium and acetylcholine at the myoneural junction is one of

(A) synergism

(B) competition for binding sites

(D) alteration of metabolism

(E) altered protein binding

2. As one moves from the apex of the lung to the dependent portions

(A) the alveoli become larger

(B) the caliber of the air passages becomes larger

(D) compliance becomes greater

(E) ventilation of the alveoli becomes less due to decreased compliance

3. A 70-year-old woman with long-standing type 2 diabetes mellitus presents for a preoperative assessment prior to femoral-popliteal bypass surgery. Her only medication is exenatide. Having never heard of this drug, the anesthesia resident looks it up and finds that it is

(A) a glucagon-like peptide-1 receptor agonist

(B) FDA approved for treatment of type 1 and type 2 diabetes mellitus

(D) a thiazolidinedione like rosiglitazone

(E) also used for prevention of heart disease in type 2 diabetics

4. The most important site of drug transformation is usually the

(A) liver

(B) spleen

(D) lungs

(E) bloodstream

5. Esmolol is chosen for a tachycardic patient with liver cirrhosis. The 9-minute half-life of the drug stems from

(A) pseudocholinesterase

(B) skeletal muscle esterase

(D) phosphodiesterase

(E) alkaline phosphatase

6. A 49-year-old man with Addison disease presents for a herniorrhaphy. All of the following statements about Addison disease are true EXCEPT

(A) patient’s with this condition undergoing even minor procedures require stress dose of steroids intraoperatively and a long postoperative taper

(B) typical laboratory abnormalities include hyponatremia and hyperkalemia

(D) both skin hyperpigmentation and vitiligo are signs of Addison disease

(E) common symptoms in untreated Addison disease are diarrhea and orthostatic hypotension

7. Bioavailability of a drug refers to the amount of drug that

(A) is administered intramuscularly

(B) is administered orally

(D) is excreted by the kidney

(E) reaches its site of action

8. A 21-year-old woman with a long history of anorexia nervosa typically has all of the following EXCEPT

(A) osteoporosis

(B) increased risk of intraoperative dysrhythmias

(D) hypotension

(E) resting tachycardia

9. In cases of unequivocal intraoperative awareness, the incidence of posttraumatic stress disorder may be approximately

(A) 0.1%

(B) 1%

(D) 50%

(E) 99%

10. A 40-year-old woman presents with a corrected QT interval (QTc) prolonged to 500 msec. She is

(A) at increased risk for perioperative morbidity and mortality related to cardiac arrhythmias

(B) recommended to receive amiodarone

(D) at risk for Wolf-Parkinson-White syndrome

(E) at risk to require intraoperative pacemaker therapy

11. Renal clearance of a drug

(A) is usually of little importance

(B) has no relationship to creatinine clearance

(D) varies with pH, urine flow rate, and renal blood flow

(E) may exceed renal blood flow

12. A 50-year-old man planned for shoulder surgery is judged to be in New York Heart Association functional class III. He has

(A) marked limitation of physical activity

(B) symptoms at rest

(D) inability to comfortably carry out any physical activity

(E) no symptoms during ordinary activity

13. All of the following are true of closing volume EXCEPT that it is

(A) measured by a single-breath nitrogen technique

(B) useful in determining disease of small airways

(D) unchanged in obesity

(E) measured at phase IV on the nitrogen washout curve

14. A patient has been given an injection of ketamine in a dose calculated to be sufficient for anesthesia. His eyes remain open, and there is slight nystagmus and occasional purposeless movements. This is an indication that

(A) the dose is inadequate

(B) more ketamine should be given to stop the movements

(D) the dose is adequate for anesthesia

(E) the patient is having a seizure

15. Under normal physiologic conditions cerebral blood flow is

(A) 1 mL/100 g/min

(B) 10 mL/100 g/min

(D) 50 mL/100 g/min

(E) 100 mL/100 g/min

16. A 50-year-old man has a bicuspid aortic valve. Surgical repair of his ascending aorta is indicated at a diameter of

(A) 4 cm

(B) 4.5 cm

(D) 5.5 cm

(E) 6 cm

17. The peripheral chemoreceptors are

(A) located in the medulla oblongata

(B) poorly perfused and, therefore, respond slowly to changes in the oxygen content of the blood

(D) influenced by oxygen content rather than oxygen tension

(E) not affected by increasing age

18. Which one of the following agents should be avoided in a patient with heparin-induced thrombocytopenia type II?

(A) danaparoid

(B) lepirudin

(D) warfarin

(E) benzodiazepines

19. Possible ways to assure proper placement of the endotracheal tube include all of the following, EXCEPT

(A) chest radiograph

(B) bronchoscopic examination

(D) continuous end-tidal carbon dioxide capnography

(E) fogging within the endotracheal tube

20. Hypoxic pulmonary vasoconstriction

(A) is not important in the intact human being

(B) is active only at high altitude

(D) causes higher dead space/tidal volume ratio (V_D/V_T) than in the nonhypoxic lung

(E) diverts blood flow from hypoxic to non-hypoxic lung areas

21. A 9-year-old boy sustained a 40% burn to the anterior portion of his body. On the twentieth day after the burn, he is brought to the operating room for a skin graft. Anesthesia is induced with thiopental, and succinylcholine is injected for relaxation. The ECG shows peaked T waves followed by asystole. The most likely cause of the arrhythmia is

(A) an overdose of thiopental

(B) hypoxia

(D) electrocution

(E) administration of the wrong drug

22. An anesthesia circuit is connected to a circle system and the combined volume of both is 5 L. The fresh gas flow is 1 L/min. After desflurane 10% is turned on, how long will it take the concentration in the circuit to reach 8.5% desflurane?

(A) 1 min

(B) 5 min

(D) 10 min

(E) 17 min

23. A 20-year-old patient with hemophilia B (Christmas disease) is planned for appendectomy. The coagulation deficit is that of clotting factor

(A) II

(B) VII

(D) IX

(E) XII

24. Propofol

(A) increases cerebral blood flow

(B) is very soluble in aqueous solutions

(D) has little analgesic activity

(E) has a longer sleep time than thiopental

25. A 50-year-old woman with metabolic syndrome presents for preoperative assessment prior to elective coronary artery bypass surgery. True statements about the metabolic syndrome include all of the following EXCEPT

(A) patients with the metabolic syndrome are at increased risk for developing overt diabetes

(B) to make the diagnosis, a patient must have 3 of the following 5 criteria: elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting blood sugar

(D) patients with the metabolic syndrome should be treated prophylactically with metformin

(E) women with polycystic ovarian syndrome are at increased risk for developing metabolic syndrome

26. A discrepancy is noted in a patient bearing two arterial catheters. Normally the systolic blood pressure is highest in the

(A) ascending aorta

(B) descending aorta

(D) dorsalis pedis artery

(E) pulmonary artery

27. Recognition of hypoxemia in the recovery room

(A) depends on the detection of cyanosis

(B) depends on the detection of apnea

(D) is best accomplished with pulse oximetry

(E) is done better with a transcutaneous oxygen monitor than with a pulse oximeter

28. A 36-year-old male who recently suffered multiple trauma including thermal injuries is to undergo general endotracheal anesthesia for elective orthopedic surgery. Which one of the following conditions would most likely explain resistance to non-depolarizing neuromuscular blockers during the operative procedure?

(A) respiratory acidosis

(B) recent large body surface area burn

(D) hypothermia

(E) hypermagnesemia

29. The Hering–Breuer reflex

(A) is accentuated in pre-term infants when compared to full-term infants

(B) causes a deep inspiration after a total expiration in the laboratory animal

(D) has a major role in the control of ventilation

(E) is stimulated by barbiturates

30. A 42-year-old African American woman with a multinodular goiter is diagnosed with hyperthyroidism. Clinical manifestations of hyperthyroidism include all of the following EXCEPT

(A) sweating

(B) fatigue

(D) shivering

(E) hypermotility and diarrhea

31. A finding that may be used to distinguish deep sedation from general anesthesia is

(A) ability to follow a simple command

(B) adequate minute ventilation

(D) unobstructed airway

(E) BIS value

DIRECTIONS: Use the following figure to answer Questions 32-33:

32. The figure shows the evoked twitch response following an unknown drug. The segment (1) is the baseline before drug administration, and (2) is the response three minutes after drug administration. From these two segments, you can say that the drug

(A) is not a muscle relaxant

(B) is a depolarizing muscle relaxant

(D) caused complete paralysis

(E) caused 90% depression

33. At the time point (3), a tetanic stimulation was applied with the depicted result. Following this, one could state that

(A) the drug is not a muscle relaxant

(B) the drug is a depolarizing muscle relaxant

(D) either the drug is a nondepolarizing muscle relaxant, or a dual block is present

(E) the tracing shown is due to artifact

34. A very fit amateur mountaineer wishes to climb without the use of supplemental oxygen or medications. He also wishes to avoid letting his arterial oxygen concentration decrease below 45 mm Hg. Using the table below, calculate the maximum height to which the mountaineer should ascend.

(A) 7,000 ft

(B) 10,000 ft

(D) 15,000 ft

(E) 18,000 ft

35. The primary difference between cisatracurium and atracurium is that cisatracurium is

(A) a different isomer than atracurium

(B) optically active

(D) less likely to result in histamine release

(E) metabolized to a greater degree by nonspecific plasma esterases

36. The second heart sound coincides with all of the following EXCEPT

(A) closing of the aortic valve

(B) isometric relaxation of myocardial fibers

(D) the T wave of the electrocardiogram

(E) closure of the pulmonic valve

37. In a carbon dioxide response curve, the minute ventilation is plotted against various concentrations of carbon dioxide. Which one of the following statements is TRUE about a carbon dioxide response curve?

(A) The patient under anesthesia will show the same effects regardless of the agent.

(B) The slope of the response may change, but the position of the curve remains the same.

(D) Increased work of breathing leads to a steeper slope.

(E) The slope of the line measures the patient’s sensitivity to carbon dioxide.

38. The blood supply to the motor tracts of the spinal cord is primarily from the

(A) posterior spinal artery

(B) anterior spinal artery

(D) artery of Adamkiewicz

(E) basilar artery

39. The inability to sustain contraction (fade) during tetanic contraction is due to

(A) inability to transmit rapid electrical impulses

(B) cellular loss of potassium

(D) inability of recording apparatus to show all contractions

(E) the inability of the endplate to release sufficient acetylcholine

40. A 39-year-old woman being evaluated for cataract surgery has Von Willebrand disease. This disease

(A) commonly first manifests as abnormal bleeding after tooth extraction or tonsillectomy in children

(B) usually affects only females

(D) is caused by factor VIII deficiency

(E) is one of the rarest of the congenital bleeding disorders

41. Calcium chloride is administered to a patient receiving citrated plasma transfusions. Calcium ion

(A) decreases myocardial contractile force

(B) decreases duration of systole

(D) decreases ventricular automaticity

(E) enters the cardiac cell, causing excitation

42. Prolonged surgery on the spine in the prone position is occasionally followed by postoperative visual loss. The most common etiology of such visual loss is

(A) central retinal artery occlusion

(B) central retinal vein occlusion

(D) anterior ischemic optic neuropathy

(E) posterior ischemic optic neuropathy

43. Transdermal scopolamine

(A) is effective in the prevention of PONV if administered preoperatively

(B) is effective in the treatment of PONV when administered postoperatively

(D) is devoid of any side effects

(E) in a multilayered adhesive unit has a duration of action of about 16 h

44. A pediatric patient weighing 14 kg is being ventilated with a traditional anesthesia machine ventilator using the following set parameters:

Tidal volume = 50 mL

Ventilatory rate = 20/min

I:E ratio = 1:2

Oxygen flow = 2.5 L/min

Nitrous oxide flow = 3.5 L/min

The resulting minute ventilation is approximately

(A) 1 L/min

(B) 1.5 L/min

(D) 2.5 L/min

(E) 3 L/min

45. Compared to the young adult, the elderly patient

(A) has an unchanged venous admixture during general anesthesia

(B) has a decrease in true pulmonary shunting during general anesthesia

(D) has an increase in closing capacity

(E) has a decrease in closing capacity

46. If succinylcholine is given to facilitate intubation, and the patient is allowed to recover fully from the depolarizing block, and then is given pancuronium, one would expect

(A) a lower than normal amount of pancuronium is needed to reestablish neuromuscular blockade

(B) the pancuronium to have a shorter duration of action as a result of the succinylcholine

(D) no change in the duration of action of pancuronium but less intensity of relaxation

(E) the development of a phase II block

47. A fourth-year medical student is on her anesthesia rotation. You are discussing local anesthetics for spinal anesthesia with her. The topic of baricity arises on which you explain that baricity is the

(A) milligram dose of an equipotent drug

(B) minimum concentration needed to reach clinical effect

(D) context sensitive half-time

(E) ratio of the specific gravity of a drug to a reference specific gravity

48. When desflurane, but not sevoflurane, in a carrier gas of 100% oxygen is passed through very dry carbon dioxide absorbent, the patient may be exposed to a toxic concentration of

(A) ozone

(B) phosgene

(D) carbon monoxide

(E) fluoride

49. Technical difficulties in treating patients with morbid obesity include all of the following EXCEPT

(A) spuriously low blood pressure cuff readings

(B) difficult venous access

(D) difficult airway maintenance with mask

(E) difficulty with nerve blocks

DIRECTIONS: Use the following scenario to answer Questions 50-52. 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 50-52, a medication is followed by five diseases or pathological states. Choose the ONE disease for which the medication may be indicated.

50. Omeprazole

(A) peptic ulcer disease

(B) diabetic gastroparesis

(D) urinary tract infection

(E) type II diabetes mellitus

51. Acetazolamide

(A) glaucoma

(B) asthma

(D) deep venous thrombosis

(E) atrial fibrillation

52. Glyburide

(A) myasthenia gravis

(B) type II diabetes mellitus

(D) glaucoma

(E) hypercalcemia

53. Somatosensory-evoked potentials (SSEP)

(A) are extinguished by propofol

(B) are unaffected by deep levels of isoflurane anesthesia

(D) are rendered unreadable by neuromuscular blocking agents

(E) are modestly affected by nitrous oxide

54. A team of anesthesiologists has traveled to a third-world country to provide anesthesia for their surgical colleagues who plan to perform plastic reconstructive procedures on children with cleft palate and similar craniofacial abnormalities. The anesthesiologists have brought an ample quantity of sevoflurane with them but find that there are no sevoflurane vaporizers at the hospital where they will work. In terms of the accuracy in delivering sevoflurane, the least difference between the set and delivered concentrations of sevoflurane will result if sevoflurane is delivered via which one of these vaporizers?

(A) Desflurane vaporizer

(B) Enflurane vaporizer

(D) Isoflurane vaporizer

(E) Methoxyflurane vaporizer

55. An 18-year-old male presents for repair of a right shoulder rotator cuff tear. He agrees to an interscalene block for postoperative analgesia. You decide to avoid using the local anesthetic that is recognized as being the most cardiotoxic. You therefore decide to avoid

(A) bupivacaine

(B) ropivacaine

(D) lidocaine

(E) mepivacaine

56. All of the following is true concerning the change in functional residual capacity (FRC) with body position, EXCEPT

(A) FRC is markedly reduced in the supine position

(B) in head-down, FRC is little different from supine

(D) FRC is greater in lateral than in supine position

(E) FRC is greater in prone than in supine position

57. The inspired partial pressure of isoflurane is lower than the partial pressure of the anesthetic in the fresh gas because of all of the following processes EXCEPT

(A) absorption of the agent by rubber hoses

(B) dilution of fresh gas in the circle absorber

(D) adsorption of the agent by soda lime

(E) uptake of the agent by the patient

58. All of the following are factors that DECREASE the rate of onset of the effects of an inhalational anesthetic EXCEPT

(A) low (as opposed to high) fresh gas flow rate

(B) low (as opposed to high) minute ventilation

(D) low (as opposed to high) blood:gas partition coefficient

(E) high (as opposed to low) cardiac output

59. Pulmonary edema in the recovery room

(A) usually occurs as a late sign

(B) is always associated with a rise of central venous pressure (CVP)

(D) may be due to airway obstruction

(E) usually occurs with normal breath sounds present

60. The number of calories required to raise the temperature of 1 g of a substance by 1°C is

(A) the heat of vaporization

(B) the specific heat

(D) thermal conductivity

(E) equal for all substances

61. Your patient has dyspnea on mild exertion and peripheral edema. Mechanisms by which patients with failing hearts compensate for low cardiac output include all of the following EXCEPT

(A) increased sympathetic drive to the heart

(B) myocardial hypertrophy

(D) secondary hyperaldosteronism

(E) peripheral vasoconstriction

62. The pin index safety system (PISS)

(A) prevents attachment of gas-administering equipment to the wrong type of gas

(B) prevents incorrect yoke-tank connections

(D) is found on the wall end, but not the machine end, of gas hoses connected to anesthesia machines

(E) is found on the machine end, but not the wall end, of gas hoses connected to anesthesia machines

DIRECTIONS: Use the following figure to answer Questions 63-64:

63. 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

64. If A depicts the dose-response relationship of a 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 non-competitive antagonist of drug X

(D) decreases the efficacy of drug X

(E) increases the potency of drug X

65. A 63-year-old male patient with end-stage renal disease from long-standing hypertension presents for preoperative assessment prior to elective repair of an abdominal aortic aneurysm. Laboratory abnormalities common in patients with end-stage renal disease include

(A) anemia

(B) thrombocytosis

(D) hypophosphatemia

(E) leukocytosis

66. Four years after a heart transplant, a patient requires bowel resection. The transplanted heart

(A) has an abnormal Frank–Starling mechanism

(B) responds as does an innervated heart to atropine

(D) does not respond to isoproterenol

(E) does not increase cardiac output with increased preload

67. Cerebrospinal fluid (CSF) flows through all of the following EXCEPT the

(A) arachnoid villi

(B) cerebral ventricle

(D) subarachnoid space

(E) epidural space

68. Verapamil

(A) is useful in the treatment of supraventricular tachycardia

(B) is contraindicated in patients with asthma

(D) is a potent vasoconstrictor

(E) has no effect on the pacemaker cells

69. A resident is carrying a Tec 5 vaporizer from the anesthesia workroom to the operating room and slips on the freshly washed floor. Although he did not drop it, he did tip it on its side when he fell. After properly mounting the vaporizer on the anesthesia machine, the proper procedure to flush the vaporizer is to

(A) leave the vaporizer setting at “off” and press the oxygen flush valve for 10 min

(B) leave the vaporizer setting at “off” and adjust the oxygen valve to deliver oxygen at 10 L/min for 10 min

(D) turn the vaporizer setting to its maximum value and adjust the oxygen valve to deliver oxygen at 10 L/min for 10 min

(E) return the vaporizer to the manufacturer for service; do not mount it on the anesthesia machine

70. A 39-year-old female presents for a vaginal hysterectomy. Ten minutes after performing a spinal anesthetic with 15 milligrams of 0.5% hyperbaric bupivacaine, you notice a slowing of the heart rhythm on continuous EKG monitoring. A short period of asystole then develops at which time you administer 10 mcg of epinephrine and perform a brief period of chest compressions. The most important independent predictor of bradycardia following spinal anesthesia is

(A) hypertension

(B) hyperlipidemia

(D) preexisting bradycardia

(E) ASA I status

71. A 45-year-old male with a history of hypertension that is controlled with a diuretic is scheduled for a hernia repair. He is completely asymptomatic, but his plasma potassium concentration is 3.0 mEq/L. The appropriate management is to

(A) cancel the procedure

(B) start a potassium infusion and proceed

(D) give 40 mEq of potassium by mouth before starting

(E) proceed with the procedure only if it can be done under regional anesthesia

72. Intracranial pressure (ICP) can be monitored with all of the following EXCEPT

(A) a catheter implanted directly into brain parenchyma

(B) by a pressure transducing bolt in the subarachnoid space

(D) a ventriculostomy catheter

(E) a catheter in the subdural space

73. In a mixture of gases (such as air)

(A) all vapors, but not all gases obey Dalton’s law

(B) each gas contributes a partial pressure that is proportional to its solubility

(D) the total pressure is equal to the sum of the gases multiplied by the number of gases

(E) the total pressure is equal to the sum of the gases divided by the number of gases

74. An effect of metoclopramide is

(A) dopamine receptor agonism

(B) β-adrenergic agonism

(D) muscarinic cholinergic agonistic effects

(E) improvement of large bowel motility

75. A 22-year-old male gunshot victim requires urgent abdominal surgery. His record indicates that he has biopsy-proven hepatic cirrhosis but no history of drug or alcohol use, autoimmune disease, or hepatitis. Possible hereditary causes for cirrhosis in this patient include all of the following EXCEPT

(A) hemochromatosis

(B) α₁-antitrypsin deficiency

(D) antithrombin III deficiency

(E) cystic fibrosis

76. Hypovolemia is suspected in a septic patient in the ICU. All of the following may be seen in hypovolemia EXCEPT

(A) increased heart rate

(B) wide pulse pressure

(D) flat neck veins

(E) pale mucous membranes

77. A 42-year-old man is scheduled for appendectomy for acute appendicitis. Four years ago, he had a myocardial infarction and was treated with the insertion of intracoronary stents. He underwent successful cardiac rehabilitation and now plays tennis regularly without angina or shortness of breath. He would be categorized as ASA Physical Status

(A) I

(B) II

(D) IIIE

(E) IV

78. A 45-year-old male is to have a gallbladder procedure. He has heart disease and is on amiodarone. This drug

(A) should be stopped before surgery

(B) has a half-life of 4 h

(D) is eliminated by the kidneys

(E) has no effects on β-adrenergic receptors

79. Spinal cord injury is feared in patients requiring thoracoabdominal aortic surgery. The arteria radicularis magna (of Adamkiewicz)

(A) is the largest of the radicular arteries supplying the spinal cord

(B) normally feeds the anteroposterior spinal artery system

(D) always originates from the suprarenal aorta

(E) may be ligated with impunity

80. The latent heat of vaporization

(A) is equal for all liquids

(B) is independent of the ambient temperature

(D) is very low for solids

(E) for water is 1 calorie/mL

81. Carbon monoxide diffusion capacity (DLCO) will decrease with

(A) smoking within 24 h of the test

(B) exercise

(D) increased hemoglobin

(E) congestive heart failure

82. A local anesthetic that inhibits the reuptake of norepinephrine is

(A) procaine

(B) cocaine

(D) mepivacaine

(E) lidocaine with epinephrine

83. A middle-aged man with a known pheochromocytoma is scheduled for elective abdominal surgery. Which one of the following statements about his preoperative pharmacologic management is correct?

(A) α-adrenergic blockade is instituted at the same time as β-adrenergic blockade

(B) diuretic antihypertensives are contraindicated

(D) dosage is adjusted according to the levels of urinary catecholamine metabolites

(E) calcium channel blockers are contraindicated in this condition

84. A patient with history of syncope is suspected of Wolff-Parkinson-White syndrome. In this condition, the

(A) heart rate is usually 60 to 80 beats/min during sinus rhythm

(B) PR interval is less than 0.12 sec during sinus rhythm

(D) the upstroke of the QRS complex is often slurred

(E) adenosine may increase heart rate

85. Atracurium

(A) has both prejunctional and postjunctional effects

(B) liberates histamine at all dose levels

(D) breaks down into laudanosine that has caused seizures in humans

(E) causes increased blood pressure

86. A 70-year-old man is receiving anticoagulant drugs to inhibit platelet glycoprotein IIb/IIIa receptor. EXCEPT for the following, the receptor

(A) is activated by cyclic AMP

(B) participates in aggregation of platelets

(D) is inhibited by eptifibatide

(E) is activated by diverse stimuli

87. Cerebrospinal fluid pressure may be increased by

(A) coughing

(B) long expiratory time during positive pressure ventilation

(D) low expiratory resistance

(E) negative expiratory phase

88. Isoflurane

(A) is a poor muscle relaxant compared with halothane

(B) has a vapor pressure of 175 mm Hg at 20°C

(D) has a MAC of approximately 1.2%

(E) should be delivered by spontaneous ventilation

89. When inhaling from functional residual capacity (FRC) to maximal inspiration, all of the following are true, EXCEPT

(A) pulmonary vascular resistance increases

(B) pleural pressure decreases

(D) basilar alveoli become larger than apical alveoli

(E) proximal airway pressure is greater than alveolar pressure

90. Propofol has all of the following pharmacological effects EXCEPT

(A) decreasing cerebral blood flow

(B) crossing the blood-brain barrier

(D) decreasing cerebral metabolic rate

(E) decreasing the latency of somatosensory evoked potentials

91. Which one of the following statements regarding heparin is most accurate?

(A) It inhibits several steps in the intrinsic pathway of blood clotting.

(B) Its dosage may be adjusted by estimating the patient’s clotting ability via the bleeding time.

(D) It interacts with drugs that inhibit the liver microsomal enzyme system.

(E) It should never be combined in therapy with an oral anticoagulant.

92. A patient undergoing a blood transfusion intraoperatively develops an acute hemolytic reaction. The diagnosis of such a reaction typically

(A) reveals ABO incompatibility to be an unlikely cause

(B) identifies incompatibility with a rare antigen after detailed testing

(D) shows that the severity of the hemolytic reaction is unrelated to the volume of transfused blood

(E) leads to shock-induced hepatic failure that is the etiology of most of the associated morbidity

93. A cyanotic child is suspected of tetralogy of Fallot. The condition includes all of the following EXCEPT

(A) atrial septal defect (ASD)

(B) ventricular septal defect (VSD)

(D) pulmonary outflow obstruction

(E) overriding aorta

94. The pressure of oxygen delivered by the wall connectors in an operating room is approximately

(A) 1900 psi

(B) 750 psi

(D) 1 atm

(E) 760 mm Hg

95. A 41-year-old patient with a history of drug abuse is admitted to the emergency department for acute onset, anterior chest pain that is radiating into the back between the shoulder blades. Vital signs on arrival include a HR of 107, and a BP of 172/98. The patient appears pale and diaphoretic. Emergent TEE findings include dilated cardiomyopathy and evidence of acute aortic dissection; the patient is referred for emergent cardiac surgery for aortic repair. When planning this patient’s anesthetic, caution has to be exercised with the administration of which one of the following drugs?

(A) labetalol

(B) epinephrine

(D) ephedrine

(E) phenylephrine

96. An application of the Bernoulli theorem is the measurement of

(A) cardiac output with a thermodilution pulmonary artery catheter

(B) mean arterial pressure using an automated noninvasive blood pressure device

(D) the pressure gradient across a stenotic mitral valve using echocardiography

(E) airway resistance using a spirometer

97. A 45-year-old man with hypertension and a 60-pack-year smoking history is being evaluated in the preoperative clinic for an elective neurosurgical procedure to remove a benign spinal tumor. All of the following statements about exposure to tobacco in the perioperative period are correct EXCEPT

(A) nicotine replacement therapy should be started 1-2 weeks before an attempt at cessation

(B) smokers are more likely to experience wound infections

(D) varenicline for smoking cessation should be started 1-2 weeks before a quit attempt

(E) bupropion is effective pharmacotherapy to assist with smoking cessation in the perioperative period

98. Arterial oxygen tension can be improved by

(A) transferring an obese patient from the supine to the Trendelenburg

(B) decreasing inspired FIO₂

(D) using PEEP in the presence of atelectasis

(E) increasing the concentration of the volatile agent

99. A 19-year-old patient presents for emergent craniotomy for evacuation of a subdural hematoma following a motor vehicle accident. Which one of the following anesthetics is most likely to increase cerebral blood flow?

(A) ketamine

(B) thiopental

(D) midazolam

(E) propofol

100. A patient has an arterial catheter in place and the anesthesiologist can view the displayed value of pulse pressure variability. This value may be correlated with

(A) the probability of cardiac ischemia

(B) the depth of anesthesia

(D) the cardiac output

(E) the compliance of the lungs

101. A 37-year-old obese female with a known difficult airway presents for a laparoscopic cholecystectomy. You discuss performing an awake fiberoptic intubation with topical anesthesia. Which local anesthetic is used exclusively for topical purposes?

(A) Prilocaine

(B) Tetracaine

(D) Ropivacaine

(E) Benzocaine

102. A 40-year-old male patient with acromegaly presenting for prostate resection is likely to have all of the following EXCEPT

(A) a difficult airway

(B) glucose intolerance

(D) hyperthyroidism

(E) cardiomegaly

103. Calcium channel blockers

(A) should be stopped prior to elective surgery

(B) have a profound negative inotropic effect when administered to a patient who has been given a high dose opioid anesthetic

(D) may antagonize the effect of muscle relaxants

(E) can be used interchangeably due to identical effect sites and mechanisms of action

104. Which one of the following is true regarding the upper airway?

(A) The hyoid bone suspends the sternothyroid muscle at the level of C7.

(B) The anatomical structure referred to as “Adam’s apple” is called cricoid cartilage.

(D) To each side of the larynx and inferior to the aryepiglottic folds is the rima glottidis, where the endotracheal tube should be placed during intubation.

(E) The laryngoscope should be positioned in the piriform sinus during direct laryngoscopy.

105. The irrigating fluid for a 55-year-old otherwise healthy man undergoing transurethral prostatic resection

(A) can cause hypotension and tachycardia in the anesthetized patient

(B) should be water

(D) should be hypertonic saline

(E) should be a solution of a non-metabolized solute

106. Hypercarbia occurring under anesthesia may be due to all of the following, EXCEPT

(A) increased dead space ventilation

(B) exhaustion of soda lime

(D) hyperventilation

(E) malignant hyperthermia

107. An anesthetic agent for which a specific antagonist exists is

(A) etomidate

(B) butorphanol

(D) propofol

(E) succinylcholine

DIRECTIONS: Use the following scenario to answer Questions 108-109. A 55-year-old male is admitted with a history of hypertensive heart disease and evidence of acute myocardial infarction. Vital signs are: blood pressure 180/110, heart rate 124 per minute, body temperature 101°F, and respiratory rate 24 per minute.

108. Efforts to improve myocardial oxygenation should include the following EXCEPT

(A) decreasing arterial blood pressure

(B) decreasing body temperature

(D) slowing heart rate

(E) administration of oxygen

109. Chest pain worsens as the heart rate and blood pressure are reduced with metoprolol and nitroglycerin. Additional measures might include

(A) an inhibitor of cyclic-GMP phosphodiesterase

(B) amiodarone

(D) anticoagulation

(E) lidocaine

110. A contraindication to the discharge to home of a previously healthy, ASA I patient, who had a hernia repair under general anesthesia would be

(A) heart rate 20% higher than baseline

(B) systolic blood pressure 20% lower than baseline

(D) oxygen saturation of 93% on room air

(E) requiring the assistance of another person to ambulate

111. Which one of the following factors introduces the greatest degree of error in the measurement of hemoglobin saturation by pulse oximetry?

(A) High concentration of fetal hemoglobin

(B) High concentration of sickle hemoglobin

(D) High concentration of deoxyhemoglobin

(E) Hyperbilirubinemia

DIRECTIONS: Use the following scenario to answer Questions 112-113: An operating room is protected by an isolated power system that is monitored by a line isolation monitor. During laparoscopic cholecystectomy surgery, the line isolation monitor alarms and the meter indicates 8 mA.

112. What action should initially be taken?

(A) Unplug the fluid warmer because it draws the most current.

(B) Unplug the surgeon’s radio because it is unnecessary to the procedure.

(D) Unplug the last device that was connected to the circuit.

(E) Unplug the anesthesia monitors and operate them on battery power.

113. If none of the maneuvers taken by the OR staff removes the alarm condition, what action should be taken next?

(A) Relocate the patient to a different operating room while maintaining anesthesia.

(B) Convert to open cholecystectomy and avoid cautery.

(D) Continue the surgery because a second, rare electrical fault will need to occur in order to cause electrical injury to the patient.

114. A 51-year-old patient is undergoing popliteal block under ultrasound guidance for postoperative pain control following ankle surgery. Midazolam 2 mg intravenously has been administered incrementally for procedural sedation. Shortly after injection of 30 mL of ropivacaine 0.5%, the patient starts to complain about visual disturbances that are quickly followed by loss of consciousness and respiratory arrest. Vital signs at the time are significant for new onset hypotension and cardiac arrhythmia. Assuming that the patient is experiencing symptoms of local anesthetic toxicity (LAST), which one of the following interventions is most appropriate?

(A) Ventilation with 100% O₂, propofol bolus, administration of lidocaine and phenylephrine

(B) Ventilation with 100% O₂, midazolam bolus, administration of lidocaine and vasopressin

(D) Ventilation with 100% O₂, administration of midazolam followed by continuous infusion of Intralipid 20%, administration of lidocaine and phenylephrine

(E) Ventilation with 100% O₂, administration of 1.5 mL/kg Intralipid 20% followed by continuous infusion, administration of phenylephrine

115. The principal disadvantage of methohexital is

(A) poor water solubility

(B) dose dependent decrease in blood pressure greater than that produced by propofol

(D) involuntary muscle movements

(E) increase in ictal activity

116. Assuming a constant rate of carbon dioxide formation, the relationship between alveolar ventilation (in a patient under general anesthesia) and carbon dioxide and hydrogen ion concentration is

(A) carbon dioxide is directly proportional to ventilation

(B) doubling ventilation will lead to respiratory alkalosis

(D) interrupting ventilation for five minutes will cause, next to hypoxemia, profound respiratory alkalosis

(E) alveolar ventilation only responds to endogenous CO₂

117. Effects of fat embolism include all of the following, EXCEPT

(A) hypoxia

(B) tachypnea

(D) neurological impairment

(E) left-axis deviation in the ECG

118. A 37-year-old woman presents for a brain biopsy under monitored anesthesia care. She has a family history of acute intermittent porphyria (AIP) and relates a history of several porphyric attacks over the last 20 years. All of the following statements about AIP are true EXCEPT

(A) propofol is safe in patients with AIP

(B) severe abdominal pain, mental status changes and peripheral neuropathy characterize acute porphyric attacks

(D) etomidate should be avoided in patients with AIP

(E) factors known to precipitate acute porphyric crisis include fasting, dehydration, and infection

119. The patient with myasthenia gravis

(A) has weakness of muscles innervated by cranial nerves

(B) usually has diaphragmatic weakness

(D) has focal sensory deficits

(E) often has associated carcinomas

120. The brain stem is supplied with blood from the

(A) middle cerebral artery

(B) cingulate artery

(D) posterior cerebral artery

(E) posterior communicating artery

121. When donated blood is initially collected, it is mixed with an anticoagulant and preservation solution containing glucose, citrate, phosphate, and adenine. It has a shelf life of five weeks. If the unit of whole blood thus collected is fractionated into its components, the shelf life of the packed red cells may be extended to six weeks by adding additional glucose and

(A) ascorbic acid (Vitamin C)

(B) 2,3-DPG

(D) α-tocopherol (Vitamin E)

(E) adenine

122. All of the following statements are true regarding smoking, EXCEPT

(A) smoking is the strongest modifiable risk factor for cardiovascular disease

(B) compared to non-smokers, FEV₁ tends to decrease more in smokers with increasing age

(D) postoperative smoking cessation may improve wound healing

(E) risk of postoperative nausea and vomiting is higher in smokers

123. Ropivacaine

(A) is supplied as a racemic mixture

(B) is less likely than bupivacaine to cause ventricular arrhythmias after accidental intravenous injection

(D) has a low degree of toxicity by virtue of its rapid intravascular metabolism

(E) is an aminoester agent

DIRECTIONS: Use the following case to answer Questions 124-126: A 67-year-old woman is brought to the operating room for an exploratory laparotomy for an intra-abdominal abscess. After induction of anesthesia, a hot air warmer is applied to the patient and but not initiated because the esophageal temperature is measured at 37.8°C. The skin is warm and wet to touch. Anesthesia is maintained with isoflurane in an air/oxygen mixture and muscle relaxation is provided by vecuronium. After opening the abdomen and washout of the abscess cavity, the temperature drops to 36.5°C.

124. The patient may sweat as a result of all of the following processes EXCEPT a

(A) thermal-regulating mechanism

(B) process mediated by β-adrenoceptors

(D) response to emotional stimuli

(E) response to hypoglycemia

125. Core temperature in the patient under general anesthesia

(A) is closely regulated by the hypothalamus

(B) is elevated if the patient is peripherally vasodilated

(D) is best assessed by skin temperature

(E) will tend to drift toward ambient temperature

126. Regulation of body core temperature involves all of the following EXCEPT

(A) heat production by muscle

(B) heat production by the liver

(D) heat dissipation by the lungs

(E) heat dissipation by the skin

127. The difference between the alveolar pressure and the ambient pressure is the sum of

(A) transpulmonary pressure and chest wall transmural pressure

(B) esophageal balloon pressure and chest wall transmural pressure

(D) pulmonary artery occlusion pressure and esophageal balloon pressure

(E) esophageal balloon pressure and transpulmonary pressure

DIRECTIONS: Use the following figure to answer Questions 128-129:

128. Drugs A and B were given by intravenous bolus every 24 h. From the graph, it can be concluded that

(A) drug A maintains persistent therapeutic levels when administered every 24 h

(B) drug B is cumulative when administered every 24 h

(D) drug B is completely destroyed in less than 24 h

(E) drug B has reached steady state plasma concentration after 4 days

129. In addition, the graph shows that

(A) drug A has a long half-life in the body

(B) a large initial dose of both drugs was given

(D) in the case of drug B, the body does not remove one dose before another is administered

(E) duration of action of the two drugs is identical

130. All of the following are true of airway resistance EXCEPT

(A) decreases with maximal inspiration

(B) increases with parasympathetic stimulation

(D) increases with acetylcholine inhalation

(E) increases with inhalation of smoke

131. Mannitol decreases cerebral edema because it

(A) blocks reuptake of sodium in the collecting system

(B) draws water across an intact blood brain barrier to dehydrate the brain

(D) is a peripheral vasodilator

(E) can be given in kidney failure

132. Sickle cell formation is facilitated by all of the following EXCEPT

(A) hypoxemia

(B) sevoflurane

(D) fever

(E) dehydration

133. A 33-year-old woman with a recent onset (3 weeks) of clinical hyperthyroidism is admitted for repair of a tendon laceration. She has not taken methimazole for 4 days. At this time the

(A) patient should be essentially euthyroid

(B) patient should have general anesthesia if at all possible

(D) patient would probably have bradycardia

(E) patient should be considered as a high-risk hyperthyroid patient

134. Which one of the following is a characteristic of general anesthetic agents?

(A) All inhaled anesthetics produce bronchodilation.

(B) All general anesthetics are gases at body temperature.

(D) General anesthetic effects may be reversed by decreasing the ambient pressure.

(E) Nitrous oxide causes a dose-dependent inhibition of DNA synthesis.

135. Milrinone

(A) inhibits Na,K-ATPase

(B) causes vasodilation

(D) stimulates phosphodiesterase

(E) has inotropic effects via β₁-adrenoceptor stimulation

DIRECTIONS: Use the following figure to answer Questions 136-137:

136. As compared to the normal Curve 2, all of the following are TRUE about Curve 3 EXCEPT

(A) residual volume is elevated

(B) late expiratory flow is reduced

(D) total lung capacity is elevated

(E) it is characteristic of restrictive lung disease

137. As compared to the normal Curve 2, all of the following are TRUE about Curve 1 EXCEPT

(A) residual volume is reduced

(B) late expiratory flow is reduced

(D) total lung capacity is reduced

(E) it is characteristic of restrictive lung disease

138. Thiopental is contraindicated in

(A) porphyria congenita

(B) porphyria cutanea tarda

(D) myotonia

(E) chorea

139. Signs of hypoxemia include all of the following EXCEPT

(A) decreased ventilatory effort due to chemoreceptor stimulation

(B) increased heart rate due to sympathetic stimulation

(D) decreased heart rate due to direct effect of hypoxemia on the heart

(E) increased blood pressure due to sympathetic stimulation

140. Dopamine

(A) in a low dose infusion can cause vasodilation and inhibit release of norepinephrine from sympathetic nerves

(B) as a low dose infusion is selective for the α₂-adrenoceptor

(D) acts via nicotinic receptors

(E) is a β₁-selective inotrope

141. Agents in anesthetic practice that can cause bronchodilatation include all of the following, EXCEPT

(A) ketamine

(B) atropine

(D) sevoflurane

(E) thiopental

DIRECTIONS (Questions 142-143): 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. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Pneumothorax

(B) Myocardial infarction

(D) Anaphylaxis

(E) Hemidiaphragmatic paresis

(F) Transient neurologic injury

(G) Spinal stenosis

(H) Total spinal anesthesia

For each patient reporting severe shortness of breath, select the most common reason for his or her symptoms

142. An 18-year-old cheerleader is scheduled to undergo open reduction and internal fixation of her wrist after sustaining a distal radial fracture. One hour before the scheduled surgical procedure she undergoes a supraclavicular brachial plexus block with 20 mL of 0.5% bupivacaine. One hour after returning to the PACU, she reports severe shortness of breath.

143. A 72-year-old patient with COPD undergoes a left interscalene brachial plexus block with 20 mL of 0.5% ropivacaine. Fifteen minutes after the local anesthetic injection, the patient reports severe shortness of breath. The monitor displays sinus tachycardia with a heart rate of 134.

DIRECTIONS (Questions 144-145): 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. Each lettered heading or component may be selected once, more than once, or not at all.

(A) T2

(B) T4

(D) T7

(E) T10

(F) L1

For each patient, select the appropriate dermatome level corresponding to the height of the spinal anesthetic block.

144. A 21-year-old female presents for a cesarean section due to an arrest in labor. You perform a spinal anesthetic with 13.5 mg of hyperbaric bupivacaine. When assessing the level of block you determine that the patient is insensate to the level of the nipple line.

145. A 78-year-old man with a history of coronary artery disease presents for transurethral resection of the prostate. You decide to perform spinal anesthetic in order to be able to monitor the patient’s neurologic status. Your goal is to achieve a level of blockade corresponding to the umbilicus.

DIRECTIONS (Questions 146-150): 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. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Acute pericarditis

(B) Chronic pulmonary hypertension

(D) Myocarditis

(E) Pericardial tamponade

(F) Post-infarction ventriculoseptal defect (VSD)

(G) Pulmonary embolism

(H) Rheumatic fever

(I) Spontaneous pneumothorax

For each patient with a cardiac symptom or sign, select the most likely mechanism causing the symptoms or sign.

146. A 70-year-old man appears to be stabilizing well after a myocardial infarction. He suddenly develops profound hypotension and respiratory distress. An endotracheal tube is placed, and an intra-aortic balloon pump is initiated.

147. A 60-year-old woman with insidious dyspnea on mild exertion has a systolic heart murmur.

148. A young adult complains of recent onset of chest pain and breathlessness.

149. A 58-year-old man underwent uneventful coronary artery bypass grafting, and is transferred to the intensive care unit. After 4 h of hemodynamic stability, he suddenly develops profound hypotension, and equalization of invasive pressures is noted on initial evaluation.

150. A 60-year-old recipient of heart transplantation has poor cardiac output initially after the surgery but improves during treatment with inhaled nitric oxide and a phosphodiesterase inhibitor.

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