Download Answers to the AANA Journal Course No. 32 Examination

Answers to the
AANA Journal Course No. 32 Examination
Update for Nurse Anesthetists
Here are the correct answers to the examination conducted as part of the AANA Journal’s 32nd course: Update for Nurse
Anesthetists. The course consists of a 6-part series, beginning in the April 2012 issue and concluding in the February 2013
issue. The examination, which is reprinted here in total to provide readers with a convenient reference and an additional
learning tool, was published in the April 2013 issue and on the AANA website.
For those of you who took the examination, we suggest that you compare your recorded answers with the correct answers
to see how you scored. We also suggest that you keep the examination and correct answers for future reference and review.
To have successfully completed the course, you must have had 42 out of the 60 questions correct (80%); a total of 6 CE
hours will be awarded for this successful completion.
We hope this 32nd Journal course has been of value to you.
Anesthetic-Induced Anaphylaxis
1.What mechanism is necessary for non-IgE anaphylaxis?
1. Previous sensitization and re-exposure to an antigen
must occur.
2. The production of an antigen-specific IgE is essential
to elicit a reaction.
3. Antigenic proteins must cross-link bind with 2 IgE
antibodies on the cell surface of mast cells or basophils.
➤ 4. Circulating mast cells and tissue basophils directly
release preformed mediators.
2.
Which mediator that is released from cardiac
mast cells during an allergic response is responsible for coronary plaque rupture?
1. Histamine
2. Tryptase
➤ 3. Platelet-activating factor
4. Carboxypeptidase A
3.What is the most common presentation of anesthetic-induced anaphylaxis?
1. Urticaria and angioedema
2. Bronchospasm and hypotension
➤ 3. Bronchospasm and cardiac arrest
4. Paradoxical bradycardia and hypotension
4.Ten minutes after receiving preoperative ampicillin/sulbactam, a surgical patient with a history of
penicillin allergy develops profound hypotension
and tachycardia, bronchospasm and hypoxia
(SaO2 <
– 92) with confusion and vomiting. What
is the patient’s anaphylaxis severity grade?
1. Grade I
2. Grade II
➤ 3. Grade III
4. Grade IV
5.Why are patients with food allergies at risk for
allergic reactions under anesthesia?
1. Prior allergy to egg lecithin promotes sensitization to
propofol.
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➤ 2. They have decreased levels of enzymes that degrade
platelet-activating factor.
3. Cross-reactive sensitization to soy increases propofol
hypersensitivity.
4. Allergy to exotic fruits, such as banana, does not
increase cross-sensitivity to latex.
6. W
hich patient is most at risk for an allergic reaction under anesthesia?
1. A 46-year-old female with chronic obstructive pulmonary disease and history of myocardial infarction
scheduled for coronary artery bypass surgery
2. A 25-year-old male with asthma and food allergies to
eggs and soy, scheduled for an open reduction internal fixation of the ankle
➤ 3. A 52-year-old female with mastocytosis and hypersensitivity to atracurium for a trigger finger release
4. A 32-year-old male with a history of allergy to peanuts for a hernia repair
7.Which drugs are most likely to elicit anaphylaxis
during anesthesia?
1. Antibiotics, especially β-lactam cephalosporins, vancomycin, or quinolone antibiotics, and irrigation with
bacitracin or rifamycin
2. Nonsteroidal anti-inflammatory drugs such as ketorolac
➤ 3. Muscle relaxants including succinylcholine and
rocuronium
4. Induction drugs including propofol and narcotics
such as morphine
8.Which anesthetic technique is recommended for
surgical patients who are at high risk of anaphylaxis?
1. Avoid the triggering agent and use general anesthesia
if possible.
2. Give a test dose before administration of the medicines to sensitive patients.
3. Ultrasound or magnetic resonance imaging and a
higher osmolarity ionic contrast media for patients
with a history of reaction to contrast
➤ 4. Pretreatment with anti-H1 and H2 histamine receptor
blockers, steroids, and leukotriene antagonists for
mastocytosis patients
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9.The immediate goals of the treatment of anaphylaxis include all EXCEPT:
1. Stop the administration of the allergen.
➤ 2. Detection of the triggers of anaphylaxis.
3. Abate the effects of the toxic mediator release.
4. Prevent further mast cell degranulation.
10.
What dose of epinephrine should be administered to a surgical patient who has grade III anaphylaxis?
1. 10-20 µg IV bolus of epinephrine
➤ 2. 100-200 µg IV bolus every 1-2 minutes or a continuous infusion at 1-4 µg/min
3. 1-3 mg IV every 3 minutes
4. 3-5 mg IV every 3 minutes, up to a continuous infusion of 4-10 µg/min
16.Which of the following statements are reported
in the preprocedural ultrasonography (U/S-P)
literature?
➤ 1. There is a strong correlation between ultrasound
depth and needle depth.
2. In obese parturients, there is a weak correlation
between body mass index and ultrasound depth and
needle depth.
3. Preprocedural ultrasonography cannot estimate the
depth to loss of resistance.
4. Preprocedural ultrasonography decreases the success
rate of epidural placement.
Evidence-Based Anesthesia: The Use of
Preprocedural Ultrasonography During Labor to
Facilitate Placement of an Epidural Catheter
11.
The reported benefits of preprocedural ultrasonography (U/S-P) to facilitate labor epidural
placement include which ONE of the following?
1. Increased number of insertion attempts
2. Decreased success rate
➤ 3. Identification of optimal insertion point
4. Prolongs learning curve in anesthesia trainees
12.Which of the following is a LIMITATION of traditional epidural placement in parturients?
➤ 1. Epidural placement in a “blind” technique.
2. Loss of resistance is difficult to detect.
3. Obesity does not contribute to difficulty in epidural
placement.
4. All of the above
13.
Which of the following ultrasound probes are
used in preprocedural ultrasound scanning of
parturients to facilitate epidural placement?
1. High-frequency linear probe
➤ 2. Low-frequency (2-5 MHz) curved probe
3. A 25-50 MHz probe
4. None of the above
14.
The longitudinal paramedian acoustic window
can be used to identify which of the following
spinal anatomy?
1. Vertebral body
2. Articular processes
3. Ligamentum flavum-dura unit
➤ 4. All of the above
15.Which of the following statements best describe
current published results of investigations on
preprocedural ultrasonography (U/S-P) to facilitate epidural placement?
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1. M
ost of the published studies are low quality.
2. A majority of the published studies are randomized
controlled trials.
➤ 3. There is a risk of “publication bias” and “dominating
center bias.”
4. A
ll of the above
17.Results of the literature review on preprocedural
ultrasonography (U/S-P) indicate that the technique is efficacious because it:
1. D
ecreases the number of puncture attempts
2. I ncreases the epidural failure rate when epidurals are
placed by trainees
3. D
ecreases number of puncture sites (interspaces)
➤ 4. A
nswers 1 and 3
18.Which of the following are LIMITATIONS of studies reviewed in this literature review?
1. In a majority of the studies, epidural catheter placement was performed by an experienced anesthesia
provider with extensive experience with preprocedural ultrasonography (U/S-P).
2. T
here is a risk of publication and center bias.
3. Randomized controlled trials evaluating the efficacy
of preprocedural ultrasonography in morbidly obese
parturients are lacking.
➤ 4. A
ll of the above
19.Which of the following are methods for incorporating preprocedural ultrasonography (U/S-P)
into clinical practice?
1. Providers should practice the technique on patients
without a potential “difficult back.”
2. Providers should attempt to gain experience in a controlled setting.
3. Providers should consider demonstrating to a new
anesthesia trainee how to perform the procedure, identify the relevant anatomy, and ideal insertion point.
➤ 4. All of the above
20.
When demonstrating to an anesthesia trainee
how to perform preprocedural ultrasonography
(U/S-P), which of the following apply?
1. As the student gets closer to the estimated depth, the
staff can provide feedback as to what tactile sensations the student should be feeling as they approach
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2. The staff should describe the relevant anatomy.
3. Demonstrate how to estimate the depth from the skin
to the vertebral body.
➤ 4. Both 1 and 2
Anesthesia and Safety Considerations for
Office-based Cosmetic Surgery Practice
21.
As compared to a hospital or an ambulatory
surgery center, which of the following is likely
to be true regarding an office-based anesthesia
practice?
➤ 1. An office-based practice is less likely to be regulated
by the state in which it is located.
2. An office-based practice is less convenient for patients.
3. An office-based practice has more human and physical resources available.
4. An office-based practice has similar credentialing and
peer review.
22.
Choose the correct characteristic to complete
the following sentence. Office-based anesthesia
practice:
➤ 1. May account for up to 25% of all surgical procedures
performed in the United States.
2. Is a very recent phenomenon.
3. Has been described as a slowly growing area of anesthesia practice.
4. Is associated with decreased practice autonomy as
compared to hospital practice.
23.
Which of the following patients would most
likely be an APPROPRIATE candidate for officebased cosmetic surgery?
1. A 46-year-old with an implanted pacemaker/defibrillator
2. A 26-year-old with a 44 body mass index
➤ 3. A 60-year-old with controlled hypertension
4. A 20-year-old with moderate sleep apnea
24.Which of the following surgeries would be most
appropriate to perform in the office-based cosmetic surgery setting?
1. Liposuction of up to 7,000 mL total aspirate
2. Abdominoplasty with an anticipated blood loss of
400 mL
➤ 3. A facelift procedure of estimated 5 hours’ duration
4. Liposuction of > 5,000 mL total aspirate volume in
combination with facelift
25.Closed claims studies suggest which of the following as the most frequent type of event leading
to adverse outcomes due to anesthesia in patients
receiving monitored anesthesia care (MAC)?
➤ 1. Respiratory events
2. Circulatory events
3. Embolic events
4. Anaphylaxis
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26.
Of the following, which is the most effective
means of monitoring ventilation in the patient
under MAC anesthesia?
1. Clinical observation
2. Pulse oximetry
➤ 3. End-tidal carbon dioxide monitoring
4. Skin color
27.Which of the following is true regarding liposuction?
1. Approximately 70% of tumescent solution infiltrated
is later removed during liposuction.
2. Large volume liposuction combined with other cosmetic procedures has not been found to increase the
incidence of complications.
➤ 3. The most frequent cause of mortality is venous
thromboembolism.
4. Less blood loss is associated with the “dry” technique
of liposuction (without the use of tumescent solution).
28.Which of the following statements is true regarding abdominoplasty procedures?
1. Intercostal nerve blocks have not been found to be an
effective technique for perioperative anesthesia and
analgesia.
2. Abdominoplasty is associated with a lower incidence
of complications than liposuction or other common
cosmetic procedures.
3. The most common cause of mortality associated with
abdominoplasty is fat embolism syndrome.
➤ 4. The incidence of thromboembolism has been reported
to be as high as 6.6% when abdominoplasty is combined with other procedures.
29.Which of the following is NOT a risk factor for the
development of a venous thromboembolism?
1. The use of birth control pills
2. Recent travel shortly before or after surgery
➤ 3. Moderate alcohol consumption
4. The use of general anesthesia
30.
Prevention measures for cosmetic surgery
patients considered at high risk for venous thromboembolism include all of the following EXCEPT:
1. The use of sequential compression devices
2. The use of enoxaparin (Lovenox) 40 mg, for 7-10
days postoperatively
3. Slight knee flexion during surgery
➤ 4. The use of epinephrine-free tumescent solution during liposuction
Is That Snoring Something to Worry About?
Anesthetic Implications for Obstructive Sleep Apnea
31.Which of the following is associated with obstructive sleep apnea (OSA)?
➤ 1. Apneic episodes that often result in fatigue and mental depression
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2. Acute onset of irregular breathing is unresponsive to
chemical or vagal stimulus
3. No respiratory effort during sleep
4. Neck size less than 40 cm
32.
What percentage of people who have sleep
apnea are estimated to be undiagnosed?
1. 10%
2. 18%
3. 20%
➤ 4. 90%
33.
Which of the following statements regarding
OSA is NOT correct?
1. Nearly 20 million people are afflicted with OSA.
➤ 2. Patients with OSA have twice the frequency of motor
vehicle accidents compared to the normal population.
3. As high as 90% of people who have sleep apnea are
undiagnosed.
4. The prevalence of OSA is approximately 25% of
middle-aged men.
34.For a patient with OSA, which of the following
would NOT be an acceptable consideration during development of an anesthetic plan?
➤ 1. Maximizing the use of opioid pharmacological agents
2. Using regional or local anesthesia vs general anesthesia
3. Anticipating a difficult airway
4. Considering general endotracheal anesthesia over
deep sedation
35.
Which of the following are characteristics of
sleep apnea?
1. Relaxed muscles during sleep and excess tissue in the
oropharyngeal area collapse the airway
2. Pause in breathing during sleep lasting at least 10
seconds and accompanied by at least a 4% decline in
oxygen saturation from baseline measurements
3. Obesity, enlarged tonsils and adenoids, and large neck
circumference all may contribute to OSA
➤ 4. All of the above
36.Periods of apnea can lead to:
1. Systemic hypotension
2. Parasympathetic stimulation
3. Hypocarbia and cerebral vasoconstriction
➤ 4. Sympathetic surge that increases epinephrine and
norepinephrine levels
37.A complication following emergence from anesthesia seen in patients with OSA is:
1. Increased intraocular pressure
➤ 2. Oxygen desaturation
3. Cardiac stability
4. Distal extremity neuropathy
38.Which of the following is NOT correct regarding
the Apnea-Hypopnea Index (AHI)?
➤ 1. AHI is defined as the product of apnea and hypopnea
events per minute during sleep.
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2. Moderate AHI is categorized as 15 to 30 episodes per
hour.
3. Hypopnea is defined as the decrease in airflow by
greater than 50% for more than 10 seconds.
4. The polysomnography study, also known as a “sleep
study,” measures AHI.
39.
The postoperative period is a critical time for
OSA patients. Which of the following statements
is NOT correct?
➤ 1. Postoperative pain management can be safely achieved
with narcotic patient-controlled analgesia (PCA) use.
2. The anesthetist should vigilantly monitor the patient
in the postanesthesia care unit and step-down floor or
intensive care unit.
3. Respiratory status should be closely monitored with
pulse oximetry.
4. Oxygen therapy and continuous positive airway pressure (CPAP) devices should be used until baseline
saturations return.
40.
Which of the following statements are recommended guidelines regarding the anesthetic management of a patient with OSA?
1. Perioperative use of CPAP should be considered.
2. Respiratory end-tidal carbon dioxide monitoring
should be used during moderate or deep sedation.
3. Spinal or epidural anesthesia should be considered for
peripheral procedures.
➤ 4. All of the above
The Perioperative Implications of Posttraumatic
Stress Disorder
41.
In order to be diagnosed with posttraumatic
stress disorder (PTSD) the patient must:
➤ 1.Have symptoms severe enough to reduce overall
functioning or cause significant subjective distress.
2.Demonstrate at least 6 of the 17 symptoms of PTSD.
3.Have a history of nightmares prior to his or her traumatic experience.
4.Have a concurrent diagnosis of psychosis.
42.The first-line medications of choice for pharmacological management of PTSD are:
1.Benzodiazapines
2.Tricyclic antidepressants
➤ 3.Selective serotonin reuptake inhibitors
4.α-agonists
43.
Compared to patients without chronic pain,
patients reporting chronic pain before major
elective surgery were approximately ______ as
likely to report posttraumatic symptoms severe
enough to suggest a diagnosis of PTSD.
1.Half
➤ 2.Twice
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3. 3 times
4. 5 times
44.
In military veterans and Holocaust survivors
undergoing cardiac surgery, the prevalence of
PTSD was approximately:
1.7%
2.10%
3.20%
➤ 4.35%
45.
The rate of comorbid depression observed in
patients with PTSD is:
➤ 1.High, possibly due to a genetic liability common to
both illnesses
2.High, but probably an erroneous diagnosis because of
the similarity of PTSD and depression symptoms
3.No different from the rate of comorbid depression
observed in patients without PTSD
4.Lower than the rate of comorbid depression observed
in patients without PTSD
46.
Compared to patients without PTSD, patients
with PTSD are more likely to:
1.Demonstrate a significant decline in cognitive function 1 week after noncardiac surgery.
➤ 2.Demonstrate a significant decline in cognitive function 1 week after cardiac surgery.
3.Demonstrate lower overall intelligence.
4.Demonstrate greater cognitive reserve.
47.To date, studies have reported that:
1.Posttraumatic symptom severity is unrelated to the
experience of surgery.
2.Posttraumatic symptom severity is unchanged in the
days and weeks after noncardiac surgery.
3.Posttraumatic symptom severity is increased only
after cardiac surgery.
➤ 4.The perioperative experience may trigger acute flashbacks.
48.
During the perioperative period, posttraumatic
symptoms can be exacerbated by:
➤ 1.Situations that remind the patient of his/her traumatic event.
2.Cardiac surgery.
3.Gastric bypass surgery.
4.Urologic surgery.
49.
While conducting a preoperative assessment
you discover that a patient has been previously
diagnosed with PTSD. To effectively prepare this
patient for surgery you should:
1.Consult psychiatry and have them assess the patient
for potential behavioral problems after surgery.
➤ 2.Specifically ask the patient about cardiovascular
comorbidities, past/present substance use, chronic
pain, and current psychoactive medication use.
3.Engage the patient in a discussion about his/her trau-
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matic experiences.
4.Discontinue any anticonvulsants and/or atypical antipsychotics the patient may be taking at least 3 days
before surgery.
50.When caring for the patient with PTSD, the anesthetist should always:
1.Prophylactically administer an α agonist.
2.Engage the patient in a discussion about his/her traumatic experiences.
3.Awaken the patient by gently tapping him/her on the
shoulder.
➤ 4.Carefully explain the perioperative process and plan
of care to minimize the element of surprise.
Anesthesia Case Management for Video-Assisted
Thoracoscopic Surgery
51.The principal physiologic change associated with
one-lung ventilation includes:
1.Enhanced hypoxic pulmonary vasoconstriction
2.A peak pressure greater than 35 cm/H2O pressure
➤ 3.Increased blood flow to the ventilated dependent lung
4.A decrease in pulmonary vascular resistance
52.
Factors known to inhibit hypoxic pulmonary
vasoconstriction and worsen right-to-left shunting and oxygenation include:
1.Dopamine
➤ 2. Inhalational agents
3. Increased ventilation to the dependent lung
4.Hypercapnea
53.A left-sided double-lumen endotracheal is most
often used for video-assisted thoracoscopic surgery (VATS) because:
1.Herniation of the tracheal cuff from the right bronchus can occur.
2.The left mainstem bronchus is more acutely angled as
compared to the right mainstem bronchus.
➤ 3.Occlusion of the right upper bronchopulmonary segment decreases right upper lobe ventilation.
4.Migration within the right mainstem bronchus is
more likely.
54.Correct positioning of a left-sided double-lumen
tube is confirmed by:
➤ 1.Visualization by fiberoptic bronchoscopy
2.Left-sided breath sounds during ventilation when
the bronchial and tracheal cuffs are inflated and the
bronchial lumen occluded
3.Right-sided breath sounds during ventilation when
the bronchial and tracheal cuffs are inflated and the
tracheal lumen is occluded
4.Bilateral breath sounds during ventilation when the
bronchial and tracheal cuffs are inflated and the
bronchial lumen is ventilated
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55.Which intervention can be used to treat hypoxia
during one-lung ventilation?
1.Continuous positive airway pressure to the ventilated
dependent lung
2.Positive end expiratory pressure to the nonventilated
nondependent lung
3. Deflation of the tracheal cuff
➤ 4. Intermittent two-lung ventilation
56.Which ventilation strategy is suggested to avoid
desaturation during one-lung ventilation and
VATS?
1.Spontaneous intermittent mandatory ventilation
➤ 2.Tidal volume 5 to 6 mL/kg
3.Positive end expiratory pressure of 15 cm/H2O
4.Respiratory rate 8 to 10 breaths per minute
57.Which complication is most often associated with
double-lumen endotracheal tube placement?
1. Tension pneumothorax
2. Subcutaneous emphysema
3. Gastric aspiration
➤ 4. Airway trauma
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58.Which peripheral nerve injury is most common
during VATS?
1. Phrenic nerve
➤ 2. Brachial plexus
3. Trigeminal nerve
4. Common peroneal nerve
59.Which medication is advocated to treat shoulder
pain after VATS?
➤ 1.Acetaminophen
2.Gabapentin
3.Amitriptyline
4.Dexamethasone
60.An epidural catheter is best placed within which
interspace before a VATS procedure?
1.T4-T6
➤ 2.T6-T8
3.T8-T10
4.T10-T12
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