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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. 314 AANA Journal August 2013 Vol. 81, No. 4 ➤ 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 www.aana.com/aanajournalonline 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? www.aana.com/aanajournalonline 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 the epidural space. AANA Journal August 2013 Vol. 81, No. 4 315 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 316 AANA Journal August 2013 Vol. 81, No. 4 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 www.aana.com/aanajournalonline 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. www.aana.com/aanajournalonline 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 AANA Journal August 2013 Vol. 81, No. 4 317 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- 318 AANA Journal August 2013 Vol. 81, No. 4 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 www.aana.com/aanajournalonline 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 www.aana.com/aanajournalonline 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 AANA Journal August 2013 Vol. 81, No. 4 319