Pharm II Quiz 2

1. In response to hypovolemia, or hypotension the juxtaglomerular cells of the kidney release what enzyme?

Angiotensin I

Angiotensin II

Angiotensin converting enzyme

Renin

2. Which of the following would be the best choice to treat a pt diagnosed with essential hypertension?

Hydrochlorothiazide

Urea

Spironolactone

Acetazolamide

3. How will mixing your local anesthetic with bicarbonate effect the anesthetic?

Greater degree of protein binding and thus longer duration

No effect at all

Decreased lipid solubility resulting in decreased potency

Increased unionized drug causing more rapid onset

4. What is the post synaptic neurotransmitter of the parasympathetic nervous system?

Acetycholine

Serotonin

Glutamate

Norepinephrine

5. LA toxicity is more likely to occur in area of the body that have…

Access to CSF

Increased fat stores

Increased blood flow

None of above

6. What are the two classifications of local anesthetics?

Esters

Ethers

Amides

Carboxylic Acids

Thiols

Submit

7. What is the most common side effect associated with ACE inhibitors?

Bradycardia

Bronchospasm

Chronic Cough

Hypokalemia

8. What is the MOA of Losartan?

Blocks the vasoconstrictor and aldosterone-secretion effects of Angiotensin II to the AT1 receptors in the smooth muscles

Blocks the conversion of angiotensin I to angiotensin II to prevent vasoconstriction

Inhibits reabsorption of sodium and chloride ions in the loop of Henle

Increases the osmolarity of the renal tubular fluid and prevents reabsorption of water

9. What is the MOA of Mannitol?

Blocks the vasoconstrictor and aldosterone-secretion effects of Angiotensin II to the AT1 receptors in the smooth muscles

Blocks the conversion of angiotensin I to angiotensin II to prevent vasoconstriction

Inhibits reabsorption of sodium and chloride ions in the loop of Henle

Increases the osmolarity of the renal tubular fluid and prevents reabsorption of water

10. How does epinephrine prolong spinal anesthesia?

By blocking passage of sodium ions into nerve cells

Through beta1 agonistic effects

Through vasoconstriction and decreasing vascular absorption

All the above

11. Accidental IV injection of bupivacaine would result in which of the following?

Precipitous Hypotension

Cardiac Dysrhythmias

AV Heart block

All the above

12. Depolarization is due to inflow of ____ ions from the extracellular to the intracellular space while repolarization is due to outflow of ____ ions from intracellular to extracellular space.

Cl , K

Na, Cl

Na, K

K, Na

13. You perform an ankle block for amputation of a toe secondary to nonhealing diabetic ulceration and sepsis. The block technique looked good but the patient almost jumped off the OR table when the surgeon made the incision. What went wrong?

The technique must have been wrong, try again.

The acidic environment of the foot cause a greater concentration of ionized anesthetic, which can not cross cell membrane.

The basic environment of the foot cause a greater concentration of ionized anesthetic, which can not cross cell membrane.

Pt must have a tolerance to local anesthetics, try again using a larger dose.

14. Which of the following would be the best choice for a 60 kg patient with acute pulmonary edema?

Mannitol 30g IV

Furosemide 40 mg IV

Aldactone 250mg PO

Enalapril 2.5 mg IV

15. How is Bupivicaine metabolized?

By hydrolysis via pseudocholinesterase

Via hepatic enzymes P450

Via proteins present within CSF

Via renal metabolism and excretion

16. Which of the following is mainly responsible for the duration of action of local anesthetics?

Degree of protein binding

Lipid Solubility

Degree of Ionization

Size of Molecule

17. What is the MOA of ACE inhibitor drugs such as captopril?

Blocks the vasoconstrictor and aldosterone-secretion effects of Angiotensin II to the AT1 receptors in the smooth muscles

Blocks the conversion of angiotensin I to angiotensin II to prevent vasoconstriction

Inhibits reabsorption of sodium and chloride ions in the loop of Henle

Increases the osmolarity of the renal tubular fluid and prevents reabsorption of water

18. Sympathetic stimulation results in all of the following except?

Increased HR

Decreased urine secretion

Secretion of norepi

Increased Saliva and mucus production

19. Which diuretic would be the best choice for a patient who suffers from chronic hypokalemia?

Hydrochlorothiazide

Furosemide

Triamterene

Ethacrynic Acid

20. Which of the following will have the greatest amount of unionized molecules when injected into physiologic pH?

Procaine – pKa 8.9

Lidocaine – pKa 7.7

Chloroprocaine – pKa 9.1

Bupivacaine – pKa 8.1

21. Which of the following has the lowest blood flow?

Subcutaneous

Sciatic

Caudal

Epidural

22. Which of the following is likely to cause bronchoconstriction and should be used cautiously in asthmatics?

Alpha 1 receptor blockers

Beta 2 receptor Blockers

Beta 1 receptor blockers

All the above will cause bronchoconstriction

23. Which of the following is given only in IV form?

Labetolol

Phenoxybenzamine

Atenolol

Esmolol

24. Which portion of the Local anesthetic molecules makes the cationic form which is most active at the intracellular site?

Lipophilic aromatic group

Esther linkage

Amide Linkage

Hydrophilic amine group

25. You are delivering spinal anesthetic to a patient when they begin to complain of feeling light headed and ringing in their ears. What should you do?

Slow down your rate of injection, and then administer rest of anesthetic.

Immediately notify MD and prepare pt for cardiac bypass, your plasma concentration is most likely too high now.

Immediately stop injection, start lipid infusion, monitor patient, your plasma concentration should still be low enough to reverse this.

Comfort the patient that this is normal to experience and deliver rest of anesthetic quickly.

26. COMIC RELIEF: Jizz in my pants

Ha ha!!

Kind of a catchy tune...

I love the looks on their faces!

All the above

27. What is the mechanism of action of local anesthetics?

Mimics acetylcholinesterase to Cause sustained depolarization rendering the NMJ unable to conduct further impulses=Muscle relaxation

Dependent upon type of anesthetic as ester and amides have different MOA’s

Prevents passage of sodium ions through ion selective channels in nerve membranes to block nerve conduction.

28. What is the post synaptic neurotransmitter for the sympathetic nervous system?

Acetycholine

Serotonin

Glutamate

Norepinephrine

29. How is Procaine metabolized?

By hydrolysis via pseudocholinesterase

Via hepatic enzymes P450

Via proteins present within CSF

Via renal metabolism and excretion

30. Risk for toxicity is directly proportionate to potency.

True

False

31. Which of the following patients would be at greatest risk for toxicity?

Pt receiving intercostal nerve block

Pt receiving caudal block

Pt receiving brachial plexus nerve block

Pt receiving sub-q local anesthetic

32. Patients taking beta adrenergic blockers, such as propanolol, are at an increased risk for bupivacaine toxicity.

True

False

33. Local anesthetic toxicity is most often due to which of the following?

Absorption from tissues during nerve blocks

Inadvertent intravascular injection

Inadvertent administration of epidural dose into subdural space

Drug interactions between pt meds and LA’s

34. You have just performed spinal anesthesia and find your patient has experienced total spinal anesthesia. What do you do?

Prepare for the patient to be placed on cardiac bypass due to arrhythmias.

Intubate the patient and wait it out.

Deliver neo and glyco to reverse the paralysis.

Begin delivering pain medication to counteract the headache.

35. Where does angiotensin converting enzyme act upon angiotenin I?

Lungs

Kidneys

Liver

Coronary Vessels

36. In regard to local anesthetics their _______ nature allows them pass through cell membranes, but once inside the cell membrane their ______ portion binds inside the cell.

Lipophilic, hydrophilic

Hydrophilic, lipophilic

Ionized, unionized

None of above

37. Which of the following diuretics is associated with hypochloremic, hypokalemic, metabolic alkalosis?

Potassium sparing diuretics

Aldosterone Antagonists

Osmotic Diuretics

Thiazide Diuretics

38. Which of the following is not a side effect associated with use of labetolol?

Chronic Cough

Orthostatic hypotension

Bronchospasm

Heart block

39. Stimulation of beta 2 receptors causes these effects except

Bronchodilation

Glycogenolysis/gluconeogenesis

Activation of Na/K pump

Vasoconstriction

40. Which of the following local anesthetic agents are Amides? (More than one answer)

Lidocaine

Chloroprocaine

Cocaine

Mepivicaine

Prilocaine

Submit

41. Which of the following will have the most rapid onset?

Procaine – pKa 8.9

Bupivacaine – pKa 8.1

Mepivacaine- pKa7.6

Ropivacaine- pKa 8.1

42. Which of the following is a selective alpha 1 receptor blocker?

Phenoxybenzamine

Prazosin

Esmolol

Labetolol

43. Stimulation of Beta 1 receptors would result in all of the following except…

Brochodilation

Increase heart rate

Increase contractility

All the above result from Beta 1 stimulation

44. You are doing a pre-op on a pt who will be receiving spinal anesthesia today for surgery. When interviewing the patient they state they previously had a serious allergic reaction to Procaine. You question the patient further and verify it is indeed a true allergy. What do you do now? The surgeon and patient both want spinal anesthesia but what about the allergy?

Use Tetracaine instead, since this is a different class of anesthetic

This pt may not receive any spinal anesthetics and will need to have GA

Cancel procedure for today and reschedule for a later time.

Use Ropivacaine instead, since this is a different class of anesthetic

45. Which of the following is responsible for the potency of local anesthetics?

Degree of protein binding

Lipid Solubility

Degree of Ionization

Size of Molecule

46. Mannitol should be given with extreme caution to patients with which of the following?

CHF

Renal Failure

Increased ICP

COPD

47. Dopamine B-hydroxylase acts upon Dopamine to convert it into what substance?

Dihydroxyphenylalanine

Norepinephrine

Epinephrine

N-methyltransferase

48. Which of the following may cause methemoglobinemia?

Lidocaine

Prilocaine

Bupivacaine

Cocaine

49. The first chemical involved in production of norepinephrine is what?

Tyrosine

DOPA

Epinephrine

Hydroxylase

50. Which of the following local anesthetic agents are Esters? (more than one answer)

Lidocaine

Chloroprocaine

Cocaine

Mepivicaine

Prilocaine

Submit

51. What would be an appropriate dose of mannitol to give to a 58 yr old pt weighing 80 kg to reduce ICP?

8 g IV

40 g IV

160 g IV

1.6 g IV

52. You were administering a levophed drip to a very sick pt which infiltrated into the pts arm. Which medication would be appropriate to give SQ to help prevent tissue necrosis?

Phenoxybenzamine 1mg/kg

Propanolol 0.05 mg/kg

Phentolamine 5mg

Labetolol 10 mg

53. Which of the following is an alpha and beta blocker?

Propanolol

Yohimbine

Labetolol

Metoprolol

54. Which of the following is not true regarding ACE inhibitors?

May cause left ventricular hypertrophy to decrease

Delay progression of diabetic renal disease

First line treatment for HTN and mitral regurge

Commonly used to treat renal stenosis

55. What is the MOA of Loop diuretics?

Inhibits reabsorption of sodium and chloride ions in the medullary portion of the ascending loop of Henle

Blocks the conversion of angiotensin I to angiotensin II to prevent vasoconstriction

Inhibits reabsorption of sodium and chloride ions in the cortical portion of the ascending loop of Henle

Increases the osmolarity of the renal tubular fluid and prevents reabsorption of water

56. Which of the following is a cardioselective beta 1 blocker?

Propanolol

Metoprolol

Nadalol

Timolol

57. The nerves of the sympathetic nervous system arise from where?

Craniosacral nerves

T1-L2

Cauda Equina

All the above, these nerves are throughout the body

58. Alpha 1 receptor agonism will result in all of the following except what?

Vasoconstriction

Pupillary Dilation

Uterine Contracture

Bronchodilation

59. When given IV, the beta to alpha potency ratio of labetolol is _______, while when given PO the ratio is _____.

1:1, 3:1

3:1, 7:1

3:1, 1:1

7:1, 3:1

60. Which of the following beta blockers is not a partial antagonist?

Pindolol

Acebutolol

Timolol

Atenolol

61. Which of the following is true?

Alpha 1 receptors are presynaptic adrenoreceptors

Alpha 2 receptors are postsynaptic adrenoreceptors

Alpha 1 receptors are postsynaptic adrenoreceptors

Botha Alpha 1 and 2 are presynaptic and postsynaptic adrenoreceptors

62. The nerves of the parasympathetic nervous system arise from where?

T1-L2

Cauda Equina

Craniosacral nerves

All the above, these nerves are throughout the body

63. What would be an appropriate drug to give to a patient with COPD to blunt the response to larnygoscopy?

Propanolol IV

Atenolol PO

Esmolol IV

Timolol PO

64. Which of the following is responsible for time until onset of action for local anesthetics?

Degree of protein binding

Lipid Solubility

Degree of Ionization

Size of Molecule

65. Which of the following is a pro-drug which must be metabolized by the liver before reaching its active form?

Captopril

Enalapril

Losartan

Hydrochlorothiazide

66. Which of the following side effects is not usually associated with thiazide diurectics?

Hypokalemia

Metabolic Alkalosis

Skeletal muscle weakness

Hemodilution

67. Parasympathetic stimulation results in all of the following except…

Pupillary Constriction

Decreased HR

Reduced Peristalsis

Bronchoconstriction

68. Which of the following drugs can inhibit seizure activity?

Urea

Captopril

Acetazolamide

Furosemide

69. How would you perform local anesthesia on a patient with a known pseudocholinesterase deficiency?

Administer local anesthesia with Bupivacaine

This has no effect on local anesthetics, only on succinylcholine.

Administer local anesthesia with Procaine

Patient may not receive any local anesthetics

70. Which of the following is not a clinical use of furosemide?

Prophylaxis against acute renal failure

Mobilization of Edema

Treatment of increased ICP

Differential diagnosis of acute oliguria

71. How will a pt who has been taking beta blockers for the past 2 years for HTN respond to administration of norepi during surgery?

Pt will have a blunted response

Pt will have an exaggerated response

Response will be no different than normal

72. Which nerve fibers are likely to be the first blocked after administration of local anesthetic?

A delta fibers

B Fibers

A Alpha fibers

C Fibers

73. What could you add to increase the duration of local anesthetic on a pt with mild aortic stenosis whose HR you do not wish to elevate?

Epinephrine

Metoprolol

Phenylephrine

Ephedrine

74. Which of the following will occur first following administration of a LA?

Loss of touch and pressure sensation

Loss of Pain and temperature sensations

Loss of proprioception

Sympathetic block

75. Which of the following is not a cardiac effect associated with propanolol?

Decreased peripheral vascular resistance

Decreased HR

Decreased cardiac output

Decreased Contractility

76. Which of the following is appropriate treatment for CNS toxicity associated with Local anesthetics?

Hyperoxygenate and give IV diazepam

Intubate pt and wait it out, no treatment

Administer Physostigmine gtt

Give Bretylium 20 mg/kg IV

77. Which form of the local anesthetic is most active at the intracellular receptor site?

Anionic Form

Lipophilic form

Cationic form

Polar form

78. Which of the following describes an appropriate oral dose of furosemide?

0.1 mg/kg

1mg/kg

5 mg/kg

0.5 mg/kg

79. How is Esmolol metabolized?

By plasma cholinesterase

By cytochrome P450

Through renal excretion

By plasma esterases

80. Which of the following may antagonize the effects of Captopril?

Aspirin

Tylenol

Furosemide

Mannitol

81. For a patient who is taking losartan, you would expect to see a 2-3 fold increase in plasma _____ activity and an increase in ______ activity due to removal of negative feedback system.

Renin, Angiotensin II

Angiotensin II, Angiotensin I

Angiotensin I, Renin

None of above

82. Which of the following is not a competitive alpha blocker?

Phentolamine

Phenoxybenzamine

Yohimbine

Prazosin

83. Which of the following is not a means of inactivating Neurotransmitters?

Enzymatic degradation

Plasma cholinesterase

Monoamine oxidase

COMT

(plasma cholinesterase inactivates SCh, while acetylcholinesterase inactivates ACh which is a NT)

Explanation

(plasma cholinesterase inactivates SCh, while acetylcholinesterase inactivates ACh which is a NT)

84. You are SRNA today for a patient who has been taking Furosemide. When your preceptors asks you if this drug effects any of the common anesthesia drugs what do you say?

Has potential to cause angioedemia if given with propofol

It does not effect any of our drugs! I’ll just watch their volume status closely though.

May potentiate Non depolarizing NMB’s

Interacts with neosynephrine to cause arrhythmias

85. What would be an appropriate pre-op treatment to give to a pt with Pheochromocytoma?

Phenoxybenzamine 1mg/kg PO

Propanolo 1mg/kg PO

Phentolamine 50 mcg/kg IV

Esmolol 0.5 mg/kg IV

86. What would be the max dose of mepivacaine plain to give to a pt who weighs 45 kg?

225 mg

112 mg

450 mg

315 mg

87. Which of the following is not true regarding Propanolol?

Decreases clearance of Amide local anesthetics

Optimal plasma concentration is evidenced by resting HR of 55-60

A much higher dose of fentanyl than normal will be required for pts on propanolol

Has extensive hepatic first pass metabolism

88. What is the half life of Esmolol?

5 minutes

9 minutes

17 minutes

2 hours

89. Administration of non-selective betablockers would have all the following effects except what?

Decreased cardiac conduction

Increased cardiac contractility

Bronchoconstriction

Sedation

90. Blockade of Alpha 2 receptors will have what effect on norepinephrine?

Increased secretion of norepi

Decreased secretion of norepi

No effect, these receptors primarily act upon ACH

91. Which of the following drugs is a non selective beta blocker that is a pure antagonist?

Pindolol

Propanolol

Esmolol

Labetolol

92. For a patient who is taking Captopril, you would expect see a decrease in serum ______ while seeing a compensatory increase in _____.

Angiotensin I, angiotensin II

Angiotensin II, Aldosterone

Renin, Angiotensin I

Aldosterone, Renin

93. Non-selective beta blockers would be safe to give to which of the following pts?

Mr. J who came in for emergent sx following MVA and has had massive blood loss

Ms. Y who has renal failure

Mr. P who has COPD

Ms. B who has diabetes and PVD

94. You are the SRNA caring for a pt about to undergo local anesthesia, and were planning to use Rpivacaine. On their medication list you see Fluoxetine, Insulin, Cardizem and nexium. Will any of these effect your plan of care?

I will use a higher dose of Ropivacaine due to induction of P450

I will plan to use Tetracaine due to inhibition of cytochrome P450

Use ropivacaine due to inhibition of pseudocholinesterase

Use higher dose of tetracaine due to induction of pseudocholinesterase

95. You are about to perform regional anesthesia when the patient informs you they are allergic to local anesthetics. You question the patient and discover that while having some dental work done a few years back the patient experienced palpitations, anxiety, sweating and tremors after receiving Procaine. (Which coincidentally is what you were going to use today!) What is your response to this?

Realize this patient has a true allergy and switch to bupivacaine which is less likely to cause an allergy.

None of the above

96. Which of the following has the longest duration of action?

Chloroprocaine

Tetracaine

Bupivacaine

Lidocaine

97. Which of the following tissues has the highest blood flow?

Intercostal

Paracervical

Subarachnoid

Tracheal

98. What would be an appropriate dose of esmolol to give to a pt with renal insufficiency who weighs 54 kg?

27 mg IV

54 mg IV

108 mg PO

5 mg IV

99. What is the half life of labetolol?

5-8 hours

30-40 minutes

2-3 hours

12-16 hours

100. Which of the following is best to give for intra-op treatment of Pheochromocytoma?

Phenoxybenzamine 1mg/kg

Propanolol 0.05 mg/kg

Labetolol 10 mg

Phentolamine 50 mcg/kg

101. Which of the following would you give to a diabetic patient with an acute MI?

Propanol 200 mg PO

Metoprolol 25 mg IV

Atenolol 5 mg IV (over 5 min)

None of above

102. What is the most selective beta 1 blocker?

Esmolol

Atenolol

Metoprolol

Propanolol

103. What would be the max dose of chloroprocaine with epi to give to a pt weighing 32 kg?

256 mg

160 mg

320 mg

480 mg

104. What is the max dose of tetracaine plain to give to a pt weighing 70 kg?

175 mg

350 mg

105 mg

560 mg

105. What would you expect a pt to say to you as an early sign of toxicity due to accidental vascular injection during administration of spinal anesthesia? (more than one answer)

“My legs are starting to feel really numb….”

“I can’t feel my tongue anymore… weird.”

“It feels a little hard to breathe... is this normal with an epidural?”

“My ears just started ringing really bad.”

"Ow! ow! Ouch!!! What the heck are you hitting back there?"

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