2012 Pharm II Quiz 1

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

Bradycardia

Bronchospasm

Chronic Cough

Hypokalemia

2. What are the two classifications of local anesthetics?

Esters

Ethers

Amides

Carboxylic Acids

Thiols

Submit

3. 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

4. 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

5. 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

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

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

Precipitous Hypotension

Cardiac Dysrhythmias

AV Heart block

All the above

14. Can be used for pregnancy induced hypertension?

Hydralazine

Adenosine

Nipride

Nitric oxide

15. 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

16. 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

17. 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

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

Lidocaine

Chloroprocaine

Cocaine

Mepivicaine

Prilocaine

Submit

19. 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

20. 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.

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

Hydrochlorothiazide

Urea

Spironolactone

Acetazolamide

22. 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

23. 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.

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

Subcutaneous

Sciatic

Caudal

Epidural

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

Angiotensin I

Angiotensin II

Angiotensin converting enzyme

Renin

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

Lungs

Kidneys

Liver

Coronary Vessels

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

True

False

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

Lidocaine

Chloroprocaine

Cocaine

Mepivicaine

Prilocaine

Submit

29. Nitroglycerin is metabolized to what substance?

CGMP

Prusside

Nitric Oxide

Cyandie

30. Which of the following is NOT true regarding NTG?

Causes Spincter of Oddi spasms

Uses special tubing when administered

May cause headaches

Decreases left end diastolic pressure

Causes spincter of oddi relaxation

Explanation

Causes spincter of oddi relaxation

31. Which drug works through blockade of receptors in autonomic ganglia?

Hydralizine

Trimethapan

Ephedrine

Nimotop

32. How is Bupivicaine metabolized?

By hydrolysis via pseudocholinesterase

Via hepatic enzymes P450

Via proteins present within CSF

Via renal metabolism and excretion

33. You are the SRNA for Mr. Avier who has been having some problems with hypertension during surgery. He has been well controlled on a Nipride drip from the ICU that has been going 9 mcg/kg/min for an unknown amount of time. During the procedure he becomes severely hypertensive, and also develops tachycardia. You send an ABG just in case and find him to have metabolic acidosis. What should you do first?

Push Methlene blue 1-2mg/kg of 1% solution over 5 min

Stop the Nipride infusion and administer 100% O2

Give Thiosulfate 150 mg/kg over 15 min

Titrate Nipride until effective dose is reached

34. How is Procaine metabolized?

By hydrolysis via pseudocholinesterase

Via hepatic enzymes P450

Via proteins present within CSF

Via renal metabolism and excretion

35. 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

36. 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

37. Risk for toxicity is directly proportionate to potency.

True

False

38. 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

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

Degree of protein binding

Lipid Solubility

Degree of Ionization

Size of Molecule

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

Captopril

Enalapril

Losartan

Hydrochlorothiazide

41. 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

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

Hyperoxygenate, Lipid rescue

Intubate the pt and wait it out, no treatment available

Tx seizures with benzos

Give Bretylium 20 mg/kg IV

Submit

43. What is the max dose of bupivacaine with epi to give to a pt weighing 60 kg?

180 mg

150 mg

300 mg

90 mg

44. 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

45. Which of the following may cause methemoglobinemia?

Lidocaine

Prilocaine

Bupivacaine

Cocaine

46. Which of the following is NOT considered to be a safe dose of Nipride?

Bolus dose of 2 mcg/kg

Pt on IV Nipride 3 mcg/kg/min for past 12 hours

Pt on IV Nipride 11 mcg/kg/min for past 4 hours

All the above are safe doses

47. Which of the following medications would be appropriate to control autonomic hyperreflexia?

Hydralizine

Trimethapan

Sodium nitroprusside

Nimotop

48. 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

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

Hypokalemia

Metabolic Alkalosis

Skeletal muscle weakness

Hemodilution

50. You are the SRNA for Ms. Khaluri who has been somewhat hypertensive throughout her whole surgery today. Her HR is 56, and O2 sat 97%. The surgeon tells you he is starting to stitch up and will be done in about 15 minutes. You are thinking ahead and decide to give her medication to help prevent even more HTN upon emergence. What can you give now to help during emergence in minutes?

Hydroxyzine

Nipride

Nicardipine

Hydralizine

51. 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

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

Urea

Captopril

Acetazolamide

Furosemide

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

Hydrochlorothiazide

Furosemide

Triamterene

Ethacrynic Acid

54. 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

55. 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

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

Aspirin

Tylenol

Furosemide

Mannitol

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

CHF

Renal Failure

Increased ICP

COPD

58. 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

59. Which of the following is NOT true regarding sodium nitroprusside?

Avoid giving in same line as sympathomimetics

Increases stroke volume by increasing preload

Must not be exposed to light

May prevent hypoxic pulmonary vasoconstriction

60. 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

61. Metabolism of NTG to Nitric Oxide stimulates the synthesis of ______ which leads to smooth muscle relaxation.

Endothelium derived relaxing factor

Bradykinin

Prostacyclin

CGMP

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

Potassium sparing diuretics

Aldosterone Antagonists

Osmotic Diuretics

Thiazide Diuretics

63. 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

64. 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

65. 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

66. Interactions between cyanide ions and which of the following will lead to cyanide toxicity?

Thiosulfate

Methhemoglobin

B12

Cytochromoxide

67. 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

68. 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

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

0.1 mg/kg

1mg/kg

5 mg/kg

0.5 mg/kg

70. 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

71. Which of the following is NOT true regarding Adenosine?

May lead to coronary steal in pts w/ CAD

Causes AV block

Opens sodium channels to hyperpolarize nodal tissues

Antagonized by caffeine

72. 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

73. 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

74. 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?"

Submit

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

175 mg

350 mg

105 mg

560 mg