Principles #3

1. Why is extubating a patient in Stage II not desirable?

Increased risk of larynospasm

Too sedated

Regular BP & RR

Not Ready

2.

What portion of the spinal vertebrae are pictured in green?

Thoracic

Lumbar

Sacral

Cervical

3. What should be included in your report to the PACU nurse?

What you did

What patient did

How patient is now

All of the above

4. The aldrete score of a patient who can move all extremities, able to take deep breaths and cough, full pre-anesthetic BP level, awake, talking and normal skin color is

10

8

5

0

5.

Identify 3.

Ligamentum Flavum

Supraspinous Ligament

Intraspinous Ligament

Dura Mater

6. What should you choose for reversal of benzodiazepine sedation?

Just sit and wait, there is no way to reverse them.

Flumazenil 0.2 mg IV over 15 seconds, may give up to 1 mg.

Narcan 2mg IV

Neostigmine .08 mg/kg given with glycopyrolate

7. What is the difference when doing a spinal vs epidural?

The location of injection

Technique used

Medications used

No difference

8. During which stage of anesthesia would a patient be at increased risk for laryngospasm?

Stage 2

Stage 1

Stage 4

Stage 3

9. Optimal depth of anesthesia will maintain the BIS Number…

40-60

60-70

80-100

15-30

10. What would be the best choice for induction of a 5 yr male undergoing repair of a broken elbow?

Intravenous induction with versed and vecuronium

IM injection with induction agents

Institute the Vulcan death grip at the base of his neck.

Inhalational Induction with sevoflurane

11.

What portion of the spinal vertebrae are pictured in red?

Thoracic

Lumbar

Sacral

Cervical

12. What is the preferred positioning of the patient for administration of spinal & epidural anesthesia?

Laying supine.

Spine flexed with pt bent at the waist and bringing the chin toward the chest.

Laying prone due to ease of performing the procedure in this position.

13. On which of the following patients would you consider using rapid sequence induction?

A patient have cardiac bypass

A patient coming in for emergent open cholecystectomy

A patient with past medical history of psychiatric illness

A patient with an anticipated difficult airway

14. What is the most frequently used method of anesthesia induction in adults?

Inhalational induction

IM injection

Intravenous induction

Administration of oral agents.

15. During general anesthesia, we should try to maintain the patient at what stage of anesthesia?

Stage 4

Stage 3

Stage 2

Stage 1

16. During anesthesia what leads would be most appropriate to choose to monitor your pt for cardiac ischemia?

I & avF

II & V5

III & V3

AvL & I

17. MAC patients should be arousable.

True

False

18. The Goals of any MAC case in include all of the following except:

Maintain Safety

Alleviate pain & minimize discomfort

Keep them heavily sedated and unarousable

Amnesia & anxiolysis

19. Why are spinals inserted at a precise level in the lumbar spine?

Because 38% of the population have herniated disks

Because you have better access to CSF

Because you minimize the risk of the injuring the spinal cord

Because it minimizes the risk of having a “wet tap”

20. You are the SRNA up on the OB floor today and are in the process of giving an epidural to a 34 yr old female in labor. Where do you want to inject your anesthetic?

SubArachnoid Space

Ligamentum Flavum

Pia Mater

Epidural Space

21. General anesthesia includes all of the following except:

Paralysis

Amnesia

Awareness

Analgesia

22. What would be an appropriate induction plan for a patient with an anticipated difficult airway?

Awake intubation under topical anesthesia

Inhalational induction and plan to mask the entire case

Rapid sequence induction and having a glide scope ready

Call the MDA to intubate this patient.

23. You have just extubated Mr. Woo, and he begins to have a laryngospasm. What should you do?

Put on a non-rebreather mask with 100% O2 and wheel him to the PACU

Give 100% O2 via face mask, use the bag to apply some positive pressure, and apply jaw thrust.

Re-intubate him immediately and then extubate at a higher stage of anesthesia.

Give an albuterol treatment.

24. Where you expect the Spinal Cord to end on an adult patient?

L1-L2

L3

L5

Sacral Hiatus

25. 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.

26. You are the SRNA for Mrs. Green who is having removal of a foriegn object from the bottom of her left foot. Her past medical history includes COPD, Diabetes, and cardiac impairment. What would be the the best choice for this patient?

Peripheral nerve block

Spinal Anesthesia

Epidural anesthesia

Tell her to stop stepping on sharp rocks.

27. The main difference between conscious sedation and deep sedation is

The kind of IV hypnotics used

Type of airway used

Ability to maintain protective reflexes

Ability to return to pre-procedural state

28. Which of the following statements is false:

There are 7 pairs of cervical nerve roots

There are 12 pairs of thoracic nerve roots

There are 5 pairs of lumbar nerve roots

There are 5 pairs of sacral nerve roots

29. What would be an appropriate BIS value to maintain during maintenance of anesthesia?

100

30

70

50

30. If you were to apply a BIS monitor to yourself RIGHT NOW, what would your BIS value most likely be?

0

76

98

54

31. The critical flaws when providing a MAC case is failure to consider which of the following except?

The surgeon

The patient

The procedure

The family

32. MAC cases are easier than General cases because the patient is conscious and cooperative.

True

False

33. Why can a higher dose of local anesthetics be given when using epinephrine?

The 2 drugs counteract one another (one is more potent than the other)

Using 2 drugs minimizes risk of toxicity

Vasoconstriction effect of Epi, localizes the concentration

Vasodilation effect of the local is counteracted by Epi

34. Which of the following cases would be inappropriate for MAC anesthesia?

Cataract surgery on an 78 yr old Female

Pacemaker insertion on 56 yr old male

Bone marrow biopsy on 5 yr old female

Open hysterectomy on a 43 yr old female

35. At what level should Spinal Anesthesia be performed?

Can be performed at any level

At level of T 12

At L1

Below level of L1

36.

Identify 2.

Supraspinous Ligament

Ligamentum Flavum

Dura Mater

Interspinous Ligament

37. CVP monitoring is most frequently used...

When wide swings in BP are expected

To measure cardiac output and left venticulat end-diastolic pressures

To help in assessment of patients intravascular status

To get a unidimensional view of the myocardium.

38. The primary site of action for both spinal and epidural anesthesia is the Nerve Root.

True

False

39. You are attemtping to give spinal anesthesia, where do you want to inject your anesthetic?

Epidural Space

Pia Mater

Subarachnoid Space

Ligamantum Flavum

40. During which level of anesthesia induced depression would your patient experience an increased somatic response and be most susceptible to laryngospasms?

Depression-Excitation

Sedated-unconscious

Deep anesthesia

Minimal anesthesia

41.

What portion of the spinal vertebrae are pictured in blue?

Thoracic

Lumbar

Sacral

Cervical

42.

Identify 1.

Interspinous Ligament

Ligamentum Flavum

Supraspinous Ligament

Dura Mater

43. When using the midline technique for application of spinal anesthesia what will be the FIRST ligament your needle encounter as it passes from the skin to the subarachnoid space?

Inerspinous ligament

Supraspinous ligament

Pia Mater

Ligamentum Flavum

44. What is the primary advantage of adding epinephrine to tetracaine for spinal anesthesia?

Increased duration of spinal anesthesia.

Decrease in ICP.

Decreased risk for neurotoxicity or neurological symptoms.

Increase in spinal cord blood flow.

45. Decreasing consciousness increases safety risk.

True

False

46. You are the SRNA for Karianne, who is having her broken finger surgically repaired. The surgeon is doing a peripheral nerve block and is using bupivicaine plain during this case. Karianne weighs approximately 60 kg and the surgeon is asking what is the max dose of bupivicaine he can give to her. What do you say?

150 mg

192 mg

240 mg

Tell him to give her all he wants.... this is a fun experiment.

47. CSF is found in the:

Epidural space

Subdural space

Subarachnoid space

48. If you have a hyperbaric solution (compared to CSF) and you place your patient in a trendelenburg to minimize any vasodilating effects, you would except the block to move:

Caudad

Cephalad

No change

Posterior

49. During Stage I of Anesthesia the patient should experience all of the following except:

Sedation

Consciousness

Paralysis

Drowsiness

50. What is the max dose of Lidocaine plain?

4 mg/kg

7 mg/kg

2.5 mg/kg

3.2 mg/kg

51. 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.

52. You are asked to do a rapid sequence induction on a burn patient is mildly hyperkalemic, what muscle relaxant agent would you choose for this induction?

Succinylcholine 1.5 mg/kg

Vecuronium 0.1 mg/kg

Rocuronium 1mg/kg

Atracurium 0.5 mg/kg

53. What is the induction dose for Succinylcholine?

1 - 1.5 mg/kg

0.1-0.2 mg/kg

3-5 mg/kg

0.6-1.2 mg/kg

54. Studying for all these tests is going to cause me to have a mental snap.

True

False

55. Small controlled boluses of Propofol achieve a more consistent sedation pattern than an infusion does.

True

False

56. The meninge that adheres to the surface of the spinal cord (furtherest from the skin) is the:

Dura Mater

Subarachnoid membrane

Arachnoid membrane

Pia Mater

57. Today you are caring for Pete, a 34 yr old male with Down’s Syndrome. He has the mental capacities of a 4-5 yr old child, and on top of his mental deficiencies he is also deaf. He is not being cooperative with nurses in pre-op and seems to be confused and frightened. What is your plan for induction of this patient?

Use a ketamine dart to calm him, then start your IV and induce the pt.

Wait for him to fall asleep… then gas the hell out of him.

58. Which of the following is NOT an absolute contraindication for spinal anesthesia?

A patient with scoliosis who is on the step-down unit and currently takes medication for back pain.

A patient with hydrocephalus who is on the 4th floor neuro step-down unit with severe headaches and vision disturbances.

A. unstable trauma patient who was in a serious MVA and has had large amounts of blood loss.

59. The most commonly selected anesthetic solution for spinal anesthetic are....

Isobaric

Umm...the one that makes you numb, and yeah... something like that.

Hypobaric

Hyperbaric

60. What BIS reading would you expect to see in a patient in Stage IV anesthesia?

100

> 40

< 40

Cannot be determined

61. What is the induction dose for Versed?

1-1.5 mg/kg

0.1-0.2 mg/kg

3-5 mg/kg

0.6-1.2 mg/kg

62. Which of the following is NOT one the goals during maintenance of anesthesia? (According to handout)

To maintain stable body temperature

To maintain an adequate and normal level of stress response

To provide suitable operating conditions for the surgeon

To maintain appropriate fluid and electrolyte balances

63. What do you predict will be the effect of intubation on BIS, BP & heart rate?

Increase BP & HR, BIS may or may not increase

BIS will not change, BP and HR will increase

BIS will increase, BP and HR will stay same

BIS will increase, BP & HR will decrease

64. How would you reverse the effects of hypnotic agents?

Just sit and wait, there is no way to reverse them.

Flumazenil 0.2 mg IV over 15 seconds, may give up to 1 mg.

Narcan 2mg IV

Neostigmine .08 mg/kg given with glycopyrolate

65. At which BIS value would you see an isoelectric EEG?

0

20

30

40

66. Which of the following will cause an increase in MAC requirements?

Acute ETOH intoxication

Pregnancy

Hyperthermia

Use of benzo’s

67. After performing Spinal anesthesia you have a Sensory blockade at the level of T 8. You would expect to see a sympathetic blockade at the level of _____ and a motor blockade at the level of _____.

T6, T10

T 4, T6

T10, T6

T10, T12

68. Some indications for extubating someone deep include all of the following except?

Required to maintain surgical site

No risk for aspiration

Able to maintain own airway

To keep them asleep while transporting to PACU

69. Which of the following drugs would not be appropriate to use during a MAC case?

Nimbex

Nitrous Oxide

Versed

Fentanyl

70. Lidocaine 1% is equivalent to how many milligrams per ml?

1 mg

0.1 mg

10 mg

100 mg

71. During which stage of anesthesia would the patient experience loss of respiration and be at risk for death?

Stage 5

Stage 1

Stage 3

Stage 4

72. You are going to do a MAC case with propofol infusion on a case today. What would be the most desirable dosing regimen to maintain the patient in therapeutic rage?

Propofol 10-20mg boluses as needed

Start with propofol 2mg/kg bolus, then give 10 mg PRN as needed

Start propofl infusion 60 mcg/kg/min

Start with propofol bolus 10-20mg then start infusion of 50 mcg/kg/min

73. You have just performed spinal anesthesia and found you have a motor blockade at the level of T6. Is this safe for your patient?

No, they are at increases risk for dural puncture headache.

Yes, this is considered a safe level of sympathetic blockade.

No, the patient is at risk for profound bradycardia.

No, the level of blockade is inadequate.

74. What is the induction dose for Rocuronium?

1-1.5 mg/kg

0.1-0.2 mg/kg

3-5 mg/kg

0.6-1.2mg/kg

75. At what level should epidural anesthesia be performed?

At L1

Below level of L1

Can be performed at any level

Identify Tuffiers line an insert there.

76. Which of the following would cause an increase in ETCO2?

Cardiac Arrest

Pulmonary Embolism

Hypothermia

Hypoventilation

77. Is it possible to confirm dentirogenation? If so, How?

By monitoring the patients O2 saturation.

By looking at your ETCO2

By using a colorimetric CO2 analyzer

By observing the percent O2 present in expired gas using an O2 analyzer.

78. Which of the following will not increase the risk for awareness during surgery?

Total intravenous anesthesia

Trauma or emergency surgery

ASA status 2 or 3

Chronic Pain Patient

79. Which of the following patients is an Absolute contraindication to spinal anesthesia?

Mrs. A what has severe mitral stenosis.

Mr. B who has advanced HIV disease

Mrs. C who weighs 350 pounds.

Mr. D who suffers from chronic back pain.

80. Which of the following is an advantage of epidural anesthesia over spinal anesthesia?

Decreased risk for dural headache

Less discomfort during placement

Less time to perform

More intense sensory & motor blockade

SM 241

Explanation

SM 241

81. When properly placing a BIS monitor on a patient, where should electrode #3 be placed?

In the center of forehead, 2 inches from bridge of nose

At the patients temple, level with their eye

Directly above the patients eyebrow.

On the right side of the pts face, adjacent to electrode #1

82. Which of the following procedures CAN be performed under MAC?

Open cholecystectomy

Breast augmentation

Kyphoplasty

Spinal Fusion

83. The aldrete score is based on which of the following characteristics except?

Activity

Respiration

Circulation

Orientation

84. When properly placing a BIS monitor on a patient, where should electrode #1 be placed?

In the center of forehead, 2 inches from bridge of nose

At the patients temple, level with their eye

Directly above the patients eyebrow.

On the right side of the pts face, adjacent to electrode #2

85. You are preparing for induction of Mr. Optimus Prime. He is 6’0” and weighs 100 kg. Pick the option below which gives you a proper induction dose for Optimus Prime.

Propofol 100 mg Sux 10 mg

Etomidate 20 mg Vec 100 mg

Propofol 200mg Vec 10 mg

Etomidate 200 mg Sux 150 mg

86. You are caring for Fat Albert today who has a past history of hypothyroidism. He is having a gastric bypass today. Considering the history of thyroid gland dysfunction, how will this affect your MAC requirements?

Increase MAC

Decrease MAC

I’m just glad Fat Albert is finally seeking help.

Nothing, thyroid dysfunction does not affect MAC.

87. You have just performed spinal anesthesia and found you have a sympathetic blockade at the level of T6. Is this safe for your patient?

No, they are at increases risk for dural puncture headache.

Yes, this is considered a safe level of sympathetic blockade.

No, the patient is at risk for profound bradycardia.

No, the level of blockade is inadequate.

88. Which of the following local anesthetics would be the best choice for a procedure requiring spinal anesthesia of long duration?

Lidocaine

Chloroprocaine

Tetracaine

Cocaine

89. The induction dose of Propofol is?

1 mg/kg

4 mg/kg

2mg/kg

2.5-3.5mg/kg

90. What is the max dose of Bupivicaine with Epi?

4 mg/kg

7 mg/kg

2.5 mg/kg

3.2 mg/kg

2.5mg/kg without epi

Explanation

2.5mg/kg without epi

91. When would you consider using the 'loss of resistance' technique?

When performing spinal anesthesia to assess when you have entered the subarachnoide space.

This is another name for midline approach which can be used for both spinal and epidural anesthesia.

When performing epidural anesthesia to assess when you have entered the epidural space.

92. According to lecture, the 3 faces of MAC are all of the following except…

Sedation & Block

Local & Sedation

Sedation Only

Sedation, Local & Block

93. The cauda equina is formed by the:

The roots of the lower lumbar, sacral and coccygeal nerves

The roots of the upper lumbar and cervical

All of the spinal roots: cervical, lumbar, sacral and coccygeal

The roots of the sacral and coccygeal only

94. What is the duration of action for lidocaine when used as a spinal anesthetic?

30-60 minutes

60-90 minutes

120- 150 minutes

10-20 minutes

95. Which of the following is one of the MOST important factors that will affect the level of spinal anesthesia?

Age of pt

Curvature of pts spine

Patients Height

Baricity of Solution

also dose and patient position

Explanation

also dose and patient position

96. Which of the following would NOT be respiratory sign that your anesthesia is too light in a patient with controlled ventilation?

Onset of respiratory efforts

Changes in peak inspiratory pressure

Appearance of an end inspiratory pause

Increase in ETCO2

97. Which needle would have the lowest risk of post-dural headache?

24 gauge bevelled tip needle

20 gauge bevelled tip needle

24 gauge pencil point needle

20 gauge pencil point needle

98. Factors that affect Fa (alveolar) include all of the following except :

Concentration

Ventilation

Uptake

Distribution

99. During induction, the level of anesthesia-induced depression which is most dangerous to the patient is…

Sedated-unconscious

Light Anesthesia

Minimal Anesthesia

Depression- Excitation

100. The benefits of using BIS monitoring do NOT include which of the following?

Reduction in use of anesthetic agent

Reduction of tourniquet time

Decreased emergence time

Decrease in post-op nausea and vomiting

101. Factors that affect Uptake include all of the following except:

Blood solubility

Cardiac Output

Partial Pressure Gradient

Hyperventilation

102. The aldrete score of a patient who is unable to move any extremities, limited breathing, BP >50 mm Hg from preanesthetic level, pale skin tone, Sats 95% on 3L O2, and arousable is...

7

5

3

1

103. Which of the following BEST describes the BIS number?

A single number derived from EG recording using a single signal processing technique, updated every 15 seconds.

Multiple numbers derived from multiple EEG recordings updated every minute

104. How will administration of methylene blue affect pulse oxymetry?

Falsely elevate readings

Falsely decrease readings

Will not be affected.

105. The aldrete score of a patient who can move 2 extremities, able to deep breathe, BP < 20% preanesthetic level, arousable and maintains normal skin color.

10

8

6

4

106. You are looking at pressure readings on your vent because you are having to use your tank nitrous oxide. Ten minutes ago the pressure read 750, but now the pressure has just started to decrease. According to our handouts how much volume (approximately) should be left in the tank?

215 L

1590 L

795 L

530 L

107. You are caring for Ms. UglyFoot who is in the OR today having a bunionectomy. She has a local block on her foot and the surgeon is asking you what is the maximum dose of Lidocaine (mixed with epi) that he can give to this patient. Ms. Ugly foot is 5’0”, weighs 50kg, is an ASA 2 patient with past medical history of HTN & DM. The physician asks for 25cc of 1% Lidocaine mixed with Epi 1:100,000. What do you do?

Question the MD, that's too much Lido

Question the MD, that's too much Epi

Question the MD, we don't mix Lido and Epi

Nothing

max lido mixed w/ epi is 7mg/kg or 350mg, 1% Lido is 10mg/ml x 25mL is 250mg, well below the max dose.

Explanation

max lido mixed w/ epi is 7mg/kg or 350mg, 1% Lido is 10mg/ml x 25mL is 250mg, well below the max dose.

108. You are performing an epidural on a patient in labor, would you expect this to change your dose of anesthetic used?

Nope, amount of anesthetic used will stay the same.

You will require more anesthetic to reach the desired effect.

This is a contraindication to epidural anesthesia, I would not do the block.

I would expect to use less anesthetic.

109. According to lecture, why are inhalation anesthetics potentially the most dangerous drugs administered in anesthesia?

Due to lipid solubility

Due to unpredictability

Due to their potency

Due to steep dose response curve

110. When using the paramedian technique for application of spinal anesthesia what will be the first ligament your needle encounter as it progresses from the skin toward the subarachnoid space?

Supraspinous ligament

Interspinous ligamant

Ligamentum Flavum

Pia Mater

111. Which of the following is an advantage of spinal anesthesia over epidural anesthesia?

Decrease risk of dural headache

Requires less local anesthetic

Lower incidence of hypotension

Greater control over intensity of block achieved.

SM 241

Explanation

SM 241

112. You are the SRNA for a 4 yr old female. Where would you expect her spinal cord would end?

L1

L5

L3

L2

113. During emergence, the patient will typically become responsive and open their eyes above what BIS level?

60

80

70

100

114. You are giving lidocaine IV prior to administration of propfol on a very small patient who only weighs 30 kg. What is the max dose of lidocane that you could give this patient IV?

30 mg

210 mg

120 mg

300 mg

115. You are the SRNA for a pt undergoing a minor procedure today. Your preceptor asks you which level of anesthesia induced depression your pt is currently in. You take note that the pt currently has minimal response to stimuli, has depressed respiration that can increase with stimuli, and only a slight cardiac response to major stimuli. Which level is this pt in?

Deep Anesthesia

Light Anesthesia

Minimal Anesthesia

Sedated- unconscious

116. During maintenance of anesthesia, where should your arterial BP and heart rate be?

Maintained at basal levels

Within 20% of basal levels

Within 10% of basal levels

Slightly more than basal levels.

117. When performing an epidural on a patient whose ligamentum flavum is not fused, this may result in?

Dural Headache

Spinal that works better on one side than other

Uncal Herniation

‘Popping’ upon insertion of epidural needle

118. The posterior or dorsal root ganglion contains:

Efferent neurons

Dendrites of motor neurons

Afferent neurons

Axons of sensory neurons

119. What is the Aldrete score for an anesthetized patient, who is paralyzed. This patients Blood pressure is within 15 mm of baseline BP. The skin is warm, dry, and has a normal color to it.

4

6

0

2

120. Which of the following decreases MAC? (more than one answer)

Hyperthermia

Chronic ETOH

Opioids

Pregnancy

Submit

121. Which of the following drugs would you be MOST cautious about when performing a MAC case?

Propofol

Morphine

Valium

Sevoflurane

122. All of the following are factors that affect the level of spinal anesthesia except:

Patient weight

Patient height

Pregnancy

Site of injection

123. Induction of anesthesia is characterized by…. (two answers)

Rapid Loss of consciousness

Production of paralysis

Progression to a light surgical plane of anesthesia

Progression to a deep surgical plane of anesthesia

Submit

124. Diastolic BP is usually lower with automated devices than with direct arterial measurement.

True

False

125. When giving spinal anesthesia it is considered ________ to add epinephrine to the lidocaine. When giving epidural anesthesia it is considered ________ to add epinephrine to the lidocaine.

Unsafe, Safe

Unsafe, Unsafe

Safe, Unsafe

Safe, Safe