C. Resistance to the hypnotic effects of thiopental
D. Resistance to the analgesic effects of opiates
20. A woman with long-standing alcoholic cirrhosis (Child-Turcotte-Pugh B) presents to
the emergency room for chronic shortness of breath and abdominal pain. A review of
her lab findings reveal a hematocrit concentration of 36% (hemoglobin 12.4 g/dL)
with an arterial blood gas revealing a PaO2 of 65 mm Hg breathing a FIO2 of 0.5 via
face mask. Her vitals are a blood pressure of 135/60 mm Hg and a heart rate of 88
bpm. The most likely cause of her hypoxemia is
A. Intrahepatic arteriovenous shunts
B. Intrapulmonary arteriovenous shunts
21. Which of the following cardiovascular abnormalities is least likely to be present in a
patient with end-stage alcoholic cirrhosis
C. Increased peripheral vascular resistance
A 120-kg diabetic male is scheduled for emergent pinning of his mandible after a motor
vehicle accident. His wife reports that he snores loudly every night with occurrences of
breathing cessation. Medical history is also significant for hypertension controlled with a
diuretic. On physical examination, he has a large tongue and a wide neck with inadequate
mouth opening revealing a Mallampati grade 4 view. His BMI is 38 kg/m2 with a neck
22. Arterial blood gas (ABG) finding that would confirm Pickwickian syndrome is
A. pH = 7.44, PaCO2 = 44, PaO2 = 90, HCO3 = 24
B. pH = 7.35, PaCO2 = 44, PaO2 = 65, HCO3 = 26
C. pH = 7.42, PaCO2 = 36, PaO2 = 80, HCO3 = 22
D. pH = 7.37, PaCO2 = 55, PaO2 = 67, HCO3 = 28
23. The dose of thiopental required for rapid-sequence induction would be increased, as
compared with what would be required at his ideal body weight, because of changes
A. Decreased basal metabolic rate
24. A patient with chronic liver disease is scheduled for a laparoscopic abdominal
operation. The risk of mortality during surgery for this patient is assessed using
A. Mayo end-stage liver disease
25. The variable not used to calculate an MELD (model for end-stage liver disease)
score to prioritize patients for liver transplantation is
B. INR (international normalized ratio)
A 30-year-old male patient without preoperative renal dysfunction is undergoing a primary
orthotopic liver transplant (OLT) for failure due to inherited α1
26. During cross-clamping of the suprahepatic inferior vena cava (IVC), the most
accurate effect created by use of venovenous bypass (VVB) is that it
B. Prevents metabolic acidosis
27. Immediately before unclamping and reperfusion of the transplanted liver, sodium
bicarbonate and calcium chloride are administered intravenously to counteract
C. Increased systemic vascular resistance
28. At the end of the case as the drapes are taken down, diffuse microvascular bleeding
is noted in this patient who required 15 U of blood during his intraoperative course.
, prothrombin time is 18 seconds, activated partial
thromboplastin time (PTT) is 54 seconds, D-dimer is 2,000 ng/mL, and serum
fibrinogen concentration is 40 mg/dL. The most likely cause of bleeding is
A. Disseminated intravascular coagulation (DIC)
C. Depressed levels of factor VIII
29. A patient presents for preoperative evaluation for upcoming surgery. He has a
history of liver transplantation 2 years ago, otherwise feeling well. Which of the
following is most likely to be present during preoperative evaluation?
A. Elevated serum creatinine concentration
C. Prolonged partial thromboplastin time
30. Following a gastric bypass procedure, a 130-kg woman is extubated and breathing
spontaneously in the recovery room (PACU). She is breathing at a rate of 24
breaths/min on 10 L/min of oxygen via nasal cannula, and is complaining of
continued subjective dyspnea. Arterial blood gas analysis shows PaO2 = 95 mm Hg,
PaCO2 = 44 mm Hg, and pH = 7.37. The parameter most closely related to her
increased alveolar–arterial oxygen-tension gradient is
B. Decreased functional residual volume
C. Decreased expiratory reserve volume
D. Decreased respiratory drive
31. During laparoscopic cholecystectomy, the risk of failure to visualize contrast
material entering the duodenum during intraoperative cholangiogram is highest with
32. Drugs that can decrease or reduce opioid-induced biliary spasm include all of the
33. Each of the following is associated with delayed gastric emptying, except
A 33-year-old otherwise-healthy female suffering from moderately severe abdominal pain
of unclear etiology is set to undergo an exploratory laparoscopy. The abdominal cavity is
insufflated using carbon dioxide (CO2
34. All of the following are correct statements regarding pathophysiologic changes
associated with creation of the pneumoperitoneum, except
A. Increased risk of reflux and aspiration
C. Decreased systemic vascular resistance (SVR)
D. Increased intrathoracic pressures
35. Inherent risks of abdominal laparoscopy include
36. The patient is placed in a steep Trendelenburg position. Her oxygen saturation
begins to gradually decline over the course of several minutes while being ventilated
with 100% oxygen (FIO2 = 1.0). The initial step in the management of her hypoxemia
A. Add positive end–expiratory pressure (PEEP)
B. Intravenous bolus of 500 mL saline
D. Switch to pressure support ventilation
37. The exploratory surgery progresses slowly. Over the next 3 hours, her EtCO2 begins
to gradually rise, requiring increasing minute ventilation. All of the following
contribute to the degree of systemic CO2 absorption, except
B. Intra-abdominal pressures (IAP)
38. Each of the following is hemodynamic change associated with hypercarbia, except
D. Low systemic vascular resistance (SVR)
differential diagnosis for hypotension during laparoscopy, except
A. Compression of the inferior vena cava
C. Too small blood pressure cuff
40. This physical exam finding is inappropriately paired with the possible nerve injury
resulting from ill positioning during surgery:
A. Inability to evert the foot common peroneal nerve
B. Inability to stand on toes sciatic nerve
C. Difficulty climbing stairs femoral nerve injury
D. Foot drop saphenous nerve injury
41. A 50-year-old male patient is to undergo an open nephrectomy for renal carcinoma.
The patient requests an epidural for perioperative pain management, as he is strongly
intolerant to μ-agonist opiate therapy with nausea and vomiting. After a T2 sensory
level is obtained, the patient is induced with propofol 200 mg and rocuronium 70 mg,
followed by tracheal intubation. The expected response to intubation in this patient
42. A 24-year-old female status postrecent living-related renal transplant requires
chronic immunosuppression with cyclosporine and steroids to combat organ
rejection. She now presents for right-knee arthroscopic anterior cruciate ligament
repair and mentions significant history of postoperative nausea and vomiting
(PONV). The most appropriate next step in planning her anesthetic management is
A. Proceed with total IV anesthesia (TIVA), avoiding inhaled anesthetics
C. Liberally infuse intravenous fluids
D. Use metoclopramide to decrease gastric secretions
A 70-year-old 70-kg male with benign prostatic hypertrophy and difficulty with urination
presents for a transurethral resection of his 65-g prostate (TURP). His other pertinent
history includes hypertension and hyperlipidemia, both well controlled. He has a remote
history of a lumbar spinal fusion with no current lumbar symptomatology. The patient
requests a general anesthetic for the procedure and refuses spinal anesthesia.
43. Assuming the use of a hypotonic irrigant, these factors will contribute to the amount
of fluid absorbed by the patient, except
B. Hydrostatic pressure of the irrigation infusion
44. In the recovery room, he complains of bothersome localized suprapubic pain and is
requesting pain medicine. He denies pain or discomfort anywhere else. His review of
systems is negative for fevers or chills. The relatively common complication of this
procedure that should be ruled out at this time is
C. Extraperitoneal perforation
45. The patient is administered hydromorphone intravenously, and 20 minutes later is
feeling well with minimal pain complaints. At this time, his postoperative
laboratories have returned, revealing a serum sodium value of 130 mEq/L. The most
appropriate next step in the management of his hyponatremia is
C. Demeclocycline administration
D. Insulin and glucose administration
46. Effects of furosemide administration in the perioperative period include
B. Decreased risk for acute tubular necrosis
A 38-year-old woman is set to undergo extracorporeal shock wave lithotripsy to
disintegrate a painful stone trapped in her upper ureter. The patient is requesting an
epidural anesthetic and is choosing to be otherwise awake and cooperative with her
47. The step of the epidural placement that should be avoided in this patient is
B. Loss of resistance to hanging drop
D. Bolus dose of local anesthetics
48. Once the epidural is adequately placed and the patient is immersed sitting in the
water tank, the physiologic change that should be expected is
A. Decreased central venous pressure
C. Increased functional residual capacity
D. Lower extremity peripheral pooling
49. Extracorporeal shock wave lithotripsy therapy proceeds with the shock wave
synchronized with what ECG phase of the cardiac cycle?
50. Which of the following statements would be considered false with regard to
extracorporeal shock wave lithotripsy (ESWL)?
A. Delivery of the shock wave is timed to coincide with the ventricular refractory
B. Neuraxial anesthesia up to T2 sensory level is adequate
C. If able to control ventilation, use high tidal volumes and low respiratory rate
D. Removal of the patient from the bath water can be accompanied by a decrease
51. All of the following are contraindications to immersion extracorporeal shock wave
B. Abdominally placed rate-responsive cardiac pacemaker
D. Large calcified abdominal aortic aneurysm
52. Which of the following is considered the most sensitive indicator of impending
A. Decreased creatinine clearance
B. Decreased central venous pressure
C. Decreased fractional excretion of sodium
53. A 26-year-old male patient with Alport syndrome requires hemodialysis (every third
day) and presents for an arteriovenous fistula creation. His last dialysis treatment
was yesterday. Patient requests general anesthesia for this procedure. Which of the
following drugs will have a prolonged duration of action?
54. Each of the following is associated with acute tubular necrosis, except
B. Urine specific gravity <1.010
D. Fractional excretion of sodium of 4%
A 75-year-old patient who is awaiting urgent laparotomy has had oliguria for the past 12
hours since the onset of his acute abdominal pain last night. His medical history includes
well-controlled hypertension. Vital signs include a BP of 120/65 mm Hg and a HR of 72
bpm. His laboratory findings reveal
Urine sodium concentration: 15 mmol/L
Fractional excretion of sodium: 0.5%
Ratio of urine-to-plasma urea concentration: 10
55. The most appropriate treatment of his oliguria is
56. Fluid resuscitation is done with 4 L of normal saline. The potential acid–base
57. A 67-year-old patient with chronic renal failure presents for hip arthroscopy to
address and treat his labral tears and associated hip pain. The best option for opioid
1. B. The initial reduction in core temperature during general anesthesia is caused
by redistribution of heat from the core to the periphery, which can be attenuated by
increasing ambient temperature to minimize the gradient.
2. D. Perioperative morbidity related to obesity is associated with changes in
respiratory (e.g., difficult airway, decreased functional residual capacity),
cardiovascular (e.g., increased cardiac output), and gastrointestinal (e.g.,
gastroesophageal reflex disease, increased abdominal pressure) systems that will
impact the delivery of anesthesia. Given that metabolism of inhalational agents is
increased over normal weight patients, higher minimum alveolar concentrations may
be required. Atracurium (including cis-atracurium) is metabolized via Hofmann
degradation and is unaffected by the obese state.
3. B. Aspiration of acidic gastric juices poses a potential threat during induction
-blockers (e.g., cimetidine, ranitidine) can decrease gastric volume
and raise pH to a level that should be protective from fatal aspiration.
Metoclopramide promotes gastrointestinal motility without directly affecting pH
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