70. A 42-year-old patient is scheduled for a hernia repair under general anesthesia. His
medications include fluoxetine, alprazolam, and lithium for bipolar disorder. In the
preoperative area, he appears confused, has tremors, and is ataxic. Your next step
C. Order a lithium blood level
71. A 34-year-old patient is to undergo an appendectomy under general anesthesia. He
is taking a monoamine oxidase inhibitor (MAOI) for depression. Intraoperatively, his
blood pressure drops to 72/36 mm Hg and a medication is administered. His blood
pressure suddenly increases to 220/120 mm Hg. The most likely medicine that was
72. All of the following are true about diabetic patients, except
A. Patients should take half or one-third of their insulin dose the morning of the
B. Patients should continue their oral hypoglycemic agents the morning of the
C. Finger-stick blood glucose should be tested before taking the patient to the
D. Patient with an insulin pump should continue the insulin at their basal rate
73. Digoxin toxicity is most likely exacerbated by
74. The most common complication of inserting a central venous catheter is
75. A patient is administered cephalexin preoperatively. Within 5 minutes of starting the
antibiotic, the patient starts to wheeze and develops tachycardia, and the blood
pressure drops to 78/42 mm Hg. Your next step would be to administer
76. All of the following may occur with an interscalene block, except
77. An axillary nerve block would not produce loss of sensation of the
A. Lateral aspect of the forearm
B. Medial aspect of the forearm
A. Medial to the femoral artery
B. Anterior to the femoral artery
C. Posterior to the femoral artery
D. Lateral to the femoral artery
79. All of the following nerves are blocked by an ankle block, except
A. More common after using an endotracheal tube
B. More common after using a laryngeal mask airway
C. Similar incidence with either endotracheal tube or a laryngeal mask airway
D. More common after using an oral airway
81. A patient with hypertrophic obstructive cardiomyopathy (HOCM) presents with
dyspnea and angina on exertion. Which of the following is the best agent to treat
82. St. John wort (Hypericum perforatum) potentiates the effects of
83. The most powerful predictor of atrial fibrillation post–cardiac surgery is
84. A patient with Parkinson disease undergoes a general anesthetic. Your plan to treat
his nausea would include all of the following, except
85. A 65-year-old patient is being treated for congestive cardiac failure. He is able to
take a shower but gets dyspneic on mowing the lawn. His New York Heart
86. The percentage of postdural puncture headaches that would resolve spontaneously
87. A 46-year-old lady is seen at the preoperative assessment clinic. She is taking 180
mg/day methadone. The most likely change to be found in her preoperative ECG is
88. You are about to anesthetize a 55-year-old man who is undergoing liver resection for
removal of metastatic carcinoid tumor. The drug of choice to treat intraoperative
89. You are performing an interscalene brachial plexus block on an awake 40-year-old
patient who is healthy with no significant medical history. Soon after injecting 20 mL
of 0.25% bupivacaine the patient becomes agitated, has a seizure, and loses
consciousness. Your first step in management is
B. Administer midazolam or propofol to control the seizure
C. Establish airway and give 100% O2 via a face mask
90. Patients with dilated cardiomyopathy exhibit all of the following, except
A. Decreased myocardial contractility
B. Afterload should be maximized
D. Left ventricular hypertrophy
91. A septic patient has a central venous pressure of 10 mm Hg, a blood pressure of
80/40 mm Hg, and a pulse rate of 96 beats/min. The best agent to treat the
92. Which of the following organs is least tolerant of ischemia for removal for
93. You have administered a patient 1.2 mg/kg of rocuronium to do an intubation. You
are unable to intubate or ventilate the patient and decide to reverse the patient’s
paralysis with sugammadex. The dosage you would use is
94. A young female patient with anorexia nervosa has just started eating again. After 4
days, she develops dyspnea and is found to have cardiac failure. Which of the
following is most important to correct?
95. A pregnant lady is to undergo general anesthesia for acute appendicitis. At what
gestational age should you monitor fetal heart rate?
96. Which of the following is the best predictor of a difficult intubation in a morbidly
97. A patient with a history of chronic obstructive pulmonary disease presents for lung
volume–reduction surgery. Which of the following is a contraindication for surgery?
D. Evidence of bullous disease
98. All of the following help increase the excretion of calcium, except
99. Which of the following is contraindicated to use during pregnancy?
100. During scoliosis surgery, monitoring of somatosensory-evoked potentials indicates
B. Anterior corticospinal tract
101. The desflurane vaporizer is heated because of desflurane’s
C. High minimum alveolar concentration
102. Which of the following is the most effective way to reduce renal failure in a patient
having an abdominal aortic aneurysm repair?
A. Fluid bolus prior to aortic clamping
B. Fluid bolus after aortic clamp release
D. Minimization of cross-clamp time
1. D. Scopolamine, an anticholinergic drug, is often applied as a transdermal patch
preoperatively for the prevention of postoperative nausea and vomiting. However,
like atropine, and unlike glycopyrrolate, scopolamine passes through the blood–brain
barrier and can cause confusion, especially in the elderly. Hence, application of
2. D. Metoclopramide is a prokinetic agent and helps to increase gastric motility. The
ASA does not recommend preoperative administration of metoclopramide for
prevention of postoperative nausea and vomiting. All the other agents have proven
benefit in preventing postoperative nausea and vomiting.
3. B. Famotidine is known to cause thrombocytopenia (both quantitative and
qualitative platelet dysfunction). Patients with ITP already have low platelets; thus,
such premedication should be avoided. Warfarin does not affect platelet function or
number, thus has no relation to perioperative bleeding due to platelet pathology;
however, it is an independent risk factor for bleeding.
receptor antagonist that antagonizes the action of
substance P in the central nervous system to prevent nausea and vomiting.
Palonosetron is a 5-HT3 antagonist, metoclopramide is an antidopaminergic agent,
and prochlorperazine is a dopamine (D2
) receptor antagonist (antipsychotic drug)
with additional antiemetic activity.
5. C. The Apfel score can be used to predict patients with a high risk for
perioperative nausea and vomiting (PONV). It includes four factors: female gender,
nonsmoking, postoperative use of opioids, and previous PONV or motion sickness in
the patients’ history. Surgeries like laparoscopy, middle-ear surgery, and strabismus
surgery are associated with a higher risk of PONV.
6. C. Etomidate administration can cause an increase in the incidence of perioperative
nausea and vomiting (PONV). Promethazine, haloperidol, and propofol all are used in
the treatment of PONV. The latter two are usually used for the treatment of
7. C. β-Lactam antibiotics must be given within 60 minutes prior to incision.
Vancomycin and fluoroquinolones require administration within 120 minutes prior to
8. D. Vancomycin and fluoroquinolones require administration within 120 minutes
prior to incision. β-Lactam antibiotics must be given within 60 minutes prior to
9. D. Effort tolerance of around 4 METs (metabolic equivalent of tasks) or more is
suggested to be a good predictor for postoperative cardiopulmonary outcome. These
activities are classified as per physical strain involved.
10. C. One metabolic equivalent is defined as the amount of oxygen consumed at rest,
/kg/min. The energy cost of any activity can be determined
by multiplying 3.5 to the oxygen consumption (mL O2
• 1 MET—can take care of self (eating, dressing, toilet)
• 4 METs—can walk up a flight of steps or a hill
• 4 to 10 METs—can do heavy household work (scrubbing floors, lifting heavy
• >10 METs—can participate in strenuous sports (swimming, tennis, basketball,
11. B. As per ASRA guidelines 2010, heparin infusion should be stopped at least 2 to
4 hours before placing an epidural. This is to prevent the potential formation of an
12. A. As per the AHA/ACC Scientific Statement, reversal of warfarin can be
achieved by using all, except choice D. However, for emergent surgery the fastest
method is the administration of fresh-frozen plasma. Peak action of injectable vitamin
13. C. As per ASRA guidelines (2010), aspirin intake by the patient is no more
considered as a contraindication to performing a neuraxial block.
14. D. The assessment of preoperative predictability for obstructive sleep apnea can
be done by using the “STOP-BANG” questionnaire. In this scoring, male gender, and
not female gender, is classified as a risk factor (S, snoring; T, tired during daytime;
O, observed for apnea during sleep; P, high blood pressure; B, BMI >35 kg/m2
age >50 years; N, neck circumference >40 cm; G, male gender). In addition to the
questionnaire, upper airway anatomical abnormalities that increase the likelihood of
obstruction are tonsillar hypertrophy, tumors of the upper airway, or facio maxillary
15. D. All, except choice D, are signs of diabetic autonomic neuropathy. Urinary
retention at this age is more likely due to prostate hypertrophy.
16. B. Weight loss due to dialysis is attributed to actual volume (ultrafiltrate) removed
from the body. Thus, a high weight loss can predict higher circulatory volume lost,
which can lead to poor compensation of hypotension in patients undergoing surgery.
17. A. Ketamine causes the least respiratory depression among the intravenous
induction agents. Therefore, it may be beneficial as an induction agent in patients
with severe asthma. However, ketamine causes an increase in secretions, and may
produce emergence delirium (vivid dreams). Pretreatment with glycopyrrolate and
midazolam alleviates these effects of ketamine. The other induction agents cause
dose-dependent respiratory depression.
18. B. Droperidol can cause a significant prolongation of the QT interval on the ECG.
Patients should have a preoperative ECG, and ECG monitoring should be continued
postoperatively for at least 2 hours, before discharging the patient.
19. D. At present, no conventional test (PT, PTT) can be used to quantify the clinical
effects of LMWH on the coagulation system. Anti–Factor Xa estimation may be used
in specific patients to monitor the coagulative effects of LMWH.
20. B. As these drugs act on different receptors, their effects are generally considered
to be synergistic. Patients receiving both these drugs may be prone to greater
sedation and respiratory depression than when receiving the drug alone.
21. D. Preoperative evaluation in fact includes a battery of tests and adds additional
costs to the total perioperative costs. However, preoperative evaluation is vital, as it
recognizes patient comorbidities, which can worsen perioperatively and cause
increased patient morbidity. Preoperative evaluation eventually lowers indirect costs
that may be incurred to treat the worsening aliment, postoperatively. During
preoperative interaction, patient anxiety is usually lowered as the risks and procedure
22. B. An anesthesia consent should be obtained during preanesthetic evaluation,
whenever possible. This is one of the prime aims that need to be fulfilled as a
component of preoperative anesthetic evaluation.
23. D. The goals of preanesthetic evaluation include all those listed in the question. In
addition, other targets of preanesthetic evaluation include education of patients and
families about anesthesia and the anesthesiologist’s role, obtaining informed consent,
motivation of patients to stop smoking and lose weight, or commit to other preventive
24. D. ASA classification does not include the nature of procedure in predicting
perioperative morbidity and mortality. It only includes patient-based morbidity rather
25. B. Healthy pregnant patients in labor are classified as an ASA II. Patients with
controlled diabetes or essential hypertension are still classified as an ASA II.
Presence of preeclampsia will step up the classification to an ASA III.
26. C. Sedatives typically alleviate anxiety in hypertensive patients (preventing blood
pressure elevations due to surgery-related anxiety), in patients with chronic alcohol
abuse, and in children to maintain cooperation for induction of anesthesia. In
neurosurgical patients, sedatives can lead to depression of respiratory drive, which
can cause hypercarbia and an increase in intracranial pressure.
27. A. As per ASRA guidelines, warfarin must be stopped at least 5 days prior and
clopidogrel 7 to 10 days prior to elective surgery. Low-molecular-weight heparin in
therapeutic doses must be stopped at least 24 hours prior, and when being used in
prophylactic doses, it must be stopped at least 12 hours prior to an elective surgery
requiring central neuraxial blockade. Aspirin use is no more considered as a
contraindication to performing a neuraxial block.
28. B. ASA classifies any medical comorbidity without functional limitation (i.e.,
hypertensive without coronary artery disease or angina) as an ASA II. Once the
patient’s activity is limited due to the disease, the patient is then categorized as an
29. D. By definition, such patients are categorized as ASA Class VI.
30. C. By definition, these patients require surgery despite being really sick. Most
often, the surgical correction of the underlying pathology (that may have led to
multiorgan involvement) may be the only option of improving their chances of
survival. A hemodynamically unstable patient secondary to perforation peritonitis,
with an acute kidney injury, would be an example. Although the patient may be
extremely sick, until the perforation peritonitis is surgically treated, the chances of
31. B. ASA III is a patient with severe systemic disease that is a constant threat to life
(functionality incapacitated).
32. C. Warfarin should be stopped at least 5 days prior to surgery. On the day of the
surgery, the prothrombin time (international normalized ratio or INR) is checked. An
INR of 1.4 or less is desirable to perform the surgery.
33. A. Before any rate/rhythm control in patients likely to have AF for more than 48
hours, left-atrial clots must be ruled out. An undiagnosed clot can lead to
catastrophic embolic consequences.
34. D. For a drug-eluting stent, it is advised to avoid elective surgery for a year (to
continue dual antiplatelet medication), and for a bare-metallic stent, it is advised to
avoid elective surgery for about 4 weeks. Performing laparoscopic surgery post–
CABG surgery is highly risky. So when surgery needs to be planned in the near
future, the patient should be advised to undergo balloon dilatation and then delay the
elective procedure for 2 to 3 weeks thereafter.
35. C. Renal failure can induce platelet dysfunction, and therefore, central neuraxial
blockade is still debated in these patients. They also have coagulation factor
abnormalities that may predispose them to deep vein thrombosis. Anemia is a result
of decreased erythropoietin production and is often labeled as “anemia of chronic
