DIRECTIONS FOR ITEMS 1-100: For each item, select the best answer to the question or response to complete the statement from the four provided.
1. Computed tomography (CT) scan evidence of which of the following in the preoperative period is MOST likely to be associated with intraoperative complications in an adult with an anterior mediastinal mass?
2.
(A) Tracheal compression
(B) Atelectasis
(C) Pericardial effusion
(D) Superior vena caval obstruction
While providing anesthesia for laser surgery on the airway, the F
IO2
is maintained at 0.40 by using a diluent gas. Use of which of the following gases is associated with the
GREATEST risk of airway fire?
3.
4.
5.
(A) Nitrogen
(B) Nitrous oxide
(C) Helium
(D) Air
A child with cerebral palsy is MOST likely to require an increased dose of which of the following drugs to achieve a standard pharmacologic effect?
(A) Succinylcholine
(B) Nondepolarizing muscle relaxants
(C) Volatile anesthetic agents
(D) Opioids
Administration of which of the following local anesthetics is MOST likely associated with the development of methemoglobinemia?
(A) Tetracaine
(B) Lidocaine
(C) 2-Chloroprocaine
(D) Mepivacaine
Which of the following individuals is MOST likely to have a normal response to latex sensitivity testing?
(A) A 6-year-old with myelomeningocele
(B) A 45-year-old registered nurse who has worked in the operating room for 15 years
(C) A 28-year-old man with a horseshoe kidney
(D) A 32-year-old woman who has been paraplegic for 7 years
1

6.
7.
8.
In a patient presenting to the emergency department with a thermal injury, which of the following is MOST likely an early indication of inhalation injury’?
(A) Carboxyhemoglobin concentration of 5%
(B) Abnormal chest radiograph
(C) Singed hair in nasal passages
(D) Partial pressure of carbon dioxide in arterial blood (Pa
CO2
) of 45 mm Hg
Which of the following fetal heart rate patterns is MOST likely to occur as a result of compression of the fetal head during contractions?
(A) Early decelerations
(B) Late decelerations
(C) Variable decelerations
(D) Loss of variability in fetal heart rate
Which of the following is MOST likely a risk factor for infectious complications of a continuous peripheral nerve block (CPNB) used for analgesia?
(A) Age greater than 65 years
(B) Tunneling of the catheter
(C) Cancer
(D) Axillary location of the catheter
9. A 45-year-old man has gradual onset of pain distributed along the L5 dermatome. There is no history of injury. On physical examination, no skin changes or sensorimotor disturbances in the lower extremities are noted. Which of the following BEST describes this type of pain?
(A) Complex regional pain syndrome I (reflex sympathetic dystrophy)
(B) Complex regional pain syndrome II (causalgia)
(C) Hyperalgesia
(D) Neuralgia
10. A patient has complaints of pain in the medial aspect of the arm and forearm radiating into the little and ring fingers. She has normal reflexes but decreased strength in the intrinsic muscles of the hand. This MOST likely indicates a lesion of which cervical nerve root?
(A) C5
(B) C6
(C) C7
(D) C8
2

11. Which of the following is MOST likely to be decreased in a parturient at term gestation?
(A) Threshold for dysrhythmias
(B) Ejection fraction
(C) Left ventricular wall thickness
(D) Diameter of mitral valve annulus
12. A 26-year-old woman at 32 weeks gestation presents to the labor and delivery suite complaining of palpitations and irregular uterine contractions. An electrocardiogram shows paroxysmal supraventricular tachycardia (PSVT) with a rate of 170 beats/min.
Her blood pressure is 85/45 mm Hg. There are late decelerations present on the fetal heart tracing. Which statement about the management of this patient is MOST likely true?
(A) Emergency cesarean delivery should be performed.
(B) Intravenous adenosine should be administered.
(C) Direct current cardioversion is contraindicated in pregnancy.
(D) Intravenous esmolol is the treatment of choice.
13. Which statement about the posterior approach to the popliteal block is MOST likely true?
(A) Stimulation of the tibial nerve results in inversion of the foot.
(B) The common peroneal nerve arises above the popliteal fossa in 90% of patients.
(C) A successful block will provide complete anesthesia to the foot and ankle.
(D) Usually 5 mL of local anesthetic is sufficient to provide adequate anesthesia.
14. Which of the following respiratory parameters is MOST likely to decrease with normal aging in adults?
(A) Residual volume
(B) Closing volume
(C) Vital capacity
(D) Difference between alveolar and arterial partial pressure of oxygen (DA-aO
2
)
15. A 35-year-old parturient at 37 weeks gestation is receiving epidural analgesia for labor.
She has moderate mitral stenosis. Her blood pressure is 87/42 mm Hg and her heart rate is 85 beats/min after receiving an epidural bolus of 0.2% ropivacaine for increased pain.
Late fetal heart rate decelerations are noted. Which of the following medications is
MOST appropriate for treatment of her hypotension?
(A) Ephedrine
(B) Epinephrine
(C) Vasopressin
(D) Phenylephrine
3

16. The administration of which of the following is MOST likely to result in a spuriously high oxygenation saturation (SP
O2
) value as reported by pulse oximetry?
(A) Desflurane
(B) Benzocaine
(C) Metoclopramide
(D) Indigo carmine
17. Which of the following complications is MOST likely to occur in a patient undergoing transurethral resection of the prostate using glycine irrigation?
(A) Permanent blindness
(B) Agitation
(C) Hypernatremia
(D) Hyperammonemia
18. Which statement about the response to carbon dioxide in awake and anesthetized patients is MOST likely true?
(A) In awake, spontaneously breathing patients, minute ventilation is poorly responsive to changes in arterial carbon dioxide tension (Pa
CO2
).
(B) In spontaneously breathing patients peripheral chemoreceptors are the main determinants of alterations in ventilation produced by changes in Pa
CO2
.
(C) In patients anesthetized with volatile anesthetics, there is a dose-dependent increase in the responsiveness of minute ventilation to changes in the Pa
CO2
.
(D) In patients anesthetized with volatile anesthetics, the apneic threshold for Pa
CO2 is generally 5 mm Hg lower than the Pa
CO2
during spontaneous ventilation.
19. A 28-year-old man presents for repair of an eye injury sustained in an altercation. He appears intoxicated and admits to heavy alcohol ingestion throughout the evening. The ophthalmologist requests that increases in intraocular pressure (IOP) be avoided. Which statement about the anesthetic management of this patient is MOST likely true?
(A) Succinylcholine is contraindicated.
(B) Ketamine is the preferred agent for induction of general anesthesia.
(C) Remifentanil can prevent an increase in IOP during intubation.
(D) Premedication with benzodiazepines will result in an increase in IOP.
20. Which statement about radiation exposure during procedures performed under fluoroscopy is MOST likely true?
(A) The position of the source has no impact on the magnitude of the exposure.
(B) Exposure is determined by the square of the distance from the source.
(C) If working close to the patient during lateral projection, standing on the same side as the x-ray tube (source) will minimize exposure.
(D) Lead shielding (eg, aprons, thyroid shields) reliably eliminates exposure.
4

21. A 1-year-old boy with uncorrected tetralogy of Fallot presents with an incarcerated hernia for an emergency herniorrhaphy. During the procedure, the oxygen saturation decreases from 83% to 65%. The heart rate is 80 beats/min and blood pressure 65/32 mm Hg.
Which of the following is the BEST initial pharmacologic management?
(A) Epinephrine
(B) Nitroglycerin
(C) Phenylephrine
(D) Atropine
22. A 72-year-old man presents to the emergency department with an episode of severe paroxysmal lancinating pain into the right jaw. He reports he had several similar episodes
6 months ago that resolved spontaneously. He notes that touching his right lower lip immediately provokes such a paroxysm, despite a normal appearance of the mucosa in the area. Which of the following statements is MOST likely true’?
(A) This condition is the result of compression of the facial nerve.
(B) Paroxysms of pain with tactile stimulation of trigger areas are characteristic of trigeminal neuralgia (tic douloureux).
(C) Carbamazepine is the only effective pharmacological treatment for this condition.
(D) Taste sensation on the anterior two thirds of the ipsilateral tongue is likely to be impaired.
23. Which statement about pheochromocytoma is MOST likely true?
(A) Hypoglycemia is a common presentation.
(B) Most tumors are bilateral.
(C) Diagnosis is made by administration of radiolabeled albumin.
D) Biochemical testing establishes the diagnosis in more than 90% of cases.
24. Which of the following parameters derived from measurements obtained from a correctly positioned pulmonary artery catheter is represented by the following equation?
(mean arterial pressure — central venous pressure) x 80 cardiac index
(A) Systemic vascular resistance index
(B) Pulmonary vascular resistance index
(C) Left ventricular stroke work index
(D) Right ventricular stroke work index
5

25. Which of the following BEST characterizes the vascular response to ephedrine in a pregnant versus a nonpregnant woman?
(A) Ephedrine-induced uterine artery dilation in a pregnant woman is secondary to greater production of nitric oxide by the vascular endothelium.
(B) Ephedrine administration leads to uterine artery dilation in a nonpregnant woman.
(C) Ephedrine administration produces no change in the diameter of peripheral arteries in a pregnant woman.
(D) Ephedrine constricts peripheral arteries to a greater degree than uterine arteries in a nonpregnant woman.
26. Which of the following congenital heart lesions is MOST likely to cause a decrease in the rate of an inhalational induction of anesthesia?
(A) Ventricular septal defect
(B) Transposition of the great arteries
(C) Patent ductus arteriosus
(D) Critical aortic stenosis
27. Which statement about dexmedetomidine is MOST likely true?
(A) It is less selective for alpha
2 receptors than is clonidine.
(B) Renal insufficiency is associated with a prolonged duration of action.
(C) It is metabolized by plasma cholinesterase.
(D) The context-sensitive half-time is affected by the duration of administration.
28. Which of the following transfusion strategies is MOST likely to reduce the risk of a nonhemolytic febrile transfusion reaction?
(A) Administration of packed red blood cells (PRBCs) collected using a leukocyte reduction filter
(B) Administration of fresh whole blood (less than 24 hours old)
(C) Administration of cytomegalovirus (CMV)-negative PRBCs
(D) Use of a blood warmer
29. Which of the following Mapleson circuits MOST likely requires the lowest fresh gas flow to prevent rebreathing during spontaneous ventilation?
(A) Mapleson A
(B) Mapleson B
(C) Mapleson D (Bain circuit)
(D) Mapleson F (Rees T-piece)
6

30. Which of the following factors is associated with the HIGHEST risk of stroke in a patient with atrial fibrillation?
(A) Hypertension
(B) Diabetes
(C) Patient age less than 60 years
(D) History of prior transient ischemic attack (TIA)
31. Which statement about the alveolar to arterial gradient for oxygen (A-a gradient) is
MOST likely true?
(A) It increases at high altitude.
(B) It is normal in right-to-left intracardiac shunt.
(C) It increases in the presence of low ventilation:perfusion ratio.
(D) It increases with hypercarbia.
32. A 43-year-old woman with multiple sclerosis (MS) presents for a knee arthroscopy.
Which statement about the perioperative considerations for this patient is MOST likely true?
(A)
Core temperature should be maintained above 37°C.
(B) MS is associated with an increased risk of malignant hyperthermia.
(C) Rapid sequence intubation with succinylcholine is the preferred technique.
(D) The patient may experience an exacerbation regardless of anesthetic technique.
33. Which of the following is MOST likely to be associated with a high level of sympathetic response in the period prior to cardiopulmonary bypass (CPB)?
(A) Harvesting of the radial artery
(B) Sternotomy
(C) Dissection of the internal mammary artery
(D) Placement of the venous CPB cannula
7

34. You are called to intubate a patient with normal body habitus who was an unrestrained driver in a motor vehicle collision and sustained multiple injuries, including possible cervical spine injury. The patient is unconscious and has an oxygen saturation of 75% during bag-mask ventilation with 100% oxygen. Which statement about the immediate management of this patient is MOST likely true?
(A) Securing the airway prior to any radiographic spine studies would be appropriate.
(B) A lateral cross-table radiograph is the most sensitive test for a cervical spine injury.
(C) A complete 3-view cervical spine series should be obtained prior to any attempt to intubate.
(D) The presence of a cervical collar has been shown to significantly reduce cervical spine movement during intubation.
35. An 80-kg man is undergoing an open appendectomy under general anesthesia with 2% sevoflurane in 1 L/min air and 1 L/min oxygen. The ventilator settings are: tidal volume
700 mL, respiratory rate 12 breaths/min. His capnogram indicates that the inspired carbon dioxide (CO
2
) is 14 mm Hg and the end-tidal CO
2
(P
ETCO2
) is 56 mm Hg. The capnogram appears normal except for the elevated inspired CO
2
. Which of the following is the
MOST effective strategy to decrease the P
ETCO2
?
(A) Administer dantrolene
(B) Administer albuterol
(C) Add 10 cm H
2
O of positive end-expiratory pressure (PEEP)
(D) Increase the fresh gas flow
36. Which of the following laboratory values is MOST consistent with prerenal oliguria?
(A) Urine specific gravity less than 1.005
(B) Urine sodium more than 50 mEq/L
(C) Urine osmolarity less than 200 mOsm/kg
(D) Fractional excretion of sodium less than 1%
37. A 54-year-old woman with liver disease is scheduled for an elective cholecystectomy. On laboratory evaluation, her serum albumin is 4.0 mg/dL, international normalized ratio
(INR) is 2.1, total bilirubin is 3.2 mg/dL, and a room air oxygen saturation is 86%. On examination she has mild ascites and no apparent encephalopathy. Which of the following is MOST consistent with a diagnosis of hepatopulmonary syndrome?
(A) Abnormal chest radiograph
(B) Echocardiographic evidence of delayed right-to-left shunting
(C) Pulmonary hypertension
(D) Restrictive pattern on pulmonary function testing
8

38. Which of the following procedures is MOST likely to decrease the rate of catheter-related bloodstream infection (CRBSI) associated with central venous catheters?
(A) Use of povidone-iodine (Betadine) rather than chlorhexidine skin prep
(B) Use of subclavian site over femoral site
(C) Application of povidone-iodine ointment at insertion site
(D) Use of a small, fenestrated drape during catheter placement
39. A 65-year-old man without evidence of traumatic brain injury undergoes an emergency pinning of a fractured hip. His only medication is amitriptyline. Following surgery his neuromuscular blockade is reversed with neostigmine and atropine. In the recovery room he is noted to be flushed, febrile, his pupils are dilated, his skin is dry, and he has persistent confusion. His vital signs are normal and his Foley catheter flushes easily.
Which statement about this patient is MOST likely true?
(A) The first step should be to replace his Foley catheter.
(B) Meperidine will be contraindicated for his postoperative pain.
(C) Dantrolene should be administered immediately.
(D) He should receive physostigmine.
40. A 48-year-old man complains of vague, atypical chest pain in the preoperative holding area prior to liver resection for removal of a metastatic lesion. An electrocardiogram
(ECG) is performed and is reproduced below.
The patient's vital signs are normal. He is apprehensive. No prior ECGs are available.
Which of the following is the MOST appropriate course of action?
(A) Administer intravenous magnesium and proceed with surgical procedure
(B) Cancel the surgical procedure
(C) Proceed with the surgical procedure but admit to a monitored bed postoperatively
(D) Proceed with the surgical procedure but place a temporary pacemaker after induction
9

41. A 68-year-old man presents for resection of a pituitary adenoma that has caused acromegaly. Which statement about perioperative management of a patient with acromegaly is MOST likely true?
(A) There is a higher rate of difficult intubation than with control patients.
(B) A tracheal tube larger than normal should be used.
(C) Hypoglycemia is common.
(D) Pheochromocytoma and acromegaly commonly coexist.
42. On the first postoperative day, a patient who has undergone emergency repair of a thoracic aortic dissection is noted to be paraplegic. A neurological examination is MOST likely to find which of the following sensory functions intact in the lower extremities?
(A) Pain
(B) Crude touch
(C) Temperature
(D) Vibration
43. A 66-year-old man presents for a magnetic resonance imaging (MRI) scan of the abdomen. Due to chronic back pain and claustrophobia, he requires deep sedation for the procedure. He has hypertension and stable coronary artery disease. Based on the
American Society of Anesthesiologists (ASA) Practice Advisory on Anesthetic Care for
Magnetic Resonance Imaging, which statement about monitoring this patient during the scan is MOST likely true?
(A) End-tidal CO
2
(P
ETCO2
) monitoring cannot be performed in the MRI scanner.
(B) The anesthesiologist must stay in the scanner room (zone IV) while monitoring the patient.
(C) Reliable ST-segment interpretation of the electrocardiogram cannot be obtained.
(D) Use of MRI-safe monitors eliminates the risk of patient burns.
44. Which statement about the occurrence of a quench (magnet releasing its stored energy as heat) in the magnetic resonance imaging (MRI) scanner is MOST likely true?
(A) It most commonly occurs when a life-threatening emergency requires shutdown of the magnet.
(B) Oxygen administration to the patient should be discontinued.
(C) All personnel should rnove into zone IV (scanner room).
(D) Precautions against the hazards of a magnetic field no longer need to be taken.
10

45. Which of the following is MOST likely a side effect of terbutaline administered to a parturient in preterm labor?
(A) Hypoglycemia
(B) Hypertension
(C) Bronchospasm
(D) Hypokalemia
46. Which statement about pain that is initially perceived following a noxious stimulus (ie, first pain) is MOST likely true?
(A) It is poorly localized.
(B) The conduction velocities of fibers transmitting second pain are the same as that of fibers transmitting first pain.
(C) First pain is conducted by C fibers.
(D) First pain is conducted by A-delta fibers.
47. A 46-year-old man is undergoing an exploratory laparotomy for excision of a suspected insulinoma. An arterial blood gas obtained during manipulation of the tumor reveals his glucose to be 45 mg/dL. Unfortunately initial vascular access was difficult and his peripheral intravenous (IV) catheter now appears to be infiltrated. While attempting to insert another IV catheter, which of the following medications would be MOST effective in treating his hypoglycemia when administered subcutaneously?
(A) Glucagon
(B) Vasopressin
(C) Epinephrine
(D) Diazoxide
48. A 54-year-old man with chronic obstructive pulmonary disease (COPD) is scheduled for a pneumonectomy for cancer. Which statement about the management of this patient is
MOST likely true?
(A) Tidal volumes of 5 mL/kg or less during one-lung ventilation are recommended.
(B) Transesophageal echocardiography (TEE) is likely to demonstrate left ventricular systolic dysfunction during pulmonary artery clamping.
(C) Use of epidural analgesia for postoperative pain control is contraindicated.
(D) Hypocapnia is a preferred goal.
11

49. A healthy woman who has undergone one previous low transverse cesarean delivery is attempting vaginal birth after cesarean delivery (VBAC). Which statement about the management of this patient is MOST likely true?
(A) Epidural analgesia with 0.125% bupivacaine should be avoided.
(B) Abdominal pain is the most common sign of uterine rupture.
(C) The risk of uterine rupture is approximately 0.1%.
(D) An anesthesiologist should be immediately available to provide anesthesia for emergency cesarean delivery.
50. Compared to younger adult patients with traumatic injuries, which statement about geriatric (age ≥ 65 years) trauma patients is MOST likely true?
(A) They are less likely to sustain chest injuries.
(B) They are more likely to die as a result of preexisting comorbidities.
(C) They are more likely to receive aggressive treatment for their injuries.
(D) They have an increased sensitivity to catecholamines.
51. Which of the following is MOST likely to be associated with a low serum concentration of plasma cholinesterase (also known as butyrylcholinesterase or pseudocholinesterase)?
(A) Renal failure
(B) Hepatocellular dysfunction
(C) Pyridostigmine administration
(D) U ntreated myasthenia gravis
52. A 40-year-old man weighs 150 kg (330 lb) and is 1.83 m (72 in) tall. Based on a standard calculation his body mass index (BMI) is 44.8 kg/m
2
. He is MOST accurately classified as
(A) overweight.
(B) obese.
(C) morbidly obese.
(D) super obese.
53. A healthy 3-month-old infant born at term (current postconceptual age 52 weeks) has bilateral inguinal hernias. Last week the hernias were difficult to reduce and the child is now scheduled for elective inguinal herniorrhaphy. The MOST appropriate fasting interval for breast milk for the child is
(A) 2 hours.
(B) 4 hours.
(C) 6 hours.
(D) 8 hours.
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54. Administration of which of the following is MOST likely to be safe in a patient with a documented sulfite allergy?
(A) Meperidine
(B) Dexamethasone
(C) Lidocaine
(D) Generic propofol
55. Exposure of a 1-day-old premature (30 weeks postconceptual age) newborn to a temperature lower than the neonate's neutral thermal environment is MOST likely to result in
(A) decreased oxygen consumption.
(B) cutaneous vasodilation.
(C) pulmonary vasoconstriction.
(D) decreased glucose consumption.
56. Which of the following values is MOST likely to be increased in a patient with Addison disease (adrenocortical insufficiency)?
(A) Serum sodium
(B) Serum potassium
(C) Serum glucose
(D) Serum chloride
57. Which of the following MOST accurately characterizes the airway anatomy of a neonate compared to that of an adult?
(A) The epiglottis is relatively shorter in a neonate than in an adult.
(B) The larynx is located more cephalad in the neck in a neonate than in an adult.
(C) The vocal cords are more perpendicular to the axis of the trachea in a neonate than in an adult.
(D) The tongue is relatively smaller in a neonate than in an adult.
58. Which of the following has the LOWEST priority for lung isolation?
(A) Bronchopleural fistula
(B) Giant unilateral bulla
(C) Massive unilateral pulmonary hemorrhage
(D) Left lower lobectomy
13

59. A 43-year-old woman presents for repair of a radius fracture. She underwent a heart transplant 6 months ago for idiopathic cardiomyopathy. Which of the following is MOST likely to alter this patient’s heart rate?
(A) Atropine
(B) Isoproterenol
(C) Carotid sinus massage
(D) Neostigmine
60. A woman at 31 weeks gestation requires surgical repair of an open wrist fracture. Due to uterine contractions and an elevated blood pressure, she is started on magnesium sulfate therapy. An axillary block with 2% lidocaine is planned. Which statement about the use of lidocaine in this patient is MOST likely true?
(A) The dose of lidocaine required to achieve a successful block will be increased compared to a nonpregnant patient.
(B) The free fraction of lidocaine will be increased compared to a nonpregnant patient.
(C) Magnesium sulfate will increase the seizure-dose threshold of lidocaine.
(D) Preeclampsia will not affect the clearance of lidocaine.
61. A 37-year-old woman who was undergoing labor induction is taken to the operating room
(OR) for emergency cesarean delivery due to fetal bradycardia. As the surgery begins, she is complaining of dyspnea and her initial oxygen saturation in the OR is 83%. She has a blood pressure of 72/33 mm Hg. The obstetrician notes diffuse bleeding in the surgical field. The MOST likely diagnosis in this patient is
(A) pulmonary thromboembolism.
(B) uterine rupture.
(C) amniotic fluid embolism.
(D) myocardial infarction.
62. Which of the following statements about brain glucose metabolism is MOST likely true?
(A) Brain requirements for glucose decrease after brain injury.
(B) Intracranial hypertension increases glucose availability.
(C) Glucose transport into neurons is independent of insulin concentration.
(D) Seizure activity decreases glucose transport across the blood-brain barrier.
63. Which of the following is MOST characteristic of injury to the median nerve?
(A) Hypothenar muscle atrophy
(B) Loss of wrist extension
(C) Inability to supinate the hand
(D) Loss of thumb flexion
14

64. Which of the following is MOST likely a criterion for the diagnosis of peripartum cardiomyopathy?
(A) Development of cardiac failure in the second trimester of pregnancy
(B) Preexisting heart disease
(C) Left ventricular ejection fraction less than 45%
(D) History of rheumatic fever
65. Of the following, which is the BEST choice for postoperative analgesia in patients with end-stage renal disease?
(A) Morphine
(B) Hydromorphone
(C) Meperidine
(D) Fentanyl
66. A young man had a rupture of a cerebral aneurysm while competing in a bicycle race during which he fell and ruptured his spleen. He is scheduled for an exploratory laparotomy and a burr hole. His current hemoglobin (Hb) is 8.5 g/dL. Which of the following statements about acute anemia for patients with a neurologic injury is MOST likely true?
(A) Transfusion should begin only after Hb falls below 7 g/dL.
(B) There is no evidence that anemia alone changes neurologic outcome.
(C) Cardiac output does not change in response to reduced oxygen delivery to the brain.
(D) Patients increase cerebral blood flow in response to anemia after cerebral aneurysm rupture.
67. Which of the following is MOST consistent with a diagnosis of fibromyalgia syndrome?
(A) Pain limited to the upper half of the body
(B) Elevated serum serotonin levels
(C) Impaired sleep
(D) Low-grade fever
68. A 1-day-old, 3-kg neonate born at 37 weeks gestation presents to the operating room for congenital diaphragmatic hernia repair. Which statement about this patient is MOST likely true?
(A) Positive pressure ventilation by mask should be performed prior to intubation.
(B) Elevated peak inspiratory pressure predisposes to pneumothorax.
(C) Orogastric suctioning is contraindicated.
(D) The vast majority of diaphragmatic hernias occur on the right side of the chest.
15

DIRECTIONS FOR ITEMS 69 THROUGH 71: These items refer to the diagnosis, treatment, or management of a single patient.
69. A 46-year-old woman is brought to the emergency room following a motor vehicle collision. In response to a sternal rub she opens her eyes and withdraws her right arm.
She does not vocalize spontaneously or to painful stimulus. Her Glasgow Coma Scale score is
(A)
(B)
4.
5.
(C) 6.
(D) 7.
70. Due to the patient’s severely altered mental status, she was emergently intubated. Which of the following additional treatments is MOST important during her initial resuscitation?
(A) Inducing hypothermia
(B) Providing mannitol therapy with 0.5 g/kg body weight dose
(C) Maintaining mean arterial blood pressure above 60 mm Hg
(D) Providing barbiturate therapy with pentobarbital 4 mg/kg body weight dose
71. The patient’s initial computed tomography (CT) scan demonstrated a frontal subdural hematoma, diffuse loss of gray-white delineation, and “slit-like" ventricles. The decision was made to place an intracranial pressure (ICP) monitor. Which statement about ICP monitoring technology is MOST likely true?
(A) An ICP transduction device can only be placed in subdural or intraventricular locations.
(B) An intraventricular catheter connected to an external transducer is the most accurate method of monitoring ICP.
(C) Intraparenchymal transducers can be easily recalibrated.
(D) A subdural bolt can drain cerebrospinal fluid to treat intracranial hypertension.
16

DIRECTIONS FOR ITEMS 72 AND 73: These items refer to the diagnosis, treatment, or management of a single patient.
72. A 3-year-old child presents to the emergency department after having ingested an unknown number of aspirin tablets. Which of the following is MOST likely to manifest if salicylate intoxication is present?
(A) Hyperventilation
(B) Polyuria
(C) Metabolic alkalemia
(D) Hyperkalemia
73. The child is awake and crying. Vital signs include respiratory rate 40 breaths/min, heart rate 140 beats/min, blood pressure 95/60 mm Hg, SP
O2
98% (room air). Assuming activated charcoal has already been administered, which of the following is the MOST appropriate treatment at this point?
(A) Tracheal intubation
(B) Administration of mannitol
(C) Administration of sodium bicarbonate
(D) Hemodialysis
DIRECTIONS FOR ITEMS 74 AND 75: These items refer to the diagnosis, treatment, or management of a single patient.
74. A 65-year-old man is scheduled for a left pneumonectomy for squamous cell carcinoma
Which of the following preoperative test results would MOST strongly suggest that this patient is at an increased risk for postoperative cardiopulmonary dysfunction?
(A) Partial pressure of carbon dioxide in arterial blood (Pa
CO2
) of 51 mm Hg
(B) Forced expiratory volume at 1 second (FEV
1
) of 2.5 L
(C) A ratio of residual volume to total lung capacity (RV/TLC) of 35%
(D) Room air SP
O2
of 93%
75. Preoperative arterial blood gas and spirometry results predict an increased risk of postoperative complications. The patient and surgeon decide to obtain further testing before proceeding with the surgery. Which of the following test results is MOST likely to predict significant postoperative complications?
(A) Mean pulmonary artery pressure of 30 mm Hg during left bronchial balloon occlusion
(B)
Split lung function test showing 85% of blood flow to nonoperative lung
(C) Pa
CO2
of 65 mm Hg during left bronchial balloon occlusion
(D) Split lung function testing utilizing ventilation-perfusion scans with radioisotopes predicting postoperative forced expiratory volume at 1 second (FEV
1
) of 1.2 L
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DIRECTIONS FOR ITEMS 76 AND 77: These items refer to the diagnosis, treatment, or management of a single patient.
76. You are asked to evaluate a postpartum patient who received uneventful lumbar epidural anesthesia for labor. She delivered 3 days ago and is now complaining of persistent numbness in her left lower extremity. The patient reports having prolonged labor with a difficult delivery of a 10-lb baby. On examination she has a diminished ability to dorsiflex her left foot and decreased sensation to pinprick along the lateral aspect of the left leg as well as the dorsal surface of the foot. Which of the following is the MOST likely cause?
(A) Nerve root trauma from an epidural needle
(B) Transient neurologic syndrome (TNS)
(C) Nerve compression from cephalopelvic disproportion
(D) Prolonged local anesthetic blockade
77. Based on the findings in this patient, which of the following structures is MOST likely to be involved?
(A) Lateral femoral cutaneous nerve
(B) Femoral nerve root (L2-4)
(C) Lumbosacral trunk (L4-5)
(D) Obturator nerve
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DIRECTIONS FOR ITEMS 78 AND 79: These items refer to the diagnosis, treatment, or management of a single patient.
78. A 54-year-old man with severe, symptomatic aortic stenosis undergoes an uneventful aortic valve replacement. Before the chest is closed, bipolar epicardial leads are placed by the surgical team and the leads are connected to a portable pacemaker/generator.
Which statement about postoperative epicardial pacing in this patient is MOST likely true?
(A) Epicardial pacing is rarely used following valvular surgery.
(B) Epicardial pacing can be used only on the right atrium.
(C) Epicardial pacing cannot be used in patients with atrial fibrillation.
(D) Epicardial pacing in the VOO mode can induce ventricular fibrillation.
79. On postoperative day 2 with bipolar epicardial pacemaker leads in place, the patient develops complete heart block. Which of the following is the MOST appropriate initial response if epicardial pacing attempts result in “failure to capture" the ventricle while using the DDD mode?
(A) Increase sensitivity of the pacemaker.
(B) Reduce the atrioventricular (AV) delay interval.
(C) Place a temporary transvenous pacing wire.
(D) Attempt temporary esophageal pacing.
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DIRECTIONS FOR ITEMS 80 THROUGH 82: These items refer to the diagnosis, treatment, or management of a single patient.
80. A 44-year-old obese woman presents complaining of tingling pain in her right hip radiating around the right thigh but not extending below the knee. She denies pain over the right buttock. Examination of the right lateral thigh reveals a deficit to pinprick and temperature sensation in the skin overlying the lateral thigh. Compression just medial to her anterior superior iliac spine reproduces her symptoms. Motor examination of the lower extremity is entirely normal with symmetric bulk in the thigh musculature. Flexion and extension of her spine fails to reproduce symptoms. Internal and external rotation of the hip is nonpainful. Palpation of the tissue overlying the greater trochanter of the right femur is also nonpainful. Radiographs of the hips and spine are normal. Which of the following is MOST likely to be involved?
(A) Lateral femoral cutaneous nerve
(B) L2 nerve root
(C) Obturator nerve
(D) Saphenous nerve
81. The MOST likely diagnosis for this patient is
(A) meralgia paresthetica.
(B) cheiralgia paresthetica.
(C) notalgia paresthetica.
(D) brachialgia statica paresthetica.
82. Which statement about the treatment of this condition is MOST likely true?
(A) Nonsteroidal antiinflammatory drugs (NSAIDs) are contraindicated.
(B) Steroid injection at the greater trochanter is the preferred treatment.
(C) Local anesthetic injected inferomedial to the anterior superior iliac spine is likely to result in immediate relief.
(D) Epidural steroid at L2-3 is effective.
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DIRECTIONS FOR ITEMS 83 THROUGH 85: These items refer to the diagnosis, treatment, or management of a single patient.
83. A 75-year-old man undergoes mitral valve replacement. After the patient has been weaned from cardiopulmonary bypass, protamine is administered intravenously to reverse the anticoagulant effect of heparin. Which statement about protamine use in this patient is MOST likely true?
(A) Protamine must be administered into a peripheral vein.
(B) Protamine should be given as a bolus over 10 seconds.
(C) Protamine dose is based on the height of the patient.
(D) Protamine has antiplatelet effects.
84. Two minutes after administration of protamine, which occurred over 11 minutes, the patient develops systemic hypotension and pulmonary hypertension. Which of the following is the MOST likely mechanism for the hemodynamic derangements?
(A) Protamine-induced histamine release
(B) Pulmonary embolism
(C) Protamine-induced pulmonary vasoconstriction
(D) Type IV allergic reaction
85. Intravenous administration of which of the following agents is MOST appropriate for the treatment of pulmonary hypertension resulting from protamine administration?
(A) Methylene blue
(B) Phenylephrine
(C) Phentolamine
(D) Epinephrine
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DIRECTIONS FOR ITEMS 86 AND 87: These items refer to the diagnosis, treatment, or management of a single patient.
86. A 36-year-old woman undergoes a general anesthetic with a tracheal tube for laparoscopic removal of an ovarian cyst. Her vital signs were stable throughout the procedure and there was minimal blood loss. At the end of the procedure she is following commands; shortly after extubation she becomes unresponsive and her oxygen saturation
(SP
O2
) begins to decrease although she is making respiratory efforts. The MOST likely cause of this change is
(A) inadvertent administration of excess drugs.
(B) intra-abdominal hemorrhage.
(C) laryngospasm.
(D) allergic reaction.
87. The patient experiences significant desaturation during a postextubation episode of laryngospasm. She is eventually reintubated and copious amounts of pink frothy fluid are suctioned from her trachea. Which statement about postobstructive pulmonary edema
(PPE, also known as negative pressure pulmonary edema) is MOST likely true?
(A) PPE produces intra-alveolar hemorrhage.
(B) Symptoms usually resolve spontaneously in 8-24 hours.
(C) PPE is caused by trying to exhale against an airway obstruction.
(D) It occurs primarily in patients with fluid overload.
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DIRECTIONS FOR ITEMS 88 AND 89: These items refer to the diagnosis, treatment, or management of a single patient.
88. The quality assurance program at your hospital wants to discontinue the use of a single- dose intrathecal (IT) morphine for postoperative analgesia in major, nonobstetric surgical procedures. As an anesthesiologist you are asked to demonstrate that IT morphine is safe and a desirable postoperative analgesic technique. Which statement about the use of a single dose of IT morphine is MOST likely true?
(A) Pain relief achieved with a single dose of IT morphine lasts approximately 36 hours.
(B) Patients receiving IT morphine are discharged 2 days sooner.
(C) Pain relief achieved with a single dose of IT morphine is similar to that reported by patients receiving nonsteroidal antiinflammatory drugs.
(D) Pain relief achieved with a single dose of IT morphine is most effective for patients who undergo abdominal surgery.
89. The quality assurance committee asks for a summary of the side effects and risks of intrathecal (IT) morphine when used for postoperative pain relief in nonobstetric patients.
Which of the following statements is MOST likely true?
(A) As many as 1 in every 15 patients who receive IT morphine will experience respiratory depression.
(B) Respiratory depression is always detected by the use of continuous pulse oximetry.
(C) Urinary retention is significantly decreased when IT morphine is administered.
(D) Patients receiving IT morphine are much less likely to have pruritus.
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DIRECTIONS FOR ITEMS 90 AND 91: These items refer to the diagnosis, treatment, or management of a single patient.
90. You place an axillary block for a patient who is about to undergo repair of a fracture of the right radius. You determine that the patient lacks anesthesia only along the lateral aspect of the forearm. Which of the following nerves is the MOST likely to have been inadequately blocked?
(A) Musculocutaneous
(B) Radial
(C) Ulnar
(D) Median
91. At which of the following sites would injection of local anesthetic be the MOST effective way of providing supplemental anesthesia to the lateral aspect of the forearm in this patient?
(A) Superior to the axillary artery around the belly of the coracobrachialis muscle
(B) Subcutaneously along the axillary crease
(C) Posterior to the triceps muscle at the midhumeral area
(D) Proximal to the medial epicondyle within the ulnar groove
DIRECTIONS FOR ITEMS 92 AND 93: These items refer to the diagnosis, treatment, or management of a single patient.
92. A general surgeon consults you about a 98-kg patient with obstructive sleep apnea (OSA) who is scheduled for a hernia repair. The patient required an intensive care unit (ICU) stay for severe hypoxia after a cholecystectomy. Which statement about the physiology of patients with OSA is MOST likely true?
(A) The negative pressure generated by the inspiratory muscles is inadequate to move respiratory gases.
(B) Fat deposits in the airway do not affect the ability of pharyngeal muscles to maintain an open upper airway.
(C) Upper airway muscles have increased tonic muscle tone.
(D) The upper airway diameter in the retropalatal region is reduced.
93. Which statement about the effects of opioids in a patient with obstructive sleep apnea
(OSA) is MOST likely true?
(A) Sensitivity to respiratory effects of opioids is independent of ethnicity.
(B) Morphine increases the apneic threshold—the arterial carbon dioxide tension above which spontaneous respiration begins—in women but not in men.
(C) Higher total dose of opioids is required to achieve adequate analgesia.
(D) Irregular respiration is more frequent in OSA patients taking opioids.
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DIRECTIONS FOR ITEMS 94 AND 95: These items refer to the diagnosis, treatment, or management of a single patient.
94. A 28-year-old woman is scheduled for open reduction and internal fixation of an ankle fracture sustained 5 days ago. She has no other injuries and is complaining only of moderate ankle pain when evaluated in the outpatient preoperative clinic the day before surgery. She reports a history of acute intermittent porphyria, but she has had no exacerbations in the past year. Her blood pressure is 122/64 mm Hg and her heart rate is
73 beats/min. Which statement about the preoperative management of this patient is
MOST likely true?
(A) She should have nothing by mouth for at least 12 hours before surgery.
(B) Opioid analgesia is contraindicated.
(C) An infusion of 10% glucose in normal saline should be initiated preoperatively.
(D) Preoperative anxiolysis with midazolam is contraindicated.
95. Which statement about the intraoperative management of this patient is MOST likely true?
(A) Regional anesthesia with bupivacaine is contraindicated.
(B) Thiopental is the preferred drug for the induction of general anesthesia.
(C) Hematin must be administered to prevent an acute porphyria attack.
(D) Nitrous oxide can be used safely.
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DIRECTIONS FOR ITEMS 96 THROUGH 98: These items refer to the diagnosis, treatment, or management of a single patient.
96. The diagnosis of primary hyperparathyroidism is being considered in a patient with hypercalcemia. Which of the following is MOST likely to be present in a patient with hyperparathyroidism?
(A) Polyuria
(B) Polycythemia
(C) Prolonged QT interval
(D) Hypotenslon
97. The patient is noted to have a serum calcium of 13 mg/dL. Administration of which of the following is MOST likely indicated in the acute management of the hypercalcemia?
(A) Hydrochlorothiazide
(B) Phosphate
(C) Digoxin
(D) Vitamin D
98. After a diagnosis of primary hyperparathyroidism due to an adenoma is established, the patient is scheduled for a parathyroidectomy. Which of the following is MOST likely indicated during the perioperative management of this patient?
(A) Overnight hydration with intravenous fluids
(B) Induction of anesthesia with ketamine
(C) Avoidance of succinylcholine
(D) Maintenance of anesthesia with sevoflurane
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DIRECTlONS FOR ITEMS 99 AND 100: These items refer to the diagnosis, treatment, or management of a single patient.
99. A 55-year-old man with a history of using 400-mg/day methadone presents for a total knee replacement. Which of the following electrocardiographic changes is MOST associated with this analgesic regimen?
(A) Peaked T waves
(B) Nonischemic ST segment depression
(C) Nonischemic ST segment elevation
(D) QTc prolongation
100. After uneventful surgery. The patient develops the following dysrhythmia while in the postanesthesia care unit.
Which of the following therapies would be MOST effective in terminating the dysrhythmia?
(A) Magnesium
(B) Synchronized cardioversion
(C) Esmolol
(D) Procainamide
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