Certified Registered Nurse First Assistant (CRNFA) — Questions and Answers

Question 1: When reviewing a patient's medication list preoperatively, which class of medications requires the MOST immediate concern regarding intraoperative bleeding risk?

Antiplatelet agents such as clopidogrel (Correct answer)
Thyroid hormone replacements
Antihypertensives
Proton pump inhibitors

Correct answer: Antiplatelet agents such as clopidogrel

Antiplatelet agents like clopidogrel inhibit platelet aggregation and significantly increase intraoperative bleeding risk; cessation timing must be confirmed with the surgeon.

Question 2: During a right colectomy, which structure lies in close proximity to the ileocolic vessels and must be identified to avoid injury?

Superior mesenteric vein
Right gonadal vein
Right ureter (Correct answer)
Right renal vein

Correct answer: Right ureter

The right ureter runs retroperitoneally along the psoas muscle near the ileocolic vessels and must be identified before ligation during right colectomy.

Question 3: This ligament is made up of two peritoneal folds that stretch laterally, posteriorly, and downward from the uterus.

Extension
Broad ligament (Correct answer)
Urinary bladder
Trochlear-eye movement

Correct answer: Broad ligament

The broad ligament is a wide fold of peritoneum that extends from the sides of the uterus to the walls and floor of the pelvis. It is composed of two layers of peritoneum and contains various structures, including blood vessels, nerves, and connective tissue. Its primary function is to support the uterus and ovaries within the pelvic cavity, anchoring them in place.

Question 4: Which of the following constructions should be avoided and an early identification made during TAH?

Colostomy
Liver
Ureters (Correct answer)
Cervix

Correct answer: Ureters

During a Total Abdominal Hysterectomy (TAH), the ureters are in close proximity to the uterus and its vascular supply. Accidental ligation, transection, or kinking of the ureters is a serious complication that can lead to hydronephrosis, kidney damage, or even renal failure. Therefore, early identification and careful dissection to avoid injury to the ureters are crucial for patient safety and preventing severe postoperative complications.

Question 5: Which preoperative finding most strongly warrants postponement of elective surgery?

Hemoglobin of 11.5 g/dL in a stable patient
Serum potassium of 2.8 mEq/L (Correct answer)
Random blood glucose of 180 mg/dL in a known diabetic
Blood pressure of 148/88 mmHg

Correct answer: Serum potassium of 2.8 mEq/L

A serum potassium below 3.0 mEq/L (hypokalemia) increases risk of life-threatening cardiac arrhythmias during anesthesia and warrants correction before elective surgery.

Question 6: A Balfour retractor with a center blade is most commonly used during which type of procedure?

Craniotomy
Abdominal/pelvic surgery (Correct answer)
Thoracotomy
Orthopedic joint replacement

Correct answer: Abdominal/pelvic surgery

The Balfour retractor is a self-retaining abdominal retractor with lateral blades and a central (bladder) blade used to hold the abdominal wall open during laparotomy.

Question 7: Debridement of wounds:

Closes a wound
Cleans a wound
Removes dead tissue from a wound (Correct answer)
Keeps a wound moist

Correct answer: Removes dead tissue from a wound

Debridement is a critical step in wound care that involves the removal of necrotic (dead) tissue, foreign material, and exudate from a wound bed. This process is essential because dead tissue can harbor bacteria, impede granulation tissue formation, and delay wound healing. By removing devitalized tissue, debridement promotes a clean wound environment conducive to healthy tissue growth and closure.

Question 8: Which AORN-recommended practice describes the appropriate management of a sharps container that reaches the fill line in the OR during an ongoing procedure?

Seal the container and replace it with a new one without interrupting the sterile field (Correct answer)
Pass the overfilled container to the sterile field for temporary storage
Manually compress the contents to create space for additional sharps
Continue adding sharps above the fill line until the procedure is complete

Correct answer: Seal the container and replace it with a new one without interrupting the sterile field

AORN's sharps safety guidelines require replacing a full sharps container immediately to prevent needlestick injuries from overfilling.

Question 9: A patient undergoing a carotid endarterectomy is heparinized intraoperatively. At the end of the procedure, the surgeon elects to reverse anticoagulation. Which agent is administered, and at what ratio to heparin?

Vitamin K at 1 mg per 100 units of heparin
Tranexamic acid at 1 g regardless of heparin dose
Fresh frozen plasma at 1 unit per 1,000 units of heparin
Protamine sulfate at 1 mg per 100 units of heparin (Correct answer)

Correct answer: Protamine sulfate at 1 mg per 100 units of heparin

Protamine sulfate reverses heparin at a ratio of 1 mg per 100 units of heparin administered, binding and neutralizing heparin activity.

Question 10: When ligating a vessel with a free tie, the CRNFA should ensure the ligature is placed:

At the midpoint of the vessel segment to be removed
Proximal to the cut end with enough tissue to prevent slippage (Correct answer)
Exactly at the cut end of the vessel for maximum security
Distal to the anticipated division point only

Correct answer: Proximal to the cut end with enough tissue to prevent slippage

A free tie placed proximal to the cut end with adequate tissue ensures the ligature cannot slip off the vessel stump.

Question 11: Which of the following most accurately describes the CRNFA examination's content blueprint as defined by CCI's practice analysis?

Standardized using the NCLEX-RN blueprint as a base
Domains derived from a task analysis of actual RNFA perioperative practice (Correct answer)
Equal weighting across anatomy, pharmacology, and law
Developed solely by AORN without CCI input

Correct answer: Domains derived from a task analysis of actual RNFA perioperative practice

CCI conducts periodic role delineation studies (practice analyses) to identify the actual tasks RNFAs perform, then weights exam content accordingly.

Question 12: During surgery, the anesthesiologist announces end-tidal CO2 of 68 mmHg, temperature of 39.8°C rising, and tachycardia of 148 bpm. The CRNFA's first action should be to:

Apply ice packs to the patient's neck and axillae only
Increase IV fluid rate
Suspend the operation, assist the team to activate the MH protocol, and call for dantrolene (Correct answer)
Administer a beta-blocker for the tachycardia

Correct answer: Suspend the operation, assist the team to activate the MH protocol, and call for dantrolene

Rising end-tidal CO2, hyperthermia, and tachycardia are cardinal signs of MH; the team must suspend surgery, switch to MH-safe anesthesia, and administer dantrolene immediately.

Question 13: According to AORN guidelines, which type of instrument count should be performed before the surgical incision is closed?

Only sponge counts are required before closure
All sponge, sharps, and instrument counts must be reconciled and documented (Correct answer)
Counts are only required for procedures lasting more than two hours
Sharps counts are performed only when the surgeon requests them

Correct answer: All sponge, sharps, and instrument counts must be reconciled and documented

AORN requires a complete reconciliation of all sponge, sharps, and instrument counts before wound closure to prevent retained surgical items.

Question 14: When passing a sharp instrument to the surgeon on the sterile field, the CRNFA should use which safety technique?

Announce 'sharp passing' and hand directly with the tip covered
Pass sharp instruments only when the surgeon requests verbally
Place the instrument in a neutral zone (kidney basin) for the surgeon to pick up (Correct answer)
Hand the instrument directly handle-first with the blade pointing toward the surgeon

Correct answer: Place the instrument in a neutral zone (kidney basin) for the surgeon to pick up

The neutral zone (hands-free) technique places sharps in a designated zone for the surgeon to retrieve, preventing direct hand-to-hand transfer and reducing needlestick injuries.

Question 15: A patient discloses herbal supplement use including garlic, ginger, and Ginkgo biloba. The CRNFA's primary concern is which potential intraoperative complication?

Increased bleeding due to antiplatelet effects of these supplements (Correct answer)
Malignant hyperthermia
Renal failure
Hypertensive crisis

Correct answer: Increased bleeding due to antiplatelet effects of these supplements

Garlic, ginger, and Ginkgo biloba all have antiplatelet properties that can increase intraoperative and postoperative bleeding risk.

Question 16: In which anatomical space does a retroperitoneal hematoma develop after injury to the aorta or inferior vena cava?

Peritoneal cavity
Retroperitoneal space (space of Retzius)
Preperitoneal space
Retroperitoneal space posterior to parietal peritoneum (Correct answer)

Correct answer: Retroperitoneal space posterior to parietal peritoneum

Retroperitoneal hematomas accumulate in the space posterior to the parietal peritoneum, where the aorta, IVC, and their branches reside.

Question 17: The purpose of pre-oxygenation (denitrogenation) before induction of general anesthesia is to:

Prevent laryngospasm
Extend the safe apnea window by maximizing lung oxygen reserves before intubation (Correct answer)
Reduce anesthetic agent requirements
Prevent malignant hyperthermia

Correct answer: Extend the safe apnea window by maximizing lung oxygen reserves before intubation

Pre-oxygenation with 100% O2 for 3–5 minutes replaces nitrogen in functional residual capacity with oxygen, extending the safe apneic window from ~1 minute to 3–8 minutes.

Question 18: When the CRNFA applies a running subcuticular (intradermal) suture for skin closure, the primary aesthetic and functional advantage over staples is:

Elimination of track marks and improved cosmesis (Correct answer)
Ability to be left permanently without removal
Faster closure time in long incisions
Greater tensile strength resisting wound dehiscence

Correct answer: Elimination of track marks and improved cosmesis

Subcuticular sutures avoid skin puncture wounds (track marks) caused by staples or percutaneous sutures, yielding superior cosmetic outcomes.

Question 19: Which nerve is at risk during a mastectomy and, if injured, causes 'winged scapula'?

Intercostobrachial nerve
Thoracodorsal nerve
Medial pectoral nerve
Long thoracic nerve (Correct answer)

Correct answer: Long thoracic nerve

Injury to the long thoracic nerve during mastectomy denervates the serratus anterior muscle, causing the medial scapular border to wing outward.

Question 20: When performing blunt dissection in surgery, the CRNFA should use which technique to minimize tissue trauma?

Gentle spreading along anatomical tissue planes using the tips of a hemostat (Correct answer)
Using electrocautery on a low setting as an alternative to sharp dissection
Finger-fracture technique applied perpendicular to the tissue
Rapid sweeping motions parallel to neurovascular structures

Correct answer: Gentle spreading along anatomical tissue planes using the tips of a hemostat

Gentle spreading along natural tissue planes with hemostatic tips preserves neurovascular structures and reduces collateral tissue damage.

Question 21: Which absorbable suture retains the most tensile strength at 6 weeks postoperatively?

Plain gut
Chromic gut
Polyglycolic acid (Dexon)
Polydioxanone (PDS II) (Correct answer)

Correct answer: Polydioxanone (PDS II)

PDS II (polydioxanone) retains approximately 50% tensile strength at 6 weeks and 25% at 6 months, outlasting all other common absorbable sutures.

Question 22: Which phase of wound healing is characterized by fibroblast proliferation and collagen deposition?

Proliferative phase (Correct answer)
Inflammatory phase
Hemostasis phase
Maturation/remodeling phase

Correct answer: Proliferative phase

The proliferative phase (days 4–21) is dominated by fibroblast migration and collagen synthesis, along with angiogenesis and wound contraction.

Question 23: A diabetic patient's point-of-care blood glucose before surgery reads 320 mg/dL. The CRNFA should:

Notify the anesthesiologist and surgeon immediately before proceeding (Correct answer)
Document the finding and proceed with the scheduled case
Recheck in 30 minutes and proceed if unchanged
Administer insulin per the sliding scale and proceed

Correct answer: Notify the anesthesiologist and surgeon immediately before proceeding

A preoperative blood glucose of 320 mg/dL represents significant hyperglycemia that increases infection risk and may require insulin management prior to proceeding with elective surgery.

Question 24: A patient reports a prior reaction to a 'caine' medication at the dentist. The CRNFA should prioritize communicating which concern to the anesthesia team?

Risk of malignant hyperthermia
Need for antihistamine premedication only
Contraindication to general anesthesia
Possible allergy to amide or ester local anesthetics (Correct answer)

Correct answer: Possible allergy to amide or ester local anesthetics

A prior reaction to local anesthetics used in dentistry may indicate allergy to amide or ester class agents, which must be clarified before administering local or regional anesthesia.

Question 25: The uterus's upper, dome-like section is referred to as the?

Cervix
Fundus (Correct answer)
Pylorus
Reticulum

Correct answer: Fundus

The fundus is the uppermost, rounded part of the uterus, situated superior to the entrance of the fallopian tubes. This region is significant as it is where the uterine wall is thickest and where implantation typically occurs during pregnancy. Its position and size are often assessed during obstetric examinations to determine uterine growth and fetal development.

Question 26: During a thyroidectomy, which nerve must be identified and preserved to prevent permanent hoarseness?

External laryngeal nerve
Recurrent laryngeal nerve (Correct answer)
Internal laryngeal nerve
Glossopharyngeal nerve

Correct answer: Recurrent laryngeal nerve

The recurrent laryngeal nerve innervates all intrinsic laryngeal muscles except the cricothyroid, and bilateral injury causes permanent hoarseness or airway obstruction.

Question 27: Which type of wound healing is occurring when a surgeon deliberately leaves a contaminated wound open and allows it to close gradually from the base?

Primary intention
Quaternary intention
Tertiary intention (delayed primary closure)
Secondary intention (Correct answer)

Correct answer: Secondary intention

Secondary intention healing occurs when a wound is left open and closes by granulation tissue formation, wound contraction, and epithelialization.

Question 28: During laparoscopic cholecystectomy, critical view of safety requires visualization of how many structures entering the gallbladder?

One structure (cystic duct)
Two structures (cystic duct and cystic artery) (Correct answer)
Three structures including the common bile duct
The gallbladder neck and hepatocystic triangle only

Correct answer: Two structures (cystic duct and cystic artery)

Critical view of safety requires that only two structures — the cystic duct and cystic artery — are seen entering the gallbladder before clipping.

Question 29: Suture ligation (stick tie) is preferred over a free tie for vessel hemostasis when the vessel:

Is located in subcutaneous tissue
Is very small and easily grasped
Has already been controlled with a clip
Is large or in a location where a free tie could slip off before it is secured (Correct answer)

Correct answer: Is large or in a location where a free tie could slip off before it is secured

A suture ligation (stick tie) anchors the suture through the tissue around the vessel, preventing slippage that could occur with a free tie on a large or deep vessel.

Question 30: Which blood supply to the sigmoid colon is most commonly divided during sigmoid colectomy?

Right colic artery
Superior rectal artery only
Middle colic artery
Inferior mesenteric artery branches (sigmoid arteries) (Correct answer)

Correct answer: Inferior mesenteric artery branches (sigmoid arteries)

The sigmoid colon is supplied by sigmoid arteries (sigmoidal branches of the inferior mesenteric artery) which are divided during sigmoid colectomy.

Question 31: When closing a laparotomy fascial layer, which suture placement technique is recommended to reduce the risk of wound dehiscence?

Figure-of-eight sutures placed 2 cm from the edge
Small bites technique — sutures placed 5 mm from edge and 5 mm apart in a continuous fashion (Correct answer)
Simple interrupted sutures placed 1 cm apart and 1 cm from the edge
Running locking sutures placed as close to the edge as possible

Correct answer: Small bites technique — sutures placed 5 mm from edge and 5 mm apart in a continuous fashion

The small bites technique (STITCH trial) using 5 mm bite size and 5 mm spacing in a running fashion significantly reduces incisional hernia and dehiscence compared to large bites.

Certified Registered Nurse First Assistant (CRNFA)

The CRNFA exam assesses experienced registered nurse first assistants on their competency in intraoperative surgical techniques, perioperative patient assessment, basic sciences, and professional practice. It is administered by the National Assistant at Surgery Certification (NASC).

Questions

35 min

Time Limit

70%

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