NBCRNA National Certification Examination (NCE) — Questions and Answers

Question 1: Succinylcholine is contraindicated in patients with burn injuries because it can cause life-threatening what?

Hyperkalemia (Correct answer)
Hypokalemia
Bradycardia
Malignant hyperthermia

Correct answer: Hyperkalemia

Burn, crush, and denervation injuries cause upregulation of extrajunctional acetylcholine receptors, and succinylcholine-induced depolarization can release lethal amounts of potassium.

Question 2: In the preoperative airway assessment, which physical finding is most predictive of difficult bag-mask ventilation?

Mouth opening less than 3 cm
Beard, obesity (BMI >26), lack of teeth, age >55, and history of snoring (BONES mnemonic) (Correct answer)
Mallampati III or IV
Short thyromental distance

Correct answer: Beard, obesity (BMI >26), lack of teeth, age >55, and history of snoring (BONES mnemonic)

The BONES factors (Beard, Obesity, No teeth, Elderly, Snoring/OSA) identify patients likely to be difficult to ventilate with a mask, which is a separate assessment from difficult intubation.

Question 3: A patient with GERD and obesity presenting for laparoscopic surgery is considered at risk for pulmonary aspiration; the most effective pharmacological prophylaxis includes:

Antacid neutralization alone
Atropine to reduce gastric secretions
Preoperative nasogastric suctioning
H2 blocker or proton pump inhibitor plus metoclopramide preoperatively (Correct answer)

Correct answer: H2 blocker or proton pump inhibitor plus metoclopramide preoperatively

Reducing gastric acid production (H2 blocker/PPI) combined with metoclopramide (to accelerate gastric emptying) decreases both gastric volume and acidity, reducing aspiration risk and severity.

Question 4: Which neuromuscular blocking agent is reversed specifically by sugammadex?

Pancuronium
Succinylcholine
Cisatracurium
Rocuronium (Correct answer)

Correct answer: Rocuronium

Sugammadex is a modified gamma-cyclodextrin that encapsulates rocuronium (and vecuronium) to reverse neuromuscular blockade.

Question 5: The circle breathing system uses soda lime to do what?

Filter bacterial contamination
Remove volatile anesthetic vapors
Absorb carbon dioxide from exhaled gases (Correct answer)
Generate fresh oxygen for rebreathing

Correct answer: Absorb carbon dioxide from exhaled gases

Soda lime (primarily calcium hydroxide with sodium and potassium hydroxide) absorbs exhaled CO2 through a chemical reaction, allowing low-flow rebreathing circuits.

Question 6: What does a sustained upslope (shark fin appearance) in the capnography waveform indicate?

Obstructive airway disease or bronchospasm (Correct answer)
Esophageal intubation
Pulmonary embolism
Hyperventilation

Correct answer: Obstructive airway disease or bronchospasm

A prolonged, slanted upslope on capnography (shark fin) reflects uneven CO2 elimination from lung units with different time constants, characteristic of obstructive disease.

Question 7: The Bain circuit (Mapleson D modification) is a co-axial design where the inner tube carries what?

Scavenged gases
Humidified air
Fresh gas flow to the patient end (Correct answer)
Exhaled gases to the APL valve

Correct answer: Fresh gas flow to the patient end

In the Bain circuit, the inner tube delivers fresh gas to the patient end while exhaled gases travel through the outer corrugated tube to the APL valve.

Question 8: A capnograph waveform showing an elevated baseline (above zero) throughout the respiratory cycle suggests what problem?

CO2 rebreathing due to exhausted absorbent (Correct answer)
Venous air embolism
Bronchospasm
Esophageal intubation

Correct answer: CO2 rebreathing due to exhausted absorbent

An elevated baseline on capnography indicates that exhaled CO2 is being rebreathed, most commonly due to exhausted CO2 absorbent or an incompetent expiratory valve.

Question 9: Which local anesthetic is most associated with cardiac toxicity due to its high protein binding and sodium channel blocking properties?

Lidocaine
Bupivacaine (Correct answer)
Mepivacaine
Chloroprocaine

Correct answer: Bupivacaine

Bupivacaine has a high affinity for cardiac sodium channels and dissociates very slowly, making cardiotoxicity severe and difficult to treat.

Question 10: Horner syndrome (ptosis, miosis, anhidrosis) occurring after a brachial plexus block indicates what?

Pneumothorax
Vertebral artery injection
Local anesthetic spread to the cervical sympathetic chain (Correct answer)
Phrenic nerve palsy

Correct answer: Local anesthetic spread to the cervical sympathetic chain

Stellate ganglion block from local anesthetic spread interrupts the cervical sympathetic fibers, producing the classic ipsilateral Horner triad; it is benign and self-limiting.

Question 11: The Venturi effect in anesthesia equipment is used primarily in which device?

Venturi oxygen mask to entrain room air (Correct answer)
Circle breathing system CO2 absorber
Variable bypass vaporizer
Scavenging system interface

Correct answer: Venturi oxygen mask to entrain room air

Venturi (air-entrainment) oxygen masks use the Bernoulli/Venturi principle to entrain precise amounts of room air, delivering accurate fixed FiO2 concentrations.

Question 12: The treatment of choice for severe LAST with cardiovascular collapse is:

High-dose epinephrine infusion
Defibrillation as primary intervention
Sodium bicarbonate bolus
Lipid emulsion therapy (Intralipid 20%) (Correct answer)

Correct answer: Lipid emulsion therapy (Intralipid 20%)

Lipid emulsion therapy acts as a 'lipid sink,' sequestering the highly lipophilic local anesthetic from cardiac sodium channels and reversing cardiovascular toxicity.

Question 13: What does BIS (Bispectral Index) monitoring measure?

Neuromuscular blockade depth
Cerebral oxygen saturation
Cardiac output
Depth of anesthesia via processed EEG (Correct answer)

Correct answer: Depth of anesthesia via processed EEG

BIS is a processed electroencephalographic parameter that provides a dimensionless number (0–100) correlating with depth of hypnosis and risk of awareness under anesthesia.

Question 14: The P wave on an ECG tracing corresponds with:

atrial depolarization. (Correct answer)
atrial repolarization.
ventricular repolarization.
ventricular depolarization.

Correct answer: atrial depolarization.

Explanation: Atrial depolarization corresponds with the P wave on ECG tracing.

Question 15: In a double-lumen endotracheal tube, which lumen is used when the bronchial cuff is positioned in the left mainstem bronchus during a right thoracotomy?

Tracheal lumen ventilates the right lung (Correct answer)
Neither lumen; one-lung ventilation is achieved differently
Bronchial lumen ventilates the right lung
Both lumens ventilate the right lung

Correct answer: Tracheal lumen ventilates the right lung

With a left-sided DLT, the bronchial lumen inflated in the left bronchus isolates the left lung, allowing the tracheal lumen to ventilate the right lung during right-sided thoracic surgery.

Question 16: The epiglottis is lifted indirectly when the laryngoscope blade tip is placed in the vallecula during which technique?

Curved (Macintosh) blade laryngoscopy (Correct answer)
Fiberoptic nasotracheal intubation
Straight (Miller) blade laryngoscopy
Video laryngoscopy with hyperangulated blade

Correct answer: Curved (Macintosh) blade laryngoscopy

The Macintosh curved blade is placed in the vallecula (between the base of tongue and epiglottis); advancement stretches the hyoepiglottic ligament, indirectly elevating the epiglottis.

Question 17: The addition of epinephrine to local anesthetic solutions for peripheral nerve blocks primarily serves what purpose?

Reduces systemic toxicity by increasing absorption
Prevents allergic reactions to the local anesthetic
Enhances nerve membrane penetration
Prolongs duration of block by causing vasoconstriction (Correct answer)

Correct answer: Prolongs duration of block by causing vasoconstriction

Epinephrine causes local vasoconstriction, reducing vascular absorption of the local anesthetic and thereby prolonging the duration of the nerve block.

Question 18: Spinal headache (post-dural puncture headache) is caused by what mechanism?

CSF leakage through the dural puncture causing traction on intracranial pain-sensitive structures (Correct answer)
Vasodilation from local anesthetic sympathectomy
Elevated intracranial pressure after dural puncture
Meningeal inflammation from skin flora contamination

Correct answer: CSF leakage through the dural puncture causing traction on intracranial pain-sensitive structures

CSF leak through the dural hole reduces intrathecal pressure, causing orthostatic traction on meninges and intracranial vessels, producing the characteristic positional headache.

Question 19: When managing a difficult pediatric airway, which sizing rule is used to estimate the appropriate uncuffed ETT internal diameter?

Weight (kg) / 10
Age + 2
(Age/4) + 4 (Correct answer)
(Age/2) + 8

Correct answer: (Age/4) + 4

The formula (age in years ÷ 4) + 4 estimates the appropriate uncuffed endotracheal tube internal diameter in millimeters for pediatric patients.

Question 20: Which of the following does NOT contribute to the increased risk of difficult intubation in obstetric patients?

Increased lower esophageal sphincter tone (Correct answer)
Large breasts
Mucosal edema of the airway
Decreased functional residual capacity

Correct answer: Increased lower esophageal sphincter tone

Pregnancy decreases lower esophageal sphincter tone (due to progesterone), which increases aspiration risk rather than intubation difficulty.

Question 21: A patient with severe aortic stenosis presents for hip replacement. Which hemodynamic goal is most important intraoperatively?

Maintain normal sinus rhythm and avoid tachycardia and hypotension (Correct answer)
Keep heart rate above 90 bpm to maintain cardiac output
Aggressive fluid restriction to prevent pulmonary edema
Allow permissive hypotension to reduce afterload

Correct answer: Maintain normal sinus rhythm and avoid tachycardia and hypotension

Severe AS requires a fixed cardiac output; tachycardia reduces diastolic filling time, hypotension removes coronary perfusion pressure, and arrhythmias can cause rapid decompensation.

Question 22: Which technique is used to minimize the risk of accidental esophageal extubation during patient positioning after intubation?

Inflating the cuff to a pressure above 30 cmH2O
Keeping the ETT taped to the upper lip rather than the teeth
Auscultation and capnography confirmation after every position change (Correct answer)
Using a reinforced (anode) tube in all cases

Correct answer: Auscultation and capnography confirmation after every position change

Repositioning the patient can cause tube migration; confirming bilateral breath sounds and continuous capnography waveform after each position change detects displacement immediately.

Question 23: What is the hourly maintenance fluid rate for an 11-pound infant?

30 mL/h
25 mL/h
10 mL/h
20 mL/h (Correct answer)

Correct answer: 20 mL/h

Explanation: The hourly maintenance fluid rate for an 11-pound infant is typically calculated using the Holliday-Segar method, which suggests a rate of approximately 4 mL/kg/hour for the first 10 kg of body weight. For an 11-pound infant (approximately 5 kg): 4 mL/kg/hour × 5 kg = 20 mL/hour

Question 24: A thoracic epidural for post-thoracotomy analgesia is most effective because it blocks which nerves?

Phrenic nerve preventing diaphragmatic splinting
Brachial plexus reducing shoulder pain
Celiac plexus reducing referred upper abdominal pain
Intercostal nerves (T4–T8) and sympathetic chain at operative levels (Correct answer)

Correct answer: Intercostal nerves (T4–T8) and sympathetic chain at operative levels

Thoracic epidural analgesia blocks intercostal nerves at the surgical levels, providing superior pain relief that reduces splinting, improves respiratory mechanics, and decreases pulmonary complications.

Question 25: Which vasopressor is currently recommended as the first-line treatment for spinal hypotension during cesarean delivery?

Dopamine
Ephedrine
Phenylephrine (Correct answer)
Epinephrine

Correct answer: Phenylephrine

Phenylephrine is the first-line vasopressor for spinal hypotension in obstetrics because it maintains uteroplacental blood flow better than ephedrine and is associated with less fetal acidosis.

Question 26: What is the recommended sensory block level for effective epidural labor analgesia?

T8 to L4
T6 to S4
L1 to S1
T10 to L1 (Correct answer)

Correct answer: T10 to L1

Labor analgesia requires a sensory block from T10 (umbilicus) to L1 to cover uterine contraction pain during the first stage of labor.

Question 27: Which drug would carry the HIGHEST risk of an adverse drug reaction with IV contrast dye during a lower limb angiography?

Omeprazole (Prilosec)
Citalopram (Celexa)
Metoprolol (Toprol)
Metformin (Glucophage) (Correct answer)

Correct answer: Metformin (Glucophage)

Explanation: Of the drugs listed, the only medication that carries an adverse drug reaction risk with contrast dye is metformin. When given in conjunction with contrast dye, it is associated with an increased potential for lactic acidosis. The combination of the 2 drugs could expose the patient to significant contrast-induced nephropathy.

Question 28: The cognitive aid (crisis checklist) most recommended for managing intraoperative crises is designed to do what?

Reduce cognitive load during high-stress events by providing stepwise protocols that prevent critical steps from being missed (Correct answer)
Replace clinical judgment with algorithmic decision-making
Serve as a documentation tool for medicolegal defense
Assign tasks automatically to operating room team members

Correct answer: Reduce cognitive load during high-stress events by providing stepwise protocols that prevent critical steps from being missed

Cognitive aids (like the Stanford Emergency Manual) address the well-documented human tendency to experience cognitive overload during emergencies, where critical steps are forgotten; the checklist externalizes the protocol so the team can focus on execution.

Question 29: During epidural anesthesia, a test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine is used to detect what?

Adequate epidural space identification
Allergic sensitivity to the local anesthetic
Intravascular catheter placement (tachycardia) and intrathecal placement (rapid spinal block) (Correct answer)
Subdural catheter migration

Correct answer: Intravascular catheter placement (tachycardia) and intrathecal placement (rapid spinal block)

The epinephrine component causes a 20+ bpm heart rate increase if injected intravascularly, while the lidocaine dose would produce a rapid dense spinal block if injected intrathecally.

Question 30: Rapid sequence induction (RSI) is indicated in patients at risk for pulmonary aspiration and includes preoxygenation followed by what drug sequence?

Induction agent only, awake intubation
Induction agent + succinylcholine (or rocuronium), no mask ventilation (Correct answer)
Induction agent + non-depolarizing NMB + mask ventilation
Inhalation induction with cricoid pressure

Correct answer: Induction agent + succinylcholine (or rocuronium), no mask ventilation

Classic RSI uses an induction agent with succinylcholine (or high-dose rocuronium for a modified RSI) without positive-pressure mask ventilation to minimize aspiration risk before cuff inflation.

Question 31: Chronic kidney disease (CrCl <30 mL/min) affects anesthetic management primarily because it impairs elimination of what drugs?

Renally cleared drugs including morphine-6-glucuronide, neostigmine, and pancuronium (Correct answer)
Propofol and remifentanil
All local anesthetics
All volatile anesthetic agents

Correct answer: Renally cleared drugs including morphine-6-glucuronide, neostigmine, and pancuronium

Renal impairment accumulates renally-cleared drugs and active metabolites; morphine-6-glucuronide (active, sedating), neostigmine, and steroidal NMBDs (pancuronium) are especially problematic.

Question 32: Calculate the cardiac output given the following hemodynamic parameters: Stroke volume: 60 mL Blood pressure: 150/70 mm Hg Heart rate: 50/min

3 L/min (Correct answer)
6 L/min
5 L/min
4 L/min

Correct answer: 3 L/min

Explanation: To calculate cardiac output (CO), you can use the formula: CO = Stroke Volume × Heart Rate Given: Stroke Volume (SV) = 60 mL Heart Rate (HR) = 50 beats per minute First, calculate the cardiac output in mL/min: CO = 60 mL × 50 beats/min CO = 3000 mL/min Now, convert mL/min to L/min (since 1 L = 1000 mL): CO = 3 L/min

Question 33: The first-line treatment for intraoperative anaphylaxis is:

Epinephrine 0.01 mg/kg IV (10–100 mcg) titrated to response (Correct answer)
Ephedrine 10 mg IV bolus
Diphenhydramine IV first, followed by corticosteroids
Norepinephrine infusion

Correct answer: Epinephrine 0.01 mg/kg IV (10–100 mcg) titrated to response

Epinephrine is the only first-line treatment for anaphylaxis; it counteracts vasodilation (alpha-1), supports heart rate and contractility (beta-1), and reverses bronchospasm (beta-2).

Question 34: Which opioid has the fastest onset due to its high lipid solubility and is most commonly used for intraoperative analgesia infusions?

Meperidine
Hydromorphone
Morphine
Remifentanil (Correct answer)

Correct answer: Remifentanil

Remifentanil is an ultra-short-acting opioid with rapid onset and offset due to ester hydrolysis metabolism, making it ideal for continuous intraoperative infusions.

Question 35: The anesthesia vaporizer is classified as variable bypass because it does what?

Uses electronic sensors to adjust output
Varies temperature to control vapor pressure
Relies on carrier gas pressure changes
Splits gas flow between a bypass chamber and a vaporizing chamber (Correct answer)

Correct answer: Splits gas flow between a bypass chamber and a vaporizing chamber

Variable bypass vaporizers split the fresh gas stream — a portion passes through the vaporizing chamber to become saturated with vapor, while the rest bypasses it; the ratio determines the output concentration.

Question 36: The Apfel score is used preoperatively to predict risk of what postoperative complication?

Deep vein thrombosis
Postoperative nausea and vomiting (PONV) (Correct answer)
Postoperative cognitive dysfunction
Surgical site infection

Correct answer: Postoperative nausea and vomiting (PONV)

The Apfel simplified risk score uses four factors (female sex, non-smoking, history of PONV/motion sickness, postoperative opioid use) to predict PONV risk and guide prophylactic antiemetic strategy.

Question 37: Which intraoperative sign is the earliest indicator of malignant hyperthermia (MH)?

Unexplained increase in end-tidal CO2 (Correct answer)
Tachycardia with ST changes
Muscle rigidity
Rising core temperature

Correct answer: Unexplained increase in end-tidal CO2

Increased metabolic rate from uncontrolled skeletal muscle calcium release produces excess CO2 before core temperature rises significantly, making elevated ETCO2 the most sensitive early MH sign.

Question 38: In pediatric patients, which calculation is used to estimate blood volume for transfusion planning?

Red cell mass = hemoglobin × 10 mL/kg
Blood volume = 4 mL/kg/hr maintenance + surgical losses
Estimated blood volume = weight (kg) × 70–80 mL/kg for term neonates (Correct answer)
Estimated blood volume = weight (kg) × 50 mL/kg

Correct answer: Estimated blood volume = weight (kg) × 70–80 mL/kg for term neonates

Term neonates have approximately 80–90 mL/kg blood volume, older infants 70–80 mL/kg, and children 70 mL/kg; this estimate guides allowable blood loss calculations and transfusion thresholds.

Question 39: Which neuromuscular blocking agent is a benzylisoquinoline compound?

Vecuronium
Mivacurium (Correct answer)
Succinylcholine
Pancuronium

Correct answer: Mivacurium

Explanation: Mivacurium is a neuromuscular blocking agent that belongs to the benzylisoquinoline class of compounds. It is a short-acting nondepolarizing muscle relaxant used in anesthesia.

Question 40: On the anesthesia machine, the fail-safe valve is designed to prevent the delivery of hypoxic gas mixtures by doing what?

Alarming when FiO2 falls below 21%
Shutting off the vaporizer when N2O is on
Increasing oxygen flow automatically
Proportionally reducing nitrous oxide flow when oxygen pressure drops (Correct answer)

Correct answer: Proportionally reducing nitrous oxide flow when oxygen pressure drops

The fail-safe (oxygen failure protection device) shuts off or proportionally reduces the flow of N2O and other gases when the oxygen supply pressure falls below a threshold.

Question 41: Saddle block is a form of spinal anesthesia providing perineal anesthesia; it is achieved by using which technique?

Continuous spinal with catheter at L5–S1
Hyperbaric solution injected with patient sitting upright for 5–10 minutes (Correct answer)
Isobaric solution with patient in lithotomy position
Bilateral pudendal nerve blocks

Correct answer: Hyperbaric solution injected with patient sitting upright for 5–10 minutes

A saddle block uses a small volume of hyperbaric local anesthetic with the patient sitting; gravity restricts spread to the sacral nerve roots (S2–S5), anesthetizing the perineal 'saddle' area.

Question 42: The Wright respirometer is used intraoperatively to measure what?

Exhaled tidal volume (Correct answer)
Airway resistance
Inspiratory oxygen fraction
End-tidal CO2

Correct answer: Exhaled tidal volume

The Wright respirometer is a mechanical device that measures exhaled tidal and minute volumes by counting rotations of a vane turned by gas flow.

Question 43: Which drug is the antidote for magnesium toxicity causing respiratory depression?

Flumazenil
Neostigmine
Naloxone
Calcium gluconate (Correct answer)

Correct answer: Calcium gluconate

Calcium gluconate (1 g IV) antagonizes the effects of magnesium and is the antidote for life-threatening magnesium toxicity.

Question 44: What finding indicates early magnesium toxicity in a preeclamptic patient receiving magnesium sulfate infusion?

Cardiac arrest
Loss of deep tendon reflexes (Correct answer)
Respiratory arrest
Widening of QRS complex

Correct answer: Loss of deep tendon reflexes

Loss of deep tendon reflexes (patellar reflex) occurs at serum magnesium levels of 7-10 mEq/L and is the earliest clinical sign of magnesium toxicity.

Question 45: In ultrasound-guided nerve block, the in-plane technique means the needle is advanced:

At a 45-degree angle to the probe
From the distal end toward the nerve
Perpendicular to the ultrasound beam, showing only a cross-section
Parallel to the ultrasound beam so the entire shaft is visualized (Correct answer)

Correct answer: Parallel to the ultrasound beam so the entire shaft is visualized

In-plane needle advancement inserts the needle parallel to the ultrasound beam in the long axis, allowing visualization of the entire needle shaft and tip throughout the procedure.

Question 46: What is the most serious complication specific to interscalene brachial plexus block?

Ipsilateral phrenic nerve palsy causing hemidiaphragm paralysis (Correct answer)
Postoperative shoulder pain rebound
Ulnar nerve sparing requiring supplemental block
Horner syndrome

Correct answer: Ipsilateral phrenic nerve palsy causing hemidiaphragm paralysis

Ipsilateral phrenic nerve block occurs in nearly 100% of interscalene blocks, reducing pulmonary function by about 25%, which is contraindicated in patients with severe respiratory disease.

Question 47: Continuous peripheral nerve block catheters are preferred over single-shot blocks for what clinical advantage?

Provide extended analgesia beyond 24 hours for prolonged post-operative pain management (Correct answer)
Provide motor block for immobilization after orthopedic repair
Allow higher total local anesthetic doses
Eliminate the need for postoperative opioids entirely

Correct answer: Provide extended analgesia beyond 24 hours for prolonged post-operative pain management

Perineural catheters allow continuous or patient-controlled local anesthetic infusion for days, significantly extending postoperative analgesia beyond the 12–24 hour duration of single-injection blocks.

Question 48: Awake fiberoptic intubation is the preferred technique in which type of patient?

Morbidly obese patient with normal airway exam
Patient with history of malignant hyperthermia
Pediatric patient with small airways
Known or anticipated difficult airway with full stomach risk (Correct answer)

Correct answer: Known or anticipated difficult airway with full stomach risk

Awake fiberoptic intubation preserves spontaneous respiration and airway reflexes, making it ideal for patients with known difficult airways where loss of airway control under anesthesia would be dangerous.

Question 49: Which finding on laryngoscopy corresponds to a Cormack-Lehane Grade III view?

No laryngeal structures visible
Posterior glottis visible
Only epiglottis visible, no glottic structures seen (Correct answer)
Full glottis visible

Correct answer: Only epiglottis visible, no glottic structures seen

A Grade III Cormack-Lehane view means only the epiglottis can be seen, with no part of the glottis visible, indicating a difficult intubation.

Question 50: A transversus abdominis plane (TAP) block targets which anatomical space to provide abdominal wall analgesia?

Epidural space at T10–L1 level
Fascial plane between internal oblique and transversus abdominis muscles (Correct answer)
Peritoneal cavity adjacent to bowel
Subcutaneous tissue above the external oblique

Correct answer: Fascial plane between internal oblique and transversus abdominis muscles

The TAP block deposits local anesthetic in the neurofascial plane between the internal oblique and transversus abdominis, blocking T10–L1 intercostal nerves supplying the anterior abdominal wall.

Question 51: Which antihypertensive agent is CONTRAINDICATED in the management of severe hypertension in a breastfeeding mother with preeclampsia?

Labetalol
Atenolol (Correct answer)
Hydralazine
Nicardipine

Correct answer: Atenolol

Atenolol is contraindicated in breastfeeding mothers because it concentrates in breast milk at high levels and can cause neonatal bradycardia and hypoglycemia.

Question 52: Venous air embolism (VAE) is detected earliest by which monitor?

Pulmonary artery catheter
ETCO2 decline
Precordial Doppler ultrasound (Correct answer)
Transesophageal echocardiography

Correct answer: Precordial Doppler ultrasound

Precordial Doppler detects as little as 0.05 mL of intracardiac air as a characteristic 'mill-wheel' murmur, earlier than any other clinical or monitoring sign.

Question 53: The Mallampati classification is used preoperatively to predict what?

Difficulty of laryngoscopy and intubation (Correct answer)
Depth of anesthesia required
Aspiration risk
Likelihood of post-operative sore throat

Correct answer: Difficulty of laryngoscopy and intubation

The Mallampati score assesses oropharyngeal structures visible with mouth open and tongue protruded; higher scores (III–IV) correlate with restricted laryngoscopic view and difficult intubation.

Question 54: A patient's preoperative HbA1c of 10.5% suggests what and has what implication for elective surgery?

Excellent glycemic control; proceed without modification
Requires insulin pump adjustment only
No anesthetic implications if fasting glucose is <200 mg/dL
Poorly controlled diabetes associated with increased risk of surgical site infection and cardiovascular complications; consider optimizing glycemic control (Correct answer)

Correct answer: Poorly controlled diabetes associated with increased risk of surgical site infection and cardiovascular complications; consider optimizing glycemic control

HbA1c >8% reflects chronic hyperglycemia and is associated with impaired wound healing, infection, and perioperative cardiovascular events; HbA1c >9–10% often warrants preoperative optimization for elective cases.

Question 55: A fetus delivered at 39 weeks has an Apgar score of 4 at 1 minute. What is the NEXT step in neonatal resuscitation?

Perform cardiac compressions immediately
Administer epinephrine via endotracheal tube
Begin positive pressure ventilation (Correct answer)
Administer naloxone IV

Correct answer: Begin positive pressure ventilation

An Apgar score of 4-6 indicates a depressed neonate; positive pressure ventilation is the most critical initial intervention in neonatal resuscitation.

Question 56: Intrathecal narcotic administration is associated with:

sympathetic nervous system denervation.
altered pain perception. (Correct answer)
loss of proprioception.
skeletal muscle weakness.

Correct answer: altered pain perception.

Explanation: Intrathecal narcotic administration affects pain perception by directly acting on opioid receptors in the spinal cord, resulting in pain relief. It does not typically cause loss of proprioception, skeletal muscle weakness, or sympathetic nervous system denervation.

Question 57: The MAC of an inhalation anesthetic is defined as the minimum alveolar concentration that prevents movement in what percentage of patients exposed to a surgical skin incision?

99%
95%
75%
50% (Correct answer)

Correct answer: 50%

MAC is the median effective dose (ED50), representing the alveolar concentration at which 50% of patients do not move in response to a surgical skin incision.

Question 58: Which preoperative finding on ECG most significantly increases perioperative risk for non-cardiac surgery?

Sinus tachycardia
First-degree AV block
Isolated T-wave inversions in V4–V6
Left bundle branch block (new or unknown onset) (Correct answer)

Correct answer: Left bundle branch block (new or unknown onset)

New or unknown LBBB can mask ST changes of ischemia, may indicate severe underlying cardiac disease (cardiomyopathy, CAD), and requires further cardiac evaluation before elective surgery.

Question 59: Which induction agent is contraindicated in patients with porphyria?

Ketamine
Thiopental (Correct answer)
Propofol
Etomidate

Correct answer: Thiopental

Barbiturates such as thiopental induce delta-aminolevulinic acid (ALA) synthase, precipitating acute porphyric crises in susceptible patients.

Question 60: What is the primary mechanism of action of propofol?

Sodium channel blockade
NMDA receptor antagonism
Opioid receptor agonism
GABA-A receptor potentiation (Correct answer)

Correct answer: GABA-A receptor potentiation

Propofol produces hypnosis primarily by enhancing GABA-mediated inhibitory neurotransmission at GABA-A receptors.

Question 61: Which is the first sign of magnesium toxicity when used for seizure prophylaxis in preeclampsia?

Loss of deep tendon reflexes (Correct answer)
Respiratory depression
Cardiac conduction defects
Hypotension

Correct answer: Loss of deep tendon reflexes

Explanation: Loss of deep tendon reflexes is typically the first sign of magnesium toxicity when used for seizure prophylaxis in preeclampsia. Magnesium can accumulate in the body, leading to neuromuscular effects such as diminished reflexes before more severe symptoms like respiratory depression, hypotension, or cardiac conduction defects occur.

Question 62: Dexmedetomidine produces sedation and analgesia primarily through which mechanism?

GABA-A receptor potentiation
Opioid receptor activation
Muscarinic receptor antagonism
Alpha-2 adrenergic receptor agonism (Correct answer)

Correct answer: Alpha-2 adrenergic receptor agonism

Dexmedetomidine acts on alpha-2 adrenergic receptors in the locus coeruleus and spinal cord to produce sedation, anxiolysis, and analgesia without respiratory depression.

Question 63: During a pre-use anesthesia machine check, which test verifies that the low-pressure circuit is leak-free?

Negative pressure (suction bulb) leak test (Correct answer)
Oxygen flush valve test
Vaporizer interlock test
Flowmeter calibration check

Correct answer: Negative pressure (suction bulb) leak test

The negative pressure leak test uses a suction bulb to apply negative pressure to the low-pressure circuit; failure to re-expand indicates an intact, leak-free system.

Question 64: Intraoperative hypertension requiring treatment is most commonly caused by what?

Hyperoxia during oxygen therapy
Volume overload with normal cardiac function
Hyperthermia causing sympathetic activation
Inadequate analgesia and depth of anesthesia during painful stimulation (Correct answer)

Correct answer: Inadequate analgesia and depth of anesthesia during painful stimulation

The most common intraoperative cause of hypertension is inadequate anesthetic depth or analgesia during surgical stimulation, causing sympathetic activation with increased heart rate and blood pressure.

Question 65: A patient taking clopidogrel for a coronary stent placed 4 months ago requires urgent hip fracture surgery. The recommended management is:

Cancel surgery until the stent is at least 12 months old
Proceed with surgery; withholding antiplatelet therapy risks in-stent thrombosis (Correct answer)
Hold clopidogrel 5–7 days before proceeding with neuraxial anesthesia
Continue clopidogrel and use general anesthesia with neuraxial anesthesia contraindicated

Correct answer: Proceed with surgery; withholding antiplatelet therapy risks in-stent thrombosis

For urgent surgery, the risk of delaying outweighs the bleeding risk; proceeding is recommended, and neuraxial anesthesia would be contraindicated per ASRA guidelines if clopidogrel was recently taken.

Question 66: High-flow nasal cannula (HFNC) used during preoxygenation before RSI provides apneic oxygenation by what mechanism?

Delivering continuous oxygen flow to maintain FRC oxygen reservoir during apnea (Correct answer)
Reducing upper airway resistance during bag-mask ventilation
Washing out nitrogen from alveoli faster than standard NC
Providing PEEP equivalent to 5 cmH2O

Correct answer: Delivering continuous oxygen flow to maintain FRC oxygen reservoir during apnea

HFNC delivers up to 70 L/min of oxygen, which diffuses from the pharynx to alveoli during apnea (apneic oxygenation), extending safe apnea time significantly.

Question 67: Etomidate is preferred for induction in hemodynamically unstable patients primarily because it does what?

Blocks sympathetic nervous system
Minimally affects cardiovascular function (Correct answer)
Causes bronchodilation
Provides profound analgesia

Correct answer: Minimally affects cardiovascular function

Etomidate provides reliable hypnosis with minimal cardiovascular depression, making it the induction agent of choice for patients with cardiovascular compromise.

Question 68: PONV (postoperative nausea and vomiting) prophylaxis is most effective when using what approach?

High-dose dexamethasone alone
Single maximum-dose ondansetron
Total inhalation anesthesia technique
Multimodal combination antiemetic therapy targeting different receptor mechanisms (Correct answer)

Correct answer: Multimodal combination antiemetic therapy targeting different receptor mechanisms

Combining antiemetics with different mechanisms (5-HT3 antagonist + dexamethasone + scopolamine patch) provides additive efficacy; each agent reduces PONV by ~26%, and combinations dramatically reduce overall risk.

Question 69: The immediate management of an accidental intravenous injection of local anesthetic (LAST) begins with:

Perform chest compressions as first action
Stop injection, call for help, secure airway, and prepare lipid emulsion (Correct answer)
Immediately administer epinephrine 1 mg IV
Administer sodium bicarbonate to alkalinize the blood

Correct answer: Stop injection, call for help, secure airway, and prepare lipid emulsion

The ASRA LAST management protocol prioritizes stopping the injection, calling for help, maintaining oxygenation and airway, controlling seizures with benzodiazepines, and preparing lipid emulsion for cardiovascular collapse.

Question 70: Train-of-four (TOF) monitoring is used to assess what?

Depth of anesthesia
Degree of neuromuscular blockade (Correct answer)
Cerebral perfusion
Cardiac rhythm

Correct answer: Degree of neuromuscular blockade

TOF monitoring applies four supramaximal electrical stimuli to a peripheral nerve and counts the resulting muscle twitches to quantify the degree of non-depolarizing neuromuscular blockade.

Question 71: Considerations for the management of a patient with myotonic dystrophy under general anesthesia should include a/an:

short-acting nondepolarizer. (Correct answer)
anticholinesterase reversal.
succinylcholine infusion.
midazolam premedication.

Correct answer: short-acting nondepolarizer.

Explanation: Myotonic dystrophy is a genetic disorder affecting muscle function, and patients may be sensitive to depolarizing muscle relaxants like succinylcholine. Therefore, using a short-acting nondepolarizing muscle relaxant is preferred to avoid complications associated with prolonged neuromuscular blockade in these patients.

Question 72: Intraoperative bronchospasm during general anesthesia is most commonly caused by what?

Excessive PEEP causing air trapping
Pulmonary embolism
Volatile anesthetic overdose
Airway manipulation (intubation, suctioning) in an inadequately anesthetized patient (Correct answer)

Correct answer: Airway manipulation (intubation, suctioning) in an inadequately anesthetized patient

Stimulation of the reactive airway by endotracheal tube placement or suctioning when the depth of anesthesia is inadequate triggers reflex bronchospasm through vagal airway reflexes.

Question 73: In the lateral position, blood flow to the dependent lung of the anesthetized patient MOST represents which zone of flow?

Zone: 7
Zone: 5
Zone: 3 (Correct answer)
Zone: 1

Correct answer: Zone: 3

Explanation: Zone 3 occurs in dependent lung regions where alveolar pressure exceeds arterial and venous pressures. This positioning allows for optimal gas exchange in these areas, which are crucial for maintaining adequate ventilation and perfusion balance during anesthesia.

Question 74: Which device is operational to prevent the simultaneous use of more than one anesthetic vaporizer?

Variable bypass
Interlock (Correct answer)
Quick connect
Agent-limiting

Correct answer: Interlock

Explanation: Anesthetic machines that contain a mounting system from multiple vaporizers incorporate an interlock system preventing the simultaneous use of more than one vaporizer.

Question 75: Tension pneumothorax during positive pressure ventilation is recognized by which clinical triad?

Hypertension, bilateral wheeze, and elevated SpO2
Bradycardia, crackles, and mediastinal shift toward affected side
Tachycardia, cyanosis, and bilateral absent breath sounds
Hypotension, absent breath sounds, tracheal deviation away from affected side (Correct answer)

Correct answer: Hypotension, absent breath sounds, tracheal deviation away from affected side

Tension pneumothorax causes one-sided absent breath sounds, hypotension from obstructed venous return, and tracheal deviation away from the affected side as mediastinal structures shift.

Question 76: According to the ASA Difficult Airway Algorithm, after a failed intubation attempt in a 'cannot intubate, cannot oxygenate' (CICO) scenario, what is the definitive rescue technique?

Blind nasal intubation
Retrograde wire intubation
Repeated direct laryngoscopy attempts
Emergency front-of-neck airway (cricothyrotomy) (Correct answer)

Correct answer: Emergency front-of-neck airway (cricothyrotomy)

In a CICO emergency, emergency front-of-neck airway access (surgical or needle cricothyrotomy) is the definitive rescue step to restore oxygenation and prevent death.

Question 77: Which factor most significantly increases the risk of post-dural puncture headache (PDPH) after accidental dural puncture with an epidural needle?

Obesity (BMI > 35)
Use of opioids in the epidural solution
Patient age over 40
Use of a 17-gauge Tuohy needle (Correct answer)

Correct answer: Use of a 17-gauge Tuohy needle

The large gauge of the Tuohy epidural needle (typically 17-18 gauge) creates a large dural tear resulting in significant CSF leak and a high incidence of PDPH when accidental dural puncture occurs.

Question 78: Which inhalation anesthetic has the lowest blood-gas partition coefficient, resulting in the fastest induction and emergence?

Sevoflurane
Isoflurane
Desflurane (Correct answer)
Halothane

Correct answer: Desflurane

Desflurane has the lowest blood-gas partition coefficient (0.42) among currently used volatile agents, enabling the most rapid alveolar equilibration.

Question 79: Which condition can cause falsely elevated pulse oximetry readings in a patient with carbon monoxide poisoning?

Nail polish interferes with both wavelengths equally
Carboxyhemoglobin absorbs light similarly to oxyhemoglobin at 660 nm (Correct answer)
Methemoglobin causes a fixed reading of 85%
Low perfusion reduces signal accuracy

Correct answer: Carboxyhemoglobin absorbs light similarly to oxyhemoglobin at 660 nm

Standard pulse oximeters cannot distinguish carboxyhemoglobin from oxyhemoglobin because both absorb red light (660 nm) similarly, leading to falsely high SpO2 readings.

Question 80: The level of epidural blockade required to provide anesthesia for a Cesarean section is typically:

T10 for pain, L1 for pressure
L1 for adequate motor block
T6 for sensation to ice
T4 bilateral sensory block (Correct answer)

Correct answer: T4 bilateral sensory block

Cesarean section requires a bilateral sensory block to T4 (nipple level) to cover peritoneal and uterine manipulation; an inadequate level results in intraoperative pain.

Question 81: Which drug is the treatment of choice for acute malignant hyperthermia crisis?

Dantrolene (Correct answer)
Propranolol
Bicarbonate
Calcium gluconate

Correct answer: Dantrolene

Dantrolene inhibits ryanodine receptor-mediated calcium release from the sarcoplasmic reticulum, directly treating the hyperthermia and muscle rigidity of MH.

Question 82: Which opioid used in labor analgesia has the fastest onset and shortest duration, making it useful for IV patient-controlled analgesia during active labor?

Morphine
Hydromorphone
Meperidine
Remifentanil (Correct answer)

Correct answer: Remifentanil

Remifentanil's ultra-short duration (context-sensitive half-life ~3 min) and fast onset make it well-suited for IV PCA in labor, though continuous monitoring is required due to maternal respiratory depression risk.

Question 83: Intraoperative ST-segment depression >1 mm in two contiguous leads suggests:

Normal response to volatile anesthetic agents
Myocardial ischemia requiring immediate assessment of hemodynamics and coronary perfusion (Correct answer)
Hyperkalemia
Ventricular hypertrophy without ischemia

Correct answer: Myocardial ischemia requiring immediate assessment of hemodynamics and coronary perfusion

New horizontal or down-sloping ST depression >1 mm in ≥2 contiguous leads indicates subendocardial ischemia; immediate intervention to restore coronary perfusion pressure (increase MAP, reduce heart rate) is required.

Question 84: Which volatile anesthetic is contraindicated in patients at risk for malignant hyperthermia?

All potent volatile agents (Correct answer)
Nitrous oxide only
Ketamine
Propofol

Correct answer: All potent volatile agents

All potent volatile anesthetic agents (halothane, isoflurane, desflurane, sevoflurane) are known triggers for malignant hyperthermia in susceptible individuals.

Question 85: Which alarm is considered the highest priority on modern anesthesia workstations according to ISO standards?

CO2 absorber exhaustion warning
Vaporizer interlock alert
Low fresh gas flow alarm
Apnea or disconnect alarm (Correct answer)

Correct answer: Apnea or disconnect alarm

Apnea/disconnect alarms are highest priority because they indicate immediate life-threatening failure of ventilation, requiring the fastest provider response.

Question 86: Which drug is MOST appropriate to treat refractory hypotension in a patient who took lisinopril (Prinivil, Zestril) on the day of surgery?

Vasopressin (Correct answer)
Isoproterenol (Isuprel)
Glucagon
Atropine

Correct answer: Vasopressin

Explanation: Patients who take ACE inhibitors (lisinopril) can manifest profound hypotension despite boluses of ephedrine and phenylephrine. The best next course of action is to administer a direct-acting catecholamine or vasopressin.

Question 87: In spinal anesthesia, which factor most influences the spread of local anesthetic in the intrathecal space?

Patient's height
Baricity of the local anesthetic solution relative to CSF (Correct answer)
Total dose of local anesthetic injected
Speed of injection

Correct answer: Baricity of the local anesthetic solution relative to CSF

Baricity (density relative to CSF) determines whether the solution is hyperbaric (sinks), hypobaric (rises), or isobaric (stays), making patient positioning and baricity the primary determinants of block spread.

Question 88: Obstructive sleep apnea (OSA) increases perioperative risk primarily due to increased sensitivity to what?

Regional anesthetics causing excessive sympatholysis
Opioids and sedatives causing upper airway obstruction and hypoxia (Correct answer)
Volatile anesthetics causing bronchospasm
Neuromuscular blocking agents requiring higher doses

Correct answer: Opioids and sedatives causing upper airway obstruction and hypoxia

OSA patients have baseline hypoxemia risk and exaggerated sensitivity to opioids and sedatives, which further depress pharyngeal muscle tone and respiratory drive, increasing postoperative airway obstruction risk.

Question 89: A patient with an emergent stroke comes for an embolization procedure. The patient is allergic to morphine and sulfonamides. He has a history of gout, hypertension, gastrointestinal bleeding, and reflux. Which medication should be avoided in the postoperative orders?

Fentanyl (Sublimaze)
Acetaminophen
Ketorolac (Toradol) (Correct answer)
Hydromorphone (Dilaudid)

Correct answer: Ketorolac (Toradol)

Explanation: Ketorolac is a nonselective inhibitor of prostaglandin synthesis. It is contraindicated in patients with a history of peptic ulcer disease and gastrointestinal bleeding.

Question 90: What dermatome level of sensory blockade is required for adequate spinal anesthesia during cesarean delivery?

T2
T4 (Correct answer)
T10
T6

Correct answer: T4

A sensory block to T4 (nipple line) is required for cesarean delivery to cover peritoneal manipulation and uterine exteriorization.

Question 91: The opioid reversal agent naloxone works by which mechanism?

Direct respiratory center stimulation
Allosteric GABA-A enhancement
Enzyme-mediated opioid metabolism
Competitive opioid receptor antagonism (Correct answer)

Correct answer: Competitive opioid receptor antagonism

Naloxone competitively antagonizes mu, kappa, and delta opioid receptors, rapidly reversing opioid-induced respiratory depression, sedation, and analgesia.

Question 92: A patient with severe preeclampsia develops a seizure intrapartum. Which drug is the treatment of choice?

Phenytoin IV
Magnesium sulfate IV bolus (Correct answer)
Lorazepam IV
Diazepam IV

Correct answer: Magnesium sulfate IV bolus

Magnesium sulfate is the drug of choice for treating and preventing eclamptic seizures; it reduces neuromuscular excitability and cerebral vasospasm.

Question 93: Which preoperative cardiac test is indicated when a patient with poor functional capacity (<4 METs) is scheduled for high-risk surgery and the result would change management?

Exercise treadmill test
Resting echocardiogram
Pharmacologic stress testing (dobutamine stress echo or nuclear stress test) (Correct answer)
Preoperative coronary angiography

Correct answer: Pharmacologic stress testing (dobutamine stress echo or nuclear stress test)

Patients who cannot achieve 4 METs and face high-risk surgery may benefit from pharmacologic stress testing to identify significant coronary artery disease that would alter perioperative management.

Question 94: At approximately what gestational age is an obstetric patient considered to have a full stomach and at increased aspiration risk during anesthesia?

8 weeks
18 weeks
14 weeks (Correct answer)
24 weeks

Correct answer: 14 weeks

From approximately 14 weeks gestation, progesterone-induced lower esophageal sphincter relaxation and uterine compression of the stomach increase aspiration risk.

Question 95: Which volatile agent is most associated with compound A formation and potential nephrotoxicity, particularly at low fresh gas flows?

Desflurane
Isoflurane
Sevoflurane (Correct answer)
Nitrous oxide

Correct answer: Sevoflurane

Sevoflurane reacts with carbon dioxide absorbents (especially desiccated barium hydroxide lime) to produce compound A, a nephrotoxic degradation product.

Question 96: According to current ASA fasting guidelines, clear liquids may be consumed up to how many hours before elective anesthesia in adults?

8 hours
4 hours
6 hours
2 hours (Correct answer)

Correct answer: 2 hours

ASA guidelines permit clear liquids (water, fruit juice without pulp, carbonated beverages, tea, black coffee) up to 2 hours before elective procedures with general, regional, or monitored anesthesia care.

Question 97: What is the primary mechanism by which neostigmine reverses non-depolarizing neuromuscular blockade?

Sugammadex encapsulation
Acetylcholinesterase inhibition (Correct answer)
Competitive displacement of NMB agent
Direct NMDA receptor activation

Correct answer: Acetylcholinesterase inhibition

Neostigmine inhibits acetylcholinesterase, increasing the concentration of acetylcholine at the neuromuscular junction to competitively overcome the non-depolarizing blockade.

Question 98: Pharmacologic characteristics that BEST describe the effect of naloxone on opioid receptors include:

intrinsic activity.
affinity. (Correct answer)
reversibility. (Correct answer)
stereo selectivity.

Correct answer: affinity.

Explanation: Naloxone is a competitive antagonist at opioid receptors, which means it binds with high affinity to these receptors and competitively blocks the effects of opioid agonists. It is also reversible, meaning its effects can be overcome as it eventually dissociates from the receptor, allowing opioids to re-bind and exert their effects again. Naloxone does not have intrinsic activity at opioid receptors, and stereoselectivity is not typically relevant in its pharmacologic action.

Question 99: A parturient develops a total spinal block after epidural catheter injection. What is the FIRST priority in management?

Place the patient in Trendelenburg position
Administer intralipid 20%
Secure the airway with rapid sequence intubation (Correct answer)
Administer vasopressors for hypotension

Correct answer: Secure the airway with rapid sequence intubation

Airway management is the immediate priority in total spinal block because apnea and unconsciousness are life-threatening; securing the airway takes precedence over other interventions.

Question 100: Which drug is metabolized by plasma cholinesterase?

Bupivacaine (Marcaine)
Tetracaine (Correct answer)
Lidocaine (Xylocaine)
Ropivacaine (Naropin)

Correct answer: Tetracaine

Explanation: Most aminoester local anesthetics—procaine (Novocain), chloroprocaine (Nesacaine), tetracaine—are hydrolyzed in the plasma by cholinesterase enzymes. The aminoamides—lidocaine, bupivacaine, prilocaine (Citanest), ropivacaine, mepivacaine (Carbocaine)—are metabolized in the liver.

Question 101: Intraoperative hypotension most commonly defined as MAP <65 mmHg is most rapidly treated with which initial intervention?

Dopamine infusion
Increasing volatile anesthetic concentration
IV fluid bolus and phenylephrine or ephedrine based on heart rate (Correct answer)
Initiating norepinephrine infusion as first line

Correct answer: IV fluid bolus and phenylephrine or ephedrine based on heart rate

A fluid bolus addresses hypovolemia while a vasopressor (phenylephrine for tachycardia, ephedrine for bradycardia) corrects vasodilation or reduced SVR; the choice depends on the underlying cause.

Question 102: Femoral nerve block at the inguinal ligament provides analgesia for which surgical procedure?

Foot and ankle procedures
Posterior knee and calf surgery
Hip fracture and anterior thigh surgery (Correct answer)
Shoulder arthroplasty

Correct answer: Hip fracture and anterior thigh surgery

The femoral nerve (L2–L4) provides sensory innervation to the anterior thigh, medial leg, and knee joint, making femoral nerve block effective for hip fracture pain and anterior thigh/knee procedures.

Question 103: When using a laryngeal mask airway (LMA), what is the maximum recommended cuff inflation volume for a size 4 LMA?

30 mL (Correct answer)
15 mL
50 mL
60 mL

Correct answer: 30 mL

The size 4 LMA (for adults 50–70 kg) has a maximum recommended cuff inflation volume of 30 mL to achieve a proper seal without excessive pressure.

Question 104: Which condition warrants postponing elective surgery for preoperative optimization?

Well-controlled hypertension on medication
Uncontrolled hypertension with BP >180/110 mmHg (Correct answer)
White coat hypertension
HTN with BP 150/95 mmHg

Correct answer: Uncontrolled hypertension with BP >180/110 mmHg

Severe uncontrolled hypertension (>180/110) is associated with increased perioperative cardiovascular complications and should be optimized when surgery permits; mild-to-moderate HTN generally does not require postponement.

Question 105: What is the reversal agent for benzodiazepine-induced sedation?

Flumazenil (Correct answer)
Physostigmine
Naloxone
Neostigmine

Correct answer: Flumazenil

Flumazenil is a competitive benzodiazepine receptor antagonist that reverses sedation, amnesia, and respiratory depression caused by benzodiazepines.

Question 106: Ketamine produces dissociative anesthesia primarily through which receptor mechanism?

GABA-A receptor agonism
Mu-opioid receptor agonism
NMDA receptor antagonism (Correct answer)
Alpha-2 adrenergic agonism

Correct answer: NMDA receptor antagonism

Ketamine blocks NMDA (N-methyl-D-aspartate) glutamate receptors, producing dissociative anesthesia, analgesia, and amnesia.

Question 107: The normal adult functional residual capacity (FRC) is significantly reduced by which factor that increases aspiration and desaturation risk?

Supine positioning and induction of general anesthesia (Correct answer)
High-flow nasal cannula use
Positive end-expiratory pressure (PEEP)
Reverse Trendelenburg positioning

Correct answer: Supine positioning and induction of general anesthesia

Supine position and induction of general anesthesia reduce FRC by 20–30% due to cephalad diaphragmatic displacement and loss of awake respiratory muscle tone, decreasing the oxygen reservoir and safe apnea time.

Question 108: What is the MOST important anesthetic consideration for a patient with placenta accreta spectrum undergoing planned cesarean hysterectomy?

Avoid neuraxial anesthesia entirely
Limit IV fluids to prevent pulmonary edema
Use ketamine as the primary induction agent
Plan for massive hemorrhage with large-bore IV access and blood products available (Correct answer)

Correct answer: Plan for massive hemorrhage with large-bore IV access and blood products available

Placenta accreta spectrum carries a high risk of massive hemorrhage; preparation with large-bore IV access, arterial line, blood products, and a cell salvage device is the most critical anesthetic priority.

Question 109: LAST (Local Anesthetic Systemic Toxicity) initial CNS symptoms include which finding?

Immediate cardiac arrest
Perioral numbness and metallic taste, progressing to seizures (Correct answer)
Hypotension with normal CNS function
Hyperthermia and muscle rigidity

Correct answer: Perioral numbness and metallic taste, progressing to seizures

LAST typically presents with CNS excitation (perioral tingling, tinnitus, metallic taste, restlessness, seizures) before CNS depression and cardiovascular collapse.

Question 110: Hypothermia (core temp <36°C) in the perioperative period increases the risk of which specific surgical complication?

Postoperative hypertension
Surgical site infection, coagulopathy, and increased blood loss (Correct answer)
Bronchospasm on extubation
Malignant hyperthermia paradoxically

Correct answer: Surgical site infection, coagulopathy, and increased blood loss

Even mild perioperative hypothermia causes vasoconstriction (tissue hypoxia promoting infection), impairs platelet function, and reduces clotting factor activity, leading to wound infections and increased surgical blood loss.

Question 111: Which muscle relaxant is MOST appropriate in patients with advanced liver disease?

Rocuronium (Zemuron)
Vecuronium (Norcuron)
Pancuronium (Pavulon)
Cisatracurium (Nimbex) (Correct answer)

Correct answer: Cisatracurium (Nimbex)

Explanation: Cisatracurium is metabolized by Hofmann elimination. All other choices have some degree of liver metabolism.

Question 112: Laryngospasm occurs when glottic and supraglottic muscles contract in response to a stimulus; the initial treatment is:

Deep extubation to prevent stimulation
Direct laryngoscopy and suction
Immediate succinylcholine administration
Positive pressure with 100% O2 and jaw thrust, followed by succinylcholine if unresolved (Correct answer)

Correct answer: Positive pressure with 100% O2 and jaw thrust, followed by succinylcholine if unresolved

Partial laryngospasm is treated with sustained CPAP and jaw thrust; if complete laryngospasm causes desaturation, succinylcholine (0.1–1 mg/kg) rapidly breaks the spasm.

Question 113: Which local anesthetic is most commonly used for spinal anesthesia in obstetric patients undergoing cesarean delivery?

Lidocaine 5%
Chloroprocaine 3%
Ropivacaine 0.5%
Bupivacaine 0.75% hyperbaric (Correct answer)

Correct answer: Bupivacaine 0.75% hyperbaric

Hyperbaric bupivacaine 0.75% is the most widely used spinal local anesthetic for cesarean delivery due to its reliable dense block, predictable spread, and long duration.

Question 114: What is the preferred anesthetic technique for cesarean delivery in most elective cases?

Epidural anesthesia
Combined spinal-epidural anesthesia
Spinal anesthesia (Correct answer)
General anesthesia with rapid sequence induction

Correct answer: Spinal anesthesia

Spinal anesthesia is preferred for elective cesarean delivery because it provides rapid onset, dense block, avoids airway instrumentation, and allows the mother to remain awake.

Question 115: A patient develops 'awareness under anesthesia' (unintended intraoperative awareness). The CRNA's primary obligation is to:

Administer amnestic drugs immediately postoperatively to suppress recall
Document only if the patient spontaneously reports it postoperatively
Immediately acknowledge, fully inform the patient, provide psychological support, and document the incident (Correct answer)
Avoid discussing the event to prevent PTSD

Correct answer: Immediately acknowledge, fully inform the patient, provide psychological support, and document the incident

Professional ethical and legal standards require disclosure of awareness events; prompt acknowledgment, empathy, psychological follow-up, and documentation are mandatory components of the response.

Question 116: What is the most common cause of maternal mortality directly related to obstetric anesthesia in developed countries?

Aspiration pneumonitis
Failed or difficult airway management (Correct answer)
Local anesthetic systemic toxicity
High spinal block

Correct answer: Failed or difficult airway management

Failed or difficult airway management during general anesthesia remains the leading direct anesthesia-related cause of maternal mortality due to airway changes in pregnancy.

Question 117: Pulse oximetry measures oxygen saturation using which principle?

Transcutaneous oxygen diffusion
Polarographic electrode measurement
Differential light absorption by oxyhemoglobin and deoxyhemoglobin (Correct answer)
Infrared CO2 analysis

Correct answer: Differential light absorption by oxyhemoglobin and deoxyhemoglobin

Pulse oximetry uses two wavelengths of light (660 nm red and 940 nm infrared) and Beer-Lambert law to calculate the ratio of oxyhemoglobin to total hemoglobin.

Question 118: Interscalene brachial plexus block provides the best anesthesia for surgery on which area?

Forearm and elbow only
Shoulder and proximal humerus (Correct answer)
Hand and digits
Axilla and chest wall

Correct answer: Shoulder and proximal humerus

The interscalene approach targets the brachial plexus at the C5–C7 roots, providing excellent coverage of the shoulder, clavicle, and proximal humerus while often missing the ulnar nerve (C8–T1).

Question 119: Which intrathecal opioid is most commonly added to spinal bupivacaine to improve intraoperative analgesia for cesarean delivery?

Sufentanil
Hydromorphone
Fentanyl (Correct answer)
Morphine

Correct answer: Fentanyl

Intrathecal fentanyl (10-25 mcg) is commonly added to spinal bupivacaine to improve intraoperative visceral analgesia without prolonged respiratory depression risk.

Question 120: During the administration of anesthesia to a patient with sickle cell disease, which action minimizes sickling?

Continued hypoventilation
Administration of 100% oxygen (Correct answer)
Restriction of fluids
Avoidance of hyperthermia

Correct answer: Administration of 100% oxygen

Explanation: Increased oxygen concentration limits the sickling process. The rest of the choices contribute to sickling. Sickling is increased with lowered oxygen tensions, acidosis, low cardiac output with low-flow states, and hypothermia. Current therapy includes prevention of hypothermia, providing hydration, controlling ventilation to avoid acidosis, and giving supplemental oxygen.

NBCRNA National Certification Examination (NCE)

The NCE is the entry-level certification exam for nurse anesthesia graduates, testing the knowledge, skills, and abilities required for safe and effective anesthesia practice across four content domains.

120

Questions

180 min

Time Limit

70%

To Pass

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