NBCRNA National Certification Examination (NCE) — Questions and Answers

Question 1: Which medication should be administered to a patient who is unresponsive and hypoxic after receiving midazolam (Versed) for a 20-minute gastrointestinal procedure?

Neostigmine (Prostigmin)
Naloxone (Narcan)
Flumazenil (Romazicon) (Correct answer)
Atropine

Correct answer: Flumazenil (Romazicon)

Explanation: A benzodiazepine antagonist such as flumazenil can be used to reverse the sedative effects of benzodiazepines such as midazolam. It can be used for excessive sedation but should not be used routinely.

Question 2: Which condition warrants postponing elective surgery for preoperative optimization?

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

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

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

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

Hyperkalemia
Normal response to volatile anesthetic agents
Myocardial ischemia requiring immediate assessment of hemodynamics and coronary perfusion (Correct answer)
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 5: Etomidate is preferred for induction in hemodynamically unstable patients primarily because it does what?

Blocks sympathetic nervous system
Causes bronchodilation
Minimally affects cardiovascular function (Correct answer)
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 6: 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?

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

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

Full glottis visible
No laryngeal structures visible
Only epiglottis visible, no glottic structures seen (Correct answer)
Posterior 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 8: Which antihypertensive agent is CONTRAINDICATED in the management of severe hypertension in a breastfeeding mother with preeclampsia?

Atenolol (Correct answer)
Nicardipine
Labetalol
Hydralazine

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 9: The opioid reversal agent naloxone works by which mechanism?

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

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

Quick connect
Interlock (Correct answer)
Variable bypass
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 11: The Wright respirometer is used intraoperatively to measure what?

Exhaled tidal volume (Correct answer)
Inspiratory oxygen fraction
Airway resistance
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 12: Laryngospasm occurs when glottic and supraglottic muscles contract in response to a stimulus; the initial treatment is:

Direct laryngoscopy and suction
Immediate succinylcholine administration
Deep extubation to prevent stimulation
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 13: The level of epidural blockade required to provide anesthesia for a Cesarean section is typically:

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

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

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

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

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

Correct answer: Cisatracurium (Nimbex)

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

Question 16: What is the recommended sensory block level for effective epidural labor analgesia?

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

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

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

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 18: 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)
Ketorolac (Toradol) (Correct answer)
Hydromorphone (Dilaudid)
Acetaminophen

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 19: Postoperative cognitive dysfunction (POCD) is most strongly associated with which patient population?

Patients with pre-existing anxiety disorders
Healthy young adults undergoing minor procedures
Pediatric patients under 5 years
Elderly patients (>65 years) undergoing major surgery (Correct answer)

Correct answer: Elderly patients (>65 years) undergoing major surgery

POCD predominantly affects elderly patients; age-related neuroinflammatory vulnerability, combined with surgical stress and anesthetic exposure, leads to persistent cognitive deficits lasting weeks to months.

Question 20: Considerations for the management of a patient with myotonic dystrophy under general anesthesia should include a/an:

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

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

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

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

Dopamine
Epinephrine
Phenylephrine (Correct answer)
Ephedrine

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 23: The narrowest part of the adult airway, which determines the maximum ETT size, is located at what structure?

Cricoid ring
Glottis (vocal cords) (Correct answer)
Carina
Subglottic space

Correct answer: Glottis (vocal cords)

In adults, the glottis (the opening between the vocal cords) is the narrowest part of the airway and is the limiting factor for endotracheal tube size selection.

Question 24: The addition of epinephrine to local anesthetic solutions for peripheral nerve blocks primarily serves what purpose?

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

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 25: Ketamine produces dissociative anesthesia primarily through which receptor mechanism?

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

Correct answer: NMDA receptor antagonism

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

Question 26: Which medication produces dissociative anesthesia?

Propofol (Diprivan)
Lidocaine (Xylocaine)
Fentanyl (Sublimaze)
Ketamine (Ketalar) (Correct answer)

Correct answer: Ketamine (Ketalar)

Explanation: Ketamine is an NMDA-receptor-blocking medication that produces a functional dissociation between the thalamocortical and limbic systems, a state that has been termed dissociative anesthesia. It produces dose-dependent CNS depression characterized by profound analgesia and amnesia by depressing neuronal function in the cerebral cortex and thalamus, while simultaneously activating the limbic system.

Question 27: Which factor most significantly increases the risk of post-dural puncture headache (PDPH) after accidental dural puncture with an epidural needle?

Obesity (BMI > 35)
Patient age over 40
Use of opioids in the epidural solution
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 28: Dexmedetomidine produces sedation and analgesia primarily through which mechanism?

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

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 29: Pulse oximetry measures oxygen saturation using which principle?

Polarographic electrode measurement
Transcutaneous oxygen diffusion
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 30: 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
Proportionally reducing nitrous oxide flow when oxygen pressure drops (Correct answer)
Increasing oxygen flow automatically

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 31: The classic presentation of a 'high spinal' or 'total spinal' includes which combination of findings?

Severe hypotension, bradycardia, and respiratory arrest (Correct answer)
Hypotension with preserved respiratory function
Nausea with normal hemodynamics
Unilateral motor block with ipsilateral sensory loss

Correct answer: Severe hypotension, bradycardia, and respiratory arrest

When local anesthetic spreads to high thoracic/cervical levels, it blocks cardiac accelerator fibers (T1–T4) and the respiratory muscles (including the diaphragm at C3–C5), causing cardiovascular collapse and apnea.

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.

Questions

35 min

Time Limit

70%

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