NBCRNA Perioperative Patient Assessment 2 — Questions and Answers
Question 1: 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)
- Aggressive fluid restriction to prevent pulmonary edema
- Keep heart rate above 90 bpm to maintain cardiac output
- 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 2: Which condition warrants postponing elective surgery for preoperative optimization?
- Uncontrolled hypertension with BP >180/110 mmHg (Correct answer)
- Well-controlled hypertension on medication
- HTN with BP 150/95 mmHg
- White coat hypertension
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 patient with GERD and obesity presenting for laparoscopic surgery is considered at risk for pulmonary aspiration; the most effective pharmacological prophylaxis includes:
- H2 blocker or proton pump inhibitor plus metoclopramide preoperatively (Correct answer)
- Antacid neutralization alone
- Preoperative nasogastric suctioning
- Atropine to reduce gastric secretions
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: The Apfel score is used preoperatively to predict risk of what postoperative complication?
- Postoperative nausea and vomiting (PONV) (Correct answer)
- Surgical site infection
- Postoperative cognitive dysfunction
- Deep vein thrombosis
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 5: Obstructive sleep apnea (OSA) increases perioperative risk primarily due to increased sensitivity to what?
- Opioids and sedatives causing upper airway obstruction and hypoxia (Correct answer)
- Volatile anesthetics causing bronchospasm
- Neuromuscular blocking agents requiring higher doses
- Regional anesthetics causing excessive sympatholysis
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 6: 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?
- Pharmacologic stress testing (dobutamine stress echo or nuclear stress test) (Correct answer)
- Resting echocardiogram
- Preoperative coronary angiography
- Exercise treadmill test
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.
NBCRNA Perioperative Patient Assessment 2
A patient with severe aortic stenosis presents for hip replacement.
Which hemodynamic goal is most important intraoperatively?