1. A pregnant woman in her 32nd wk of gestation is given magnesium sulfate for pre-eclampsia.

The earliest clinical indication of hypermagnesemia is: a. Loss of deep tendon reflexes b. Flaccid paralysis c. Respiratory arrest d. Hypotension e. Stupor

2. The chief surgical risk to which patients with polycythemia vera are exposed is that due to: a. Anemic disturbances b. Hemorrhage c. Infection d. Renal dysfunction e. Cardiopulmonary complications

3. Signs and symptoms of hemolytic transfusion reactions include: a. Hypothermia b. Hypertension c. Polyuria d. Abnormal bleeding e. Hypesthesia at the transfusion site

4. The surgeon should be particularly concerned about which coagulation function in patients receiving anti-inflammatory or analgesic medications? a. APTT b. PT c. Reptilase time d. Bleeding time e. Thrombin time

5. The substrate depleted earliest in the postoperative period is: a. Branched-chain amino acids b. Non-branched-chain amino acids 6. Hypocalcemia is associated with: a. Acidosis b. Shortened QT interval c. Hypomagnesemia d. Myocardial irritability e. Hyperproteinemia c. Ketone d. Glycogen e. Glucose

7. Which of the following characteristics of this patient might increase the risk of a wound infection? a. History of colon surgery b. Hypertension c. Male sex Items 810 An in-hospital workup of a 78- year-old, hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and a urinalysis with 1825 WBCs and gram-negative bacteria. On call to the operating room he receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3 the patient develops a wound infection. 8. Which of the following changes could make this wound a less favorable environment for infection? a. Decreasing the operative time and wound contamination by omitting the common bile duct exploration b. Placing a Penrose drain exiting directly through the lateral corner of the wound c. Using oral rather than intravenous penicillin perioperatively d. Leaving a seroma in the wound to prevent desiccation of the tissues e. Reinforcing the wound closure with a sheet of prosthetic polypropylene mesh. 9. Which of the following characteristics of this patient might increase the risk of a wound infection? a. b. c. d. e. History of colon surgery Hypertension Male sex Receipt of chemotherapy Asthma d. Receipt of chemotherapy e. Asthma

10. Which of the following changes in the care of this patient could decrease the chance of a postoperative wound infection? a. Increasing the length of the preoperative hospital stay to prophylactically treat the asthma with steroids b. Treating the urinary infection prior to surgery c. Shaving the abdomen the night prior to surgery d. Continuing the prophylactic antibiotics for three postoperative days e. Use of a closed drainage system brought out through the operative incision 11. Signs and symptoms associated with early sepsis include: a. b. c. d. e. Respiratory acidosis Decreased cardiac output Hypoglycemia Increased arteriovenous oxygen difference Cutaneous vasodilation

12. The most common physiologic cause of hypoxemia is: a. b. c. d. e. Hypoventilation Incomplete alveolar oxygen diffusion Ventilation-perfusion inequality Pulmonary shunt flow Elevated erythrocyte 2,3-diphosphoglycerate level (2,3-DPT)

13. Major alterations in pulmonary function associated with adult respiratory distress syndrome (ARDS) include: a. b. c. d. e. Hypoxemia Increased pulmonary compliance Increased resting lung volume Increased functional residual capacity Decreased dead space ventilation

14. An 18-year-old woman develops urticaria and wheezing after an injection of penicillin. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats/min, and respiratory rate is 30 breaths/min. Immediate therapy should include:

a. b. c. d. e.

Intubation Epinephrine Beta blockers Iodine Fluid challenge

15. During blood transfusion, clotting of transfused blood is associated with: a. b. c. d. e. ABO incompatibility Minor blood group incompatibility Rh incompatibility Transfusion through Ringers lactate Transfusion through 5% dextrose and water

16. Among patients who require nutritional resuscitation in an intensive care unit, the best evidence that nutritional support is adequate is: a. b. c. d. e. Urinary nitrogen excretion levels Total serum protein level Serum albumin level Serum transferrin levels Respiratory quotient

17. Signs and symptoms of unsuspected Addisons disease include: a. b. c. d. e. Hypothermia Hypokalemia Hyperglycemia Hyponatremia Hypervolemia

18. The etiologic factor implicated in the development of pulmonary insufficiency following major nonthoracic trauma is: a. b. c. d. e. Aspiration Atelectasis Fat embolism syndrome Fluid overload Pneumonia

19. Treatment for clostridial myonecrosis (gas gangrene) includes which of the following measures? a. b. c. d. e. Administration of an antifungal agent Administration of antitoxin Wide debridement Administration of hyperbaric oxygen Early closure of tissue defects

20. Spontaneous retroperitoneal hemorrhage during anticoagulant therapy: a. b. c. d. e. Is best confirmed by bleeding scan Is equally likely with parenteral and oral anticoagulants May mimic an acute surgical abdomen Frequently requires laparotomy for ligation of the bleeding site Is seen in over 30% of patients receiving long-term anticoagulation

21. With regard to wound healing, which one of the following statements is correct? a. b. c. d. Collagen content reaches a maximum at approximately 1 wk after injury Monocytes are essential for normal wound healing Fibroblasts appear in the wound within 2436 h after the injury The function of the monocyte in wound healing is limited to phagocytosis of bacteria and debris e. Early in wound healing, type I collagen is predominant 22. A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an air fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. The next best step in management is: a. b. c. d. e. Placement of a left chest tube Immediate thoracotomy Immediate celiotomy Esophagogastroscopy Removal and replacement of the nasogastric tube; diagnostic peritoneal lavage

23. Which of the following conditions is most likely to follow a compression-type abdominal injury? a. b. c. d. e. Renal vascular injury Superior mesenteric thrombosis Mesenteric vascular injury Avulsion of the splenic pedicle Diaphragmatic hernia

24. A 65-year-old man who smokes cigarettes and has chronic obstructive pulmonary disease falls and fractures the 7th, 8th, and 9th ribs in the left anterolateral chest. Chest x-ray is otherwise normal. Appropriate treatment might include: a. b. c. d. e. Strapping the chest with adhesive tape Immobilization with sandbags Tube thoracostomy Peritoneal lavage Surgical fixation of the fractured ribs

25. Blunt trauma to the abdomen most commonly injures which of the following organs? a. b. c. d. e. Liver Kidney Spleen Intestine Pancreas

26. A 27-year-old man sustains a single gunshot wound to the left thigh. In the emergency room he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his foot. On examination there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient would be: a. b. c. d. e. Angiography Immediate exploration and repair Fasciotomy of anterior compartment Observation for resolution of spasm Local wound exploration

27. 140. Among the physiologic responses to acute injury is: a. b. c. d. e. Increased secretion of insulin Increased secretion of thyroxine Decreased secretion of vasopressin (ADH) Decreased secretion of glucagon Decreased secretion of aldosterone

28. 141. In a stable patient, the management of a complete transection of the common bile duct distal to the insertion of the cystic duct would be optimally performed with a: a. b. c. d. e. Choledochoduodenostomy Loop choledochojejunostomy Primary end-to-end anastomosis of the transected bile duct Roux-en-Y choledochojejunostomy Bridging of the injury with a T tube

29. 142. Nonoperative management of penetrating neck injuries has been advocatedasanalternative tomandatory exploration in asymptomatic patients. Which of the following findings would constitute a relative, rather than an absolute, indication for formal neck exploration? a. b. c. d. e. Expanding hematoma Dysphagia Dysphonia Pneumothorax Hemoptysis

30. 143. Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a coiled spring appearance in the second and third portions. Appropriate management is a. b. c. d. e. Gastrojejunostomy Nasogastric suction and observation Duodenal resection TPN to increase the size of the retroperitoneal fat pad Duodenojejunostomy

31. 144. Following traumatic peripheral nerve transection, regrowth usually occurs at which of the following rates? a. b. c. d. e. 0.1 mm per day 1 mm per day 5 mm per day 1 cm per day None of the above

32. A 31-year-old man is brought to the emergency room following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax, but a large pulmonary contusion is developing. Proper treatment would consist of which of the following? a. Tracheostomy, mechanical ventilation, and positive end-expiratory pressure b. Stabilization of the chest wall with sandbags c. Stabilization with towel clips d. Immediate operative stabilization e. No treatment unless signs of respiratory distress develop 33. A 30-year-old man is stabbed in the arm. There is no evidence of vascular injury, but he cannot flex his three radial digits. He has injured the: a. b. c. d. e. Flexor pollicis longus and flexor digitus medius tendons Radial nerve Median nerve Thenar and digital nerves at the wrist Ulnar nerve

34. Following a 2-h fire-fighting episode, a 36-year-old fireman begins complaining of a throbbing headache, nausea, dizziness, and visual disturbances. He is taken to the emergency room where his carboxyhemoglobin (COHb) level is found to be 31%. Appropriate treatment would be to: a. Begin an immediate exchange transfusion b. Transfer the patient to a hyperbaric oxygen chamber

c. Begin bicarbonate infusion and give 250 mg acetazolamide (Diamox) intravenously d. Administer 100% oxygen by mask e. Perform flexible bronchoscopy with further therapy determined by findings 35. An elderly pedestrian collides with a bicycle-riding pizza delivery man and suffers a unilateral fracture of his pelvis through the obturator foramen. You would manage this injury by: a. External pelvic fixation b. Angiographic visualization of the obturator artery with surgical exploration if the artery is injured or constricted c. Direct surgical approach with internal fixation of the ischial ramus d. Short-term bed rest with gradual ambulation as pain allows after 3 days e. Hip spica 36. Regarding high-voltage electrical burns to an extremity: a. Injuries are generally more superficial than those of thermal burns b. Intravenous fluid replacement is based on the percentage of body surface area burned c. Antibiotic prophylaxis is not required d. Evaluation for fracture of the other extremities and visceral injury is indicated e. Cardiac conduction abnormalities are unlikely 37. Which of the following fractures or dislocations of the extremities induced by blunt trauma is associated with significant vascular injuries? a. b. c. d. e. Knee dislocation Closed posterior elbow dislocation Midclavicular fracture Supracondylar femur fracture Tibial plateau fracture

38. Regarding myocardial contusion from blunt chest trauma, which of the following statements is correct?

a. Elevated cardiac isoenzyme levels sensitively identify patients at risk for life-threatening arrhythmias b. The majority of patients have abnormalities on the initial ECG post injury c. First-pass radionuclide angiography (RNA) and echocardiography are considered the gold standard for diagnosis d. RNA and echocardiography are good predictors of subsequent cardiac complications such as arrhythmias and pump failure e. All patients diagnosed with myocardial contusion should be monitored in an intensive care unit setting for 72 h 39. Protein metabolism after trauma is characterized by: a. Decreased liver gluconeogenesis b. Inhibition of skeletal muscle breakdown by interleukin 1 and tumor necrosis factor (TNF, cachectin) c. Decreased urinary nitrogen loss d. Hepatic synthesis of acute-phase reactants e. Decreased glutamine consumption by fibroblasts, lymphocytes, and intestinal epithelial cells 40. A 36-year-old man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an xray of the abdomen shows the bullet to be located in the right lower quadrant. Correct management of a suspected rectal injury would include: a. b. c. d. e. Barium studies of the colon and rectum Barium studies of the bullet track Endoscopy of the bullet track Angiography Sigmoidoscopy in the emergency room

41. Correct statements regarding blunt trauma to the liver include which of the following? a. Hepatic artery ligation for control of bleeding is associated with decreased morbidity and mortality b. The incidence of intraabdominal infections is significantly lower in patients with abdominal drains c. Intracaval shunting has dramatically improved survival among patients with hepatic vein injuries

d. Nonanatomic hepatic debridement, with removal of the injured fragments only, is preferable to resection along anatomic planes e. Major hepatic lacerations that are sutured closed will result in intrahepatic hematomas, hemobilia, and bile fistulas 42. If injury to a major artery in an extremity is suspected, surgical exploration should be carried out regardless of the presence of palpable pulses distal to the injury. The rationale is that the presence of palpable distal pulses does not reliably exclude: a. b. c. d. e. Significant arterial injury Significant injury to adjacent motor nerve trunks Significant injury to adjacent long bones Significant injury to adjacent veins Subsequent development of a compartment syndrome and the need for fasciotomy

43. The response to shock includes which of the following metabolic effects? a. b. c. d. e. Increase in sodium and water excretion Increase in renal perfusion Decrease in cortisol levels Hyperkalemia Hypoglycemia

44. Appropriate treatment for an acute stable hematoma of the pinna of the ear includes which of the following measures? a. b. c. d. e. Ice packs and prophylactic antibiotics Excision of the hematoma Needle aspiration Incision, drainage, and pressure bandage Observation alone

45. Animal and clinical studies have shown that administration of lactated Ringers solution to patients with hypovolemic shock may: a. Increase serum lactate concentration b. Impair liver function

c. Improve hemodynamics by alleviating the deficit in the interstitial fluid compartment d. Increase metabolic acidosis e. Increase the need for blood transfusion 46. True statements concerning penetrating pancreatic trauma include: a. Most injuries do not involve adjacent organs b. Management of a ductal injury to the left of the mesenteric vessels is Roux-en-Y pancreaticojejunostomy c. Management of a ductal injury in the head of the pancreas is pancreaticoduodenectomy d. Small peripancreatic hematomas need not be explored to search for pancreatic injury e. The major cause of death is exsanguination from associated vascular injuries 47. Rapid fluid resuscitation of the hypovolemic patient after abdominal trauma is significantly enhanced by which of the following? a. b. c. d. Placement of long 18-gauge subclavian vein catheters Placement of percutaneous femoral vein catheters Bilateral saphenous vein cutdowns Placement of short, large-bore percutaneous peripheral intravenous catheters e. Infusion of cold whole blood 48. Tissue injury or infection results in the release of tumor necrosis factor (TNF) by which of the following cells? a. b. c. d. e. Fibroblasts Damaged vascular endothelial cells Monocytes/macrophages Activated T lymphocytes Activated killer lymphocytes

49. A cross-match is performed by incubating: a. Donor serum with recipient lymphocytes and complement b. Donor lymphocytes with recipient serum and complement

c. Donor lymphocytes with recipient lymphocytes d. Recipient serum with a known panel of multiple donor lymphocytes e. Recipient serum with donor red blood cells and complement 50. In order to activate helper/inducer T (CD41) lymphocytes, macrophages release: a. b. c. d. e. Interleukin 1 Interleukin 2 Interleukin 3 Interleukin 4 Interferon

51. Which of the following cells cause immunologically restricted tumor cell lysis? a. b. c. d. e. Macrophages Cytotoxic T lymphocytes Natural killer cells Polymorphonuclear leukocytes Helper T lymphocytes

52. Which of the following statements regarding heart transplantation is true? a. Heart transplants are matched by size and ABO blood type rather than tissue typing b. Cadaveric graft survival is significantly lower with heart transplants as compared with renal transplants c. Cold ischemia time for donor hearts should not be more than 48 h d. The upper age limit for heart transplant eligibility is 55 years e. The leading cause of death after the first year of cardiac transplantation is chronic rejection 53. A 47-year-old man with hypertensive nephropathy develops fever, graft tenderness, and oliguria 4 wk following cadaveric renal transplantation. Serum creatinine is 3.1 mg/dL. A renal ultrasound reveals mild edema of the renal papillae but normal flow in both the renal artery and renal vein. Nuclear scan demonstrates sluggish uptake and excretion. The next most appropriate step is: a. Performing an angiogram b. Decreasing steroid and cyclosporine dose c. Beginning intravenous antibiotics

d. Performing renal biopsy, steroid boost, and immunoglobulin therapy e. Beginning FK 506 54. Posttransplant cytomegalovirus infection may cause: a. b. c. d. e. Plyelonephritis GI ulceration and hemorrhage Cholecystitis Intraabdominal abscess Parotitis

55. In centers with experienced personnel, 1-year liver transplant survival is now approximately: a. b. c. d. e. 95% 80% 65% 50% 35%

56. Graft-versus-host disease has occurred with the transplantation of which of the following? a. b. c. d. e. Kidney Lung Heart Bone marrow Pancreas

57. Which of the following diseases is appropriately treated with combined heartlung transplantation? a. b. c. d. Primary pulmonary hypertension Cystic fibrosis End-stage emphysema Idiopathic dilated cardiomyopathy with long-standing secondary pulmonary hypertension e. End-stage pulmonary fibrosis secondary to sarcoidosis