FINAL EXAMINATION FOR

MD IN CLINICAL ANAESTHESIA
MCQ PAPER II
3 HOURS

1. A patient involved in a motor vehicle accident required a prolonged

extraction time from the vehicle at the scene. After transport by
helicopter to the hospital, the patient is brought to the operating room
for removal of a ruptured spleen and fixation of multiple lower
extremity fractures. After induction of general anaesthesia and
endotracheal intubation, an oesophageal temperature probe is
inserted. The patient's temperature is 32°C. All of the following
problems may be expected EXCEPT
a. metabolic acidosis
b. impairment of the intrinsic clotting cascade
c. cardiac dysrhythmias
d. platelet dysfunction
e. profound peripheral vasodilatation✓

2. Signs of inadequate general anesthesia include all of the following

EXCEPT
a. eyelid movement
b. pupillary constriction✓
c. hyperventilation
d. sweating
e. limb movement

3. A patient has chronic obstructive pulmonary disease requiring the

constant administration of oxygen. He is dyspnoeic at rest and can
walk at the most 20 ft before needing to rest. He is scheduled to
undergo an exploratory laparotomy because of a small bowel
obstruction. He would be classified by the American Society of
Anesthesiologists as physical status
a. III
b. IIIE
c. IVE✓
d. V
e. VE

4. The first use of cocaine as a local anaesthetic was performed by

a. Karl Koller✓
b. Sigmund Freud
c. August Bier
d. Heinrich Quincke
e. Heinrich Braun

5. If nitrous oxide is administered at a constant concentration, the uptake

into the bloodstream in milliliters per minute will
 a. be constant
b. increase with time
c. decrease with time✓
d. depend on temperature
e. be independent of concentration

6. The correlation of anaesthetic potency with lipid solubility is known as

the rule of
(A) Ferguson
(B) Michaelis and Menten
(C) Henderson and Hasselbalch
(D) Singer and Nicholson
(E) Meyer and Overton✓

7. The state of general anaesthesia may be reversed by

(A) the administration of a competitive antagonist
(B) increasing the atmospheric pressure✓
(C) increasing the ambient temperature
(D) decreasing the ambient temperature
(E) the administration of any medication which increases cerebral
perfusion

8. A 55-year-old man has had a total hip arthroplasty under general

anaesthesia. His only significant preoperative medical problem is
osteoarthritis. Which of the following is the LEAST important criterion
in determining when he may be sent to his hospital room from the
post-anaesthesia care unit?
(A) Thirty minutes have elapsed since he was given morphine 4-mg i.v. for
pain.
(B) Sixty minutes have elapsed since his admission to the PACU from the
operating room✓
(C) He has voided 100 mL of urine in the last 30 minutes.
(D) His vital signs before the induction of general anesthesia were pulse
110 and blood pressure 140/90; these values are 75 and 110/65,
respectively/ at the present time.
(E) His oxygen saturation is 94% on room air.

9. If the uptake of gaseous anaesthetic in L/min is x, and the patient's

cardiac output suddenly doubles, the rate of uptake will become
(A) cannot be calculated without further information
(B) x/2
(C) 2x✓
(D) 4x
(E) x2

10. The likelihood of intraoperative awareness under general anesthesia is

highest with the use of
(A) inadequate benzodiazepine doses
(B) high-dose opioids
(C) muscle relaxants✓
(D) no premedication
(E) nitrous oxide as the sole gaseous anaesthetic

11. Stage 2 anesthesia can be characterised by all of the following signs

EXCEPT
(A) amnesia
(B) purposeless movement
(C) hypoventilation✓
(D) disconjugate gaze
(E) increased airway reflexes

12. Which of the following medications is not recommended during

general anesthesia for the removal of a phaeochromocytoma?
(A) morphine✓
(B) fentanyl
(C) sevoflurane
(D) vecuronium
(E) diazepam

13. An anaesthesiologist’s usual practice is to administer the combination

of neostigmine and atropine for reversal of neuromuscular blockade. In
a patient with glaucoma, managed with the topical administration of a
β-adrenergic agonist, how should this anaesthesiologist’s usual
practice for reversing neuromuscular blockade be modified?
(A) substitution of glycopyrrolate for atropine
(B) substitution of edrophonium for neostigmine
(C) avoidance of all nondepolarising neuromuscular blocking agents
(D) use of mivacurium followed by spontaneous recovery of
neuromuscular function
(E) no modification is necessary✓

14. A patient is brought to the operating room for repair of an open fracture
sustained from a fall from a window during a house fire. The patient
was intubated at the scene by a paramedic and given 100% oxygen via
Ambu bag during transport to the hospital. The most reliable method
for determining whether the patient has carbon monoxide poisoning
while being ventilated with 100% O2 is
(A) routine arterial blood gas analysis
(B) pulse oximetry
(C) capnometry
(D) arterial carboxyhaemoglobin level✓
(E) electrocardiogram (ECG) evidence of carbon monoxide-induced
arrhythmias

15. Contraindications to the discharge to home of a patient who had a

hernia repair under general anaesthesia include all of the following
EXCEPT
(A) nausea✓
(B) inability to drink liquids without vomiting
(C) heart rate 50% higher than the preoperative value
(D) inability to walk due to groin pain
(E) disorientation to person and place

Regional Anesthesia
16. The dermatome level at the nipple line is
(A) C8
(B) T2
(C) T4✓
(D) T6
(E) T8

17. The superior laryngeal nerve lies

(A) superior to the hyoid bone
(B) deep to the hyoid bone
(C) immediately above the notch of the thyroid cartilage
(D) between the great cornu of the hyoid bone and the superior cornu of
the thyroid cartilage✓
(E) deep to the cricothyroid membrane

18. In order to provide an adequate sensory level for transurethral prostate

resection, the sensory level must be
(A) T4
(B) T6
(C) T8
(D) T10✓
(E) T12

19. The axillary approach to the brachial plexus

(A) carries the risk of pneumothorax
(B) uses the axillary artery as a landmark✓
(C) is made from the lateral aspect of the arm
(D) uses the pectoralis minor insertion as a landmark
(E) is the preferable route if there is an infection in the axilla

20. When using the caudal approach to the epidural space

(A) the needle enters through the sacral hiatus✓
(B) an inadvertent subarachnoid block is much less likely than when using
the lumbar approach
(C) the patient must be positioned prone
(D) the technique becomes relatively more contraindicated as the patient's
age decreases
(E) small volumes of agent are needed, since the volume of the canal is
only 8 to 12 mL

21. When performing digital nerve blocks

(A) 5 to 10 mL of local anaesthetic are used for each nerve
(B) epinephrine-containing solution should be used to decrease systemic
absorption
(C) the nerves can be blocked by injecting only on the medial side of the
digits where the nerves course
(D) the course of the nerve lies close to the dorsum of the finger
(E) one must remember that the digital arteries are terminal arteries✓

22. The dermatome level that supplies the inguinal area is

(A) T6
(B) T8
(C) T10
(D) L1✓
(E) L3

23. In performing a lumbar puncture by the paramedian approach, all of the

following are true EXCEPT that
(A) it is necessary to flex the spine✓
(B) the needle penetrates the ligamentum flavum
(C) the lateral or sitting position is satisfactory
(D) the needle does not penetrate the interspinous ligament
(E) the needle enters between the laminae

24. The first modality to be lost on the onset of spinal anesthesia is

(A) touch
(B) motor power
(C) temperature
(D) vibration
(E) autonomic activity✓

25. The sciatic nerve is formed by all of the following nerve roots EXCEPT
(A) L3✓
(B) L4
(C) L5
(D) S1
(E) S2

Anaesthesia for Cardiothoracic and Vascular Surgery

26. If a patient with a pacemaker in place requires surgery that entails the
use of cautery
(A) the cutaneous electrode (skin pad) of a unipolar electrocautery unit
should be as close to the pulse generator as possible
(B) electrocardiographic monitoring is necessary only if the patient is
being paced
(C) electrocardiographic monitoring will give the best information
(D) little danger is present if the pacer is a demand unit
(E) constant palpation of the pulse or listening through an oesophageal
stethoscope is necessary✓
27. The clamping of the thoracic aorta in aneurysm repair is followed by
(A) immediate hypotension
(B) immediate hypertension✓
(C) cardiac standstill
(D) no change
(E) loss of blood pressure in the right arm

28. The blood flow during total cardiopulmonary bypass

(A) is not adjustable
(B) is virtually nonpulsatile✓
(C) provides a pulsatile pressure
(D) is a pulsatile flow
(E) mimics normal flow in all respects

29. The most reliable monitor for detection of intra-operative myocardial

ischemia is
(A) creatine phosphokinase levels
(B) pulmonary artery catheterization
(C) transoesophageal echocardiography✓
(D) troponin levels
(E) exhaled nitric oxide

30. A patient with oesophageal obstruction is to have a general

anaesthetic for oesophagoscopy. He has had a barium swallow on the
previous day. One of the greatest dangers of the planned procedure is
(A) bleeding
(B) hypotension
(C) difficult intubation
(D) aspiration✓
(E) arrhythmia

Anaesthesia for Neurosurgery

31. Of the many factors affecting intracerebral blood flow, which of the
following is a correct description?
(A) vasomotor paralysis: vasoconstriction of vessels in or near ischemic
areas
(B) autoregulation: ability of vessels to respond in a manner consistent
with maintaining homeostasis✓
(C) luxury perfusion: metabolic requirements in excess of blood flow
(D) intracerebral steal: decrease of blood flow in normal areas with
increased flow to ischemic areas
(E) inverse steal: diversion of flow to normal areas from ischemic areas

32. When ventilating the patient with a head injury, all of the following
statements are true EXCEPT
(A) the patient should be kept supine✓
(B) prolonged hyperventilation has diminished efficacy in reducing ICP
(C) PEEP may be appropriate
(D) hypoxia and hypercarbia should be avoided
(E) the patient should be prevented from coughing

33. Which of these is the best agent to decrease cerebral oxygen

requirement?
(A) a muscle relaxant
(B) a glucose solution
(C) an anticonvulsant
(D) a barbiturate✓
(E) oxygen by mask

34. Signs of air embolism include all of the following EXCEPT

(A) arrhythmia
(B) hypertension✓
(C) heart murmur
(D) bubbles at the operative site
(E) decreased end-expired carbon dioxide

35. Following closed head injury, systemic sequelae may include all of the
following EXCEPT
(A) disseminated intravascular coagulation
(B) diabetes insipidus
(C) syndrome of inappropriate secretion of antidiuretic hormone
(D) hyperglycemia
(E) hypocarbia✓

Obstetric Anesthesia
36. Magnesium sulfate
(A) does not cross the placenta
(B) has therapeutic levels between 6 and 8 mEq/L
(C) may produce respiratory depression in the neonate✓
(D) is a CNS stimulant
(E) decreases sensitivity to NMB agents

37. A parturient is diagnosed with retained placenta after delivery and

requires manual exploration of the uterus. All of the following are
acceptable alternatives except
(A) intravenous analgesia
(B) epidural analgesia
(C) saddle block
(D) intravenous nitroglycerine, 400 mcg✓
(E) induction of general anesthesia with 1 mg/kg ketamine
38. Regional anesthesia techniques that can be used for forceps deliveries
include all of the following except
(A) bilateral pudendal block
(B) paracervical block✓
(C) subarachnoid block
(D) caudal block
(E) epidural block

39. Neural pathways responsible for the transmission of pain during the
first and second stages of labour include
(A) T10 to L1 and S2 to S4✓
(B) T8 to L2 and S1 to S3
(C) T6 to T12 and S1 to S4
(D) T10 to L5
(E) T12 to L3 and S2 to S5

40. Prophylactic measures taken to prevent maternal hypotension

following spinal anaesthesia include all of the following except
(A) administration of 500 to 1000 mL of fluid before induction
(B) lateral displacement of the uterus
(C) head-down tilt immediately after injection✓
(D) placing the patient on her side after block is established
(E) infusion of vasopressor

41. The pregnant woman at term

(A) shows no anatomic changes in the respiratory system
(B) is primarily a nose breather
(C) is primarily a mouth breather✓
(D) is less susceptible to hypoxia
(E) has decreased oxygen consumption

42. In preeclamptic or eclamptic patients

(A) regional anesthesia is contraindicated
(B) hyporeflexia is common
(C) fluid restriction is necessary because of presence of oedema
(D) resistance to vasopressors is common
(E) significant coagulopathies may occur✓

43. Nerve injury during labour and delivery can result from all of the
following EXCEPT
(A) compression of lumbosacral trunk by the head of foetus
(B) peroneal nerve injury by lithotomy stirrup
(C) epidural haematoma secondary to block
(D) femoral nerve compression by the lithotomy stirrup✓
(E) chemical contamination of the subarachnoid space

44. Which of the following statements is true regarding neuraxial opioids?

(A) Spinal opioids augment sympathetic blockade produced by local
anaesthetics.
(B) Naloxone does not reverse nausea and vomiting caused by intrathecal
opioids.
(C) Epidural opioids are as effective as a bupivacaine-opioid mixture in
relieving pain.
(D) Intrathecal morphine produces approximately 24 hours of analgesia.✓
(E) Intrathecal fentanyl produces approximately 16 hours of analgesia.

Paediatric Anesthesia
45. A 2-year-old child (weight 13 kg) is scheduled for circumcision. The
most suitable dose of local anaesthetic for a dorsal penile block is
(A) bupivacaine 0.25% 8 mL✓
(B) lidocaine 1% 8 mL
(C) lidocaine 1.5% with epinephrine 1:200,000 8 mL
(D) bupivacaine 0.25% 15 mL
(E) bupivacaine 0.125% 15 mL

46. A 3-year-old healthy child is in preop holding for elective repair of an

umbilical hernia. The mother informs you that the child had 4 oz of
apple juice 2 hours ago. You respond
(A) cancel surgery
(B) delay surgery 2 hours
(C) delay surgery 4 hours
(D) delay surgery 6 hours
(E) proceed with surgery now✓

47. An infant is born with Apgar scores of 2 and 5 at 1 minute and 5

minutes of life, respectively. Initial resuscitation should include all of
the following EXCEPT
(A) oxygen
(B) radiant heat
(C) intubation
(D) glucose✓
(E) bicarbonate

48. An infant under anesthesia loses body heat by all of the following
routes EXCEPT
(A) the metabolism of brown fat✓
(B) breathing dry gases
(C) conduction to cold surroundings
(D) cold skin preparation solutions
(E) exposure of abdominal contents

49. The first sign of malignant hyperthermia in an anesthetised infant is

frequently
(A) rapid rise in body temperature
(B) tachycardia✓
(C) hot skin
(D) arrhythmia
(E) hot circle absorber

50. The typical 2-year-old child should be intubated with an endotracheal

tube having an internal diameter of
(A) 3 mm
(B) 3.5 mm
(C) 4.5 mm✓
(D) 5.5 mm
(E) 6.5 mm

51. If a child who is admitted with an incarcerated inguinal hernia has a

mild upper respiratory tract infection
(A) the surgery should be cancelled
(B) the surgery should be allowed to proceed, but the child should not be
intubated
(C) the child should be started on antibiotics, and the surgery should
proceed
(D) the surgery should proceed with careful monitoring✓
(E) the patient should be operated on only under spinal anaesthesia

52. Preparation for surgery of the patient with sickle cell disease should
include all of the following EXCEPT
(A) transfuse to a haemoglobin level of 15 g/dL✓
(B) treat infection
(C) maintain good hydration
(D) provide good pulmonary care
(E) avoid stasis of blood flow

53. A 7-year-old 35-kg girl is scheduled for excision of a large

intra-abdominal mass. Her starting haematocrit is 36% and the
minimally acceptable haematocrit is 24%. How much blood could the
patient lose before transfusion is necessary?
(A) 250 mL
(B) 450 mL
(C) 650 mL
(D) 950 mL✓
(E) 1100 mL

ICU
54. The following values are obtained from a patient receiving treatment in
an intensive care unit:

Heart rate 110 bpm

Blood pressure 95/60mmHg
Cardiac output 3.0 L/min
Arterial oxygen saturation 90%
 Mixed venous oxygen saturation 70%
Arterial pH 7.36
PaO2 60 mmHg
PaCO2 40 mmHg
Haemoglobin 10 g/dL

Which of the following will result in the greatest oxygen delivery?

(A) use of an inotrope to double cardiac output✓
(B) transfusion of packed red blood cells to increase the haemoglobin
concentration to 15 g/dL
(C) increase in FIO2 to oxygenation saturation equal to 100% and PaO2
equal to 150 mmHg
(D) increase in heart rate to 130 bpm
(E) hyperventilation to pH equal to 7.40 and PaCO2 equal to 35 mmHg

55. A technique most useful in treatment of bronchopleural fistula is

(A) spontaneous breathing with a mask
(B) assisted ventilation with positive pressure
(C) controlled ventilation with a mechanical ventilator
(D) positive end-expiratory pressure
(E) high-frequency jet ventilation✓

56. A patient given supplemental oxygen at 4 L/min via a nasal cannula will
have an FIO2 of approximately
(A) 24%
(B) 26%
(C) 30%
(D) 32%
(E) 36%✓

57. An example of a central pain state is

(A) postoperative incision pain
(B) gallbladder pain
(C) phantom limb pain✓
(D) bone fracture pain
(E) headache

58. Inhibitory substances that are believed to modulate the transmission of

nociceptive signals in the dorsal horn of the spinal cord include the
following EXCEPT
(A) substance P✓
(B) β-endorphins
(C) dopamine
(D) epinephrine
(E) adenosine

59. The one best block for pain secondary to pancreatic cancer is a
(A) stellate ganglion block
(B) Bier block
(C) block of the hypogastric plexus
(D) celiac plexus block✓
(E) intrathecal neurolysis

60. Which of the following is TRUE about post-dural puncture headache?

(A) Using large gauge cutting needles is the best preventive measure when
performing a spinal anaesthetic.
(B) It results from decreased CSF pressure secondary to loss of CSF at the
puncture site.✓
(C) Gender has no influence on incidence.
(D) Early ambulation will increase the incidence.
(E) An epidural blood patch is always indicated.