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Egyptian Board Anesthesia study materials
Egyptian Board Anesthesia study resources

Egyptian Board Anesthesia practice questions

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Question 1Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

During direct laryngoscopy, the vocal cords are located immediately posterior to which laryngeal structure?

  1. The cricothyroid membrane
  2. The thyroid cartilage prominence
  3. The arytenoid cartilages Correct answer.
  4. The epiglottis

Explanation

The true vocal cords attach posteriorly to the vocal processes of the arytenoid cartilages, which sit at the posterior end of the glottic opening. The epiglottis lies anterior and superior to the cords, while the thyroid prominence and cricothyroid membrane are anterior structures. This is why cords appear as a posterior V during laryngoscopy.

Question 2Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient's oxygen–haemoglobin dissociation curve is shifted to the right. Which set of conditions best explains this shift?

  1. Acidosis, hyperthermia and raised 2,3-DPG Correct answer.
  2. Alkalosis, hypothermia and low 2,3-DPG
  3. Reduced PaCO2 with hypocapnia
  4. Presence of fetal haemoglobin

Explanation

A rightward shift of the dissociation curve reduces haemoglobin affinity for oxygen, releasing oxygen to tissues. Acidosis (Bohr effect), hyperthermia and increased 2,3-diphosphoglycerate all produce this rightward shift. Alkalosis, hypothermia, low 2,3-DPG and fetal haemoglobin shift the curve left.

Question 3Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which inhalational agent has the lowest blood:gas partition coefficient and therefore the most rapid alveolar-to-blood equilibration?

  1. Isoflurane
  2. Desflurane Correct answer.
  3. Sevoflurane
  4. Halothane

Explanation

The blood:gas partition coefficient determines how avidly an agent is taken up by blood; a lower value means faster equilibration and quicker induction and recovery. Desflurane has the lowest coefficient of the volatile agents in common use, close to 0.42. Halothane, isoflurane and sevoflurane all have higher coefficients and slower equilibration.

Question 4Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

In a circle breathing system, the soda lime absorber primarily performs which function?

  1. Scavenging volatile agent from the circuit
  2. Humidifying inspired gas
  3. Removing carbon dioxide from exhaled gas Correct answer.
  4. Filtering bacterial contamination

Explanation

Soda lime contains calcium hydroxide that neutralises carbon dioxide in exhaled gas, allowing rebreathing of the remaining gases within a low-flow circle system. Heat and water are generated as by-products, but humidification is incidental rather than the primary purpose. Scavenging and filtration are performed by separate components.

Question 5Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which nerve is blocked during a classical interscalene brachial plexus block, producing the characteristic ipsilateral diaphragmatic paresis?

  1. The phrenic nerve Correct answer.
  2. The radial nerve
  3. The ulnar nerve
  4. The median nerve

Explanation

Local anaesthetic injected in the interscalene groove spreads medially to the phrenic nerve as it lies on the anterior scalene muscle, causing hemidiaphragmatic paresis in most patients. The ulnar, radial and median nerves are components of the brachial plexus itself and their blockade causes limb effects, not diaphragm paralysis. This is why interscalene block is avoided in severe respiratory disease.

Question 6Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

According to the Frank–Starling relationship, what happens to stroke volume when ventricular end-diastolic volume increases within the physiological range?

  1. Stroke volume increases Correct answer.
  2. Stroke volume decreases
  3. Stroke volume remains unchanged
  4. Stroke volume becomes independent of contractility

Explanation

The Frank–Starling mechanism states that increasing preload stretches myocardial fibres, increasing force of contraction and stroke volume within physiological limits. Beyond a point, further increases in end-diastolic volume produce little additional output. Stroke volume does not fall with rising preload in the normal range.

Question 7Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which receptor mediates the bronchoconstrictor and bradycardic effects of acetylcholine released at vagal nerve endings?

  1. Beta-2 adrenergic receptors
  2. Muscarinic M2 receptors Correct answer.
  3. Alpha-1 adrenergic receptors
  4. Nicotinic receptors

Explanation

Acetylcholine acts on muscarinic M2 receptors at the heart to slow the sinoatrial node and on M3 receptors in airways to cause bronchoconstriction. Antimuscarinic drugs such as glycopyrrolate block these effects. Nicotinic receptors are at autonomic ganglia and the neuromuscular junction, while adrenergic receptors respond to catecholamines.

Question 8Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A vaporiser delivers a set concentration of volatile agent. Which variable most directly determines the partial pressure delivered to the patient?

  1. The patient's cardiac output
  2. The circuit's reservoir bag volume
  3. The agent's saturated vapour pressure at the vaporiser temperature Correct answer.
  4. The fresh gas flow rate

Explanation

The saturated vapour pressure of the agent at the vaporiser's temperature determines the maximum partial pressure achievable, and the splitting ratio controls the fraction that reaches the patient. Fresh gas flow affects the total amount delivered over time but not the dialled concentration. Cardiac output and bag volume influence uptake and mixing but not the vaporiser output setting.

Question 9Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient receives a depolarising neuromuscular blocker that causes prolonged paralysis in a person with atypical plasma cholinesterase. Which drug and mechanism explain this?

  1. Vecuronium, metabolised by the liver
  2. Rocuronium, reversed by sugammadex
  3. Suxamethonium, metabolised by plasma cholinesterase Correct answer.
  4. Atracurium, eliminated by Hofmann degradation

Explanation

Suxamethonium is rapidly hydrolysed by plasma cholinesterase, so patients with reduced or atypical enzyme activity have prolonged block. Vecuronium and rocuronium are non-depolarising agents, and atracurium undergoes organ-independent Hofmann degradation. This is why suxamethonium apnoea is the classic presentation of cholinesterase deficiency.

Question 10Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with severe aortic stenosis is being induced. Which physiological goal is most important to maintain during induction?

  1. Adequate preload with avoidance of tachycardia and hypotension Correct answer.
  2. Deep vasodilation to lower systemic vascular resistance
  3. Tachycardia with reduced afterload
  4. Hyperventilation to reduce preload

Explanation

In aortic stenosis, the hypertrophied left ventricle has fixed outflow obstruction and depends on adequate preload and sinus rhythm to maintain cardiac output. Tachycardia shortens diastolic filling time and worsens ischaemia, while vasodilation causes dangerous falls in coronary perfusion pressure. Maintaining preload, systemic vascular resistance and a controlled heart rate is therefore essential.

Question 11Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which change in arterial blood gases is expected in a patient with chronic obstructive pulmonary disease who is retaining carbon dioxide?

  1. Raised PaCO2 with renal compensation raising bicarbonate Correct answer.
  2. Raised PaCO2 with no metabolic compensation
  3. Low PaCO2 with raised bicarbonate
  4. Low PaCO2 with renal compensation lowering bicarbonate

Explanation

Chronic hypercapnia from alveolar hypoventilation triggers renal retention of bicarbonate over days, partially correcting the pH toward normal. This is a compensated respiratory acidosis. Acute rises in PaCO2 would show little or no bicarbonate change, distinguishing acute from chronic retention.

Question 12Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient is given a large dose of a highly lipid-soluble intravenous induction agent. Which property most determines its rapid offset after a single bolus?

  1. Renal excretion of unchanged drug
  2. Redistribution from brain to muscle and fat Correct answer.
  3. Hepatic clearance rate
  4. Plasma protein binding

Explanation

Highly lipid-soluble agents such as thiopentone produce rapid recovery from a single dose because the drug redistributes away from the well-perfused brain into muscle and fat. Metabolism is slow and does not explain the fast offset after a bolus, though it determines recovery after repeated dosing. Redistribution is therefore the key pharmacokinetic concept.

Question 13Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

During a laparoscopy with carbon dioxide insufflation, which physiological change is most consistently observed?

  1. Respiratory acidosis from CO2 absorption Correct answer.
  2. Increased functional residual capacity
  3. Increased venous return to the right heart
  4. Bradycardia from vagal stimulation

Explanation

Carbon dioxide absorbed from the peritoneum raises PaCO2, producing respiratory acidosis if ventilation is not increased. Pneumoperitoneum also reduces functional residual capacity and venous return and can cause bradycardia from peritoneal stretch, but these are less consistent than the acid–base effect. Ventilation is usually adjusted to compensate.

Question 14Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which statement best describes the effect of adding a small dose of adrenaline to a local anaesthetic solution?

  1. It reduces block intensity at the nerve
  2. It prolongs block duration by reducing local clearance Correct answer.
  3. It increases the risk of systemic toxicity by increasing absorption
  4. It has no effect on bleeding at the surgical site

Explanation

Adrenaline causes local vasoconstriction, slowing absorption and clearance of the local anaesthetic from the injection site. This prolongs the block and reduces peak plasma concentration, lowering toxicity risk. It also improves surgical haemostasis, which is why it is used in many regional techniques.

Question 15Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with myasthenia gravis is sensitive to non-depolarising neuromuscular blockers. What is the most appropriate anaesthetic consideration?

  1. Reduce the dose and monitor with a nerve stimulator Correct answer.
  2. Avoid neuromuscular monitoring as it is unreliable
  3. Use standard doses and expect prolonged block
  4. Prefer suxamethonium for prolonged relaxation

Explanation

Myasthenia gravis involves reduced acetylcholine receptors at the neuromuscular junction, so patients are sensitive to non-depolarising blockers and require reduced doses with quantitative monitoring. Suxamethonium may show resistance rather than normal response and can cause prolonged block in some patients. Nerve stimulation remains reliable for titrating reversal.

Question 16Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which gas law explains why a nitrous oxide cylinder pressure gauge remains constant until the liquid is exhausted?

  1. Dalton's law
  2. Henry's law Correct answer.
  3. Gay-Lussac's law
  4. Boyle's law

Explanation

Henry's law describes the solubility of a gas in a liquid, and for a liquefied gas such as nitrous oxide the vapour pressure depends only on temperature while liquid remains. The cylinder pressure therefore stays constant until all liquid has vaporised. Boyle's law relates pressure and volume, Dalton's law concerns partial pressures in a mixture, and Gay-Lussac's law relates pressure and temperature.

Question 17Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with a high spinal block becomes hypotensive and bradycardic. Which mechanism best explains the bradycardia?

  1. Blockade of cardiac accelerator fibres with unopposed vagal tone Correct answer.
  2. Direct myocardial depression from local anaesthetic
  3. Reduced venous return causing reflex tachycardia
  4. Increased circulating adrenaline

Explanation

High neuraxial block interrupts sympathetic cardioaccelerator fibres (T1–T4), leaving vagal tone unopposed and producing bradycardia. Reduced venous return from sympathetic blockade also contributes and can trigger the Bezold–Jarisch reflex. Treatment includes vasopressors, fluid and antimuscarinic drugs such as atropine.

Question 18Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which agent is most appropriate for rapid sequence induction in a patient with a full stomach and haemodynamic stability who requires a fast onset?

  1. Suxamethonium Correct answer.
  2. Sevoflurane
  3. Midazolam
  4. Propofol

Explanation

Suxamethonium is a depolarising blocker with the fastest onset of the commonly used neuromuscular blockers, making it suitable for rapid sequence induction. Propofol, sevoflurane and midazolam do not provide rapid muscle relaxation for intubation. The choice must still account for contraindications such as hyperkalaemia.

Question 19Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which nerve is most at risk of injury during a supraclavicular brachial plexus block?

  1. The phrenic nerve Correct answer.
  2. The recurrent laryngeal nerve
  3. The spinal accessory nerve
  4. The ulnar nerve

Explanation

The phrenic nerve lies close to the anterior scalene and can be affected by spread of local anaesthetic during supraclavicular and interscalene blocks. Phrenic nerve palsy with hemidiaphragmatic paresis is a recognised complication. The recurrent laryngeal and spinal accessory nerves are not the principal structures at risk in this approach.

Question 20Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

During mechanical ventilation, which change would increase the risk of barotrauma?

  1. Reducing tidal volume
  2. Applying high peak airway pressure with a high tidal volume Correct answer.
  3. Adding positive end-expiratory pressure of 5 cmH2O
  4. Increasing respiratory rate at low tidal volume

Explanation

Barotrauma results from excessive pressure and volume delivered to the alveoli, so high peak airway pressure with a large tidal volume increases risk. Lung-protective ventilation uses lower tidal volumes and limits plateau pressure. Modest PEEP of 5 cmH2O is generally safe and reduces atelectasis.

Question 21Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which statement about the pharmacology of ketamine is most accurate?

  1. It is a pure GABA-A agonist
  2. It produces profound hypotension at induction doses
  3. It has no bronchodilator effect
  4. It acts as an NMDA receptor antagonist with analgesic properties Correct answer.

Explanation

Ketamine is an NMDA receptor antagonist that provides dissociative anaesthesia with analgesia and sympathetic stimulation. It tends to preserve blood pressure and is a useful bronchodilator in reactive airways. It is not a GABA-A agonist, and hypotension is not typical at induction doses.

Question 22Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with chronic kidney disease is to receive a neuromuscular blocker. Which agent's duration is least affected by renal impairment?

  1. Atracurium Correct answer.
  2. Neostigmine
  3. Vecuronium
  4. Pancuronium

Explanation

Atracurium undergoes organ-independent Hofmann degradation and ester hydrolysis, so its duration is largely unaffected by renal failure. Pancuronium and vecuronium depend on renal and hepatic clearance and can accumulate in kidney disease. Neostigmine is a reversal agent, not a neuromuscular blocker.

Question 23Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

Which mechanism best explains the reduced minimum alveolar concentration (MAC) seen in a patient receiving a large dose of opioids?

  1. Reduced alveolar ventilation
  2. Increased hepatic metabolism of the volatile agent
  3. Increased volatile agent solubility in blood
  4. Additive or synergistic central nervous system depression Correct answer.

Explanation

MAC is the alveolar concentration at which 50% of patients do not respond to a surgical stimulus, and it is reduced by central depressant drugs. Opioids act on central receptors to enhance anaesthetic effect, lowering the volatile concentration required. Solubility, metabolism and ventilation do not directly lower MAC.

Question 24Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with a large pneumothorax has a chest drain inserted. Which physiological change explains the improvement in oxygenation after drainage?

  1. Reduced pulmonary blood flow to the affected lung
  2. Increased shunt fraction
  3. Reduced dead space from collapsed lung
  4. Re-expansion of collapsed alveoli and improved ventilation-perfusion matching Correct answer.

Explanation

A pneumothorax causes lung collapse and shunt, so drainage re-expands alveoli and restores ventilation to perfused regions, improving ventilation-perfusion matching. Dead space and shunt fraction fall rather than rise. Pulmonary blood flow may be redistributed but the key benefit is alveolar re-expansion.

Question 25Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

During a general anaesthetic, a patient develops a malignant hyperthermia reaction. Which physiological mechanism underlies the rise in end-tidal CO2?

  1. Excessive calcium release from the sarcoplasmic reticulum with sustained muscle contraction Correct answer.
  2. Increased aerobic metabolism from shivering
  3. Blockade of the sympathetic nervous system
  4. Reduced oxygen consumption with hyperventilation

Explanation

Malignant hyperthermia results from uncontrolled calcium release from the sarcoplasmic reticulum via a ryanodine receptor defect, causing sustained muscle contraction and greatly increased metabolism. This produces rising end-tidal CO2, hyperthermia and acidosis. Treatment is dantrolene, which inhibits calcium release.

Question 26Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

During one-lung ventilation with the right lung collapsed, which change in pulmonary blood flow distribution is expected?

  1. Blood flow is diverted away from the collapsed lung toward the ventilated lung by hypoxic pulmonary vasoconstriction Correct answer.
  2. Blood flow distribution between the two lungs remains unchanged because the pulmonary circulation lacks autoregulation
  3. Blood flow increases to the collapsed lung because its vessels dilate from alveolar hypoxia
  4. Blood flow to the ventilated lung falls because positive pressure raises its vascular resistance above that of the collapsed lung

Explanation

Alveolar hypoxia in the non-ventilated lung constricts its small pulmonary arteries, a response known as hypoxic pulmonary vasoconstriction, which shifts blood toward the ventilated lung and limits shunt. This reflex is the main reason oxygenation is preserved during one-lung ventilation.

Question 27Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with long-standing hypertension has a mean arterial pressure of 60 mmHg. Which mechanism is most responsible for maintaining glomerular filtration rate in this setting?

  1. Afferent arteriolar constriction mediated by tubuloglomerular feedback
  2. Angiotensin II preferentially constricting the efferent arteriole Correct answer.
  3. Increased sympathetic tone constricting the afferent arteriole
  4. Autoregulation of renal blood flow by the myogenic response of the afferent arteriole

Explanation

Angiotensin II constricts the efferent arteriole more than the afferent arteriole, which raises glomerular hydrostatic pressure and preserves filtration when renal perfusion pressure falls. This is why angiotensin blockade can cause acute kidney injury in patients who depend on this mechanism.

Question 28Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A 70 kg patient is receiving a continuous infusion of a drug with a clearance of 4 L/min and a desired steady-state plasma concentration of 2 mg/L. Which infusion rate is required?

  1. 8 mg/min Correct answer.
  2. 4 mg/min
  3. 0.5 mg/min
  4. 2 mg/min

Explanation

At steady state the infusion rate equals clearance multiplied by the target concentration, so 4 L/min times 2 mg/L gives 8 mg/min. This relationship holds once distribution is complete and is independent of volume of distribution.

Question 29Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient with a body weight of 80 kg requires a dose of a drug whose volume of distribution is 0.5 L/kg. Which volume must be loaded to achieve the target plasma concentration initially?

  1. 16 L
  2. 40 L Correct answer.
  3. 80 L
  4. 160 L

Explanation

The loading dose is determined by the volume of distribution, here 0.5 L/kg multiplied by 80 kg, giving 40 L. This volume reflects the apparent space into which the drug distributes and predicts the dose needed to reach a given concentration.

Question 30Basic Sciences Applied to Anesthesia (anatomy, physiology, pharmacology, physics and equipment)

A patient is artificially ventilated using a circle breathing system with a fresh gas flow of 1 L/min. Which factor most limits the accuracy with which a variable-bypass vaporiser delivers the dialled concentration?

  1. The patient's functional residual capacity
  2. The resistance of the breathing circuit tubing
  3. The solubility of the volatile agent in blood
  4. The fresh gas flow relative to the vaporiser's calibrated range Correct answer.

Explanation

Variable-bypass vaporisers are calibrated for a range of fresh gas flows, and at very low flows the splitting ratio and back pressure change so the delivered concentration deviates from the dialled value. Blood solubility and circuit resistance affect uptake and work of breathing, not the vaporiser's output accuracy.

Question 31Preoperative Assessment and Perioperative Risk Management

A 62-year-old man scheduled for elective hemicolectomy has a preoperative hemoglobin of 8.1 g/dL with normocytic indices. Which preoperative action is most appropriate before proceeding to surgery?

  1. Cancel surgery permanently because hemoglobin below 10 g/dL is an absolute contraindication
  2. Investigate the cause of anemia and optimize hemoglobin before elective surgery Correct answer.
  3. Proceed with surgery and transfuse only if intraoperative blood loss exceeds 500 mL
  4. Schedule surgery after a single unit of whole blood is given in the holding area

Explanation

Preoperative anemia is an independent predictor of perioperative morbidity and mortality, and elective surgery allows time to identify the cause (iron deficiency, chronic disease, occult malignancy) and treat it. Transfusion thresholds are not fixed at 10 g/dL; modern restrictive strategies are used. Deferring for investigation rather than blind transfusion is the safest pathway.

Question 32Preoperative Assessment and Perioperative Risk Management

Which finding on preoperative assessment most strongly predicts difficult mask ventilation in an adult patient?

  1. Mallampati class II airway
  2. History of treated hypertension
  3. Body mass index greater than 30 kg/m2 with a beard Correct answer.
  4. Age over 65 years

Explanation

Obesity, presence of a beard, edentulous state, and age over 55 are recognized independent risk factors for difficult mask ventilation, with obesity plus beard being a strong combination. Mallampati classification predicts difficult laryngoscopy more than mask ventilation. Hypertension and isolated advanced age are weak predictors.

Question 33Preoperative Assessment and Perioperative Risk Management

A patient on long-term prednisolone 20 mg daily for rheumatoid arthritis is undergoing major abdominal surgery. What is the most appropriate perioperative corticosteroid plan?

  1. Give supplemental hydrocortisone perioperatively in addition to the maintenance dose Correct answer.
  2. Stop prednisolone 48 hours before surgery to avoid wound infection
  3. Switch to inhaled corticosteroids for the perioperative period
  4. Continue the usual dose only and give no additional supplementation

Explanation

Chronic supraphysiologic glucocorticoid therapy suppresses the hypothalamic-pituitary-adrenal axis, so major surgery requires supplemental hydrocortisone (commonly 100 mg at induction then divided doses) alongside the maintenance dose to prevent adrenal crisis. Abrupt cessation risks adrenal insufficiency. Inhaled therapy does not provide systemic coverage.

Question 34Preoperative Assessment and Perioperative Risk Management

Which preoperative laboratory test is most clearly indicated in an asymptomatic 45-year-old woman with no comorbidities before minor ambulatory surgery?

  1. Coagulation profile
  2. No routine laboratory testing is indicated Correct answer.
  3. Serum electrolytes and creatinine
  4. Chest radiograph

Explanation

Guidelines recommend against routine preoperative testing in healthy asymptomatic patients undergoing low-risk surgery because abnormal results rarely change management and can trigger unnecessary investigation and delay. Testing should be targeted to history, comorbidity, and the invasiveness of the procedure.

Question 35Preoperative Assessment and Perioperative Risk Management

A 70-year-old man with an ejection fraction of 30% and recent decompensated heart failure is scheduled for elective major surgery. Which preoperative strategy best reduces perioperative risk?

  1. Proceed immediately to avoid delaying surgery
  2. Optimize heart failure therapy and delay elective surgery until the patient is clinically stable Correct answer.
  3. Give a single large fluid bolus preoperatively to improve cardiac output
  4. Start a nonsteroidal anti-inflammatory drug for preemptive analgesia

Explanation

Decompensated heart failure is a major perioperative risk factor, and elective surgery should be deferred until the patient is optimized on guideline-directed therapy and euvolemic. Proceeding during decompensation markedly increases the risk of pulmonary edema and arrhythmia. NSAIDs cause fluid retention and should be avoided in this setting.

Question 36Preoperative Assessment and Perioperative Risk Management

Which risk index is specifically designed to estimate 30-day cardiac risk for patients undergoing noncardiac surgery?

  1. CHA2DS2-VASc score
  2. Revised Cardiac Risk Index Correct answer.
  3. APACHE II score
  4. Child-Pugh score

Explanation

The Revised Cardiac Risk Index uses six factors (high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and renal impairment) to estimate major cardiac events after noncardiac surgery. APACHE II predicts critical illness mortality, CHA2DS2-VASc estimates stroke risk in atrial fibrillation, and Child-Pugh grades hepatic reserve.

Question 37Preoperative Assessment and Perioperative Risk Management

A patient with a hip fracture on warfarin has an INR of 3.2 and requires urgent surgery within hours. Which approach is most appropriate for reversal?

  1. Give fresh frozen plasma only after the INR falls below 2.0
  2. Give protamine sulfate
  3. Give intravenous vitamin K plus a prothrombin complex concentrate Correct answer.
  4. Give vitamin K alone and wait 24 hours

Explanation

For urgent surgery with warfarin-associated coagulopathy, rapid reversal requires intravenous vitamin K plus a prothrombin complex concentrate, which corrects the INR within minutes. Vitamin K alone acts too slowly for urgent surgery, and protamine reverses heparin, not warfarin.

Question 38Preoperative Assessment and Perioperative Risk Management

Which preoperative finding is an indication to postpone elective surgery for further evaluation?

  1. Well-controlled type 2 diabetes with HbA1c of 7.0%
  2. Mild intermittent claudication
  3. Blood pressure of 138/86 mmHg
  4. New-onset atrial fibrillation with a rapid ventricular rate Correct answer.

Explanation

Uncontrolled new-onset atrial fibrillation with a rapid ventricular response is an unstable cardiac condition that warrants evaluation and rate or rhythm control before elective surgery. Mild hypertension, stable claudication, and well-controlled diabetes are not reasons to postpone elective procedures.

Question 39Preoperative Assessment and Perioperative Risk Management

A 55-year-old smoker with a 40 pack-year history is scheduled for major abdominal surgery. Which preoperative intervention most effectively reduces postoperative pulmonary complications?

  1. Routine preoperative incentive spirometry training only on the day of surgery
  2. Routine use of a nasogastric tube postoperatively
  3. Smoking cessation begun 4 to 8 weeks before surgery Correct answer.
  4. Starting a course of prophylactic antibiotics

Explanation

Smoking cessation at least 4 to 8 weeks before surgery reduces postoperative pulmonary complications, with longer abstinence conferring greater benefit. Prophylactic antibiotics address infection rather than pulmonary complications, and single-day spirometry training is insufficient on its own.

Question 40Preoperative Assessment and Perioperative Risk Management

Which preoperative assessment tool is used to estimate the risk of postoperative nausea and vomiting in adults?

  1. Mallampati classification
  2. Aldrete score
  3. ASA physical status classification
  4. Apfel simplified risk score Correct answer.

Explanation

The Apfel score predicts postoperative nausea and vomiting using four factors: female sex, nonsmoker status, history of motion sickness or postoperative nausea and vomiting, and planned postoperative opioid use. The ASA classification describes overall physical status, Mallampati assesses the airway, and the Aldrete score assesses recovery and fitness for discharge.

Question 41Preoperative Assessment and Perioperative Risk Management

A patient with severe aortic stenosis is scheduled for elective cholecystectomy. Which perioperative consideration is most important?

  1. Maintaining sinus rhythm, preload, and systemic vascular resistance while avoiding tachycardia and hypotension Correct answer.
  2. Routine use of a pulmonary artery catheter for all cases
  3. Inducing deliberate hypotension to reduce blood loss
  4. Rapid intravenous fluid loading to increase cardiac output

Explanation

In severe aortic stenosis the fixed obstruction makes cardiac output dependent on adequate preload, atrial contribution from sinus rhythm, and systemic vascular resistance; tachycardia and hypotension can cause myocardial ischemia and collapse. Routine pulmonary artery catheters and deliberate hypotension are not indicated, and rapid fluid loading can precipitate pulmonary edema.

Question 42Preoperative Assessment and Perioperative Risk Management

Which statement about perioperative management of a patient on a direct oral anticoagulant (apixaban) for nonvalvular atrial fibrillation undergoing elective surgery is correct?

  1. Apixaban should be continued unchanged for all procedures
  2. Apixaban is typically stopped 24 to 48 hours before surgery depending on renal function and bleeding risk, without routine bridging Correct answer.
  3. Apixaban should be replaced with warfarin two weeks before surgery
  4. Apixaban must always be bridged with low molecular weight heparin

Explanation

Direct oral anticoagulants have short half-lives, so they are usually interrupted 24 to 48 hours before elective surgery based on renal function and procedural bleeding risk. Routine heparin bridging is not recommended for DOACs because it increases bleeding without reducing thromboembolism. Switching to warfarin before surgery is unnecessary and increases risk.

Question 43Preoperative Assessment and Perioperative Risk Management

A 68-year-old woman with type 2 diabetes on metformin and glibenclamide is scheduled for morning surgery. Which preoperative fasting and medication plan is most appropriate?

  1. Stop all diabetes medications for 72 hours before surgery
  2. Continue both drugs and allow clear fluids up to 2 hours before surgery
  3. Hold glibenclamide on the morning of surgery and manage glucose with a variable-rate insulin infusion if needed Correct answer.
  4. Give a double dose of glibenclamide to prevent hyperglycemia

Explanation

Sulfonylureas such as glibenclamide can cause prolonged hypoglycemia during fasting, so they are typically withheld on the day of surgery, with glucose controlled by insulin if necessary. Metformin is usually continued for minor surgery but may be held for major procedures or when renal dysfunction is present. Clear fluids are allowed up to 2 hours before anesthesia.

Question 44Preoperative Assessment and Perioperative Risk Management

Which preoperative condition most strongly increases the risk of aspiration pneumonitis during induction of anesthesia?

  1. Treated hypothyroidism
  2. Mild chronic kidney disease
  3. Well-controlled asthma
  4. Gastroesophageal reflux disease with an untreated full stomach and delayed gastric emptying Correct answer.

Explanation

Aspiration risk is highest when gastric volume and acidity are increased and protective reflexes are impaired, as with a full stomach, delayed gastric emptying, and reflux. Asthma, treated hypothyroidism, and mild renal impairment do not independently create a large aspiration risk.

Question 45Preoperative Assessment and Perioperative Risk Management

A patient is scheduled for surgery and has a history of anaphylaxis to penicillin. Which preoperative step is most important to reduce the risk of a repeat reaction?

  1. Give a test dose of penicillin in the operating room
  2. Ignore the history because anaphylaxis is rare
  3. Document the allergy, identify cross-reactive agents, and select alternative antibiotics Correct answer.
  4. Give a prophylactic antihistamine and proceed with penicillin

Explanation

Accurate allergy documentation and selection of structurally unrelated antibiotics is the cornerstone of preventing recurrent anaphylaxis; cephalosporins may be considered based on specific side-chain cross-reactivity rather than blanket avoidance. Prophylactic antihistamines do not prevent anaphylaxis, and test dosing in the operating room is dangerous.

Question 46Preoperative Assessment and Perioperative Risk Management

Which preoperative factor is most associated with an increased risk of postoperative delirium in older adults?

  1. Preoperative cognitive impairment Correct answer.
  2. Male sex alone
  3. Use of regional anesthesia
  4. Mild obesity

Explanation

Preoperative cognitive impairment and dementia are among the strongest predictors of postoperative delirium in older adults, along with advanced age, frailty, and sensory impairment. Sex alone, choice of regional anesthesia, and mild obesity are not strong independent predictors.

Question 47Preoperative Assessment and Perioperative Risk Management

A 60-year-old man with cirrhosis (Child-Pugh class C) and ascites requires emergency surgery. Which preoperative consideration is most important?

  1. Coagulation is normal because the INR is the only measure that matters
  2. Assume he has a hypercoagulable state and give therapeutic heparin
  3. Assess for coagulopathy, thrombocytopenia, and renal dysfunction, and optimize volume and electrolyte status Correct answer.
  4. Proceed without assessment because emergency surgery overrides all risk

Explanation

In advanced cirrhosis, synthetic failure causes coagulopathy, portal hypertension causes thrombocytopenia, and splanchnic vasodilation with renal dysfunction (hepatorenal syndrome) is common, so comprehensive assessment and optimization are essential. The INR does not reflect the full rebalanced hemostatic picture, and routine therapeutic heparin is not indicated.

Question 48Preoperative Assessment and Perioperative Risk Management

Which preoperative measure is recommended to reduce the risk of surgical site infection in a patient undergoing colorectal surgery?

  1. Using tap water to prepare the skin
  2. Shaving the surgical site with a razor the night before
  3. Routine postoperative antibiotic administration for 7 days
  4. Administering appropriate prophylactic antibiotics within 60 minutes before incision Correct answer.

Explanation

Timely administration of appropriate prophylactic antibiotics, typically within 60 minutes before incision (or according to the agent's pharmacokinetics), is a key evidence-based measure to reduce surgical site infection. Razor shaving the night before increases infection risk, prolonged postoperative antibiotics are not recommended, and tap water is not an appropriate skin preparation.

Question 49Preoperative Assessment and Perioperative Risk Management

A patient with a history of malignant hyperthermia susceptibility requires surgery. Which preoperative plan is most appropriate?

  1. Avoid triggering agents such as volatile anesthetics and succinylcholine, and use a trigger-free anesthetic technique Correct answer.
  2. Use halothane with dantrolene prophylaxis
  3. Proceed with any anesthetic because susceptibility is not clinically relevant
  4. Use succinylcholine for rapid sequence induction

Explanation

Malignant hyperthermia susceptibility requires avoidance of triggering agents (volatile anesthetics and succinylcholine) and use of a trigger-free technique, with dantrolene available. Prophylactic dantrolene is not routinely required when triggers are avoided. Succinylcholine and halothane are both triggers.

Question 50Preoperative Assessment and Perioperative Risk Management

Which preoperative assessment finding suggests the need for a difficult airway plan and awake fiberoptic intubation in a patient with a neck mass?

  1. Mild obesity
  2. Stridor and a fixed, noncompressible neck mass causing airway deviation Correct answer.
  3. Prior uncomplicated appendectomy
  4. Controlled hypertension

Explanation

Stridor with a fixed neck mass and airway deviation suggests significant upper airway obstruction and distortion, where loss of spontaneous ventilation during induction could be catastrophic. Awake fiberoptic intubation or another awake technique preserves airway tone and allows assessment. The other findings do not imply a difficult airway.