Download APEX FINAL 1 LATEST 2024 ACTUAL EXAM 1000+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH R and more Exams Nursing in PDF only on Docsity!
APEX FINAL 1 LATEST 2024 ACTUAL EXAM
1000+ QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
Major cause of apnea with neuraxial anesthesia (and what is usually not the cause) - ANSWER- Usually the result of cerebral hypoperfusion, not phrenic nerve paralysis Cause of drowsiness with neuraxial anesthesia - ANSWER- reduces sensory input to the Reticular Activating System (RAS), causing drowsiness. saddle block - ANSWER- given at the lower end of the spinal column (sacrum) to block the perineal area, or hyperbaric solution in lumbar w/ sitting position maintained until block sets up. opioid moa - ANSWER- inhibit pain transmission (afferent signals) in the substantia gelatinosa via the dorsal horn benefit to using opioids with LA - ANSWER- creates a denser block
Recommendations for block placement: Glycoprotein IIb/IIIa antagonists - ANSWER- Abciximab: Hold 1-2 days Tirofiban, Eptifibatide: Hold 8h Recommendations for block placement: Cox inhibitors - ANSWER- Proceed if pt has normal clotting mechanism and is not on any other blood thinners Recommendations for block placement: Thienopyridine inhibitors - ANSWER- Clopidogrel: Hold 7 days Ticlopidine: Hold 14 days Recommendations for block placement/catheter removal: Unfractionated Heparin - ANSWER- SQ: Proceed if pt has normal clotting mechanism and is not on any other blood thinners IV: Hold 2-4 hours b/f block, and 1h after block placement Hold 2-4h after removing catheter Recommendations for block placement/catheter removal: low molecular weight Heparin - ANSWER- Enoxaparin, Dalteparin, Tinzaparin Before block placement: Prophylactic (Once daily): Hold 12h
Normal length of transient neurological symptoms (TNS) - ANSWER- 1 - 7 days Most common LA to cause transient neurological symptoms (TNS) - ANSWER- Lidocaine List the structures a needle passes through for an epidural block
- ANSWER- Skin - > subcutaneous tissue - > subcutaneous fat - > supraspinous ligament - > intraspinous ligament - > ligamentum flavum - > epidural space List the structures a needle passes through for a subarachnoid block - ANSWER- Skin - > subcutaneous tissue - > subcutaneous fat - > supraspinous ligament - > intraspinous ligament - > ligamentum flavum - > epidural space - > dura mater - > subdural space - > arachnoid mater - > subarachnoid space Organism most likely to cause post-spinal bacterial meningitis? - ANSWER- Streptococcus viridans neurotransmission is reduced by: - ANSWER- - decreased cAMP
- decreased Ca2+ conductance
- decreased K+ conductance
Acinus - ANSWER- Functional unit of liver lobule
- hepatocytes surrounding a central vein Perfusion of liver lobule (blood flow) - ANSWER- Arterioles: hepatic artery (25% bld flow, 50% O2) & portal vein (75% bld flow, 50% O2) Capillaries: sinusoids Venules: central vein 30% CO Kupfer cells - ANSWER- Macrophages in the liver that clean the blood of bacteria b/f it goes to the vena cava Bile - ANSWER- - produced by hepatocytes
- drained by canaliculi into bile ducts - >common hepatic duct Sphincter of Oddi - ANSWER- controls the flow of bile released from the common hepatic duct contraction increases biliary pressure (narcotics - esp morphine)
Lipids: beta oxidation, trigylceride storage Synthesis of cholesterol, phospholipids, lipoproteins Conjugates bilirubin w/ glucuronic acid, excreted in bile Drug metabolism hepatotoxic drugs - ANSWER- Acetaminophen (toxic metabolite NAPQI) Halothane (inorganic fluoride & TFA) alcohol (impairs fatty acid metabolism) Hepatitis - ANSWER- - alcohol most common cause (hep C is 2nd)
- dx: liver enzymes, bili, liver inflammation
- s/s: jaundice, fatigue, thrombocytopenia, glomerulonephritis, neuropathy, arthritis, myocarditis prolonged PT, decreased albumin Drugs to avoid w/ liver dx - ANSWER- acetaminophen, halothane, amiodarone, tetracycline, sulfonamides, penicillin Anesthetic considerations for acute hepatitis - ANSWER- Delay surgery if possible until stabilized
Use Iso = best for hepatic bld flow (never halothane) Avoid PEEP (decreased hepatic drainage) normocapnea liberal use of IV fluids Liver dx effects on NMB's - ANSWER- Decrease pseudocholinesterase (prolongs succ) Roc, Vec biliary excretion (prolongs) Larger vol of distribution Consider cis - not dependent on hepatic metabolism Anesthetic considerations for alcoholsims - ANSWER- Acute intoxication (↓MAC - need less drug) Chronic alcoholism (↑MAC-need more drug) EtOH potentiates GABA-increased effect of benzo's EtOH inhibits NMDA receptors Wernicke-Korsakoff syndrome - ANSWER- loss of neurons in cerebellum brought on by thiamine deficiency Anesthetic considerations for acute intoxication - ANSWER- - Less anesthesia is needed
chronic hepatitis (inflammation) right-sided heart failure (↑ hepatic vascular resistance) α₁-antitrypsin deficiency (genetic) Wilson's disease (genetic) hemochromatosis (iron overload) cirrhosis - ANSWER- healthy hepatic tissue is replaced by fibrous tissue and nodules CV changes w/ liver dx - ANSWER- - hyperdynamic circulation=↑CO, ↓SVR, ↑RAAS activation, ↓response to vasopressors, diastolic dysfxn, ↓blood viscousity, anemia
- portal HTN=↑hepatic vascular reisistance - > ↑back flow (esophageal varisces, splenomegaly)-> arteriovenous shunting d/t extensive systemic collateral vessels
- Ascites (↓oncotic pressure, ↓protein binding)
- alcoholic cardiomyopathy
- preop HF Hematologic changes w/ liver dx - ANSWER- Anemia (Acceptable hematocrit: 30%) Thrombocytopenia (Acceptable PLT is 100,000) Leukopenia
Coagulation disorders Preservation of hepatic arterial bld flow is critical: portal venous blood flow is reduced What causes thrombocytopenia in liver dx - ANSWER- decreased platelet production and splenic consumption Renal changes w/ liver dx - ANSWER- Renal hypoperfusion - > ↓GFR - > ↑RAAS - > dilutional hyponatremia Protein loss and low oncotic pressure - > Ascites & Edema correct hypovolemia and diurese = Consider albumin, mannitol, potassium sparing diuretics CNS changes w/ liver dx - ANSWER- Encephalopathy = accumulation of toxins (Nitrogen compounds= ammonia) breaks down the blood brain barrier Increased levels of GABA ↑Cerebral uptake of benzos Pulmonary changes in liver dx - ANSWER- Hepatopulmonary syndrome: pleural effusions & Pulmonary hypertension
Phase 2 drug metabolism - ANSWER- Conjugation reactions Phase I product (substrate) conjugates with a second molecule to make it water soluble Leads to formation of covalent linkage b/w functional group and glucuronic acid, sulfate, glutathione, amino acid, or acetate (e.g.,morphine,acetaminophen) TIPS procedure - ANSWER- Transjugular intrahepatic portal- systemic shunt, lowers portal pressure in portal HTN Bypasses portion of the hepatic circulation by shunting blood from the portal vein to the hepatic vein reduces back pressure on sphlanic organs and ↓ bleeding from varices & ↓ascites sig risk: hemhorrage Cather placed in R IJ and advanced via Inferior Vena Cava into the right hepatic vein Can have lg amounts of bld loss Avoid N2O TIPs fluid management - ANSWER- Lg amounts of albumin crystalloid not advised LR exacerbates liver failure secondary to the breakdown of bicarbonate in the liver
Sodium retention limits amounts of NS Mannitol to maintain urine output of at least 50 mL/hour (avoid Lasix) Complications to watch for include liver laceration, gallbladder perforation, oliguric renal failure (secondary to contrast dye) and stent embolization Indication for TIPS - ANSWER- Used to treat portal hypertension usually caused by cirrhosis or as a temporary solution for hepatorenal syndrome Liver dx preop labs - ANSWER- Albumin, CBC, coags, electrolytes, glucose, ALT & AST, AlkPhos, Blood type and screen, serum ammonia level, toxicology screen if suspected substance abuse Liver dx CV considerations - ANSWER- hyperdynamic circulatory state drugs that relax the sphincter of oddi - ANSWER- Glucagon Glycopyrrolate Atropine Naloxone
Mechanisms responsible for ascites - ANSWER- Portal hypertension = ↑hydrostatic pressure-> transudation of fluid across the intestine into the peritoneal cavity Hypoalbumenia Seepage of protein-rich lymphatic fluid from the serosal surface of the liver secondary to distortion and obstruction of lymph channels in the liver water & sodium retention (↑RAAS) Gallstones - ANSWER- 3F's: Fat, Female, 40 s/s: leukocytosis, fever, RUQ pain, pain is worse w/ inspiration (murphy's sign) cholecyctitis - ANSWER- inflammation of the gallbladder cholecysectomy Cholethiasis - ANSWER- gallstones cholecysectomy choledocholithiasis - ANSWER- stones in the common bile duct ERCP
ERCP (endoscopic retrograde cholangiopancreatography) - ANSWER- Indications: biliary or pancreatic ductal disorder, Biliary or pancreatic drainage, Biopsy, Bile or pancreatic juice collection, Mapping of the pancreatic duct before intended surgery MAC, conscious sedation or GA Glucagon given to relax sphincter of Oddi: 0.4 - 1 mg IV drug induced hepatitis - ANSWER- TB meds- INH, rifampin, pyrazinamide Toxic - alcohol, Acetaminophen Tetracycline, penicillin, Sulfonamide, Volatile anesthetics (halothane) Amiodarone, Methyldopa Chronic hepatitis - ANSWER- Hep B: 1-10% Hep C: 10-40%
- Chronic persistent (relatively benign and confined to portal areas)
- Chronic lobular (recurrent exacerbations of acute inflammation
- progression to cirrhosis rare)
•decreased GFR stimulate RAAS which leads to water and sodium retention •This can cause hyponatremia (dilutional) •Increased BUM comes from the failing liver being able to clear nitrogenous waste (this can lead to cerebral edema Anesthetic mgmt of cirrohsis - ANSWER- - depressed response to inotropes and vasopressors
- alcoholic cardiomyopathy
- HF
- Preserve hepatic blood flow (volatile anesthetics decrease hepatic bld flow)
- Maintain normocapnia
- Avoid peep altered pharmacokinetics/dynamics w/ liver dx - ANSWER- Altered volume of distribution: Intravascular volume unpredictable, esp with ascites tx ↓ serum albumin ↑ gamma globulins Porto-systemic shunted blood bypasses liver Drugs highly extracted by liver esp affected
↑ sensitivity to sedative medications (decreased metabolism, increased duration, increased GABA, NMDA inhibition) Ascites - ANSWER- Decreased renal perfusion Altered intrarenal hemodynamics Enhanced proximal and distal sodium reabsorption Often an impairment of free water clearance Liver dx risk factors for mortality - ANSWER- High Child- Pughs core Presence of ascites Elevated serum creatinine Pre-op upper GI bleed High ASA rating Anesthetic concerns w/ liver dx - ANSWER- Hypoglycemia Coagulopathies (Vitamin k factors) PLT sequestration and thrombocytopenia (Splenomegaly secondary to portal HTN) ↓ protein synthesis and protein oncotic pressure= third spacing-> ↑ vol of distribution, (must consider for medication dosing) Varices (careful w/ NG/OG)
