3rd Shift Samplex

SURGERY SHIFTING EXAMINATION 1 CHOOSE

THE BEST ANSWER:

1.

C The effect of uncontrolled inflammatory reaction secondary to cytokines and other substrates is best manifested in what type of shock? A. cardiogenic B. hypovolemic C. septic D. obstructive shock

2.

A One of the following is not consistent with proinflammatory action? A. vasoconstriction capillary permeability C. chemoattractant to neutrophils and microphages D. hypertension

3.

C In patients with severe sepsis it has been shown in studies that inhibiting excessive activation of the coagulation system improves survival. Which of the following may inhibit the coagulation system? A. infliximab B. methotrexate C. drotrecogin alfa D. etanercept

4.

C What enzyme mediates the effect of nitric oxide? cyclase D. lactamase

5.

C A post colon resection patient on chemotherapy is exposed to an area experiencing severe endemic infection. To help the patient resist possible severe infection we can give A. steroids B. IL-13 C. Interferon γ D. IL-10

6.

B These are small proteins or glycoproteins secreted for the purpose of altering the function of target cells in an endocrine fashion. A. insulin B. cytokines C. thyroxine D. lymphocytes

7. 8.

A

9.

D These substances are produced by the inflammatory cascade and induces refractory vasodilation: B. prostaglandins C. peroxynitrite anion D. All are correct

A. cyclooxygenase

Which of the following is inflammatory cytokine? A. IL-2

B. IL-4

B. increased

B. lipooxygenase

C. IL-10

C. guanylyl

D. IL-13

C Which cytokines produced by macrophages stimulates transformation of TH2 cells to active TH1 thus producing Interferon γ? A. IL-4 B. IL-13 C. IL-18 D. All are correct

10. A

Believed to be the mediator for COX-2 to exert its vasodilatory and increase permeability effect (peroxynitrate anion) B. thromboxine C. arachidonic acid D. guanylyl cyclase

11. A

Hypovolemic shock can result from any of the following: pancreatitis D. all of the above

A. intestinal obstruction

12. B

Cellular change in hypovolemic shock: A. intracellular loss of Na+ extracellular loss of K+ D. normal cellular membrane potential

13. D

Renal response to hyvolemic shock: A. decreased renal artery perfusion C. increased water permeability D. all of the above

14.

A. ONOO

B. burns

C.

B. depletion of cellular ATP

C.

B. rennin-angiotensin activation

A patient with decreased CVP is most likely having: A. hypovolemic shock cardiogenic shock D. all of the above bns

A. NO

B. neurogenic shock

C.

15. D

The most reliable method of assessing the patient’s adequacy of resuscitation is the hourly urine ourput, which should be: A. 100 mL/hr B. 10 mL/hr C. 10 mL/kg D. 1 mL/kg

16. C

Compensatory responses that occur during shock: A. increased capillary hydrostatic pressure B. decreased sympathetic activity C. release of epinephrine and norepinephrine D. decreased peripheral vascular resistance

17. A

A 35-year-old is seen at the ER after a vehicular crash. Vital signs were as follows BP 80/60 PR 110/min, RR 35/min, and T 36°C. On physical examination breath sounds is decreased over the right and there is no apparent source of bleeding. Shock in this patient should be presumed to be due to: A. hemorrhage B. neurogenic C. cardiogenic D. vasodilatory

18. D

is:

The possible site that can harbour sufficient extravascular blood volume that induces shock in this patient A. external loss B. long bone fracture C. retroperitoneal sequestration D. intrathoracic

19. B

A 38-year-old male had abdominal exploration for multiple gunshot wounds. He is febrile T 38.5°C on the 2nd post-op day. HR is 98 bpm, BP 100/80. WBC count is 13000. The patient is hooked to a ventilator. On the 5th day post-op the patient in addition to the above findings now show erythema and draining pus from the abdominal incision site. The patient now is developing: A. SIRS B. sepsis C. severe sepsis D. septic shock

20. D

On the 10th day post-op, the above patient is persistently febrile with an increased WBC count (18000) and oliguria that is unresponsive to fluid resuscitation. The patient now is developing: A. SIRS B. sepsis C. severe sepsis D. septic shock

21. C

The treatment of hemorrhagic shock requires prompt control of bleeding and: A. rapid administration of oxygen B. administration of digitalis C. volume replacement D. use of antibiotics

22. D

Regardless of etiology, the common factor in the development of shock is: A. diminution of intravascular volume B. peripheral vasodilation C. failed sympathetic response to injury D. inadequate delivery of oxygen to the tissues

23. C

Regarding the diagnosis and treatment of cardiac tamponade, which of the following statements is true? A. accumulation of greater than 250 mL of blood in the pericardial sac is necessary to impair cardiac output B. Beck’s triad includes distended neck veins, pulsus paradoxius, and hypertension C. approximately 15% of needle pericardiocentesis give a false negative result D. cardiopulmonary bypass is required to repair most penetrating cardiac injuries

24. C

Initial fluid resuscitation in shock should be: A. full blast through 1 line until the cause of bleeding is corrected B. must attain normal BP, then decrease rate C. 2 liters are routinely given in 15 minutes D. 50 cc at fast drip, re-evaluate at 15-minute intervals

25.

A patient presents with hypotension, tachycardia, tachypnea and an ABP showing metabolic acidosis. Your primary consideration is: A. hypovolemic shock B. neurogenic shock C. septic shock D. cardiogenic shock bns

26. D

The most common etiology among non-trauma patient of the above condition is: A. acute massive but subtle hemorrhage B. third space fluid sequestration C. loss of autonomic nervous system control D. gramnegative bacteremia

27. C

Early phase of hypovolemic shock among young patients is characterized by: A. hypotension with decreased cardiac output B. hypodynamic cardiac rate C. normotensive and tachycardia D. increased peripheral resistance and unresponsive to volume replacement

28. D

The difference between septic shock and hypovolemic shock is/are: A. decrease peripheral resistance in septic shock versus increase of peripheral resistance in hypovolemic shock B. hyperdynamic state in septic shock versus hypodynamic state in hypovolemic shock C. presence of mediators in septic shock versus simply neuro-humoral response in hypovolemic shock D. All of the above

29. C

The three most common cause of death in hypovolemic shock are: A. acute renal failure, ARDS, and multiorgan failure B. hemorrhage, DIC, and encephalopathy C. hypotension, hypothermia and DIC D. antibiotic overdose, severe dehydration and pulmonary overload

30. A

Among trauma patients in shock, the goal of ER resuscitation is: A. adequate tissue perfusion B. to attain normal vital signs C. to provide time for diagnostic procedures D. to convert an emergency operation to an elective one

31. A

After the last bag of blood has been transfused, the patient developed fever and had a bloody urine output. What is going on in the patient? A. transfusion reaction B. allergy to the pre-op antibiotics C. SSI D. expected after any blood transfusion

32. C

The most common reason why this patient developed this problem is: pre-op antibiotics C. human error D. under hydration intra-op

A. air embolism

B. absence of

33. A

This patient has been taking aspirin for the past week, which was prescribed by his physician prior to the accident. This blood test finding is expected in our patient: A. prolonged bleeding time B. normal partial thromboplastin time C. prolonged prothrombin time D. delayed clotting time

34. D

If the patient taking aspirin is scheduled for elective laparoscopic cholecystectomy, how will you correct the bleeding problem? A. transfuse WB during the operation B. discontinue aspirin use for several days prior to the operation C. go on with schedule and disregard the aspirin use D. transfuse platelets 3 days prior to scheduled operation

35. C

The above patient eventually is operated with normal blood parameter, immediately post-op the patient is bleeding from the operative site. Bleeding is secondary to: A. uncorrected hypovolemia B. reaction to the anesthetic C. inadequate hemostasis intra-operatively D. use of aspirin.

36. D

In the awake, nonanesthetized patient suspected of having a haemolytic posttransfusion reaction, the most characteristic signs are: A. diffuse bleeding and hypotension B. nausea and vomiting C. fever and chills D. oliguria and hemoglobinuria

37. A

The most common clinical manifestation of a haemolytic transfusion reaction is: A. oliguria B. flank pain C. jaundice D. shaking chill 38. A Platelets in the wound form a hemostatic clot and release clotting factors to produce: A. fibrin B. fibrinogen C. fibroblast D. thrombin 39. bns A hemophilic patient needs transfusion, what component is needed: A. PRBC B. WB C. FFP D. cryoprecipitate 40. B In a patient scheduled for thyroidectomy with no known bleeding problem, what will you request prior to the operation? A. bleeding time B. platelet count C. partial thromboplastin time D. clotting time 41. A Which of the following diseases may be transmitted by all blood components? A. malaria B. Hep B C. Hep A D. syphilis 42. A A 10-year old female is scheduled to undergo craniotomy for a brain tumor. If you want to screen the patient regarding her hemostatic risk, which of the following information is most helpful? A. history of abnormal bleeding B. prolonged PT C. platelet count of 100,000 D. prolonged clotting time

43. C 44. A 45. A 46. B

Which of the following laboratory exams will you request for this patient with a history of prolonged bleeding? A. PT & PTT B. platelet count & bleeding time C. both D. none During operation, it was noted that the patient has excessive bleeding, which of the following factors should be considered? A. ineffective local hemostasis B. previously undetected hemostatic defect C. complications of blood transfusion D. all of the above Vitamin K was given intra-operatively, which of the following coagulation factor does not require vitamin K for their production? A. V B. IX C. VII D. X A 75-year-old male is admitted because of persistent vomiting of previously ingested food of 7 days duration. He was diagnosed with gastric antral carcinoma 8 months ago. PE reveals a lethargic male with the following vita signs: BP: 90/60 PR: 115/min RR: 28/min and T of 36.5C. His weight is 49 kg. Skin is loose, oral mucous membrane is dry and the tongue is furrowed. A positive succussion splash is elicited. The acid base disturbance most likely present in this patient is: A. metabolic acidosis B. metaboloic alkalosis C. respiratory acidosis D. respiratory alkalosis

47. D

The best sign of restoration of his intravascular volume after fluid resuscitation is: A. increase in the volume of the pulse B. BP of 110/80 mm Hg C. improved level of consciousness D. urine output of 50 cc/hr

48. C

In an attempt by the kidneys to conserve Na, the following electrolyte will be excreted: A. ClC. K+ D. Mg++

49. D

Fluid resuscitation should initially begin with: A. albumin solutions frozen plasma D. crystalloid solutions

50. A 51. 52. 53.

54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.

B. synthetic colloid solutions

B. HCO3C. fresh

Postoperatively, a patient who has undergone a major procedure is not passing adequate urine output. BUN and serum creatinine ratio showed pre-renal azotemia. Your fluid of choice is: A. D5LRS B. 0.3 NaCl C. D5W D. D5NR B? A patient who is in a state of severe hyponatremia will appear: A. easily excited B. drowsy C. tachycardic D. pale C Majority of the patients with metabolic alkalosis have some degree of hypokalemia, due to: A. loss of potassium due to diarrhea B. loss of potassium due to severe vomiting or fluid sequestration C. failure of the kidney to reabsorb the potassium D. influx of potassium into the cells as hydrogen ion efflux to the serum A Twenty-four hours after an uneventful excision of a brain tumor, a 42-year-old male developed polyuria and unique thirst. If uncorrected, your patient’s fluid and electrolyte state will most likely by: A. relative hypernatremia with hypovolemia B. volume excess with dilutional hyponatremia C. low serum osmolarity D. intravascular volume excess C The normal serum K+ value is: A. 1-2 meq/L B. 1.5-3 meq/L C. 3.5-4.5 meq/L D. 3-7 meq/L A The principal cation in the extracellular fluid compartment is: A. sodium B. potassium C. chloride D. bicarbonate C The common cause of extracellular fluid volume excess in surgical patients: A. trauma B. peritonitis C. excessive fluid administration D. intestinal obstruction B Sign of ECF volume overload: A. diminished tendon reflexes B. pulmonary edema C. hypothermia D. abdominal distention A If D5W is used for fluid replacement in a post-operative patient with nasogastric tube drainage of 2 liters/day, the patient will develop: A. ECF deficit with hyponatremia B. ECF deficit with hypernatremia C. ICF deficit with hyponatremia D. ECF deficit with hypernatremia C A 48-year-old female undergoes laparoscopic cholecystectomy. On the first post-operative day, she complains of severe operative site pain and develops fever. The most likely cause of the fever is: A. wound infection B. dehydration C. atelactasis D. anesthetic reaction A Two days after resuscitation from shock, fluid mobilization starts. A frequent fluid and electrolyte disorder at this stage will be: A. dilutional hyponatremia B. hypovolemia C. hypotention D. decreased venous return A A 44-year-old male with a neglected intraperitoneal infection will most probably have: A. volume deficiency B. sodium excess C. volume excess D. potassium excess B In the above patient, manifestation of your answer will be initially be evident in the: A. skin and mucosa B. cardiovascular system C. central nervous system D. renal system D If still uncorrected during the hospital course, the most likely concentration change is: A. hyponatremia B. hyperkalemia C. hypocalcemia D. hypomagnesia D The most useful method of following the long-term trend in fluid balance is: A. weigh the patient daily B. maintain a careful daily I & O chart C. serial measurements of serum Na+ D. maintain a daily record of urine volume and specific gravity C After an extensive abdominal operation, the pancreatic duct stream along with the biliary juice was completely diverted to drain externally. Which of the following will disappear by significant amounts from the GI tract? A. potassium B. sodium C. bicarbonate D. chloride A A 65-kg male underwent pancreatic resection. Parenteral nutrition is started post-operatively. The recommended daily protein intake is: A. 80 to 100 g/day B. 40-60 g/d 30-40 g/d D. 60-80 g/day B This patient should receive this amount of kcal/kg/day to meet his daily energy requirements: A. 15 B. 25 C. 60 D. 40 B After several days on parenteral nutrition, this patient complains of anosmia and shows darkening of skin creases. The trace mineral deficient is: A. calcium B. chromium C. magnesium D. zinc A If the above patient develops a dry flaky skin with alopecia. This condition is most likely a result of: A. linoleic acid deficiency B. zinc deficiency C. vitamin C deficiency D. magnesium deficiency C The most appropriate route for the administration of protein and calories to a patient after a pancreatic resection is through: A. nasogastric tube feedings B. gastrostomy tube feedings C. jejunostomy tube feedings D. central venous hyperalimentation B The daily enteral nutritional support for this patient should contain which of the following? A. saturated fatty acids B. trace minerals C. large amounts of K D. fructose D A 66-kg male after a total colonic resection requires nutritional support, the recommended daily protein intake is: A. 90 g/d B. 60 g/d C. 50 g/d D. 100 g/d. D? The primary reason/s why nutritional support in this patient is necessary: A. for metabolic processes B. core temperature maintenance C. tissue repair D. all of the above

74. A In assessing the nutritional deficiency in this patient, the following anthropometric data should be obtained: A. ideal body weight B. creatinine excretion C. dietary habits prior to injury D. presence of chronic illness 75. D A 52-year-old patient is comatose, which route is appropriate for the administration of protein and calories? A. jejunostomy B. gastrostomy C. nasogastric D. any of the above is acceptable

76. C

77. 78. 79. 80.

A 42-year-old male is admitted for hernia surgery. He complains of on & off abdominal pain, but tolerates regular diet. His weight on admission is 60 kg, which was 72 kg six months ago. He has poor appetite but regular bowel movement. PE is normal except for a large inguino-scrotal mass ® that could be reduced with difficulty. What is the Subjective Global Assessment diagnosis? A. well-nourished B. mild malnutrition C. moderate malnutrition D. severe malnutrition B Using the “Rule of Thumb”, his total caloric requirement is: A. 1500 Kcal B. 1800 Kcal C. 2000 Kcal D. 2500 Kcal C The protein component of his nutrition is: A. 150 Kcal B. 200 Kcal C. 250 Kcal D. 300 Kcal B The carbohydrate component of his nutrition is: A. 800 Kcal B. 1000 Kcal C. 1200 Kcal D. 1400 Kcal B In the hospital, his fasting blood sugar is 250 mg/dL. His carbohydrate component is adjusted to how much % of his total caloric requirement: A. 30% B. 45% C. 60% D. 75%