Surgery Pretest

SURGERY 1Finals Pretest

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 arrestd. Hypotensione. Stupor

2. The chief surgical risk to which patients with polycythemia vera are exposed is that due to:

a. Anemic disturbancesb. Hemorrhagec. Infection

d. Renal dysfunctione. Cardiopulmonary

complications

3. Signs and symptoms of hemolytic transfusion reactions include:

a. Hypothermiab. Hypertensionc. Polyuria

d. Abnormal bleedinge. 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. APTTb. PTc. Reptilase time

d. Bleeding timee. Thrombin time

5. The substrate depleted earliest in the postoperative period is:

a. Branched-chain amino acids

b. Non-branched-chain amino acids

c. Ketoned. Glycogene. Glucose

6. Hypocalcemia is associated with:

a. Acidosisb. Shortened QT

intervalc. Hypomagnesemia

d. Myocardial irritability

e. Hyperproteinemia


7. Which of the following characteristics of this patient might increase the risk of a wound infection?

a. History of colon surgery

b. Hypertensionc. Male sex

d. Receipt of chemotherapy

e. Asthma

Items 8–10

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 18–25 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 perioperativelyd. Leaving a seroma in the wound to prevent desiccation of the

tissuese. 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. History of colon surgeryb. Hypertensionc. Male sexd. Receipt of chemotherapye. 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 surgeryc. Shaving the abdomen the night prior to surgeryd. Continuing the prophylactic antibiotics for three postoperative

dayse. Use of a closed drainage system brought out through the

operative incision

11. Signs and symptoms associated with early sepsis include:

a. Respiratory acidosisb. Decreased cardiac outputc. Hypoglycemiad. Increased arteriovenous oxygen differencee. Cutaneous vasodilation

12. The most common physiologic cause of hypoxemia is:

a. Hypoventilationb. Incomplete alveolar oxygen diffusionc. Ventilation-perfusion inequalityd. Pulmonary shunt flowe. Elevated erythrocyte 2,3-diphosphoglycerate level (2,3-DPT)

13. Major alterations in pulmonary function associated with adult respiratory distress syndrome (ARDS) include:

a. Hypoxemiab. Increased pulmonary compliancec. Increased resting lung volumed. Increased functional residual capacitye. 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. Intubationb. Epinephrinec. Beta blockersd. Iodinee. Fluid challenge


15. During blood transfusion, clotting of transfused blood is associated with:

a. ABO incompatibilityb. Minor blood group incompatibilityc. Rh incompatibilityd. Transfusion through Ringer’s lactatee. 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. Urinary nitrogen excretion levelsb. Total serum protein levelc. Serum albumin leveld. Serum transferrin levelse. Respiratory quotient

17. Signs and symptoms of unsuspected Addison’s disease include:

a. Hypothermiab. Hypokalemiac. Hyperglycemiad. Hyponatremiae. Hypervolemia

18. The etiologic factor implicated in the development of pulmonary insufficiency following major nonthoracic trauma is:

a. Aspirationb. Atelectasisc. Fat embolism syndromed. Fluid overloade. Pneumonia

19. Treatment for clostridial myonecrosis (gas gangrene) includes which of the following measures?

a. Administration of an antifungal agentb. Administration of antitoxinc. Wide debridementd. Administration of hyperbaric oxygene. Early closure of tissue defects


20. Spontaneous retroperitoneal hemorrhage during anticoagulant therapy:

a. Is best confirmed by bleeding scanb. Is equally likely with parenteral and oral anticoagulantsc. May mimic an acute surgical abdomend. Frequently requires laparotomy for ligation of the bleeding sitee. 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. Collagen content reaches a maximum at approximately 1 wk after injury

b. Monocytes are essential for normal wound healingc. Fibroblasts appear in the wound within 24–36 h after the injuryd. The function of the monocyte in wound healing is limited to

phagocytosis of bacteria and debrise. 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. Placement of a left chest tubeb. Immediate thoracotomyc. Immediate celiotomyd. Esophagogastroscopye. 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. Renal vascular injuryb. Superior mesenteric thrombosisc. Mesenteric vascular injuryd. Avulsion of the splenic pediclee. 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. Strapping the chest with adhesive tapeb. Immobilization with sandbagsc. Tube thoracostomyd. Peritoneal lavagee. Surgical fixation of the fractured ribs

25. Blunt trauma to the abdomen most commonly injures which of the following organs?

a. Liverb. Kidneyc. Spleend. Intestinee. 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. Angiographyb. Immediate exploration and repairc. Fasciotomy of anterior compartmentd. Observation for resolution of spasme. Local wound exploration

27. 140. Among the physiologic responses to acute injury is:

a. Increased secretion of insulinb. Increased secretion of thyroxinec. Decreased secretion of vasopressin (ADH)d. Decreased secretion of glucagone. 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. Choledochoduodenostomyb. Loop choledochojejunostomyc. Primary end-to-end anastomosis of the transected bile ductd. Roux-en-Y choledochojejunostomye. 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. Expanding hematomab. Dysphagiac. Dysphoniad. Pneumothoraxe. 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. Gastrojejunostomyb. Nasogastric suction and observationc. Duodenal resectiond. TPN to increase the size of the retroperitoneal fat pade. Duodenojejunostomy

31. 144. Following traumatic peripheral nerve transection, regrowth usually occurs at which of the following rates?

a. 0.1 mm per dayb. 1 mm per dayc. 5 mm per dayd. 1 cm per daye. 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 sandbagsc. Stabilization with towel clipsd. Immediate operative stabilizatione. 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. Flexor pollicis longus and flexor digitus medius tendonsb. Radial nervec. Median nerved. Thenar and digital nerves at the wriste. 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 transfusionb. Transfer the patient to a hyperbaric oxygen chamberc. Begin bicarbonate infusion and give 250 mg acetazolamide

(Diamox) intravenouslyd. Administer 100% oxygen by maske. 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 fixationb. Angiographic visualization of the obturator artery with surgical

exploration if the artery is injured or constrictedc. Direct surgical approach with internal fixation of the ischial

ramusd. 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 requiredd. Evaluation for fracture of the other extremities and visceral

injury is indicatede. 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. Knee dislocationb. Closed posterior elbow dislocationc. Midclavicular fractured. Supracondylar femur fracturee. 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 gluconeogenesisb. Inhibition of skeletal muscle breakdown by interleukin 1 and

tumor necrosis factor (TNF, cachectin)c. Decreased urinary nitrogen lossd. 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. Barium studies of the colon and rectumb. Barium studies of the bullet trackc. Endoscopy of the bullet trackd. Angiographye. 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. Significant arterial injuryb. Significant injury to adjacent motor nerve trunksc. Significant injury to adjacent long bonesd. Significant injury to adjacent veinse. Subsequent development of a compartment syndrome and the

need for fasciotomy

43. The response to shock includes which of the following metabolic effects?

a. Increase in sodium and water excretion


b. Increase in renal perfusionc. Decrease in cortisol levelsd. Hyperkalemiae. Hypoglycemia

44. Appropriate treatment for an acute stable hematoma of the pinna of the ear includes which of the following measures?

a. Ice packs and prophylactic antibioticsb. Excision of the hematomac. Needle aspirationd. Incision, drainage, and pressure bandagee. Observation alone

45. Animal and clinical studies have shown that administration of lactated Ringer’s solution to patients with hypovolemic shock may:

a. Increase serum lactate concentrationb. Impair liver functionc. Improve hemodynamics by alleviating the deficit in the

interstitial fluid compartmentd. Increase metabolic acidosise. Increase the need for blood transfusion

46. True statements concerning penetrating pancreatic trauma include:

a. Most injuries do not involve adjacent organsb. Management of a ductal injury to the left of the mesenteric

vessels is Roux-en-Y pancreaticojejunostomyc. Management of a ductal injury in the head of the pancreas is

pancreaticoduodenectomyd. Small peripancreatic hematomas need not be explored to

search for pancreatic injurye. 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. Placement of long 18-gauge subclavian vein cathetersb. Placement of percutaneous femoral vein cathetersc. Bilateral saphenous vein cutdownsd. 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. Fibroblastsb. Damaged vascular endothelial cellsc. Monocytes/macrophagesd. Activated T lymphocytese. Activated killer lymphocytes

49. A cross-match is performed by incubating:

a. Donor serum with recipient lymphocytes and complementb. Donor lymphocytes with recipient serum and complementc. Donor lymphocytes with recipient lymphocytesd. Recipient serum with a known panel of multiple donor

lymphocytese. Recipient serum with donor red blood cells and complement

50. In order to activate helper/inducer T (CD41) lymphocytes, macrophages release:

a. Interleukin 1b. Interleukin 2c. Interleukin 3d. Interleukin 4e. Interferon

51. Which of the following cells cause immunologically restricted tumor cell lysis?

a. Macrophagesb. Cytotoxic T lymphocytesc. Natural killer cellsd. Polymorphonuclear leukocytese. 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 yearse. 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 angiogramb. Decreasing steroid and cyclosporine dosec. Beginning intravenous antibioticsd. Performing renal biopsy, steroid boost, and immunoglobulin

therapye. Beginning FK 506

54. Posttransplant cytomegalovirus infection may cause:

a. Plyelonephritisb. GI ulceration and hemorrhagec. Cholecystitisd. Intraabdominal abscesse. Parotitis

55. In centers with experienced personnel, 1-year liver transplant survival is now approximately:

a. 95%b. 80%c. 65%d. 50%e. 35%

56. Graft-versus-host disease has occurred with the transplantation of which of the following?

a. Kidneyb. Lungc. Heartd. Bone marrowe. Pancreas


57. Which of the following diseases is appropriately treated with combined heart-lung transplantation?

a. Primary pulmonary hypertensionb. Cystic fibrosisc. End-stage emphysemad. Idiopathic dilated cardiomyopathy with long-standing secondary

pulmonary hypertensione. End-stage pulmonary fibrosis secondary to sarcoidosis

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Surgery Pretest