Thomas Halaszynski
1. An 85-year-old male is scheduled for a right distal radius and ulnar open reduction interior fixation at the wrist. Medical history is significant for chronic obstructive pulmonary disease dependent on 2 L of oxygen, hypertension, diabetes mellitus, and coronary artery disease with a stent inserted one year ago. Given that the surgeon plans to use a forearm tourniquet, the regional anesthesia technique that would be most appropriate for this patient is
A. An interscalene brachial plexus block plus an intercostal brachial nerve block
B. A supraclavicular approach to the brachial plexus plus an intercostal brachial nerve block
C. An infraclavicular block of the brachial plexus at the cords plus an intercostal brachial nerve block
D. Superficial cervical plexus blockade plus an intercostal brachial nerve block
2. While performing an axillary brachial plexus block, all of the following nerves are spared, except
A. Musculocutaneous nerve
B. Ulnar nerve
C. Lateral brachial cutaneous nerve
D. Medial brachial cutaneous nerve
3. Contraindications to safely perform peripheral regional anesthesia include all of the following, except
A. Patients who may not provide absolute cooperation during nerve block placement (mental retardation) without administration of sedation
B. Patient refusal
C. Severe coagulopathy while anticipating a deep nerve plexus blockade
D. Evidence of infection at injection site
4. While performing a peripheral nerve block in an awake patient, access and/or use of all of the following should be considered mandatory, except
A. Administer supplemental oxygen
B. Apply standard ASA monitors
C. Access to resuscitation medications and equipment
D. Immediate access to a mechanical ventilator
5. The most correct statement regarding the appropriate use of ultrasound equipment during performance of regional anesthesia is
A. Higher frequency ultrasound probes are used for deeper penetration
B. High-frequency ultrasound probes provide for higher image resolution
C. Liner array probes are typically used for imaging deeper anatomical structures
D. The curvilinear probe is designed to best image superficial structures
6. Which of the following nerves is typically spared during performance of an interscalene brachial plexus block?
A. Median
B. Axillary
C. Musculocutaneous
D. Ulnar
7. Following successful performance of a right interscalene block for surgical rotator cuff repair in a 27-year-old patient with no other medical issues, you are called to the recovery room (post–anesthesia care unit) 3 hours later to evaluate the patient. The patient’s symptoms include drooping of the right eyelid, redness of the conjunctiva, and pupillary constriction. The most likely diagnosis is
A. Spinal anesthesia
B. Subdural injection of local anesthetic
C. Horner syndrome
D. Cerebrovascular accident (CVA)
8. A supraclavicular block of the brachial plexus does not provide consistent surgical anesthesia for shoulder surgery secondary to potential sparing of which of the following nerve branches of the brachial plexus?
A. Musculocutaneous and axillary nerve branches
B. Axillary and suprascapular nerve branches
C. Ulnar and axillary nerve branches
D. Suprascapular and supraclavicular nerve branches
9. Performing an infraclavicular approach for brachial plexus blockade would deposit local anesthetics at which of the following anatomical levels of the plexus?
A. Trunks
B. Divisions
C. Cords
D. Roots
10. A supraclavicular approach for brachial plexus blockade would deposit local anesthetics at which of the following anatomical levels of the plexus?
A. Branches
B. Trunks/Divisions
C. Cords
D. Roots
11. When performing an axillary block of the brachial plexus for distal upper extremity surgery, which of the following nerves most often needs to be targeted separately?
A. Ulnar
B. Radial
C. Musculocutaneous
D. Median
12. Anatomical location of the musculocutaneous nerve in the upper forearm is most frequently found within which of the following muscles?
A. Triceps brachii
B. Biceps brachii
C. Coracobrachialis
D. Brachialis
13. While performing an ultrasound-guided axillary nerve block along with a nerve stimulator, your needle tip is imaged inferior to the pulsating axillary artery, and you see evidence of flexion of fourth and fifth digits. The stimulating needle tip is in closest proximity to which of the following peripheral nerve branches of the brachial plexus?
A. Median
B. Ulnar
C. Musculocutaneous
D. Radial
14. During placement of an ultrasound-guided and nerve stimulator–assisted axillary nerve block, your needle tip is imaged superiorly to the axillary artery. You also see pronation of the patient’s forearm. The needle tip is in closest proximity to which of the following branches of the brachial plexus?
A. Median nerve
B. Axillary nerve
C. Musculocutaneous nerve
D. Interscalene nerve
15. While performing an axillary nerve block by both ultrasound guidance and nerve-stimulator assistance, the image of your needle tip is seen posterior to axillary artery, and you observe supination of the forearm. The needle tip is closest to which of the following brachial plexus nerve branches?
A. Infraclavicular nerve
B. Ulnar
C. Intercostal brachial nerve
D. Radial nerve
16. After performing an axillary peripheral nerve block, your ultrasound probe moves to scan laterally and you see what appears to be an oval and hyperechoic nerve structure within the belly of the coracobrachialis muscle. When the needle tip is advanced closer to this structure and the nerve stimulator is activated, you notice that the elbow begins to flex. The most likely nerve branch that is being stimulated is
A. Median nerve
B. Triceps brachii nerve
C. Musculocutaneous nerve
D. Radial nerve
17. You successfully perform a right supraclavicular nerve block for a right wrist open reduction interior fixation. You are called to the post–anesthesia care unit 2 hours later because the patient is complaining of pain on the back of the wrist, which extends distal to the index, middle, and ring fingers on the dorsal surface of the hand. You consent the patient to perform a terminal branch nerve block to supplement the initial block. The nerve that would be needed to be blocked is
A. Median nerve
B. Radial nerve
C. Infraclavicular nerve
D. Interscalene nerve
18. You have just successfully performed a Bier block using 50 mL 0.5% lidocaine for carpal tunnel release surgery in a 45-year-old male (height, 6 ft; weight, 200 lb). The patient was sedated with 2 mg of midazolam upon arrival to the OR. Ten minutes following the local anesthetic placement, the surgeon indicates that the surgery is finished. At the surgeon’s request, the nurse releases the tourniquet that was placed on the upper arm. The patient soon becomes agitated, and you notice twitching of the patient’s arms and legs. The most likely diagnosis is
A. Anaphylaxis to midazolam
B. New-onset seizure disorder
C. Allergic reaction to the local anesthetic
D. Local anesthetic systemic toxicity (LAST)
19. A properly performed lumbar plexus block will result in blockade of all the following nerve branches, except
A. Femoral nerve
B. Lateral femoral cutaneous nerve
C. Obturator nerve
D. Sciatic nerve
20. Electrical nerve stimulation of which of the following nerves will produce quadriceps muscle contraction?
A. Femoral nerve
B. Sciatic nerve
C. Lateral femoral cutaneous nerve
D. Obturator nerve
21. You have just performed a femoral nerve block in preparation for a tibial plateau fracture repair using 20 mL 0.5% ropivacaine. Three hours postsurgery in the recovery room, the patient complains of lateral thigh pain. Was the femoral nerve block a failure and what would be the most appropriate action?
A. Yes, repeat the femoral nerve block due to a failed block
B. No, repeat the femoral nerve block as the effectiveness of the local anesthetic has worn off after 4 hours
C. No, the pain expressed is not located within the distribution of the femoral nerve, supplement with a lateral femoral cutaneous nerve block
D. Yes, the pain is due to a failed femoral block, but do not repeat the block as there exists a high risk of nerve injury
22. A properly placed psoas compartment block or posterior lumbar plexus block can be associated with any of the following complications, except
A. Retroperitoneal hematoma
B. Spinal anesthesia
C. Local anesthetic systemic toxicity
D. Sciatic nerve injury
23. You are consulted on an ASA IV patient for a right-ankle surgery. The patient has a known history of difficult intubation and status post–spinal fusion surgery. The surgeon is requesting for a peripheral nerve block that will provide for surgical anesthesia. Which of the following nerves will need to be blocked in order to provide for complete anesthesia during performance of foot and ankle surgery?
A. Both sciatic and femoral nerve blockade
B. Sciatic nerve block alone
C. Femoral nerve block alone
D. Sciatic, femoral, and obturator nerve blocks
24. All of the following nerves provide sensory innervation to the foot, except
A. Lateral femoral cutaneous nerve
B. Sural nerve
C. Deep peroneal nerve
D. Superficial peroneal nerve
25. The most correct statement concerning a unilateral paravertebral block is
A. Such a block is always associated with a similar degree of sympathectomy as with an epidural block
B. Such a block is often associated with a higher serum level of local anesthetic than that achieved with an intercostal nerve block due to high vascularity
C. It is not likely to be associated with a pneumothorax
D. Such a block may be associated with epidural spread of local anesthetic
26. The most incorrect statement regarding transversus abdominis plane (TAP) block is
A. TAP blocks can provide analgesia following hernia repair surgeries
B. TAP blocks can often alleviate both somatic and visceral pain
C. One potential complication includes liver injury
D. Unilateral TAP blocks never cross over the midline
27. When performing a transversus abdominis plane (TAP) block, the goal is to deposit/inject local anesthetic between which of the following two muscle layers?
A. External oblique and internal oblique muscles
B. Internal oblique and transversus abdominis muscles
C. Transversus abdominis and external oblique muscles
D. Rectus abdominis and external oblique muscles
28. While performing the popliteal approach for a sciatic nerve block under ultrasound guidance, you are able to identify the popliteal artery adjacent to two hyperechoic nerve structures that appear to become one nerve structure upon proximal movement of the ultrasound probe placed within the popliteal fossa. The correct identity of the two nerve branches is
A. The nerve on the lateral side is the common peroneal nerve, and the nerve on the medial side is the tibial nerve (combined nerve is the sciatic nerve)
B. The nerve on the lateral side is the sciatic nerve, and nerve on the medial side is the deep peroneal nerve (combined nerve is the femoral nerve)
C. The nerve on the lateral side is the common tibial nerve, and nerve on the medial is the superficial peroneal nerve (combined nerve is the sciatic nerve)
D. The nerve on the lateral side is the common posterior tibial nerve, and the nerve on the medial side is the superficial peroneal nerve (combined nerve is the femoral nerve)
29. The most appropriate statement regarding the function of the saphenous nerve is
A. It serves as both a motor nerve and a sensory nerve
B. It is the motor terminal branch of the femoral nerve
C. It is the sensory terminal branch of the femoral nerve
D. It is a sensory terminal branch of the sciatic nerve
30. An interscalene block will typically deposit the local anesthetic between which of the following two muscles?
A. Anterior and middle scalene muscles
B. Middle and posterior scalene muscles
C. Anterior and posterior scalene muscles
D. Sternocleidomastoid and anterior scalene muscles
31. A 45-year-old healthy male is scheduled for bilateral elbow open reduction interior fixation secondary to a motor vehicle accident. Successful bilateral supraclavicular blocks were planned and performed under ultrasound guidance, with 20 mL 0.5% ropivacaine injected for each block on each side. In the operating room, the patient is receiving 25 μg/kg/min of a propofol infusion and oxygen via a non-rebreather bag. The patient also received 2 mg of midazolam, but no opioids. Thirty minutes after incision, the patient is experiencing progressive respiratory depression, and the oxygen saturation decreases from 100% to 85%. The most likely diagnosis is
A. Local anesthetic systemic toxicity (LAST)
B. Dysfunction of the diaphragm (diaphragm palsy)
C. Methemoglobinemia
D. Aspiration pneumonia
32. The most appropriate treatment for the patient in the above scenario is
A. Methylene blue due to local anesthetic systemic toxicity
B. Flumazenil to antagonize midazolam (oversedation)
C. Endotracheal intubation to provide respiratory support
D. Antibiotics to treat aspiration pneumonia
33. A 56-year-old woman is scheduled for a right total knee replacement. She has a medical history of hypertension, diabetes mellitus, obesity, and is status post L1–L5 vertebral fusion. The regional anesthetic technique that will provide her the most optimal perioperative pain management is
A. A femoral nerve block and an epidural
B. A femoral and proximal sciatic nerve block
C. Both a femoral and popliteal sciatic nerve block
D. A sciatic nerve block and a spinal
34. A 65-year-old female is scheduled for a right total shoulder replacement. Under ultrasound guidance, you perform a right interscalene nerve block and place a catheter for continuous local anesthetic infiltration planned for 3 days. One week later, the patient complains of persistent parasthesia of the entire right arm, including the wrist, hand, and all fingers (from the shoulder to the fingers). An MRI shows a diffuse swelling of the brachial plexus at the level of the cords. The most likely diagnosis is
A. Direct nerve injury/trauma from the block needle used
B. Irritation of the brachial plexus at the level of the branches from the continuous peripheral nerve catheter
C. Surgical trauma/manipulation of the brachial plexus at the level of the cords
D. Local anesthetic toxicity of the brachial plexus at the level of the roots/trunks
35. The foot is supplied mainly by which of the following nerve(s)?
A. Sciatic nerve
B. Obturator and tibial nerves
C. Femoral and lateral femoral cutaneous nerves
D. Saphenous and common peroneal nerves
36. The following local anesthetic medication is associated with the highest risk for cardiovascular collapse in the event of local anesthetic systemic toxicity (LAST)
A. Lidocaine
B. Bupivacaine
C. Ropivacaine
D. Mepivacaine
37. The most appropriate nerve block for pain management in a patient scheduled for a total hip replacement is
A. Femoral nerve block
B. Lumbar plexus block
C. Femoral and obturator nerve block
D. Femoral and lateral femoral cutaneous nerve block
38. The femoral nerve provides sensory innervation to the
A. Lower extremity below the knee
B. Anterior and medial thigh
C. Posterior and medial thigh
D. Almost the entire ankle
39. Sciatic nerve blockade provides sensory loss of the
A. Anterior and lateral thigh
B. Posterior thigh and majority of the leg below the knee
C. Medial and posterior thigh
D. Medial leg below the knee
40. You perform a right-side T3–T5 paravertebral blockade for a patient who is to undergo a right mastectomy with axillary lymph node dissection. Medical history of the patient includes alcohol abuse and panic attacks. After the surgery in the post–anesthesia care unit, the patient complains of a new-onset right-arm paresthesia. Vital signs remain stable along with strong and equal upper extremity bilateral pulses. The most likely diagnosis is
A. Surgery-related brachial plexus nerve injury and/or positional injury
B. The patient is experiencing withdrawal from alcohol
C. Side effects/complications of the paravertebral block on the brachial plexus
D. Patient is having a panic attack
41. You successfully perform and place a bilateral T8 continuous paravertebral block catheters for an open–partial hepatectomy. Eighteen hours postoperatively, the patient complains of 7/10 pain. To improve postoperative analgesia, 10 mL of 0.2% ropivacaine is administered through each catheter. Twenty minutes later, the patient indicates that the pain has decreased to 4/10. The most likely aspect of paravertebral blockade that can account for the reason why the patient did not achieve a pain-free condition is
A. The block level was too high; it should have been placed at the T10 level
B. The block level is too low; it should have been placed at the T6 level
C. Paravertebral blockade analgesia provides for mostly somatic blockade and does not provide for complete coverage of visceral pain
D. The local anesthetic volume administered is too small
42. A patient is to undergo surgery to create an arteriovenous fistula for hemodialysis on the antecubital area of the right upper extremity. You perform a right supraclavicular block uneventfully using 20 mL 0.5% ropivacaine. The patient has a medical history significant for hypertension and end-stage renal disease. Three days following the surgery, the patient complains that she has no sensation from the right elbow to the tips of all her fingers, but she can move all of her fingers normally. The most likely etiology is
A. Neurotoxicity of the trunks/divisions of the brachial plexus secondary to the ropivacaine
B. Nerve injury secondary to the regional block needle used
C. Prolonged effect of the local anesthetic secondary to the patient’s renal failure
D. Possible surgery-related injury at the elbow that may warrant an electrophysiology study
43. While performing an axillary brachial plexus blockade, the goal is to deposit local anesthetic medications at what location of the brachial plexus and to target which specific nerve structures?
A. Level of the branches and targeting the radial, median, and ulnar peripheral nerves
B. Level of the trunks and targeting the interscalene, radial, and ulnar peripheral nerves
C. Level of the divisions and targeting the supraclavicular, median, and radial peripheral nerves
D. Level of the cords and targeting the infraclavicular, ulnar, and radial peripheral nerves
44. Which of the following approaches to blockade of the brachial plexus is associated with the highest incidence of a pneumothorax?
A. Interscalene and axillary approaches
B. Supraclavicular and interscalene approaches
C. Infraclavicular and axillary approaches
D. Axillary and interscalene approaches
45. All of the following medication adjuvants can be used in combination with local anesthetic solutions during performance of a peripheral nerve blockade to extend the duration/effectiveness of nerve blockade, except
A. Epinephrine
B. Ketamine
C. Dexamethasone
D. Clonidine
46. While performing a femoral nerve block guided with a nerve stimulator, you observe a strong sartorius muscle twitch that disappears at 0.2 mA. What does this mean and how should you proceed further?
A. The stimulating block needle tip is in the correct position, and the local anesthetic can be injected
B. The needle tip is likely superficial to the femoral nerve, and the block needle needs to be readjusted (twitch may not be from stimulation of the femoral nerve) prior to local anesthetic injection
C. Sartorius muscle twitch indicates that the needle tip is in the correct location, but you need to get closer to the nerve as 0.2 mA stimulus is too high
D. The block needle needs to be repositioned more medially, and a paresthesia must be elicited prior to local anesthetic injection
47. The trauma team in the ICU did not want a thoracic epidural placed on a trauma patient with bilateral rib fractures secondary to concerns about the potential hemodynamic instability that may result. Therefore, both right T7 and left T5 continuous paravertebral catheters were successfully placed for this patient under ultrasound guidance. Twenty minutes following the administration of 10 mL of 0.2% ropivacaine administered through each catheter (following evidence of negative aspiration), the systolic blood pressure dropped by 50 mm Hg. The most likely diagnosis is
A. Performance of paravertebral blockade creates identical concerns about potential hemodynamic compromise as do thoracic epidural blocks
B. Local anesthetic toxicity as the paravertebral space is very vascular
C. Possible epidural spread of local anesthetics from either one or both the paravertebral catheters
D. Venous bleeding into the paravertebral space resulting in large volumes of local anesthetic absorption from the paravertebral blocks
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