Addendum D. Procedural Sedation Test MERCY MEDICAL CENTER- SIOUX CITY Procedural Sedation Questions Individuals applying for moderate sedation privileges must achieve a score of 80%. PRACTITIONER NAME (PRINT): Date: 1. Which of the following is true concerning ketamine? a. it is one of the safer agents for use in acute alcohol intoxication b. it produces excessive salivation c. frequent adverse effects limit its use in pediatric patients d. it depresses pharyngeal-laryngeal reflexes 2. Select the situation that requires use of the Procedural Sedation protocol: a. 50-year old male who received 2-mg Dilaudid for abdominal pain in the ED b. 30-year old female who received 10-rng valium IV to abort an active seizure. c. 70-year old intubated and sedated male who needs to undergo I&D of a subcutaneous abscess d. 25-year old female who needs to undergo a closed reduction of a left posterior shoulder dislocation. e. 1-year old boy who is crying because he is afraid of the ED staff 3. Which procedural sedation agent can cause adrenal suppression? a. midazolam b. propofol c. etomidate d. methohexital 4. A 45-year old male was given a combination of fentanyl and midazolam to undergo a colonoscopy. The patient is somnolent. However, he opens his eyes when the nurse loudly calls his name. He also smiles when she touches his forehead. What level of sedation is he in? a. general anesthesia b. deep sedation c. moderate sedation d. anxiolysis 5. Which one of the following patients, with diabetes is considered ASA class 2 according to the American Society of Anesthesiologists: a. 60-year old female with blood pressure of 180/100 and fasting glucose of 230. She ambulates with a cane b. 70-year old male with blood pressure of 120/80 and Hemoglobin A1c of 5.9%. c. 55-year old male with blood pressure of 140/90 and fasting blood glucose of 166. He is on home 02 and wheelchair-bound because of diabetic neuropathy d. 75-year old male with a leaking abdominal aortic aneurysm who needs immediate surgical intervention Moderate Sedation Exam MMC-SC Updated 5.15 Page 1
6. Which of the following is true concerning propofol? a. propofol does not have analgesic or antiemetic effects b. adverse effects with propofol include hypotension, bradycardia, apnea and anaphylaxis c. propofol does not potentiate the respiratory depression caused by midazolam d. there are no special precautions associated with the use of propofol 7. All of the following are considered a part of the Pre-Sedation Assessment except: a. Current History and Physical b. Airway assessment c. List of current medications d. Modified Ramsey scale e. Vital signs 8. While you are examining a 40-year old female, and out of your eagerness to follow every step of the Procedural Sedation protocol, you ask the patient to open her mouth so you can evaluate her airway. You can see only the soft palate and the base of the uvula. What isthe Mallampati class? a. Class I b. Class II c. Class III d. Class IV e. Class E 9. The following scenarios are considered risk factors that can potentially complicate the course of Procedural Sedation. Which one is LEAST likely to do so? a. The patient has violated the NPO status b. The patient has received Procedural Sedation 8 hours earlier c. A history of acute myocardial infarction 2 years ago d. A history of COPD with current bilateral wheezing on physical exam e. A history of obstructive sleep apnea but tolerating BiPAP at home 10. In order to administer propofol or methohexital for sedation: a. the practitioner must be credentialed for moderate sedation b. a qualified RN must be present to manage the airway c. the practitioner must have the skills and training to rescue a patient from general anesthesia d. the practitioner must be immediately available 11. If you have to remember only one complication of Procedural Sedation it must be: a. hypertension b. arrhythmias c. nausea and vomiting d. respiratory depression e. urinary retention 12. The following equipment needs to be present during Procedural Sedation except: a. A standard crash cart b. Supplemental wall oxygen source c. Suction equipment d. ECG monitor e. An extra oxygen tank for emergencies Moderate Sedation Exam MMC-SC Updated 5.15 Page 2
13. A patient with long-standing end stage renal disease requires procedural sedation for colonoscopy. She is concerned because following a previous colonoscopy she experienced prolonged sedation. The agent most likely to be responsible was: a. fentanyl b. propofol c. etomidate d. midazolam 14. Which one of the following changes in physiologic parameters is considered alarming and requires immediate intervention: a. An increase in systolic blood pressure of 20mm Hg from pre-sedation levels b. A sinus tachycardia at 100-110 in a well-sedated patient c. The drowsy patient who clears his throat frequently and swallows his secretions d. A decrease in baseline oxygen saturation by more than 5% from pre-sedation baseline e. An increase in baseline end tidal C02 by 5 mmhg 15. A 67-year old male who is undergoing Procedural Sedation for chest tube placement has dropped his blood pressure from 140/80 to 90/50. His chronic atrial fibrillation is now uncontrolled at 130 bpm. The first intervention needed is: a. DC cardioversion b. IV cardiazem c. IV digoxin d. Call code blue e. supplemental oxygen 16. Etomidate is often the drug of choice for sedating a patient with limited cardiac reserve. The most frequent problem associated with its use is a. myoclonus b. nausea c. euphoria d. QT prolongation 17. Which of the following is true concerning meperidine? a. It is the safest narcotic in patients with renal dysfunction b. It is contraindicated in patients receiving a MA0 inhibitor c. Its efficacy is enhanced by combining it with Vistaril d. It is less likely to cause seizures than other narcotics 18. Which of the following is true concerning midazolam? a. drug interactions are less likely with the oral form b. there can be up to an 11-fold variation in duration of action c. it has analgesic activity d. it is less likely to cause hypotension than diazepam or lorazepam 19. Continuous ETCO2 monitoring is required for procedural sedation because: a. it is a more sensitive monitor of hypoventilation than oxygen saturation b. it is the most sensitive indicator effective of bag-mask ventilation c. it is an accurate reflection of arterial C02 d. all of the above Moderate Sedation Exam MMC-SC Updated 5.15 Page 3
20. An elderly, opiate naive female patient was given 6 mg IV morphine and 1mg midazolam for procedural sedation. She developed respiratory distress and was given 1mcg/kg naloxone to reverse it. Which of the following is correct concerning this case: a. with naloxone, it is safer to start with a high dose b. the patient is at risk for developing respiratory depression when the naloxone wears off in 1-2 hours c. naloxone will reverse the respiratory effects of narcotics but not the analgesia d. when giving both a benzodiazepine and a narcotic the dose of the narcotic should be reduced by 10% 21. On pre-procedure evaluation, it is noted that a patient can only open her mouth 1cm because of TMJ disease. Which of the following is of greatest concern? a. the patient will have difficulty breathing while awake b. it may be difficult to rescue the patient if she stops breathing c. the patient is likely to become hypoxic during minimal sedation (anxiolysis) d. the patient will require a greater-than-expected dose of sedation medications 22. Following administration of midazolam and meperidine for colonoscopy, a patient becomes sedated to the point where his airway is partially obstructed, but he responds purposefully following painful stimulation. This corresponds to which of the following levels of sedation? a. minimal sedation b. moderate sedation c. deep sedation d. general anesthesia 23. Findings of the pre-procedure evaluation should be reconfirmed at which of the following times? a. only if a complication occurs b. within a week before the procedure c. on the day before the procedure d. immediately before the procedure 24. An otherwise healthy patient requires moderation sedation for elective cardiac catheterization. He should not consume clear liquids for a minimum of how many hours before the beginning of the procedure? a. 1 b. 3 c. 4 d. 6 25. During sedation with propofol, a patient stops breathing and becomes unresponsive to verbal or tactile stimulation. The pulse oximeter reads 86%. Which of the following is most likely to improve the patient's oxygenation? a. positive pressure ventilation b. supplemental nasal oxygen c. intravenous flumazenil d. intravenous naloxone Moderate Sedation Exam MMC-SC Updated 5.15 Page 4
26. A patient who is breathing supplemental nasal oxygen develops complete airway obstruction during moderate sedation. Which of the following is likely to occur first? a. decreased in oxygen saturation b. cessation of breath sounds c. sinus bradycardia d. hypotension 27. According to the procedural sedation protocol, which of the following individuals is required to be present in the procedure room? a. RN certified in life support b. anesthesiologist c. critical care physician d. ED physician 28. A patient receives ketamine for sedation and analgesia. Her eyes are open but her breathing is labored and she is completely unresponsive to both verbal and painful stimulation. This corresponds most closely to a state of: a. anxiolysis b. moderate sedation c. deep sedation d. general anesthesia 29. The use of supplemental oxygen during sedation and analgesia a. Increases the likelihood of hypoxia b. Delays the detection of apnea by pulse oximetry c. Should be avoided during moderate sedation d. Decreases the likelihood of airway obstruction 30. Which of the following defines moderate sedation? a. a medically controlled state of depressed consciousness in which the patient responds to painful tactile stimuli b. CNS depression produced by sedatives and/or analgesics that allow patients to respond to verbal or tactile stimuli c. the administration of morphine to treat post-operative pain d. the administration of a sedation/hypnotic agent to facilitate sleep 31. Patients being evaluated for procedure-related sedation need: a. an advanced directive b. an ASA physical status assignment c. an anesthesiology consult d. baseline EKG 32. What equipment must be used or available in the room during procedural sedation? a. procedural supply cart b. a two-way communication device c. a portable X-ray machine d. malignant hyperthermia cart Moderate Sedation Exam MMC-SC Updated 5.15 Page 5
33. A 5'2", 200 Ib. woman is under deep sedation for cardioversion. The ETCO2 monitor is most likely to show: a. hypercapnea and obstruction b. normocapnea c. hypercapnea d. re-breathing 34. The first response for an obstructed airway is to: a. suction the patient b. intubate the patient c. insert an oral airway d. perform a chin lift/neck extension 35. Guidelines for patients at discharge after sedation should include: a. written release of the hospital from responsibility b. discussion of all potential adverse effects of sedation c. discussion of the effects of sedation and activity restrictions d. a follow-up visit with the physician who performed the procedure 36. Which of the following statements about opioids and apnea is true? a. apnea can occur in responsive patients b. apnea is an uncommon adverse reaction c. apnea doesn't usually lead to cardiac arrest d. apnea is inversely related to the rate of opioid administration 37. Which of the following is an adverse effect of naloxone (Narcan)? a. tachycardia b. adrenal insufficiency c. methemoglobinemia d. prolonged QT 38. When using a bag-valve mask, providers must pay special attention to'? a. maintaining a specific ventilatory rate b. pressing down on the mask in order to prevent leaking of the delivered volume c. volume of air moved with each squeeze of the bag as assessed by chest movement and auscultation d. the supplemental oxygen flow rate 39. Post-anesthesia recovery score is: a. an objective measure used to determine a patient suitability for discharge b. the same as an ASA physical status classification c. a neurological assessment of level of consciousness d. a test of how well a patient has tolerated a given procedure By completing this examination, I attest to reading and understanding the Mercy Medical Center-Sioux City Adult Moderate Sedation by Non Anesthesia Personnel Policy. Signature Date Moderate Sedation Exam MMC-SC Updated 5.15 Page 6