NIFA Perioperative Exam Questions and Answers 2024, Exams of Nursing

Download NIFA Perioperative Exam Questions and Answers 2024 and more Exams Nursing in PDF only on Docsity! 1 NIFA Perioperative Exam Questions and Answers 2024 A 40-year-old man presents with clinical and endocrinological features of acromegaly. A microadenoma of the pituitary gland is identified. Which one of the following is the most compelling reason for treating this tumour? Select one: Avoidance of cardiovascular complications Avoidance of colonic cancer Avoidance of diabetes Avoidance of optic pathway compression Avoidance of radiological progression Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Cardiovascular complications have most effect on survival and are best avoided by early treatment. All other conditions can occur but have less effect upon survival and are therefore less compelling. Radiological progression would initiate additional treatment. Optic pathway compression will not occur with a micro adenoma unless significant growth occurs. The correct answer is: Avoidance of cardiovascular complications You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 2 Correct CBM mark 1.00 Weight 1.00 Flag question Question text A 54-year-old man with osteoarthritis of the left knee presents at your pre-operative clinic. He also suffers with mild portal hypertension, fibrotic pulmonary disease and chronic kidney disease. He is taking captopril (an ACE inhibitor), 50 mg TDS for hypertension. On examination, his blood pressure is 160/120 mmHg. Why has the captopril not lowered his blood pressure? Select one: It acts in the kidney to inhibit release of renin from the juxta-glomerular apparatus It acts in the liver to inhibit conversion of angiotensin I to angiotensin II 2 It acts in the liver to inhibit conversion of angiotensinogen to angiotensin I It acts in the lungs to inhibit conversion of angiotensin I to angiotensin II It acts in the lungs to inhibit conversion of angiotensinogen to angiotensin I Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback ACE is found in the lung, its acts on angiotensin 1, converting it to angiotensin II. The correct answer is: It acts in the lungs to inhibit conversion of angiotensin I to angiotensin II You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 3 Correct CBM mark 1.00 Weight 1.00 Question text Flag question An elderly patient with an intra-capsular fractured neck of femur is due to have a hip hemiarthroplasty performed. Which of the following describe anatomical steps to access the hip joint during the most commonly used approach for a hemiarthroplasty? Select one: Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter Detaching piriformis and the short external rotators from their femoral insertion Developing a plane between the gracilis and adductor longus muscles Developing a superficial plane between sartorius and tensor fasciae latae Elevation of vastus lateralis Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The most commonly used approach for hip hemiarthroplasty is the antero - lateral (modified hardinge) approach to the hip. During this approach the gluteus medius and minimus are detached as one or separate layers from the greater trochanter anteriorly to gain access to the hip joint. 5 A 46-year-old man with severe asthma and type 2 diabetes is admitted for elective repair of left inguinal hernia. He weighs 92 kg and poses a number of anaesthetic risks. You are discussing anaesthetic options with the anaesthetist and hope to perform the procedure under local block and hope to optimise his COPD. Which one of the following statements is true given his severe COPD? Select one: FEV1:FVC ratio is likely to be increased FEV1:FVC ratio is likely to be normal FEV1 is likely to normalise with a beta-2 agonist FEV1 is unlikely to change with a beta-2 agonist FVC would be expected to be significantly below normal values Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback FVC is commonly normal in asthma. However there is often a reduced FEV1 and reduced FEV1:FVC ratio. FEV1 returns towards normal with bronchodilator (beta-2 agonist) treatment. The correct answer is: FEV1 is likely to normalise with a beta-2 agonist You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 7 Correct CBM mark 1.00 Weight 1.00 Flag question Question text A 54-year-old woman suffers a major bile duct leakage 24 hours following a laparoscopic cholecystectomy. A main duct leak is confirmed by an ultra-sound scan and there is a significant leakage volume. The duct appears to be in tact, not transected. Which one of the following is the most likely treatment? Select one: Balloon dilatation Endoscopic (ERCP) and stent insertion 6 Hepaticojejunostomy IV antibiotics and close observation Percutaneous Trans-hepatic Cholangiography (PTC) and stent insertion Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback A main duct breach is classified as a type B bile leak. ERCP is unlikely to be successful and a PTC and stent insertion will most likely be required. Type A leaks (peripheral leaks) can usually be successfully scented via ERCP. Type B leaks as above Type C (strictures) can be successfully treated with balloon dilatation Type D (complete transections) usually require a Roux-en-Y-hepaticojejjunostomy The correct answer is: Percutaneous Trans-hepatic Cholangiography (PTC) and stent insertion You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 8 Correct CBM mark 1.00 Weight 1.00 Flag question Question text You are looking after a 15-year-old patient with 35% burn injury by burn surface area. You are discussing nutritional requirements with the nursing team. Which of the following should you ensure in this patient? Select one: A low protein intake to minimise 3rd space losses Maintain body weight to within 25% of pre-burn weight Permissive hyperglycaemia ensues to increase calorie availability for healing Receive enteral feeding within 72 hours of burn injury Receive vitamin supplementation 7 Certainty: C=1 (Unsure: <67%) Feedback C=2 (Mid: >67%) C=3 (Quite sure: >80%) Burns patients should receive high protein intake via enteral feeding ideally within 18 hours of injury. Hyperglycaemia should be avoided. Weight should ideally be maintained to within 10% of pre-injury weight. Vitamin supplementation, though not the primary objective of nutritional management is very important for burn healing and the only correct response above. The correct answer is: Receive vitamin supplementation You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 9 Correct CBM mark 1.00 Weight 1.00 Question text Flag question A patient with a traumatic brain injury is managed on the intensive care unit. The intracranial pressure is 25 mmHg. Blood pressure is 140/80. Which one of the following is the cerebral perfusion pressure? Select one: 55 mmHg 75 mmHg 85 mmHg 100 mmHg 195 mmHg Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback CPP is calculated in normal clinical practice in management of traumatic brain injury patients. Tests candidates knowledge of the equation CPP = Mean BP - ICP Candidate needs to calculate Mean BP = Diastolic BP (80) + 1/3 x Sys (140) - Dis (80) = 100 CPP = 100 - 25 = 75 10 Question text Flag question You assess a patient preoperatively who has been diagnosed with carcinoma of the colon and is to undergo a Hartmann's procedure. Which one of the following do you advise the patient? Select one: The left side of the colon will be removed and a permanent colostomy will be fashioned The left side of the colon will be removed and if possible a direct anastamosiss will be made without loop colostomy The left side of the colon will be removed and if possible a loop colostomy will be fashioned to temporarily protect the anastomosis The right side of the colon together with the caecum will be removed and a direct anastomosis will be made The right side of the colon together with the caecum will be removed and a temporary ileostomy will be formed Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Hartmann's procedure involves excision of the distal colon and/or rectum, for very low colonic/rectal disease. Patients with a Hartmann's procedure are advised that they may have a permanent colostomy. The colostomy may be eligible for re-anastamosis to the rectum at a later date, although this may not be possible. The correct answer is: The left side of the colon will be removed and a permanent colostomy will be fashioned You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 13 Correct CBM mark 1.00 Weight 1.00 Question text Flag question 11 A 65-year-old woman develops a hoarse voice, evident in theatre recovery, following an anterior cervical discectomy at the C3/4 level. Anaesthesia was uncomplicated. Surgery, via a 4 cm transverse skin crease incision, was uneventful. A post-operative MRI scan shows no evidence of a haematoma. Which one of the following is the most likely explanation for her symptoms? Select one: External laryngeal nerve transection Laryngeal oedema Recurrent laryngeal nerve transection Superior laryngeal nerve neuropraxis Vagal nerve neuropraxis Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Recurrent larnygeal not at risk for surgery at this level (much more common with C6/7 pathology). Laryngeal oedema could be a cause but given anaesthetic uncomplicated unlikely. The superior laryngeal is at risk in upper cervical surgery - more commonly due to retraction (neuropraxis) than transection. The correct answer is: Superior laryngeal nerve neuropraxis You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 14 Correct CBM mark 1.00 Weight 1.00 Flag question Question text A 44-year-old woman presents with Cushingoid features. Which one of the following tests results is the most reliable at distinguishing Cushing's disease from Cushing's syndrome? Select one: Elevated BP on 24h monitoring Elevated levels of CRF (corticotrophin releasing factor) 12 Elevated levels of HbA1C Failure to suppress ACTH No diurnal variation in cortisol level Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Cushing's disease is pituitary driven. CRF is normally released by hypothalamus. Other features are non-specific co sequences of raised cortisol levels. The correct answer is: Failure to suppress ACTH You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 15 Correct CBM mark 1.00 Weight 1.00 Question text Flag question A 60-year-old man with acromegaly undergoes a trans-sphenoidal procedure to resect a pituitary adenoma. 48 hours post-operatively he develops severe thirst, and passes volumes of urine exceeding 5 litres/24h. His sodium level is 166 mmol/l. Which one of the following is the most appropriate treatment to commence? Select one: 1.8% saline administration Demeclocycline Desmopressin Furosemide High dose dexamethasone Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback 15 Question text You are asked to see a 42-year-old woman over the weekend who had a total thyroidectomy on Friday for a large multinodular goitre causing compressive symptoms. She has paraesthesia in her fingers and lips and the F1 doctor tells you that her corrected calcium level is 1.6 mmol/L and they have done an ECG. What ECG changes would you be looking for? Select one: Atrial fibrillation Prolonged PR interval Prolonged QTc interval P wave inversion Widened QRS complexes Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The parathyroid glands and their blood supply are at risk of damage during thyroidectomy. This may lead to profound hypocalcaemia can cause life threatening arrhythmias, including complete atrioventricular block and torsades de pointes. Prolonged QTc (corrected QT) interval may be seen before these develop. Other ECG changes include: narrow QRS complex, reduced PR interval, and flat or inverted T-waves. The correct answer is: Prolonged QTc interval You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 19 Incorrect CBM mark 0.00 Weight 1.00 Question text Flag question Flag question 16 A 22-year-old man is involved in a RTC and undergoes intra-medullary nailing for a grossly contaminated open tibial fracture. He is commenced on IV broad spectrum antibiotics due to the wound contamination. 48 hours post-operatively he develops a widespread petechial rash, neurological dysfunction and respiratory insufficiency. Which one of the following is the most ely diagnosis? Select one: Fat embolism syndrome Penicillin allergy Post-operative pneumonia Streptococcal septicaemia Venous thromboembolism Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback FES can occur 1 to 3 days after trauma with an incidence of 1-20% (depending on diagnostic criteria). Increasing risks are associated with younger age, closed fracture (not exclusively), intra- medullary nailing for fracture. Classic symptoms include tachycardia, fever and respiratory insufficiency. The pathognominc petechial rash in FES affects conjunctiva, oral mucosa and neck. The CXR can show bilateral, diffuse, non-specific shadowing, but most commonly is normal despite clinical and laboratory evidence of hypoxaemia. The correct answer is: Venous thromboembolism You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 20 Correct CBM mark 1.00 Weight 1.00 Question text Flag question You assess a 24-year-old motorcyclist who underwent an intra-medullary fixation of the femur for closed femoral fracture. 36 hours post-operatively he presents with shortness of breath and you suspect Fat Embolism Syndrome (FES). Which one of the following findings would confirm the diagnosis? Select one: 17 Sub-conjunctival haemorrhages, bradycardia, pyrexia, thrombocytopenia, lowered ESR Sub-conjunctival haemorrhages, bradycardia, pyrexia, thrombocytopenia, raised ESR Sub-conjunctival haemorrhages, bradycardia, pyrexia, thrombocytosis, raised ESR Sub-conjunctival haemorrhages, tachycardia, pyrexia, thrombocytosis, lowered ESR Sub-conjunctival haemorrhages, tachycardia, pyrexia, thrombocytosis, raised ESR Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback FES is diagnosed using Gurd's criteria; one major and 4 minor criteria are required. Major criteria - Axillary or subconjunctival petechiae - Hypoxaemia PaO2 <60 mm Hg - Central nervous system depression disproportionate to hypoxaemia - Pulmonary oedema Minor criteria - Tachycardia - Pyrexia - Emboli present in the retina on fundoscopy - Fat present in urine - A sudden inexplicable drop in haematocrit or platelet values - Increasing ESR - Fat globules present in the sputum The correct answer is: Sub-conjunctival haemorrhages, tachycardia, pyrexia, thrombocytosis, raised ESR You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 21 Correct CBM mark 1.00 Weight 1.00 Question text Flag question 20 Somatosensory evoked potentials Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Imaging investigations such as an MRI scan are useful for identifying structural abnormalities. However, CTS is best investigated by nerve conduction studies, which will identify a slower nerve conduction rate, due to nerve compression, which is diagnostic. The correct answer is: Nerve conduction studies You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 24 Correct CBM mark 1.00 Weight 1.00 Question text Flag question You are discussing an 89-year-old man with the anaesthetic pre-assessment team. He is booked for umbilical hernia repair under local anaesthetic. He weighs 100 kg and has multiple co-morbidities including ischaemic heart disease, non-oxygen requiring severe COPD and type II diabetes mellitus and liver failure. The consultant anaesthetist hopes to perform the procedure without a GA, using local anaesthetic blocks. You agree on which of the following to provide safe and importantly longer acting local anaesthesia for the duration of surgery? Select one: Judicious use of intra-venous lignocaine Ultrasound guided transversus abdominis plane block Using a combination of local anaesthetics Using Epinephrine as part of your block Using the maximum possible volume of bupivacaine of 2 mg/kg Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The dose of local anaesthetic (LA) can be effected by liver failure and depends on its severity. They are predominantly metabolised by the liver, although changes in dosage are not needed normally. If they have advanced liver disease or large doses are being used (as potentially in this case), dosage 21 reduction needs to be considered. The dose for bupivacaine is 2mg/kg and many experts recommend calculating the dose used is calculated using ideal body weight not actual. The dose for bupivacaine plus epinephrine in the non-obese patient is 2.5mg/kg. Adding Epinephrine reduces absorption and decreases chance of toxicity, it does not significantly prolong duration of block. Lignocaine bolus doses and post-operative infusion have shown to have an opioid sparing analgesic effect for post-operative pain relief. The best regional anaesthetic block for this case is bilateral rectus sheath blocks (or a spinal if coagulation was normal). The correct answer is: Judicious use of intra-venous lignocaine You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 25 Correct CBM mark 1.00 Weight 1.00 Question text Flag question A 60-year-old woman presents with left sided weakness and headaches that have developed and progressed over two weeks. There is no history of seizures. On examination her GCS is 15/15, there is mild weakness of the left upper and lower limbs (grade 4/5). The following pre and post contrast CT scans were performed. Which of the following drugs is most appropriate to prescribe to help control her symptoms? Select one: Codeine 22 Dexamethasone Hypertonic saline Levetiracetam (Keppra) Mannitol Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The patient has symptoms of raised ICP and focal neurological deficit. Codeine might improve HA. Keppra reduces risk of fits. Hypertonic and mannitol both reduce ICP and may improve HA and perhaps neurology. However, dexamethasone is much more appropriately prescribed to have a more sustained effect upon the oedema with a good prospect of improving HA and focal deficit. The correct answer is: Dexamethasone You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 26 Incorrect CBM mark 0.00 Weight 1.00 Flag question Question text You are looking after a 59-year-old woman with type II diabetes. She has complex learning needs and difficulty in retaining and synthesising information. Her HBA1C is 92 and she is mildly pyrexial. She is very reluctant to undergo surgical treatment for an infected great toe that has significantly deteriorated and is likely to result in worsening lower limb ascending ection. Which of the following will support you to intervene, even ugh it may be against the patient's wishes? Select one: Deprivation of Liberties Safeguards 2015 Human Rights Act 1998 (Safeguarding) Mental Capacity Act 2005 Mental Health Act 2007 25 Question text Flag question A 32-year-old man attends the Emergency Department with a superficial knife wound to his left arm, the result of an accident whilst decorating. There are no apparent neurological, muscular or vascular defects. You will close the wound under local anaesthesia, by regional infiltration of lignocaine (2%, with adrenaline). Which of the following actions will produce local anaesthesia to the surgical field? Select one: Blocking neuronal membrane Na channels Inhibiting pre-synaptic release of Acetylcholline Inhibiting production of soluble inflammatory mediators at the wound Opening neuronal membrane Na channels Stimulating neuronal membrane Na/K ATPase Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Lignocaine blocks Na channels, so preventing the conduction of an action potential. It may also block Na/K ATPase, but does not block this pathway. The correct answer is: Blocking neuronal membrane Na channels You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 30 Correct CBM mark 1.00 Weight 1.00 Question text Flag question You are discussing a complicated patient preoperatively with the anaesthetist, during theatre list brief. The patient is about to undergo an elective laparoscopic cholecystectomy, a requirement of which is to establish a pneumoperitoneum using carbon dioxide. He has previously suffered a 26 myocardial infarction though a recent echocardiogram shows normal cardiac function. The anaesthetist advises about the effects of the imminent surgery on the patients cardiorespiratory parameters. Which of the following will cause a CO2 pneumopertineum in this patient? Select one: Decreased peripheral vascular resistance Decreased stroke volume Increased cardiac output No increased risk of pulmonary embolus Respiratory alkalosis Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The CO2 pneumoperitoneum necessary to perform laparoscopic surgery, increases intra-peritoneal pressure. This results in a decreased stroke volume, resulting in a decrease in cardiac output by 30%, an increase in peripheral vascular resistance of approximately 40% and and increased risk of a venous thrombus formation. The absorption of CO2 all contributes to an overall respiratory acidosis. The correct answer is: Decreased stroke volume You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 31 Correct CBM mark 1.00 Weight 1.00 Question text Flag question You are called to the ward to see a 26-year-old woman who underwent a lumbar discectomy a few hours ago. On examination the patient has retracted eyelids. Her eyes are upturned and in a fixed position. Her teeth are tightly clenched and her neck is extended. She appears to hear what you say but is unable to relax her contracted muscles. Since surgery she has received morphine for pain relief and metoclopramide for the prophylactic prevention of nausea. Which one of the following is the most likely explanation for her symptoms? 27 Select one: Complex partial seizure Generalised tonic clonic seizure Oculogyric crisis Simple partial seizure Somatoform conversion disorder Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Metoclopramide is approved for use to prevent post-operative nausea. Oculogyric crisis is an idiosyncratic reaction that the junior doctor may have to recognise and manage. It is most common in young women shortly after starting treatment (see BNF). Ditractors are plausible alternatives but description is typical of oculogyric crisis. The correct answer is: Oculogyric crisis You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 32 Correct CBM mark 1.00 Weight 1.00 Flag question Question text You are called to theatre recovery to see a 4-year-old child who had a tonsillectomy earlier. She has been spitting out fresh blood for the past 30 minutes, which the recovery nurse has collected. 250 ml of blood is in the bowl and the nurse tells you the child weighs 32 kg. Assuming that there is minimal saliva in the bowl, and that the child has not swallowed any blood, approximately what percentage of her total blood volume has she lost? Select one: 0.05 0.1 0.15 30 Question text A 35-year old-man presents with a 12 hour history of right iliac fossa pain, vomiting and anorexia. His rectal temperature is 38.9oC. A diagnosis of acute appendicitis is made. Which one of the following other criteria would need to be present to allow a diagnosis of Systemic Inflammatory Response Syndrome? Select one: Heart rate 85bpm PaCo2 4.5kPa Respiratory Rate 18 bpm White cell count 5,500 per uL White cell count, 15,500 per uL Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Only E meets the criterion for a diagnosis of SIRS The correct answer is: White cell count, 15,500 per uL You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 36 Correct CBM mark 1.00 Weight 1.00 Question text Flag question A 45-year-old man is re-admitted three weeks after undergoing an L4/5 lumbar microdiscectomy. He has severe low back pain and a very poor range of spinal movements. Power assessment appears normal but is difficult to conduct due to severe back pain. Sensation and reflexes are intact. There is no saddle anaesthesia and he can contract his anus. The wound appears healthy. His temperature Flag question 31 is 38.1oC. Blood tests show a CRP of 215 and a white cell count of 16. Which one of the following is the most likely cause of his symptoms? Select one: Infected wound haematoma Infective discitis Meningitis Recurrent central disc prolapse Sterile discitis Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback Classical post-operative discitis. No clinical signs of wound infection or subcutaneous haematoma. No signs of meningitis reported. Lab evidence of infection is present. The correct answer is: Infective discitis You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 37 Correct CBM mark 1.00 Weight 1.00 Flag question Question text A 30-year-old Caucasian woman is due to undergo elective laparoscopic cholecystectomy for symptomatic gall stones. At her preoperative assessment it is noted that she has had two previous spontaneous DVTs. There is also a significant family history of venous thrombo-embolism, her mother having suffered a pulmonary embolism during pregnancy. Further investigations are ordered. Which of the following abnormalities is most likely to be present? Select one: Antithrombin III deficiency 32 Factor V Leiden Factor XIII mutation Protein C deficiency Protein S deficiency Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback The family history suggests a congenital thrombophilic state of which Factor V Leiden is the commonest in Caucasians. Up to a third of all patients presenting with venous thrombo-embolism have this condition. The correct answer is: Factor V Leiden You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 38 Correct CBM mark 1.00 Weight 1.00 Flag question Question text You are the surgical registrar on call and are called by the ward sister to see a previously healthy 40- year-old woman who has undergone a total thyroidectomy earlier in the day. When you arrive on the ward, the patient is clearly in extremis, sitting forward in her bed, has marked stridor and a large, tense swelling in her lower neck anteriorly. Her observations are: pulse 120/min, respiratory rate 30/min, blood pressure 120/80mmHg, SpO2 87% on O2 via rebreather mask. She has two vacuum drains which each contain approximately 5- 10ml blood. Which one of the following is the most appropriate immediate next step? Select one: Call the on call anaesthetist Call your consultant Perform an emergency cricothyroidotomy Perform an emergency tracheostomy 35 Certainty: C=1 (Unsure: <67%) Feedback C=2 (Mid: >67%) C=3 (Quite sure: >80%) The British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guideline for open fractures states that intravenous antibiotics should be administered ideally within 1 hour of injury. Wounds should only be handled to remove gross contamination, dressed with saline soaked gauze and covered with an occlusive film. Washouts in the emergency department are not indicated, nor is betadine soaked dressings. Indications for immediate theatre intervention include highly contaminated wounds (agricultural, aquatic, sewage), arterial injuries and signs of compartment syndrome. For solitary high energy open fractures, the aim is to be in theatre within 12 hours of injury. Initial surgery should be carried out by consultants in orthopaedics and plastic surgery - a combined orthoplastic approach. The correct answer is: Apply a saline soaked gauze and occlusive dressing to the wound and splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours. You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 41 Correct CBM mark 1.00 Weight 1.00 Question text Flag question You are assessing a patient who underwent laparoscopic cholecystectomy 48 hours previously. A small post-operative bile leak occurred, for which they received 36 hours of oral co-amoxiclav, then changed to IV gentamicin 6 hours ago. You have been asked to assess the patient who has become acutely unwell with abdominal cramps, vomiting, wheeze and a pruritic rash and fever. Blood tests show that the patient has thrombocytopenia and CRP is 120. You diagnose a Type 1 Hypersensitivity reaction due to which one of the following? Select one: Fever Raised CRP Rash Thrombocytopenia Symptom onset 48 hours after oral penicillin 36 Certainty: C=1 (Unsure: <67%) Feedback C=2 (Mid: >67%) C=3 (Quite sure: >80%) Type 1 Hypersensitivity (HPS) reactions occur rapidly (within hours) of drug administration. Type 1 HPS may present with angio-oedema, rash, wheeze or gastro-intestinal symptoms. Raised CRP and fever are not related to type 1 HPS. Thrombocytopenia is related to type 2 HPS The correct answer is: Rash You did not select a certainty. Assuming: C=1 (Unsure: <67%). Question 42 Correct CBM mark 1.00 Weight 1.00 Question text Flag question An otherwise healthy 25-year-old woman presents with a swollen calf during pregnancy and significantly raised blood pressure. There is a strong family history of venous thrombo-embolism. Given the history, which one of the following is the most likely underlying disorder? Select one: Arterial embolic event secondary to hypertension Factor V Leiden deficiency Protein C deficiency Thrombocytopaenia Vitamin K deficiency Certainty: C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%) Feedback VTE in a young patient is often a sign of an underlying clotting disorder. The correct answer is: Factor V Leiden deficiency You did not select a certainty. Assuming: C=1 (Unsure: <67%). 37