CVICU EXAM QUESTIONS AND ANSWERS
Example of a depolarizing neuromuscular blocking agent - Answer- succinylcholine
Example of a non-depolarizing neuromuscular blocking agent - Answer- rocuronium
Classification of NMBA that competes with acetylcholine to occupy the receptor sites on
the motor end plate - Answer- non-depolarizing neuromuscular blocking agent.
By blocking access to the receptors, they prevent acetylcholine-induced depolarization
(no ion channels are opened, no action potential is generated).
Type of NMBA that is reversed by anticholinesterase drugs? What is an example of an
anticholinesterase drug? - Answer- non-depolarizing neuromuscular blocking agent.
Reversed by neostigmine.
What NMBA causes contraction of skeletal muscle cells? - Answer- depolarizing
neuromuscular blocking agents.
Initially causes fasciculations, then flaccid paralysis caused by desensitization at the
receptor to acetylcholine.
What NMBA mimics the actions of acetylcholine? - Answer- Succinylcholine
(depolarizing neuromuscular blocking agents).
Stimulate nicotinic receptors and open up the ion channels, leading to depolarization.
What NMBA causes the diaphragm muscle to be 'paralyzed' last and recovered first? -
Answer- non-depolarizing.
Small muscles in the eyelids are paralyzed first, followed by extremities, jaw, intercostal
muscles, abdominal muscles and then the diaphragm.
4 indications for the administration of a neuromuscular blocking agent. - Answer- 1. To
facilitate intubation.
2. To facilitate mechanical ventilation.
3. To reduce metabolic demands by stopping muscle movement.
4. Cessation of movement for critical diagnostic studies on intubated/ventilated patients.
5. To control status epilepticus or severe agitation.
Primary indication for administration of anticholinesterase agents. - Answer- To reverse
the effects of non-depolarizing neuromuscular blockade agents. They allow increased
transmission of nerve impulses by inhibiting the activity of cholinesterase, which
normally destroys acetylcholine. For example, neostigmine.
,Give two examples of anticholinergic agents used with anticholinesterase agents. -
Answer- 1. Atropine
2. Glycopyrrolate
What interventions must be provided prior to administering a non-depolarizing agent? -
Answer- 1. Patient must be intubated and ventilated on a control mode of ventilation.
2. Bagging unit must be at bedside.
3. Sedation must be administered prior to NMBA!
4. Explain procedures to patient and family if possible.
5 nursing care responsibilities for the patient receiving neuromuscular blockade agents.
- Answer- 1. Patient must be under extremely close observation (totally ventilator
dependent).
2. Cardiac and ventilator alarms MUST be set and in operation at all times.
3. Provide mouth care q2h (and prn) to prevent ventilator acquired pneumonia.
4. Provide skin care and turning q2h (and prn) to prevent skin breakdown.
5. Monitor electrolytes (imbalances can potentiate or diminish the effects of NMBA).
What medications should be given to all patients receiving neuromuscular blocking
agents? - Answer- Analgesia and sedation.
Sedation MUST be administered prior to neuromuscular blocking agents! Analgesics
should be considered and administered if necessary.
Succinylcholine should be administered with extreme caution in the setting of what
electrolyte imbalance? - Answer- Hyperkalemia. Caused by prolonged opening of the
ion channels of the nicotinic receptors during the depolarization phase, which lets a lot
of potassium ions into the extracellular fluid.
Why should range of motion exercises only be done by physiotherapy when patients are
receiving NMBA? - Answer- Paralysis decreases joint and limb protection and increases
risk for joint dislocation.
Identify 3 potential adverse effects of a neuromuscular blocking agent - Answer- 1.
Prolonged action of the drug after discontinuation
2. Hypotension
3. Tachycardia
4. Bronchoconstriction
Clinical assessment is performed to determine subsequent dosing of NMBA. Identify
four clinical responses to assess for. - Answer- 1. A cleft in the plateau portion of the
ETCO2 waveform.
2. Ventilator asynchrony.
3. Patient movement or diaphragmatic movement (triggering the ventilator).
4. Peripheral nerve stimulator (>2 twitches).
5. Increased airway pressures or desaturations.
, If performing Train of Four (TOF), what are the nerve testing sites, and what is the
expected response? - Answer- 1. Ulnar nerve - Adduction of Thumb
2. Facial Nerve - Winking motion
3. Posterial Tibial Nerve - Flexion of the great toe
How to assess neurological function on a patient receiving neuromuscular blocking
agents? - Answer- Check pupil size and reactivity frequently!
Pupils reactivity is preserved with NMBs and provides the only method for neurological
assessment.
What is the purpose of a peripheral nerve stimulator? - Answer- A peripheral nerve is
stimulated to monitor the level of neuromuscular blockade and ensure the desired level
of paralysis.
What does the dicrotic notch on the arterial pressure waveform represent? - Answer-
Closure of the aortic valve. Marks the end of systole and the onset of diastole.
Conditions that impede left ventricular ejection, such as aortic valve stenosis, will have
what effect on the arterial pressure waveform? - Answer- The upstroke is slow and
appears to rise at an angle (because the ventricle struggles to squeeze blood though
the stenosed aortic valve).
May have a narrow pulse pressure, and the diacrotic notch is not well-defined (due to
stiff closing movement of the valves).
For an arterial line:
The flush solution must be changed at least q____hours.
The pressure tubing must be changed q___hours. - Answer- 24 hours (for solution
bags)
72 hours (for pressure tubing)
For an arterial line, which flush solution is used to maintain line patency? - Answer-
500mL N/S with 1000 U Heparin
A pressure bag is placed over the solution and inflated to 300 mmHg, allowing delivery
of a continuous flow of 3 mL/hr.
The phlebostatic axis is anatomically located at: - Answer- The 4th intercostal space in
the mid-axillary line.
The transducer is leveled to the right atrium!
Upon arterial line removal, the nurse should maintain pressure for a minimum of _____
minutes for RADIAL site and ____ minutes for FEMORAL site. What type of dressing
Example of a depolarizing neuromuscular blocking agent - Answer- succinylcholine
Example of a non-depolarizing neuromuscular blocking agent - Answer- rocuronium
Classification of NMBA that competes with acetylcholine to occupy the receptor sites on
the motor end plate - Answer- non-depolarizing neuromuscular blocking agent.
By blocking access to the receptors, they prevent acetylcholine-induced depolarization
(no ion channels are opened, no action potential is generated).
Type of NMBA that is reversed by anticholinesterase drugs? What is an example of an
anticholinesterase drug? - Answer- non-depolarizing neuromuscular blocking agent.
Reversed by neostigmine.
What NMBA causes contraction of skeletal muscle cells? - Answer- depolarizing
neuromuscular blocking agents.
Initially causes fasciculations, then flaccid paralysis caused by desensitization at the
receptor to acetylcholine.
What NMBA mimics the actions of acetylcholine? - Answer- Succinylcholine
(depolarizing neuromuscular blocking agents).
Stimulate nicotinic receptors and open up the ion channels, leading to depolarization.
What NMBA causes the diaphragm muscle to be 'paralyzed' last and recovered first? -
Answer- non-depolarizing.
Small muscles in the eyelids are paralyzed first, followed by extremities, jaw, intercostal
muscles, abdominal muscles and then the diaphragm.
4 indications for the administration of a neuromuscular blocking agent. - Answer- 1. To
facilitate intubation.
2. To facilitate mechanical ventilation.
3. To reduce metabolic demands by stopping muscle movement.
4. Cessation of movement for critical diagnostic studies on intubated/ventilated patients.
5. To control status epilepticus or severe agitation.
Primary indication for administration of anticholinesterase agents. - Answer- To reverse
the effects of non-depolarizing neuromuscular blockade agents. They allow increased
transmission of nerve impulses by inhibiting the activity of cholinesterase, which
normally destroys acetylcholine. For example, neostigmine.
,Give two examples of anticholinergic agents used with anticholinesterase agents. -
Answer- 1. Atropine
2. Glycopyrrolate
What interventions must be provided prior to administering a non-depolarizing agent? -
Answer- 1. Patient must be intubated and ventilated on a control mode of ventilation.
2. Bagging unit must be at bedside.
3. Sedation must be administered prior to NMBA!
4. Explain procedures to patient and family if possible.
5 nursing care responsibilities for the patient receiving neuromuscular blockade agents.
- Answer- 1. Patient must be under extremely close observation (totally ventilator
dependent).
2. Cardiac and ventilator alarms MUST be set and in operation at all times.
3. Provide mouth care q2h (and prn) to prevent ventilator acquired pneumonia.
4. Provide skin care and turning q2h (and prn) to prevent skin breakdown.
5. Monitor electrolytes (imbalances can potentiate or diminish the effects of NMBA).
What medications should be given to all patients receiving neuromuscular blocking
agents? - Answer- Analgesia and sedation.
Sedation MUST be administered prior to neuromuscular blocking agents! Analgesics
should be considered and administered if necessary.
Succinylcholine should be administered with extreme caution in the setting of what
electrolyte imbalance? - Answer- Hyperkalemia. Caused by prolonged opening of the
ion channels of the nicotinic receptors during the depolarization phase, which lets a lot
of potassium ions into the extracellular fluid.
Why should range of motion exercises only be done by physiotherapy when patients are
receiving NMBA? - Answer- Paralysis decreases joint and limb protection and increases
risk for joint dislocation.
Identify 3 potential adverse effects of a neuromuscular blocking agent - Answer- 1.
Prolonged action of the drug after discontinuation
2. Hypotension
3. Tachycardia
4. Bronchoconstriction
Clinical assessment is performed to determine subsequent dosing of NMBA. Identify
four clinical responses to assess for. - Answer- 1. A cleft in the plateau portion of the
ETCO2 waveform.
2. Ventilator asynchrony.
3. Patient movement or diaphragmatic movement (triggering the ventilator).
4. Peripheral nerve stimulator (>2 twitches).
5. Increased airway pressures or desaturations.
, If performing Train of Four (TOF), what are the nerve testing sites, and what is the
expected response? - Answer- 1. Ulnar nerve - Adduction of Thumb
2. Facial Nerve - Winking motion
3. Posterial Tibial Nerve - Flexion of the great toe
How to assess neurological function on a patient receiving neuromuscular blocking
agents? - Answer- Check pupil size and reactivity frequently!
Pupils reactivity is preserved with NMBs and provides the only method for neurological
assessment.
What is the purpose of a peripheral nerve stimulator? - Answer- A peripheral nerve is
stimulated to monitor the level of neuromuscular blockade and ensure the desired level
of paralysis.
What does the dicrotic notch on the arterial pressure waveform represent? - Answer-
Closure of the aortic valve. Marks the end of systole and the onset of diastole.
Conditions that impede left ventricular ejection, such as aortic valve stenosis, will have
what effect on the arterial pressure waveform? - Answer- The upstroke is slow and
appears to rise at an angle (because the ventricle struggles to squeeze blood though
the stenosed aortic valve).
May have a narrow pulse pressure, and the diacrotic notch is not well-defined (due to
stiff closing movement of the valves).
For an arterial line:
The flush solution must be changed at least q____hours.
The pressure tubing must be changed q___hours. - Answer- 24 hours (for solution
bags)
72 hours (for pressure tubing)
For an arterial line, which flush solution is used to maintain line patency? - Answer-
500mL N/S with 1000 U Heparin
A pressure bag is placed over the solution and inflated to 300 mmHg, allowing delivery
of a continuous flow of 3 mL/hr.
The phlebostatic axis is anatomically located at: - Answer- The 4th intercostal space in
the mid-axillary line.
The transducer is leveled to the right atrium!
Upon arterial line removal, the nurse should maintain pressure for a minimum of _____
minutes for RADIAL site and ____ minutes for FEMORAL site. What type of dressing
