COMSAE PHASE 1 FORM 116
COMPREHENSIVE REVIEW 150
DETAILED CORRECT ANSWERS WITH
RATIONALES CORRECT VERIFIED
ANSWERS GRADE A+ | INSTANT
DOWNLOAD
COMSAE Phase 1 Form 116: Comprehensive Review & Key
Concepts
Note: The COMSAE (Certified Medical-Surgical Anesthesia
Examination) is a standardized exam used by CRNA programs to
assess clinical knowledge. The following questions reflect the high-level
clinical reasoning, pharmacology, physiology, and equipment
knowledge required for Phase 1.
Question 1: A 45-year-old male with no significant medical history
undergoes general anesthesia for an inguinal hernia repair. During
emergence, he develops laryngospasm. His SpO2 drops to 85%. What is
the most appropriate immediate intervention? A) Administer
succinylcholine 0.1 mg/kg IV. B) Apply continuous positive airway
pressure (CPAP) with 100% oxygen and perform a jaw thrust. C)
Intubate immediately with a smaller endotracheal tube. D) Administer
epinephrine 0.3 mg IM. Correct Answer: B Apply continuous
positive airway pressure (CPAP) with 100% oxygen and
perform a jaw thrust. Rationale: The first-line treatment for
laryngospasm is to break the spasm mechanically by applying positive
pressure (CPAP) and lifting the jaw to open the airway. Succinylcholine
is reserved for cases that do not resolve with positive pressure or if
hypoxia persists.
Question 2: Which of the following volatile anesthetics has the lowest
blood-gas partition coefficient? A) Isoflurane B) Sevoflurane C)
Desflurane D) Halothane Correct Answer: C Desflurane
Rationale: Desflurane has a blood-gas partition coefficient of 0.42,
,which is lower than Sevoflurane (0.65), Isoflurane (1.4), and Halothane
(2.4). This low solubility allows for rapid induction and emergence.
Question 3: A patient with severe aortic stenosis is scheduled for non-
cardiac surgery. Which hemodynamic goal is most critical to maintain
myocardial oxygen supply? A) Tachycardia to increase cardiac output. B)
Maintenance of sinus rhythm and adequate diastolic filling time. C)
Reduction of systemic vascular resistance (afterload). D) Aggressive fluid
resuscitation to increase preload. Correct Answer: B
Maintenance of sinus rhythm and adequate diastolic filling
time. Rationale: In aortic stenosis, the hypertrophied left ventricle is
stiff and dependent on atrial kick (sinus rhythm) and adequate diastolic
time for coronary perfusion. Tachycardia shortens diastole, reducing
supply, while hypotension reduces coronary perfusion pressure.
Question 4: During a laparoscopic cholecystectomy, the patient’s end-
tidal CO2 (EtCO2) suddenly decreases from 35 mmHg to 15 mmHg, and
the blood pressure drops. The surgeon reports difficulty insufflating.
What is the most likely diagnosis? A) Malignant hyperthermia. B)
Venous air embolism. C) Endobronchial intubation. D) Hypothermia.
Correct Answer: B Venous air embolism. Rationale: A
sudden drop in EtCO2 combined with hypotension during laparoscopy
suggests a venous air embolism (VAE). Air enters the venous system,
obstructing pulmonary blood flow, increasing dead space, and
decreasing cardiac output.
Question 5: Which neuromuscular blocking agent is metabolized by
plasma cholinesterase? A) Rocuronium B) Vecuronium C)
Succinylcholine D) Cisatracurium Correct Answer: C
Succinylcholine Rationale: Succinylcholine is rapidly hydrolyzed
by plasma cholinesterase (pseudocholinesterase). Mivacurium is also
metabolized by this enzyme. Rocuronium and Vecuronium are
primarily eliminated by the liver/kidneys, and Cisatracurium
undergoes Hofmann elimination.
Question 6: A patient receives 20 mg of ephedrine IV for hypotension.
Five minutes later, the blood pressure remains low. Why might
subsequent doses of ephedrine be less effective? A) Rapid metabolism by
the liver. B) Tachyphylaxis due to depletion of norepinephrine stores. C)
Downregulation of alpha receptors. D) Increased renal excretion.
Correct Answer: B Tachyphylaxis due to depletion of
,norepinephrine stores. Rationale: Ephedrine acts indirectly by
releasing norepinephrine from presynaptic nerve terminals. Repeated
dosing depletes these stores, leading to tachyphylaxis (diminished
response). Direct-acting agents like phenylephrine do not exhibit this
effect.
Question 7: Which monitor is considered the standard of care for
detecting esophageal intubation? A) Pulse oximetry B) Capnography C)
Chest auscultation D) Esophageal detector device Correct Answer:
B Capnography Rationale: Capnography is the most reliable and
immediate method for confirming endotracheal tube placement. The
presence of a consistent waveform indicates CO2 exchange, confirming
tracheal placement. Absence of CO2 suggests esophageal intubation or
cardiac arrest.
Question 8: A patient with myasthenia gravis is undergoing
thymectomy. How does this condition affect the response to
neuromuscular blockers? A) Increased sensitivity to succinylcholine and
decreased sensitivity to non-depolarizers. B) Decreased sensitivity to
succinylcholine and increased sensitivity to non-depolarizers. C) No
change in sensitivity to either agent. D) Increased sensitivity to both
agents. Correct Answer: B Decreased sensitivity to
succinylcholine and increased sensitivity to non-depolarizers.
Rationale: Myasthenia gravis involves a reduction in functional
acetylcholine receptors. Succinylcholine requires binding to these
receptors to cause depolarization, so resistance occurs. Non-
depolarizers compete for the same fewer receptors, making the patient
more sensitive.
Question 9: What is the primary mechanism of action of
dexmedetomidine? A) GABA-A receptor agonist B) NMDA receptor
antagonist C) Alpha-2 adrenergic agonist D) Mu-opioid receptor agonist
Correct Answer: C Alpha-2 adrenergic agonist Rationale:
Dexmedetomidine is a selective alpha-2 adrenergic agonist. It acts in
the locus coeruleus to produce sedation, anxiolysis, and analgesia
without significant respiratory depression.
Question 10: A patient develops malignant hyperthermia (MH). What
is the initial dose of dantrolene? A) 1 mg/kg B) 2.5 mg/kg C) 5 mg/kg D)
10 mg/kg Correct Answer: B 2.5 mg/kg Rationale: The
recommended initial dose of dantrolene for MH is 2.5 mg/kg IV. It can
, be repeated every 5-10 minutes until symptoms subside, up to a total
cumulative dose of 10 mg/kg or more if needed.
Question 11: Which of the following is a contraindication to the use of
nitrous oxide? A) Asthma B) Pneumothorax C) Hypertension D)
Diabetes mellitus Correct Answer: B Pneumothorax
Rationale: Nitrous oxide diffuses into closed air-filled spaces faster
than nitrogen can diffuse out, causing expansion of the space. This can
worsen a pneumothorax, bowel obstruction, or air embolism.
Question 12: A patient is receiving a transfusion of packed red blood
cells. They develop fever, chills, and hypotension. The urine is dark.
What is the most likely diagnosis? A) Febrile non-hemolytic reaction B)
Acute hemolytic transfusion reaction C) Transfusion-related acute lung
injury (TRALI) D) Allergic reaction Correct Answer: B Acute
hemolytic transfusion reaction Rationale: Fever, hypotension,
and hemoglobinuria (dark urine) are classic signs of an acute hemolytic
transfusion reaction, usually due to ABO incompatibility. This is a
medical emergency requiring immediate cessation of the transfusion.
Question 13: Which of the following local anesthetics is an ester? A)
Lidocaine B) Bupivacaine C) Chloroprocaine D) Ropivacaine Correct
Answer: C Chloroprocaine Rationale: Chloroprocaine is an ester
local anesthetic. Esters are metabolized by plasma cholinesterase.
Lidocaine, bupivacaine, and ropivacaine are amides, metabolized by
the liver.
Question 14: A patient with chronic obstructive pulmonary disease
(COPD) is mechanically ventilated. Which ventilator setting adjustment
helps prevent air trapping? A) Increase tidal volume B) Increase
respiratory rate C) Increase inspiratory time D) Increase expiratory time
Correct Answer: D Increase expiratory time Rationale:
COPD patients have increased airway resistance and require more time
to exhale. Increasing expiratory time (by decreasing respiratory rate or
adjusting I:E ratio) prevents auto-PEEP and air trapping.
Question 15: What is the primary advantage of using remifentanil in
outpatient surgery? A) Long duration of action B) Context-sensitive half-
time is independent of infusion duration C) High potency D) Lack of
respiratory depression Correct Answer: B Context-sensitive
COMPREHENSIVE REVIEW 150
DETAILED CORRECT ANSWERS WITH
RATIONALES CORRECT VERIFIED
ANSWERS GRADE A+ | INSTANT
DOWNLOAD
COMSAE Phase 1 Form 116: Comprehensive Review & Key
Concepts
Note: The COMSAE (Certified Medical-Surgical Anesthesia
Examination) is a standardized exam used by CRNA programs to
assess clinical knowledge. The following questions reflect the high-level
clinical reasoning, pharmacology, physiology, and equipment
knowledge required for Phase 1.
Question 1: A 45-year-old male with no significant medical history
undergoes general anesthesia for an inguinal hernia repair. During
emergence, he develops laryngospasm. His SpO2 drops to 85%. What is
the most appropriate immediate intervention? A) Administer
succinylcholine 0.1 mg/kg IV. B) Apply continuous positive airway
pressure (CPAP) with 100% oxygen and perform a jaw thrust. C)
Intubate immediately with a smaller endotracheal tube. D) Administer
epinephrine 0.3 mg IM. Correct Answer: B Apply continuous
positive airway pressure (CPAP) with 100% oxygen and
perform a jaw thrust. Rationale: The first-line treatment for
laryngospasm is to break the spasm mechanically by applying positive
pressure (CPAP) and lifting the jaw to open the airway. Succinylcholine
is reserved for cases that do not resolve with positive pressure or if
hypoxia persists.
Question 2: Which of the following volatile anesthetics has the lowest
blood-gas partition coefficient? A) Isoflurane B) Sevoflurane C)
Desflurane D) Halothane Correct Answer: C Desflurane
Rationale: Desflurane has a blood-gas partition coefficient of 0.42,
,which is lower than Sevoflurane (0.65), Isoflurane (1.4), and Halothane
(2.4). This low solubility allows for rapid induction and emergence.
Question 3: A patient with severe aortic stenosis is scheduled for non-
cardiac surgery. Which hemodynamic goal is most critical to maintain
myocardial oxygen supply? A) Tachycardia to increase cardiac output. B)
Maintenance of sinus rhythm and adequate diastolic filling time. C)
Reduction of systemic vascular resistance (afterload). D) Aggressive fluid
resuscitation to increase preload. Correct Answer: B
Maintenance of sinus rhythm and adequate diastolic filling
time. Rationale: In aortic stenosis, the hypertrophied left ventricle is
stiff and dependent on atrial kick (sinus rhythm) and adequate diastolic
time for coronary perfusion. Tachycardia shortens diastole, reducing
supply, while hypotension reduces coronary perfusion pressure.
Question 4: During a laparoscopic cholecystectomy, the patient’s end-
tidal CO2 (EtCO2) suddenly decreases from 35 mmHg to 15 mmHg, and
the blood pressure drops. The surgeon reports difficulty insufflating.
What is the most likely diagnosis? A) Malignant hyperthermia. B)
Venous air embolism. C) Endobronchial intubation. D) Hypothermia.
Correct Answer: B Venous air embolism. Rationale: A
sudden drop in EtCO2 combined with hypotension during laparoscopy
suggests a venous air embolism (VAE). Air enters the venous system,
obstructing pulmonary blood flow, increasing dead space, and
decreasing cardiac output.
Question 5: Which neuromuscular blocking agent is metabolized by
plasma cholinesterase? A) Rocuronium B) Vecuronium C)
Succinylcholine D) Cisatracurium Correct Answer: C
Succinylcholine Rationale: Succinylcholine is rapidly hydrolyzed
by plasma cholinesterase (pseudocholinesterase). Mivacurium is also
metabolized by this enzyme. Rocuronium and Vecuronium are
primarily eliminated by the liver/kidneys, and Cisatracurium
undergoes Hofmann elimination.
Question 6: A patient receives 20 mg of ephedrine IV for hypotension.
Five minutes later, the blood pressure remains low. Why might
subsequent doses of ephedrine be less effective? A) Rapid metabolism by
the liver. B) Tachyphylaxis due to depletion of norepinephrine stores. C)
Downregulation of alpha receptors. D) Increased renal excretion.
Correct Answer: B Tachyphylaxis due to depletion of
,norepinephrine stores. Rationale: Ephedrine acts indirectly by
releasing norepinephrine from presynaptic nerve terminals. Repeated
dosing depletes these stores, leading to tachyphylaxis (diminished
response). Direct-acting agents like phenylephrine do not exhibit this
effect.
Question 7: Which monitor is considered the standard of care for
detecting esophageal intubation? A) Pulse oximetry B) Capnography C)
Chest auscultation D) Esophageal detector device Correct Answer:
B Capnography Rationale: Capnography is the most reliable and
immediate method for confirming endotracheal tube placement. The
presence of a consistent waveform indicates CO2 exchange, confirming
tracheal placement. Absence of CO2 suggests esophageal intubation or
cardiac arrest.
Question 8: A patient with myasthenia gravis is undergoing
thymectomy. How does this condition affect the response to
neuromuscular blockers? A) Increased sensitivity to succinylcholine and
decreased sensitivity to non-depolarizers. B) Decreased sensitivity to
succinylcholine and increased sensitivity to non-depolarizers. C) No
change in sensitivity to either agent. D) Increased sensitivity to both
agents. Correct Answer: B Decreased sensitivity to
succinylcholine and increased sensitivity to non-depolarizers.
Rationale: Myasthenia gravis involves a reduction in functional
acetylcholine receptors. Succinylcholine requires binding to these
receptors to cause depolarization, so resistance occurs. Non-
depolarizers compete for the same fewer receptors, making the patient
more sensitive.
Question 9: What is the primary mechanism of action of
dexmedetomidine? A) GABA-A receptor agonist B) NMDA receptor
antagonist C) Alpha-2 adrenergic agonist D) Mu-opioid receptor agonist
Correct Answer: C Alpha-2 adrenergic agonist Rationale:
Dexmedetomidine is a selective alpha-2 adrenergic agonist. It acts in
the locus coeruleus to produce sedation, anxiolysis, and analgesia
without significant respiratory depression.
Question 10: A patient develops malignant hyperthermia (MH). What
is the initial dose of dantrolene? A) 1 mg/kg B) 2.5 mg/kg C) 5 mg/kg D)
10 mg/kg Correct Answer: B 2.5 mg/kg Rationale: The
recommended initial dose of dantrolene for MH is 2.5 mg/kg IV. It can
, be repeated every 5-10 minutes until symptoms subside, up to a total
cumulative dose of 10 mg/kg or more if needed.
Question 11: Which of the following is a contraindication to the use of
nitrous oxide? A) Asthma B) Pneumothorax C) Hypertension D)
Diabetes mellitus Correct Answer: B Pneumothorax
Rationale: Nitrous oxide diffuses into closed air-filled spaces faster
than nitrogen can diffuse out, causing expansion of the space. This can
worsen a pneumothorax, bowel obstruction, or air embolism.
Question 12: A patient is receiving a transfusion of packed red blood
cells. They develop fever, chills, and hypotension. The urine is dark.
What is the most likely diagnosis? A) Febrile non-hemolytic reaction B)
Acute hemolytic transfusion reaction C) Transfusion-related acute lung
injury (TRALI) D) Allergic reaction Correct Answer: B Acute
hemolytic transfusion reaction Rationale: Fever, hypotension,
and hemoglobinuria (dark urine) are classic signs of an acute hemolytic
transfusion reaction, usually due to ABO incompatibility. This is a
medical emergency requiring immediate cessation of the transfusion.
Question 13: Which of the following local anesthetics is an ester? A)
Lidocaine B) Bupivacaine C) Chloroprocaine D) Ropivacaine Correct
Answer: C Chloroprocaine Rationale: Chloroprocaine is an ester
local anesthetic. Esters are metabolized by plasma cholinesterase.
Lidocaine, bupivacaine, and ropivacaine are amides, metabolized by
the liver.
Question 14: A patient with chronic obstructive pulmonary disease
(COPD) is mechanically ventilated. Which ventilator setting adjustment
helps prevent air trapping? A) Increase tidal volume B) Increase
respiratory rate C) Increase inspiratory time D) Increase expiratory time
Correct Answer: D Increase expiratory time Rationale:
COPD patients have increased airway resistance and require more time
to exhale. Increasing expiratory time (by decreasing respiratory rate or
adjusting I:E ratio) prevents auto-PEEP and air trapping.
Question 15: What is the primary advantage of using remifentanil in
outpatient surgery? A) Long duration of action B) Context-sensitive half-
time is independent of infusion duration C) High potency D) Lack of
respiratory depression Correct Answer: B Context-sensitive
