COMSAE 115 COMPREHENSIVE EXAM
REVIEW 150 DETAILED CORRECT
ANSWERS WITH RATIONALES CORRECT
VERIFIED ANSWERS GRADE A+
INSTANT DOWNLOAD
COMSAE 115 EXAM / ACTUAL COMSAE 115 EXAM
COMSAE 115 Exam: Comprehensive Review & Key Concepts
Note: The COMSAE (Certified Medical Surgical Anesthesia
Examination) is a high-stakes exam for CRNAs. The following questions
cover core domains including Airway Management, Pharmacology,
Physiology, Pathophysiology, and Anesthetic Management for common
surgical procedures. These items are designed to reflect the depth and
clinical reasoning required for the actual exam.
Question 1: A 65-year-old male with severe COPD and a history of
smoking is scheduled for an open cholecystectomy. During induction,
you note difficult mask ventilation and a Cormack-Lehane Grade 3 view
on laryngoscopy. You successfully intubate with a bougie. Post-
intubation, his peak inspiratory pressure (PIP) rises to 45 cmH2O, and
plateau pressure is 25 cmH2O. What is the most likely cause of this
increased airway resistance? A) Decreased lung compliance due to
pneumothorax. B) Bronchospasm or kinking of the endotracheal tube. C)
Pulmonary edema. D) Abdominal insufflation pressure. Correct
Answer: B Bronchospasm or kinking of the endotracheal
tube. Rationale: The difference between Peak Inspiratory Pressure
(PIP) and Plateau Pressure represents airway resistance. A large
gradient (45 - 25 = 20 cmH2O) indicates high resistance, commonly
caused by bronchospasm, secretions, or tube kinking. Compliance
issues (like pneumothorax) would raise both PIP and Plateau pressures
similarly.
Question 2: A patient undergoing total knee arthroplasty under spinal
anesthesia develops sudden hypotension (BP 70/40 mmHg) and
bradycardia (HR 45 bpm) 20 minutes after the block. The surgeon is
,applying a tourniquet. What is the primary physiological mechanism
causing this hemodynamic collapse? A) Hypovolemia from blood loss. B)
High spinal block affecting cardioaccelerator fibers (T1-T4). C) Bezold-
Jarisch reflex due to decreased venous return. D) Anaphylaxis to latex.
Correct Answer: C Bezold-Jarisch reflex due to decreased
venous return. Rationale: Spinal anesthesia causes sympathetic
blockade, leading to venous pooling and decreased preload. In a
relatively hypovolemic state, the underfilled ventricle triggers
mechanoreceptors, causing paradoxical bradycardia and vasodilation
via the vagus nerve (Bezold-Jarisch reflex).
Question 3: Which of the following volatile anesthetics produces the
highest amount of Compound A when exposed to dry CO2 absorbents,
posing a potential risk for nephrotoxicity? A) Sevoflurane B) Desflurane
C) Isoflurane D) Halothane Correct Answer: A Sevoflurane
Rationale: Sevoflurane reacts with strong bases in dry CO2
absorbents to form Compound A (fluoromethyl-2,2-difluoro-1-
(trifluoromethyl)vinyl ether), which has been shown to be nephrotoxic
in rats. While clinically significant renal injury in humans is rare, low-
flow anesthesia with sevoflurane requires caution regarding absorbent
dryness.
Question 4: A patient with Myasthenia Gravis is scheduled for
thymectomy. Which neuromuscular blocking agent strategy is most
appropriate? A) Use standard doses of rocuronium and reverse with
sugammadex. B) Avoid neuromuscular blockers if possible; if necessary,
use reduced doses of non-depolarizers and monitor with TOF. C) Use
succinylcholine as it is unaffected by the disease. D) Use high-dose
neostigmine for reversal regardless of TOF count. Correct Answer:
B Avoid neuromuscular blockers if possible; if necessary, use
reduced doses of non-depolarizers and monitor with TOF.
Rationale: Patients with Myasthenia Gravis are extremely sensitive
to non-depolarizing neuromuscular blockers (NDNMBs) due to fewer
functional acetylcholine receptors. They are resistant to
succinylcholine. Careful titration and quantitative monitoring are
essential to prevent postoperative residual curarization.
Question 5: During a laparoscopic hysterectomy, the patient’s EtCO2
suddenly drops from 35 mmHg to 15 mmHg, followed by hypotension
and a "mill wheel" murmur on precordial auscultation. What is the most
,likely diagnosis? A) Pneumothorax. B) Venous Air Embolism (VAE). C)
Malignant Hyperthermia. D) Endobronchial intubation. Correct
Answer: B Venous Air Embolism (VAE). Rationale: The
sudden drop in EtCO2 (due to increased dead space and decreased
cardiac output), hypotension, and the classic "mill wheel" murmur are
hallmark signs of a significant venous air embolism, a known risk in
laparoscopic surgery due to pressurized gas entry into open veins.
Question 6: A 40-year-old female with no prior medical history
undergoes general anesthesia. Thirty minutes into the case, her
temperature rises to 39.5°C, EtCO2 rises to 65 mmHg despite increased
ventilation, and she develops masseter rigidity. What is the immediate
first step in management? A) Administer dantrolene 2.5 mg/kg IV. B)
Stop all triggering agents, hyperventilate with 100% oxygen, and call for
help. C) Cool the patient with ice packs. D) Switch to propofol infusion.
Correct Answer: B Stop all triggering agents, hyperventilate
with 100% oxygen, and call for help. Rationale: These are classic
signs of Malignant Hyperthermia (MH). The immediate priority is to
stop the trigger (volatile anesthetics/succinylcholine) and
hyperoxygenate/hyperventilate to combat hypermetabolism and
acidosis. Dantrolene is administered after these initial steps.
Question 7: Which of the following best describes the pharmacokinetic
profile of Remifentanil? A) Long elimination half-life, hepatic
metabolism. B) Context-sensitive half-time remains constant regardless
of infusion duration due to ester hydrolysis by plasma cholinesterases. C)
Renal excretion unchanged. D) High lipid solubility leading to prolonged
accumulation in fat tissue. Correct Answer: B Context-sensitive
half-time remains constant regardless of infusion duration
due to ester hydrolysis by plasma cholinesterases. Rationale:
Remifentanil is unique among opioids because it is metabolized by non-
specific plasma and tissue esterases. This results in an ultra-short
context-sensitive half-time (3-5 minutes) that does not increase with
prolonged infusion, allowing for rapid emergence.
Question 8: A patient with End-Stage Renal Disease (ESRD) on
dialysis is scheduled for emergency appendectomy. His pre-op
potassium is 5.8 mEq/L. Which induction agent should be avoided? A)
Propofol. B) Ketamine. C) Succinylcholine. D) Etomidate. Correct
Answer: C Succinylcholine. Rationale: Succinylcholine can
, cause a transient increase in serum potassium by approximately 0.5-
1.0 mEq/L due to efflux from muscle cells. In a patient with pre-existing
hyperkalemia (5.8 mEq/L), this could precipitate life-threatening
arrhythmias. Rocuronium is a safer alternative.
Question 9: During a carotid endarterectomy, the surgeon clamps the
carotid artery. The patient’s EEG shows slowing, and the Stump Pressure
is measured at 25 mmHg. What is the significance of this finding? A)
Adequate collateral circulation; no shunt needed. B) Inadequate
collateral circulation; consideration for shunt placement or raising MAP.
C) Normal finding; ignore EEG changes. D) Indicates impending stroke;
abort surgery. Correct Answer: B Inadequate collateral
circulation; consideration for shunt placement or raising
MAP. Rationale: Stump pressure < 40-50 mmHg and EEG changes
during clamping suggest inadequate cerebral perfusion via collateral
flow (Circle of Willis). This increases the risk of intraoperative ischemic
stroke, prompting the need for a shunt or hemodynamic augmentation.
Question 10: A patient receives 10 units of packed red blood cells
rapidly during trauma surgery. He develops oozing from IV sites and the
surgical field. Lab results show prolonged PT/PTT and low fibrinogen.
What is the most likely cause? A) Heparin contamination. B) Dilutional
coagulopathy and consumption of clotting factors. C) Vitamin K
deficiency. D) Disseminated Intravascular Coagulation (DIC) secondary
to sepsis. Correct Answer: B Dilutional coagulopathy and
consumption of clotting factors. Rationale: Massive transfusion
of packed RBCs (which lack platelets and clotting factors) leads to
dilutional thrombocytopenia and coagulopathy. Replacement with FFP,
platelets, and cryoprecipitate is required based on viscoelastic testing
or standard ratios.
Question 11: Which nerve is most commonly injured during
thyroidectomy, resulting in hoarseness? A) Superior Laryngeal Nerve. B)
Recurrent Laryngeal Nerve. C) Vagus Nerve. D) Hypoglossal Nerve.
Correct Answer: B Recurrent Laryngeal Nerve. Rationale:
The Recurrent Laryngeal Nerve (RLN) innervates all intrinsic muscles
of the larynx except the cricothyroid. Injury leads to vocal cord
paralysis and hoarseness. The Superior Laryngeal Nerve affects pitch
and sensation.
REVIEW 150 DETAILED CORRECT
ANSWERS WITH RATIONALES CORRECT
VERIFIED ANSWERS GRADE A+
INSTANT DOWNLOAD
COMSAE 115 EXAM / ACTUAL COMSAE 115 EXAM
COMSAE 115 Exam: Comprehensive Review & Key Concepts
Note: The COMSAE (Certified Medical Surgical Anesthesia
Examination) is a high-stakes exam for CRNAs. The following questions
cover core domains including Airway Management, Pharmacology,
Physiology, Pathophysiology, and Anesthetic Management for common
surgical procedures. These items are designed to reflect the depth and
clinical reasoning required for the actual exam.
Question 1: A 65-year-old male with severe COPD and a history of
smoking is scheduled for an open cholecystectomy. During induction,
you note difficult mask ventilation and a Cormack-Lehane Grade 3 view
on laryngoscopy. You successfully intubate with a bougie. Post-
intubation, his peak inspiratory pressure (PIP) rises to 45 cmH2O, and
plateau pressure is 25 cmH2O. What is the most likely cause of this
increased airway resistance? A) Decreased lung compliance due to
pneumothorax. B) Bronchospasm or kinking of the endotracheal tube. C)
Pulmonary edema. D) Abdominal insufflation pressure. Correct
Answer: B Bronchospasm or kinking of the endotracheal
tube. Rationale: The difference between Peak Inspiratory Pressure
(PIP) and Plateau Pressure represents airway resistance. A large
gradient (45 - 25 = 20 cmH2O) indicates high resistance, commonly
caused by bronchospasm, secretions, or tube kinking. Compliance
issues (like pneumothorax) would raise both PIP and Plateau pressures
similarly.
Question 2: A patient undergoing total knee arthroplasty under spinal
anesthesia develops sudden hypotension (BP 70/40 mmHg) and
bradycardia (HR 45 bpm) 20 minutes after the block. The surgeon is
,applying a tourniquet. What is the primary physiological mechanism
causing this hemodynamic collapse? A) Hypovolemia from blood loss. B)
High spinal block affecting cardioaccelerator fibers (T1-T4). C) Bezold-
Jarisch reflex due to decreased venous return. D) Anaphylaxis to latex.
Correct Answer: C Bezold-Jarisch reflex due to decreased
venous return. Rationale: Spinal anesthesia causes sympathetic
blockade, leading to venous pooling and decreased preload. In a
relatively hypovolemic state, the underfilled ventricle triggers
mechanoreceptors, causing paradoxical bradycardia and vasodilation
via the vagus nerve (Bezold-Jarisch reflex).
Question 3: Which of the following volatile anesthetics produces the
highest amount of Compound A when exposed to dry CO2 absorbents,
posing a potential risk for nephrotoxicity? A) Sevoflurane B) Desflurane
C) Isoflurane D) Halothane Correct Answer: A Sevoflurane
Rationale: Sevoflurane reacts with strong bases in dry CO2
absorbents to form Compound A (fluoromethyl-2,2-difluoro-1-
(trifluoromethyl)vinyl ether), which has been shown to be nephrotoxic
in rats. While clinically significant renal injury in humans is rare, low-
flow anesthesia with sevoflurane requires caution regarding absorbent
dryness.
Question 4: A patient with Myasthenia Gravis is scheduled for
thymectomy. Which neuromuscular blocking agent strategy is most
appropriate? A) Use standard doses of rocuronium and reverse with
sugammadex. B) Avoid neuromuscular blockers if possible; if necessary,
use reduced doses of non-depolarizers and monitor with TOF. C) Use
succinylcholine as it is unaffected by the disease. D) Use high-dose
neostigmine for reversal regardless of TOF count. Correct Answer:
B Avoid neuromuscular blockers if possible; if necessary, use
reduced doses of non-depolarizers and monitor with TOF.
Rationale: Patients with Myasthenia Gravis are extremely sensitive
to non-depolarizing neuromuscular blockers (NDNMBs) due to fewer
functional acetylcholine receptors. They are resistant to
succinylcholine. Careful titration and quantitative monitoring are
essential to prevent postoperative residual curarization.
Question 5: During a laparoscopic hysterectomy, the patient’s EtCO2
suddenly drops from 35 mmHg to 15 mmHg, followed by hypotension
and a "mill wheel" murmur on precordial auscultation. What is the most
,likely diagnosis? A) Pneumothorax. B) Venous Air Embolism (VAE). C)
Malignant Hyperthermia. D) Endobronchial intubation. Correct
Answer: B Venous Air Embolism (VAE). Rationale: The
sudden drop in EtCO2 (due to increased dead space and decreased
cardiac output), hypotension, and the classic "mill wheel" murmur are
hallmark signs of a significant venous air embolism, a known risk in
laparoscopic surgery due to pressurized gas entry into open veins.
Question 6: A 40-year-old female with no prior medical history
undergoes general anesthesia. Thirty minutes into the case, her
temperature rises to 39.5°C, EtCO2 rises to 65 mmHg despite increased
ventilation, and she develops masseter rigidity. What is the immediate
first step in management? A) Administer dantrolene 2.5 mg/kg IV. B)
Stop all triggering agents, hyperventilate with 100% oxygen, and call for
help. C) Cool the patient with ice packs. D) Switch to propofol infusion.
Correct Answer: B Stop all triggering agents, hyperventilate
with 100% oxygen, and call for help. Rationale: These are classic
signs of Malignant Hyperthermia (MH). The immediate priority is to
stop the trigger (volatile anesthetics/succinylcholine) and
hyperoxygenate/hyperventilate to combat hypermetabolism and
acidosis. Dantrolene is administered after these initial steps.
Question 7: Which of the following best describes the pharmacokinetic
profile of Remifentanil? A) Long elimination half-life, hepatic
metabolism. B) Context-sensitive half-time remains constant regardless
of infusion duration due to ester hydrolysis by plasma cholinesterases. C)
Renal excretion unchanged. D) High lipid solubility leading to prolonged
accumulation in fat tissue. Correct Answer: B Context-sensitive
half-time remains constant regardless of infusion duration
due to ester hydrolysis by plasma cholinesterases. Rationale:
Remifentanil is unique among opioids because it is metabolized by non-
specific plasma and tissue esterases. This results in an ultra-short
context-sensitive half-time (3-5 minutes) that does not increase with
prolonged infusion, allowing for rapid emergence.
Question 8: A patient with End-Stage Renal Disease (ESRD) on
dialysis is scheduled for emergency appendectomy. His pre-op
potassium is 5.8 mEq/L. Which induction agent should be avoided? A)
Propofol. B) Ketamine. C) Succinylcholine. D) Etomidate. Correct
Answer: C Succinylcholine. Rationale: Succinylcholine can
, cause a transient increase in serum potassium by approximately 0.5-
1.0 mEq/L due to efflux from muscle cells. In a patient with pre-existing
hyperkalemia (5.8 mEq/L), this could precipitate life-threatening
arrhythmias. Rocuronium is a safer alternative.
Question 9: During a carotid endarterectomy, the surgeon clamps the
carotid artery. The patient’s EEG shows slowing, and the Stump Pressure
is measured at 25 mmHg. What is the significance of this finding? A)
Adequate collateral circulation; no shunt needed. B) Inadequate
collateral circulation; consideration for shunt placement or raising MAP.
C) Normal finding; ignore EEG changes. D) Indicates impending stroke;
abort surgery. Correct Answer: B Inadequate collateral
circulation; consideration for shunt placement or raising
MAP. Rationale: Stump pressure < 40-50 mmHg and EEG changes
during clamping suggest inadequate cerebral perfusion via collateral
flow (Circle of Willis). This increases the risk of intraoperative ischemic
stroke, prompting the need for a shunt or hemodynamic augmentation.
Question 10: A patient receives 10 units of packed red blood cells
rapidly during trauma surgery. He develops oozing from IV sites and the
surgical field. Lab results show prolonged PT/PTT and low fibrinogen.
What is the most likely cause? A) Heparin contamination. B) Dilutional
coagulopathy and consumption of clotting factors. C) Vitamin K
deficiency. D) Disseminated Intravascular Coagulation (DIC) secondary
to sepsis. Correct Answer: B Dilutional coagulopathy and
consumption of clotting factors. Rationale: Massive transfusion
of packed RBCs (which lack platelets and clotting factors) leads to
dilutional thrombocytopenia and coagulopathy. Replacement with FFP,
platelets, and cryoprecipitate is required based on viscoelastic testing
or standard ratios.
Question 11: Which nerve is most commonly injured during
thyroidectomy, resulting in hoarseness? A) Superior Laryngeal Nerve. B)
Recurrent Laryngeal Nerve. C) Vagus Nerve. D) Hypoglossal Nerve.
Correct Answer: B Recurrent Laryngeal Nerve. Rationale:
The Recurrent Laryngeal Nerve (RLN) innervates all intrinsic muscles
of the larynx except the cricothyroid. Injury leads to vocal cord
paralysis and hoarseness. The Superior Laryngeal Nerve affects pitch
and sensation.
