Agency for Toxic Substances and Disease Registry 
Case Studies in Environmental Medicine (CSEM) 

Nitrate/Nitrite Toxicity
Posttest Instructions

Introduction

ATSDR seeks feedback on this course so we can assess its usefulness and effectiveness. We ask you to complete the assessment questionnaire online for this purpose.

In addition, if you complete the assessment and posttest online, you can receive continuing education credits as follows:

Accreditation Council for Continuing Medical Education (ACCME)

The Centers for Disease Control and Prevention (CDC) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

American Nurses Credentialing Center (ANCC), Commission on Accreditation

This activity for 1.5 contact hours is provided by the Centers for Disease Control and Prevention, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

National Commission for Health Education Credentialing, Inc. (NCHEC)

The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the Certified Health Education Specialist (CHES) to receive 1.5 Category I contact hours in health education, CDC provider number GA0082.

International Association for Continuing Education and Training (IACET)

The Centers for Disease Control and Prevention (CDC) has been reviewed and approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), Suite 800, McLean, VA 22102. CDC will award 0.1 of CEU's to participants who successfully complete this program.

Disclaimer

In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.

CDC/ATSDR, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.

Online Instructions

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You can immediately print your continuing education certificate from your personal transcript online. No fees are charged.

Posttest

Please select the best correct answer.

1. Nitrites and nitrates are
   1. naturally occurring organic ions
   2. relatively insoluble in water
   3. ions that readily migrate in ground water
   4. All of the above.
2. Which of the following subpopulations are most at risk of adverse effects from nitrate exposure?
   1. girls age 13-18 years old
   2. telephone line workers
   3. the elderly
   4. infants younger than 4 months of age
   5. individuals with anemia
3. Which of the following are possible sources of nitrate exposure?
   1. certain topical burn medications
   2. shallow domestic wells in rural areas
   3. meat preservatives
   4. seepage from septic tanks
   5. all of the above
4. Which statement about nitrates is true?
   1. Nitrates can be converted into more toxic nitrites in the gut.
   2. The higher alkalinity of an infant's gut protects it from nitrate toxicity.
   3. Vomiting and diarrhea do not affect the absorption of nitrates or nitrites.
   4. No case of nitrate poisoning has been reported since 1950.
   5. Adults are immune from nitrate toxicity if they drink water from public water systems
5. The present maximum contaminant level appears to adequately protect even sensitive populations from nitrate-induced toxicity.
   1. true
   2. false.
6. The mean intake of nitrate per person in the United States is about
   1. 40-100 mg/day
   2. 1 cup/year
   3. 5 grams/day
   4. 1 pound/year
7. The toxicity of nitrates is enhanced by in vivo conversion to
   1. urea
   2. CO2
   3. protein
   4. nitrites.
8. Effects of methemoglobinemia include which of the following?
   1. cyanosis
   2. coma or convulsions
   3. dysrhythmias
   4. All of the above.
9. Methemoglobinemia can be induced by which of the following?
   1. chloroquine
   2. lidocaine
   3. nitroglycerine
   4. dapsone
   5. All of the above.
10. Which of the following systems is most directly affected by nitrates?
    1. cardiovascular system
    2. pulmonary system
    3. hematologic system
    4. neurological system
    5. immune system.
11. Which statement is true?
    1. Signs and symptoms of methemoglobinemia are precisely correlated with percent total oxidized hemoglobin.
    2. Fetal hemoglobin is less readily oxidized by nitrites to methemoglobin than is adult hemoglobin.
    3. Methemoglobin causes arterial blood to be bright red in color.
    4. Pulse oximetry is the most useful diagnostic test for nitrate toxicity.
    5. None of the above.
12. What key areas should be addressed in the exposure history?
    1. recent use of medications by infant and mother
    2. type of formula, feeding regimen, and source of dilution water
    3. drinking water source and supply
    4. all of the above
13. Which of the following is/are true regarding the clinical assessment?
    1. All cyanotic patients should be assessed for possible cardiac and lung disease (cardiac murmurs, gallops, arrhythmias, rales, rhonchi, wheezes, dullness, or hyperresonance in the chest).
    2. A central chocolate brown or slate gray cyanosis that does not respond to administration of 100% oxygen is suggestive of methemoglobinemia
    3. the victim is often less ill than one would expect from the severity of 'cyanosis'
    4. all of the above
14. Useful diagnostic test(s) for nitrate toxicity include which of the following?
    1. measurements of nitrates in blood, urine, or saliva
    2. measurements of nitrites in blood, urine, or saliva
    3. blood methemoglobin level.
    4. All of the above.
15. Which of the following treatments can be used for patients with nitrate toxicity?
    1. hyperbaric oxygen therapy
    2. methylene blue
    3. 100% oxygen
    4. exchange transfusion
    5. All of the above.
16. What condition is a relative contraindication to methylene blue treatment?
    1. psoriasis
    2. G6PD deficiency
    3. methemoglobinemia
    4. diarrhea and vomiting
    5. None of the above.

Relevant Content

What are nitrates/nitrites?

Who is at risk?

What are nitrates/nitrites?

What is the biologic fate of nitrates/nitrites?

What Are the U.S. Standards for nitrate/nitrite levels?

What is the biologic fate of nitrates/nitrites?

What is the biologic fate of nitrates/nitrites?

What are the physiologic effects of exposure to nitrates/nitrites?

What are the physiologic effects of exposure to nitrates/nitrites?

What are the physiologic effects of exposure to nitrates/nitrites?

How should patients exposed to nitrates/nitrites be evaluated?
What laboratory tests can assist with diagnosis of nitrate/nitrite toxicity?

How should patients exposed to nitrates/nitrites be evaluated?

How should patients exposed to nitrates/nitrites be evaluated?

What laboratory tests can assist with diagnosis of nitrate/nitrite toxicity?

How should patients exposed to nitrates/nitrites be treated?

How should patients exposed to nitrates/nitrites be treated?