Ch. 8 Test, Initial Pt Assessment Flashcards
The first step in the assessment and documentation of patient-ventilator interaction following the placement of a patient on a mechanical ventilator is which of the following?
a. Verifying physician’s orders
b. Verifying a passing operational verification procedure
c. Checking the integrity of the ventilator circuit and the humidifier system
d. Assessment of the patient’s vital signs, breath sounds, and level of consciousness
ANS: A
The first step in the process of assessment and documentation of patient-ventilator interaction after a patient has been placed on a mechanical ventilator involves the respiratory therapist verifying the physician’s orders. The second step is to verify that the ventilator passed an operational verification procedure (OVP). The OVP involves checking the integrity of the ventilator circuit and the humidification system. The patient assessment is performed during the patient-ventilator system check.
DIF: 1 REF: pg. 125
The operational verification procedure (OVP) involves checking the ventilator circuit for leaks. Ventilator settings that could be used to perform this procedure include which of the following?
a. Tidal volume (VT) = 500 mL, Flow rate = 60 L/min, High pressure limit = 50 cm H2O
b. VT = 1000 mL, Flow rate = 20 L/min, High pressure limit = maximum
c. VT = 500 mL, Flow rate = 20 L/min, High pressure limit = maximum, Inspiratory pause = 2 seconds
d. VT = 200 mL, Flow rate = Maximum, High pressure limit = 50 cm H2O, Inspiratory pause = 1 second
ANS: C
To check for leaks in the ventilator circuit the operator should set the tidal volume to 500 mL, the gas flow low (e.g., 20 L/min), the maximum pressure limit high (e.g., 100 to 120 cm H2O), and an inspiratory pause of 1 to 2 seconds.
DIF: 1 REF: pg. 125
How often should the fractional inspired oxygen (FIO2) of an adult be measured with an oxygen analyzer?
a. Twice daily
b. Continuously
c. Every patient-ventilator system check
d. Every other patient-ventilator system check
ANS: C
The fractional inspired oxygen (FIO2) for a ventilated adult should be measured during each patient-ventilator system check.
DIF: 1 REF: pg. 125
How long after beginning mechanical ventilation on a patient should an arterial blood gas sample be drawn?
a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 20 minutes
ANS: C
An arterial blood gas sample should be obtained about 15 minutes following the initiation of mechanical ventilation. This is vital for the evaluation of the effectiveness of ventilation and oxygenation.
DIF: 1 REF: pg. 126
A female patient who is 5’7” tall and weighs 68 kg is being mechanically ventilated with volume-controlled continuous mandatory ventilation (VC-CMV), set rate 12, patient trigger rate 25 bpm, tidal volume (VT) 500 mL, set flow rate 60 L/min, fractional inspired oxygen (FIO2) 40%, positive-end-expiratory pressure (PEEP) 5 cm H2O. The patient is currently in distress using accessory muscles of inspiration. A patient-ventilator system check is performed by the respiratory therapist. The flow-time waveform shows a failure of the expiratory flow to return to zero before the next breath is triggered. The most appropriate action for the respiratory therapist to take includes which of the following?
a. Sedate the patient.
b. Switch to pressure-controlled continuous mandatory ventilation (PC-CMV).
c. Decrease set rate to 8 bpm.
d. Switch to volume-controlled synchronized intermittent mandatory ventilation (VC-SIMV).
ANS: D
There are two clues to the fact that this patient is having problems because of unintended positive-end-expiratory pressure (auto-PEEP): the patient’s trigger rate of 25 bpm and the flow-time curve not returning to zero before the next breath is triggered. Sedating the patient is not the most appropriate action to take in this situation. Sedating and paralyzing the patient is reserved as a last resort for respiratory distress from patient-ventilator asynchrony. Switching to pressure-controlled continuous mandatory ventilation (PC-CMV) will most likely not change the situation too much, unless the pressure is markedly reduced to reduce the tidal volume. Decreasing the set rate to 8 bpm will not affect the patient’s trigger rate and therefore will not change the situation. Switching to a mode where there is more spontaneous breathing is an acceptable strategy for dealing with auto-PEEP.
DIF: 3 REF: pgs. 128, 129
Calculate the volume delivered to the patient when the tubing compliance (CT) is 2.5 mL/cm H2O, the tidal volume (VT) at the exhalation port is 550 mL, and the peak inspiratory pressure (PIP) is 28 cm H2O.
a. 70 mL
b. 330 mL
c. 480 mL
d. 620 mL
ANS: C
Volume Lost = PIP × CT and Delivered VT = measured VT – volume lost
DIF: 2 REF: pgs. 129, 130
A 6’2” male patient is being ventilated in the volume-controlled continuous mandatory ventilation (VC-CMV) mode with a set tidal volume (VT) of 650 mL. There is 40 mL of mechanical dead space. Calculate the final alveolar ventilation.
a. 432 mL
b. 445 mL
c. 510 mL
d. 535 mL
ANS: A
Volume of anatomical dead space (VDanat) = 1 mL/lb ideal body weight (IBW);
IBW = 106 + 6 (ht inches – 60); tidal volume (VT) volume of mechanical dead space (VDmech) VDanat
DIF: 2 REF: pg. 130
An increasing PIP may indicate which of the following?
a. Decreasing lung compliance
b. Decreasing airway resistance
c. Leak in the ventilator circuit
d. Increasing dynamic compliance
ANS: A
Compliance is equal to tidal volume divided by peak inspiratory pressure (PIP). If the PIP is rising the compliance is decreasing. Therefore, the answer is “A.” An increasing PIP would be caused by a rise in airway resistance and decreased dynamic compliance. A leak in the system would be indicated by a decreased PIP.
DIF: 1 REF: pg. 131
A pathophysiologic condition that causes an increase in peal inspiratory pressure (PIP) while transairway pressure (PTA) remains the same is which of the following?
a. Acute respiratory distress syndrome (ARDS)
b. Asthma
c. Emphysema
d. Chronic Bronchitis
ANS: A
An increase in peak inspiratory pressure (PIP) with a constant transairway pressure (PTA) is due to an increase in plateau pressure (Pplateau). The most common reason for a rise in Pplateau is acute respiratory distress syndrome (ARDS). The three other choices are all obstructive diseases that would cause an increase in the PTA with no significant change in Pplateau.
DIF: 1 REF: pg. 131
During the course of several patient-ventilator system checks a respiratory therapist notices that the patient’s peak inspiratory pressure (PIP) is rising, while the plateau pressure (Pplateau) has remained the same. This most likely indicates which of the following?
a. Decrease in dynamic compliance
b. Increase in airway resistance
c. Decrease in static compliance
d. Increase in elastic recoil of alveolar walls
ANS: B
The difference between the peak inspiratory pressure (PIP) and plateau pressure (Pplateau) readings (PIP - Pplateau) is the transairway pressure (PTA). PTA is the amount of pressure required to overcome airway resistance (Raw) (Raw = PTA/Flow). Notice that PTA includes the resistance of the endotracheal tube (ET). A higher than expected difference between PIP and Pplateau suggests an increased Raw.
DIF: 2 REF: pg. 131
The data on the following ventilator flow sheet for a patient being ventilated in the volume-controlled continuous mandatory ventilation (VC-CMV) mode demonstrates which of the following?
Time PIP Pplat PEEP Exh.VT Flow rate 0800 35 30 5 1000 60 1000 39 34 5 1000 60 1100 45 39 5 1000 60 1130 50 44 5 1000 60
a. Airway resistance is increasing.
b. Lung compliance is decreasing.
c. Dynamic compliance is increasing.
d. Water is accumulating in the patient circuit.
ANS: B
This ventilator flow sheet shows that while the peak inspiratory pressure (PIP) and plateau pressure (Pplateau) are both increasing over the course of the 3 hours, the transairway pressure (PTA = PIP Pplateau) has remained almost unchanged (either 5 cm H2O or 6 cm H2O). This means that there has been little change in airway resistance between 0800 and 1130. What is demonstrated is that there is an increase in the Pplateau and that reflects an increase in the elastic resistance of the alveolar walls and thoracic cage against the volume being delivered. This is due to decreasing lung compliance or stiffening of the lungs. The other answers would cause an increase in the PTA.
DIF: 2 REF: pg. 131
A patient’s transairway pressure (PTA) is rising while the plateau pressure (Pplateau) remains unchanged. The treatment plan that could correct this problem includes which of the following?
- Administer a bronchodilator.
- Insert a chest tube.
- Increase extrinsic positive-end-expiratory pressure (PEEPE)
- Suction airway secretions.
a. 2 only
b. 2 and 4 only
c. 1 and 4 only
d. 1 and 3 only
ANS: C
An increase in the transairway pressure (PTA) reflects the need for an increased amount of pressure to overcome airway resistance (Raw). Raw most often increases when the patient`s airway needs suctioning, the patient is biting on the tube, the tube is kinked, or the patient has mucosal edema or bronchospasms (or both). Bronchospasm is treated with the administration of a bronchodilator, and retained airway secretions may be removed by suctioning. The presence of a pneumothorax requiring a chest tube would manifest an increase in plateau pressure (Pplateau) along with other signs not present in this scenario. If the Pplateau had been increased or if there was intrinsic positive-end-expiratory pressure (PEEPI), increasing extrinsic positive-end-expiratory pressure (PEEPE) might be a viable solution.
DIF: 3 REF: pg. 132
The respiratory therapist is evaluating the following ventilator flow sheet. The recommendation that is most appropriate in this situation is which of the following?
Time PIP Pplat PEEPE Exh.VT Flow rate 0800 35 30 5 1000 60 1000 39 34 5 1000 60 1100 45 39 5 1000 60 1130 50 44 5 1000 60
a. Increase extrinsic positive-end-expiratory pressure (PEEPE).
b. Suction the airway.
c. Switch out the heat moisture exchanger (HME).
d. Administer a bronchodilator.
ANS: A
What is demonstrated here is that there is an increase in the plateau pressure (Pplateau) and this reflects a decreasing lung compliance or stiffening of the lungs. Adding extrinsic positive-end-expiratory pressure (PEEPE) to this patient could result in a decrease in the Pplateau. Since the transairway pressure (PTA) has remained stable over the 3.5 hours, there is no increase in airway resistance and no need to suction the airway, switch out the heat moisture exchanger (HME), or administer a bronchodilator.
DIF: 3 REF: pg. 132
Following initiation of volume-controlled continuous mandatory ventilation (VC-CMV) ventilation, the patient’s average peak inspiratory pressure (PIP) is 23 cm H2O. The high pressure limit alarm should be set at which of the following?
a. 28 cm H2O
b. 33 cm H2O
c. 38 cm H2O
d. 43 cm H2O
ANS: B
The high pressure limit alarm should be set to about 10 cm H2O.
DIF: 1 REF: pg. 133
A 31-year-old woman is admitted to the emergency department following a motor vehicle accident. The paramedics brought her into the ER in respiratory distress. She was intubated in the field and started on mechanical ventilation as soon as she arrived. Breath sounds were clear on the left and absent on the right. Percussion revealed resonance on the left and hyperresonance on the right. The patient’s trachea was shifted to the left. The most likely cause of this patient’s clinical presentation is which of the following?
a. Acute respiratory distress syndrome (ARDS)
b. Flail chest
c. Pneumothorax
d. Pleural effusion
ANS: C
Absent breath sounds on the right side with hyperresonance means there is excessive air in the pleural cavity on the right side. A tracheal shift to the left indicates that there is either a right- sided pneumothorax or left-sided atelectasis. The presence of the hyperresonance with the tracheal shift and absent breath sounds points to the pneumothorax.
DIF: 2 REF: pg. 133
