Egans Chapter 36 Airway Management

Question 1

What is the primary indication for tracheal suctioning?

a. Presence of pneumonia
b. Presence of atelectasis
c. Ineffective coughing
d. Retention of secretions

Answer 1

ANS: D
Excerpts from the AARC guideline (CPG 36-1) include indications, contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring.

DIF: Recall REF: p. 741 OBJ: 1

Question 2

Complications of tracheal suctioning include which of the following?

1. Bronchospasm
2. Hyperinflation
3. Mucosal trauma
4. Elevated intracranial pressure
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 1, 3, and 4 only

Answer 2

ANS: D
Complications of tracheal suctioning include bronchospasm, mucosal trauma, and elevated intracranial pressures.

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Question 3

How often should patients be suctioned?

a. At least once every 2 to 3 hr
b. Whenever they are moved or ambulated
c. When physical findings support the need
d. Whenever the charge nurse requests it

Answer 3

ANS: C
A patient should never be suctioned according to a preset schedule.

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Question 4

What is the normal range of negative pressure to use when suctioning an adult patient?

a. –100 to –120 mm Hg
b. –80 to –100 mm Hg
c. –60 to –80 mm Hg
d. –20 to –30 mm Hg

Answer 4

ANS: A
The suction pressure should be set at the lowest effective level. Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended

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Question 5

What is the normal range of negative pressure to use when suctioning children?

a. –60 to –80 mm Hg
b. –80 to –100 mm Hg
c. –100 to –120 mm Hg
d. –120 to –150 mm Hg

Answer 5

ANS: C
The suction pressure should be set at the lowest effective level. Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended.

DIF: Recall REF: p. 742 OBJ: 1

Question 6

You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case?

a. 6 Fr
b. 8 Fr
c. 10 Fr
d. 14 Fr

Answer 6

ANS: C
See Rule of Thumb 36-1.

DIF: Application REF: p. 742 OBJ: 1

Question 7

You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case?

a. 8 Fr
b. 10 Fr
c. 12 Fr
d. 14 Fr

Answer 7

ANS: D
See Rule of Thumb 36-1.

DIF: Application REF: p. 742 OBJ: 1

Question 8

To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following?

a. Manually ventilate the patient with a resuscitator.
b. Preoxygenate the patient with 100% oxygen.
c. Give the patient a bronchodilator treatment.
d. Have the patient hyperventilate for 2 min.

Answer 8

ANS: B
First, preoxygenation helps minimize the incidence of hypoxemia during suctioning.

DIF: Application REF: p. 743 OBJ: 1

Question 9

To maintain positive end expiratory pressure (PEEP) and high FiO2 when suctioning a mechanically ventilated patient, what would you recommend?

a. Limit suction time to no more than 5 sec.
b. Use a closed-system multiuse suction catheter.
c. Limit suctioning to once an hour.
d. Use the smallest possible catheter.

Answer 9

ANS: B
Basic indications for the use of closed suction catheters can be found in Box 36-2.

DIF: Application REF: p. 743 OBJ: 1

Question 10

Total application time for endotracheal suction in adults should not exceed which of the following?

a. 20 to 25 sec
b. 15 to 20 sec
c. 10 to 15 sec
d. 3 to 5 sec

Answer 10

ANS: C
Keep total suction time to less than 10 to 15 sec.

DIF: Recall REF: p. 743 OBJ: 1

Question 11

While suctioning a patient, you observe an abrupt change in the electrocardiogram waveform being displayed on the cardiac monitor. Which of the following actions would be most appropriate?

a. Change to a smaller catheter and repeat the procedure.
b. Stop suctioning and immediately administer oxygen.
c. Stop suctioning and report your findings to the nurse.
d. Decrease the amount of negative pressure being used.

Answer 11

ANS: B
If any major change is seen in the heart rate or rhythm, immediately stop suctioning and administer oxygen to the patient, providing manual ventilation as needed.

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Question 12

Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning?

1. Limit the amount of negative pressure used.
2. Hyperinflate the patient before and after the procedure.
3. Suction for as short a period of time as possible.
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 12

ANS: D
Atelectasis can be caused by removal of too much air from the lungs. You can avoid this complication by (1) limiting the amount of negative pressure used, (2) keeping the duration of suctioning as short as possible, and (3) providing hyperinflation before and after the procedure.

DIF: Recall REF: p. 744 OBJ: 1

Question 13

Which of the following can help to minimize the likelihood of mucosal trauma during suctioning?

1. Use as large a catheter as possible.
2. Rotate the catheter while withdrawing.
3. Use as rigid a catheter as possible.
4. Limit the amount of negative pressure.
   a. 1 and 2 only
   b. 2 and 4 only
   c. 3 and 4 only
   d. 1, 2, and 4 only

Answer 13

ANS: B
To avoid this problem, limit the amount of negative pressure used and always rotate the catheter while withdrawing.

DIF: Recall REF: p. 744 OBJ: 1

Question 14

Absolute contraindication for nasotracheal suctioning includes which of the following?

1. Epiglottitis
2. Croup
3. Irritable airway
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 14

ANS: A
Excerpts from the AARC guideline (CPG 36-2) include indications, contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring.

DIF: Recall REF: p. 741 OBJ: 1

Question 15

Which of the following equipment is needed to perform nasotracheal suctioning?

1. Suction kit (catheter, gloves, basin, etc.)
2. Laryngoscope with MacIntosh and Miller blades
3. Oxygen delivery system (mask and manual resuscitator)
4. Bottle of sterile water or saline solution
   a. 1 and 3 only
   b. 1, 3, and 4 only
   c. 2 and 4 only
   d. 2, 3, and 4 only

Answer 15

ANS: B
See Box 36-1.

DIF: Recall REF: p. 742 OBJ: 1

Question 16

After repeated nasotracheal suctioning over 2 days, a patient with retained secretions develops minor bleeding through the nose. Which of the following actions would you recommend?

a. Perform a tracheotomy for better access to the lower airway.
b. Discontinue nasotracheal suctioning for 48 hr and reassess.
c. Stop the bleeding and use a nasopharyngeal airway for access.
d. Orally intubate the patient for better access to the lower airway.

Answer 16

ANS: C
Placement of a nasopharyngeal airway can help minimize nasal trauma when repeated access is needed.

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Question 17

Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem?

a. Secretions are still present and the patient should be suctioned again.
b. The patient has hyperactive airways and has developed bronchospasm.
c. A pneumothorax has developed and the patient needs a chest tube.
d. The patient has developed a mucous plug and should undergo bronchoscopy.

Answer 17

ANS: B
The bronchospastic response may be particularly strong in patients with hyperactive airway disease. These patients should be assessed for the development of wheezes associated with suctioning.

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Question 18

What general condition requires airway management?

1. Airway compromise
2. Respiratory failure
3. Need to protect the airway
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 18

ANS: D
Excerpts from the AARC guideline (CPG 36-3) include indications, contraindications, precautions, hazards, and/or possible complications, assessment of need and outcome, and monitoring.

DIF: Recall REF: pp. 747-748 OBJ: 3

Question 19

Which of the following conditions require emergency tracheal intubation?

1. Upper airway or laryngeal edema
2. Loss of protective reflexes
3. Cardiopulmonary arrest
4. Traumatic upper airway obstruction
   a. 1 and 4 only
   b. 3 and 4 only
   c. 1, 2, and 3 only
   d. 1, 2, 3, and 4

Answer 19

ANS: D
Excerpts from the AARC guideline (CPG 36-3) include indications, contraindications, precautions, hazards, and/or possible complications, assessment of need and outcome, and monitoring.

DIF: Recall REF: pp. 747-748 OBJ: 3

Question 20

Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management?

1. Hypotension
2. Bradycardia
3. Cardiac arrhythmias
4. Laryngospasm
   a. 1, 2, and 3 only
   b. 1 and 4 only
   c. 3 and 4 only
   d. 1, 2, 3, and 4

Answer 20

ANS: D
Excerpts from the AARC guideline (CPG 36-3) include indications, contraindications, precautions, hazards, and/or possible complications, assessment of need and outcome, and monitoring.

DIF: Recall REF: pp. 747-748

Question 21

Which of the following indicate an inability to adequately protect the airway?

1. Wheezing
2. Coma
3. Lack of gag reflex
4. Inability to cough
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 21

ANS: D
Excerpts from the AARC guideline (CPG 36-3) include indications, contraindications, precautions, hazards, and/or possible complications, assessment of need and outcome, and monitoring.

DIF: Recall REF: pp. 747-748 OBJ: 4

Question 22

Which of the following types of artificial airways are inserted through the larynx?

1. Pharyngeal airways
2. Tracheostomy tubes
3. Nasotracheal tubes
4. Orotracheal tubes
   a. 1 and 4 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 1, 2, 3, and 4

Answer 22

ANS: C
The two basic types of tracheal airways are endotracheal (translaryngeal) tubes and tracheostomy tubes. Endotracheal tubes are inserted through either the mouth or nose (orotracheal or nasotracheal), through the larynx, and into the trachea.

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Question 23

Compared with the nasal route, the advantages of oral intubation include which of the following?

1. Reduced risk of kinking
2. Less retching and gagging
3. Easier suctioning
4. Less traumatic insertion
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 1, 2, 3, and 4
   d. 1, 3, and 4 only

Answer 23

ANS: D
A summary of the advantages and disadvantages of each of these three approaches appears in Table 36-1.

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Question 24

Compared with the oral route, the advantages of nasal intubation include which of the following?

1. Reduced risk of kinking
2. Less retching and gagging
3. Less accidental extubation
4. Greater long-term comfort
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 24

ANS: D
A summary of the advantages and disadvantages of each of these three approaches appears in Table 36-1.

DIF: Recall REF: p. 750 OBJ: 3

Question 25

Compared with translaryngeal intubation, the advantages of tracheostomy include which of the following?

1. Greater patient comfort
2. Reduced risk of bronchial intubation
3. No upper airway complications
4. Decreased frequency of aspiration
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 25

ANS: B
A summary of the advantages and disadvantages of each of these three approaches appears in Table 36-1.

DIF: Recall REF: p. 750 OBJ: 3

Question 26

What is the standard size for endotracheal or tracheostomy tube adapters?

a. 22-mm external diameter
b. 15-mm external diameter
c. 15-mm internal diameter
d. 22-mm internal diameter

Answer 26

ANS: B
The proximal end of the tube is attached to a standard adapter with a 15-mm external diameter.

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Question 27

What is the purpose of the additional side port (Murphy eye) on most modern endotracheal tubes?

a. Protect the airway against aspiration.
b. Help ascertain proper tube position.
c. Minimize mucosal trauma during insertion.
d. Ensure gas flow if the main port is blocked.

Answer 27

ANS: D
In addition to the beveled opening at the tip, there should be an additional side port or “Murphy eye,” which ensures gas flow if the main port should become obstructed. The tube cuff is permanently bonded to the tube body. Inflation of the cuff seals off the lower airway, either for protection from aspiration or to provide positive pressure ventilation.

DIF: Recall REF: p. 749 OBJ: 3

Question 28

What is the purpose of a cuff on an artificial tracheal airway?

a. To seal off and protect the lower airway
b. To stabilize the tube and prevent its movement
c. To provide a means to determine tube position via radiograph
d. To help clinicians determine the depth of tube insertion

Answer 28

ANS: A DIF: Recall REF: p. 749 OBJ: 7

Question 29

What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube?

a. To help ascertain proper tube position
b. To minimize mucosal trauma during insertion
c. To monitor cuff status and pressure
d. To protect the airway against aspiration

Answer 29

ANS: C
A small filling tube leads from the cuff to a pilot balloon, used to monitor cuff status and pressure once the tube is in place.

DIF: Recall REF: p. 749 OBJ: 6

Question 30

Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement?

1. Length markings on the curved body of the tube
2. Imbedded radiopaque indicator near the tube tip
3. Additional side port (Murphy eye) near the tube tip
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 30

ANS: A
Not shown, but included with most modern endotracheal tubes, is a radiopaque indicator that is embedded in the distal end of the tube body. This indicator allows for easy identification of tube position on radiograph.

DIF: Recall REF: p. 749 OBJ: 6

Question 31

The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes?

1. Aid in routine tube cleaning and tracheostomy care
2. Prevent the tube from slipping into the trachea
3. Provide a patent airway should it become obstructed
   a. 1 and 3 only
   b. 2 and 3 only
   c. 3 only
   d. 1, 2, and 3

Answer 31

ANS: A
A removable inner cannula with a standard 15-mm adapter is normally kept in place within the outer cannula but can be removed for routine cleaning or if it becomes obstructed.

DIF: Recall REF: p. 751 OBJ: 7

Question 32

What is the purpose of a tracheostomy tube obturator?

a. To minimize trauma to the tracheal mucosal during insertion
b. To provide a patent airway should the tube become obstructed
c. To help ascertain the proper tube position by radiograph
d. To provide a means to inflate and deflate the tube cuff

Answer 32

ANS: A
An obturator with a rounded tip is used for tube insertion. Prior to insertion, the obturator is placed within the outer cannula, with its tip extending just beyond the far end of the tube. This minimizes mucosal trauma during insertion.

DIF: Recall REF: p. 751 OBJ: 7

Question 33

In the absence of neck or facial injuries, what is the procedure of choice to establish a patent tracheal airway in an emergency?

a. Surgical tracheotomy
b. Orotracheal intubation
c. Nasotracheal intubation
d. Cricothyrotomy

Answer 33

ANS: B
Orotracheal intubation is the preferred route for establishing an emergency tracheal airway.

DIF: Application REF: p. 753 OBJ: 5

Question 34

While checking a crash cart for intubation equipment, you find the following: suction equipment, oxygen apparatus, two laryngoscopes and assorted blades, five tubes, Magill forceps, tape, lubricating gel, and local anesthetic. What is missing?

1. Obturator
2. Syringe(s)
3. Resuscitator bag and mask
4. Tube stylet
   a. 1, 2, and 3 only
   b. 2 and 4 only
   c. 2, 3, and 4 only
   d. 1, 2, 3, and 4

Answer 34

ANS: C
Box 36-3 lists the equipment necessary for intubation.

DIF: Application REF: p. 753 OBJ: 5

Question 35

Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following?

1. Laryngoscope light source
2. Endotracheal tube cuff
3. Suction equipment
4. Cardiac defibrillator
   a. 1, 2, and 3 only
   b. 2 and 4 only
   c. 3 and 4 only
   d. 1, 3, and 4 only

Answer 35

ANS: A
Before beginning an intubation procedure, the practitioner should confirm the operation of suction equipment, oxygen, airway equipment, monitors, and esophageal detectors and check position of the patient.

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Question 36

While checking a Miller and a MacIntosh blade on an intubation tray during an emergency intubation, you find that the Miller blade “lights” but the MacIntosh blade does not. What should you do now?

a. Swap the defective MacIntosh for the good Miller blade.
b. Check and replace the bulb in the MacIntosh blade.
c. Replace the batteries in the laryngoscope handle.
d. Check and clean the laryngoscope handle electrical contact.

Answer 36

ANS: B
If the light does not function, first check that the bulb is tight. If the scope still does not light, check the batteries or replace the bulb.

DIF: Analysis REF: p. 753 OBJ: 5

Question 37

What size endotracheal tube would you select to intubate a 3-year-old child?

a. 3.0 to 4.0 mm
b. 4.5 to 5.0 mm
c. 5.5 to 6.0 mm
d. 6.0 to 7.0 mm

Answer 37

ANS: B
Table 36-4 lists recommended orotracheal tube sizes according to patient weight or age.

DIF: Application REF: p. 753 OBJ: 5

Question 38

What size endotracheal tube would you select to intubate a 1500-g newborn infant?

a. 2.5 mm
b. 3.0 mm
c. 3.5 mm
d. 4.0 mm

Answer 38

ANS: B
Table 36-4 lists recommended orotracheal tube sizes according to patient weight or age.

DIF: Application REF: p. 753 OBJ: 5

Question 39

What size endotracheal tube would you select to intubate an adult female?

a. 6 mm
b. 7 mm
c. 8 mm
d. 9 mm

Answer 39

ANS: C
Table 36-4 lists recommended orotracheal tube sizes according to patient weight or age.

DIF: Application REF: p. 753 OBJ: 5

Question 40

What is the purpose of an endotracheal tube stylet?

a. It helps ascertain proper tube position.
b. It adds rigidity and shape to ease insertion.
c. It minimizes mucosal trauma during insertion.
d. It protects the airway against aspiration.

Answer 40

ANS: B
Some clinicians insert a stylet into the tube to add rigidity and maintain shape during insertion.

DIF: Recall REF: p. 753 OBJ: 5

Question 41

To make oral intubation easier, how should the patient’s head and neck be positioned?

a. Neck extended over the edge of the bed, with head dangling down
b. Neck extended, with head supported by towel and flexed forward
c. Both the neck and head fully extended, with neck supported by towel
d. Neck flexed, with head supported by towel and tilted back

Answer 41

ANS: D
You achieve this alignment by combining moderate cervical flexion with extension of the atlantooccipital joint. Placement of one or more rolled towels under the patient’s head helps. You then flex the neck and tilt the head backward with your hand (Figure 36-14).

DIF: Recall REF: p. 753 OBJ: 5

Question 42

What should be the maximum time devoted to any intubation attempt?

a. 30 sec
b. 60 sec
c. 90 sec
d. 2 min

Answer 42

ANS: A
Do not devote more than 30 sec to any intubation attempt.

DIF: Recall REF: p. 754 OBJ: 5

Question 43

Which of the following statements are true about methods used to displace the epiglottis during oral intubation?

a. Regardless of the blade used, the laryngoscope is lifted up and forward.
b. The curved (MacIntosh) blade lifts the epiglottis indirectly.
c. The straight (Miller) blade lifts the epiglottis directly.
d. Levering the laryngoscope against the teeth can aid displacement.
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only

Answer 43

ANS: B
In lifting the tip of the blade, you should avoid levering the laryngoscope against the teeth, as this can damage the teeth and gums.

DIF: Recall REF: p. 754 OBJ: 5

Question 44

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far?

a. Until its cuff has passed the cords
b. Just far enough so that the tube cuff is no longer visible
c. Until its cuff has passed the cords by 2 to 3 in
d. Until its tip has passed the cords by 2 to 3 cm

Answer 44

ANS: A
Once you see the tube tip pass through the glottis, advance it until the cuff has passed the vocal cords.

DIF: Recall REF: p. 754 OBJ: 5

Question 45

Immediately after insertion of an oral endotracheal tube on an adult, what should you do?

1. Stabilize it with your right hand.
2. Inflate the tube cuff.
3. Provide ventilation or oxygenation.
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 45

ANS: D
Once the tube is in place, stabilize it with the right hand, and use the left hand to remove the laryngoscope and stylet. Then inflate the cuff to seal the airway and immediately provide ventilation and oxygenation.

DIF: Application REF: p. 755 OBJ: 5

Question 46

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned approximately how far above the carina?

a. 1 to 3 cm
b. 3 to 6 cm
c. 7 to 9 cm
d. 4 to 6 in

Answer 46

ANS: B
Ideally, the tip of an endotracheal tube should be positioned in the trachea approximately 5 cm above the carina.

DIF: Recall REF: p. 755 OBJ: 6

Question 47

Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachea?

a. Auscultation
b. Observation of chest movement
c. Tube length (cm to teeth)
d. Fiberoptic laryngoscopy

Answer 47

ANS: D
With the exception of fiberoptic laryngoscopy, none of these methods can absolutely confirm proper tube placement.

DIF: Recall REF: pp. 755-756 OBJ: 6

Question 48

What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man?

a. 16 to 18 cm
b. 19 to 21 cm
c. 21 to 23 cm
d. 24 to 26 cm

Answer 48

ANS: C
As indicated in Table 36-2 the average length from the teeth (incisors) to the tip of a properly positioned oral endotracheal tube in males is between 21 and 23 cm.

DIF: Recall REF: p. 755 OBJ: 6

Question 49

When using a bulb-type esophageal detection device (EDD) during an intubation attempt, how do you know that the endotracheal tube is in the esophagus?

a. The bulb fails to reexpand upon release.
b. The bulb quickly reexpands upon release.
c. The bulb cannot be completely squeezed closed.
d. The bulb cannot be attached to the endotracheal tube.

Answer 49

ANS: A
If the tube is in the esophagus, it will not reinflate because the esophagus collapses around the endotracheal tube.

DIF: Recall REF: p. 755 OBJ: 6

Question 50

After an intubation attempt, an expired capnogram indicates a CO2 level near zero. What does this finding probably indicate?

a. Abnormally high ventilation/perfusion ratio ( )
b. Placement of the endotracheal tube in the esophagus
c. Placement of the endotracheal tube in the trachea
d. Failure of the cuff to properly seal the airway

Answer 50

ANS: B
If the tube is in the esophagus, CO2 levels remain near zero.

DIF: Recall REF: p. 756 OBJ: 6

Question 51

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in a false-negative finding (i.e., no CO2 present even when the tube is in the trachea)?

a. Cardiac arrest
b. Gastric CO2 diffusion
c. Right main stem intubation
d. Delivery of a high FiO2

Answer 51

ANS: A
In cardiac arrest victims, however, expired CO2 levels may be near zero because of poor pulmonary blood flow, yielding a false-negative result.

DIF: Recall REF: p. 756 OBJ: 6

Question 52

After intubation of a cardiac arrest victim, you observe a slow but steady rise in the expired CO2 levels as measured by a bedside capnometer. Which of the following best explains this observation?

a. Return of spontaneous circulation
b. Abnormally high
c. Placement of the endotracheal tube in the esophagus
d. Failure of the cuff to properly seal the airway

Answer 52

ANS: A
Generally, expired CO2 levels increase with the return of spontaneous circulation.

DIF: Application REF: p. 756 OBJ: 6

Question 53

Serious complications of oral intubation include which of the following?

1. Cardiac arrest
2. Acute hypoxemia
3. Bradycardia
4. Tongue lacerations
   a. 2 and 4 only
   b. 1, 2, and 3 only
   c. 2, 3, and 4 only
   d. 1, 2, 3, and 4

Answer 53

ANS: B
The most common complication of emergency airway management is tissue trauma. The most serious complications are acute hypoxemia, hypercapnia, bradycardia, and cardiac arrest. Examples include intubation of patients when the oral route is unavailable, such as maxillofacial injuries or oral surgery.

DIF: Recall REF: p. 758 OBJ: 8

Question 54

You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support. Which of the following airway approaches would you recommend?

a. Intubate via the oral route.
b. Insert an oropharyngeal airway.
c. Perform an emergency tracheotomy.
d. Intubate via the nasal route.

Answer 54

ANS: D
With the maxillofacial injury, the oral cavity will not be accessible. Intubation via the nasal route may be required. It is a short term need so a tracheotomy will not be necessary.

DIF: Application REF: p. 758 OBJ: 3

Question 55

To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend?

a. Nasal spray of 0.25% phenylephrine
b. SVN aerosol delivery of 2% lidocaine for 10 min
c. Mixture of 0.25% phenylephrine and 3% lidocaine
d. SVN aerosol delivery of 0.25% phenylephrine for 10 min

Answer 55

ANS: C
A mixture of 0.25% phenylephrine and 3% lidocaine may be applied to the nasal mucosa with a long cotton tip swab to provide local anesthesia and vasoconstriction of the nasal passage.

DIF: Application REF: p. 758 OBJ: 5

Question 56

Successful tube passage through the larynx during blind nasotracheal intubation is indicated by which of the following?

1. Louder breath sounds
2. Harsh cough
3. Vocal silence
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 56

ANS: C
Successful passage of the tube through the larynx usually is indicated by a harsh cough, followed by vocal silence.

DIF: Recall REF: p. 759 OBJ: 6

Question 57

What is the primary indication for tracheostomy?

a. When a patient loses pharyngeal or laryngeal reflexes
b. When a patient has a long-term need for an artificial airway
c. When a patient has been orally intubated for more than 24 hr
d. When a patient has upper airway obstruction due to secretions

Answer 57

ANS: B
Tracheotomy is the preferred, primary route for overcoming upper airway obstruction or trauma and for long-term care of patients with neuromuscular disease.

DIF: Recall REF: p. 759 OBJ: 7

Question 58

Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube?

1. Patient’s tolerance of the endotracheal tube
2. Relative risks of continued intubation versus tracheostomy
3. Patient’s severity of illness and overall condition
4. Length of time that the patient will need an artificial airway
5. Patient’s ability to tolerate a surgical procedure
   a. 1, 3, and 4 only
   b. 3, 4, and 5 only
   c. 2, 3, 4, and 5 only
   d. 1, 2, 3, 4, and 5

Answer 58

ANS: D
Pertinent factors that should be considered in making this decision are summarized in Box 36-5.

DIF: Recall REF: p. 759 OBJ: 7

Question 59

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area?

a. Through or between the first and second tracheal rings
b. Through the ligament between the thyroid and cricoid cartilages
c. Through or between the second and third tracheal rings
d. Between the cricoid cartilage and the first tracheal ring

Answer 59

ANS: C
In the traditional surgical tracheotomy, the surgeon makes an incision in the neck over the second or third tracheal ring.

DIF: Recall REF: p. 759 OBJ: 7

Question 60

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action?

a. Remove the oral tube just before tracheostomy tube insertion.
b. Remove the oral tube before the tracheotomy is performed.
c. Pull the oral tube only after the tracheostomy tube is placed.
d. Withdraw the oral tube 2 to 3 in while the incision is made.

Answer 60

ANS: D
After dissection to the anterior tracheal wall, the endotracheal tube is retracted to keep the tip of the tube inside the larynx.

DIF: Application REF: p. 759 OBJ: 7

Question 61

Compared with traditional surgical tracheostomy, which of the following are true about percutaneous dilatational tracheostomy?

1. Percutaneous dilatational tracheostomy has a lower incidence of complications.
2. Percutaneous dilatational tracheostomy is faster than traditional tracheostomy.
3. Percutaneous dilatational tracheostomy can be performed at the bedside.
4. Percutaneous dilatational tracheostomy does not require anterior neck dissection.
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 61

ANS: B
Compared with the traditional surgical procedure, percutaneous dilatational tracheotomy is rapid with fewer complications from the surgical site and has a better cosmetic appearance after decannulation.

DIF: Recall REF: pp. 760-761 OBJ: 7

Question 62

Which of the following techniques may be used to diagnose injury associated with artificial airways?

1. Laryngoscopy or bronchoscopy
2. Physical examination
3. Air tomography
4. Pulmonary function studies
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2, 3, and 4 only
   d. 1, 2, 3, and 4

Answer 62

ANS: D
Techniques commonly used to diagnose airway damage include physical examination, air tomography, fluoroscopy, laryngoscopy, bronchoscopy, magnetic resonance imaging, and pulmonary function studies.

DIF: Recall REF: p. 763 OBJ: 8

Question 63

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?

a. Difficulty in swallowing
b. Wheezing
c. Orthopnea
d. Hoarseness

Answer 63

ANS: D
The primary symptoms of glottic edema and vocal cord inflammation are hoarseness and stridor.

DIF: Recall REF: p. 763 OBJ: 8

Question 64

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend?

a. STAT-heated aerosol treatment with saline
b. STAT racemic epinephrine aerosol treatment
c. Careful observation of the patient for 6 hr
d. Immediate reintubation via the nasal route

Answer 64

ANS: B
Stridor is often treated with epinephrine (2.25% racemic solution or levoepinephrine 1:1000) via aerosol.

DIF: Application REF: p. 763 OBJ: 8

Question 65

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem?

a. Vocal cord paralysis
b. Tracheoesophageal fistula
c. Glottic edema or cord inflammation
d. Tracheomalacia

Answer 65

ANS: A
Vocal cord paralysis is likely in extubated patients with hoarseness and stridor that does not resolve with treatment or time.

DIF: Recall REF: p. 763 OBJ: 8

Question 66

Which of the following injuries are seen with tracheostomy tubes?

1. Tracheomalacia
2. Tracheal stenosis
3. Glottic edema
4. Vocal cord granulomas
   a. 1 and 2 only
   b. 2 and 4 only
   c. 3 and 4 only
   d. 1, 2, and 3 only

Answer 66

ANS: A
Whereas laryngeal lesions occur only with oral or nasal endotracheal tubes, tracheal lesions can occur with any tracheal airway. These tracheal lesions are granulomas, tracheomalacia, and tracheal stenosis.

DIF: Recall REF: p. 763 OBJ: 8

Question 67

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur?

1. Cuff site
2. Tip of the tube
3. Stoma site
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 67

ANS: D
In patients with tracheostomy tubes, stenosis may occur at the cuff, tube tip, or stoma sites, with the stoma site being the most common.

DIF: Recall REF: p. 763 OBJ: 8

Question 68

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?

a. Tracheomalacia
b. Laryngeal web
c. Cord paralysis
d. Tracheal stenosis

Answer 68

ANS: D
Tracheal stenosis will appear as a fixed obstructive pattern, with flattening of both the inspiratory and expiratory limbs of the flow-volume loop (Figure 36-25).

DIF: Recall REF: p. 763 OBJ: 8

Question 69

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem?

a. Paralysis of the vocal cords
b. Underinflated tube cuff
c. Tracheoesophageal fistula
d. Tracheoinnominate fistula

Answer 69

ANS: C
Diagnosis can be made by a history of recurrent aspiration and abdominal distention as air is forced into the esophagus during positive-pressure ventilation.

DIF: Recall REF: p. 763 OBJ: 8

Question 70

A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheotomy and is now receiving 40% oxygen through a T tube (Briggs adapter). Which of the following would be the best way to limit tube movement in this patient?

a. Give a neuromuscular blocker to prevent patient movement.
b. Secure the T tube delivery tubing to the bed rail.
c. Tape the T tube to the tracheostomy tube connector.
d. Switch from the T tube to a tracheostomy collar.

Answer 70

ANS: D
If the tracheostomy patient requires oxygen therapy, tracheostomy collars are preferred to T tubes or Briggs adapters.

DIF: Recall REF: p. 767 OBJ: 8

Question 71

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma?

1. Regular aseptic stoma cleaning
2. Adherence to sterile techniques
3. Regular change of tracheostomy dressings
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 71

ANS: D
Good tracheostomy care, including aseptic cleaning of the stoma with sterile normal saline or half strength hydrogen peroxide, should be carried out routinely.

DIF: Recall REF: p. 768 OBJ: 8

Question 72

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?

a. 1 to 2 cm
b. 2 to 4 cm
c. 3 to 6 cm
d. 6 to 8 cm

Answer 72

ANS: C
The tube tip should be approximately 3 to 6 cm above the carina in adults, or between the second and fourth tracheal rings.

DIF: Recall REF: p. 765 OBJ: 6

Question 73

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 2 cm above the carina. Which of the following actions would you recommend?

a. Withdraw the tube by 2 to 3 cm (using tube markings as a guide).
b. Withdraw the tube by 7 to 8 cm (using tube markings as a guide).
c. Advance the tube by 2 to 3 cm (using tube markings as a guide).

Answer 73

ANS: A
If the tube is malpositioned, you should remove the old tape and reposition the tube, using the centimeter markings as a guide.

DIF: Application REF: p. 765 OBJ: 6

Question 74

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better?

1. Use a letter, phrase, or picture board.
2. Consider switching to a fenestrated tracheostomy tube.
3. Consider a “talking” tracheostomy tube.
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 74

ANS: B
A better solution is a letter, phrase, or picture board. These devices allow patients to communicate by simple pointing. Large and simple drawings are particularly important for patients who cannot clearly see print. For conscious patients with a long-term tracheostomy and ventilator dependent, communication can be enhanced with a “talking” tracheostomy tube (Figure 36-29).

DIF: Application REF: pp. 766-767 OBJ: 9

Question 75

To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?

a. 32° to 35° C
b. 37° to 40° C
c. 30° to 32° C
d. 40° to 42° C

Answer 75

ANS: A
These devices can provide saturated gas to the airway at temperatures between 32° and 35° C.

DIF: Recall REF: p. 767 OBJ: 9

Question 76

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons?

1. Lower levels of humidification
2. Increased aspiration of pharyngeal material
3. Contaminated equipment or solutions
4. Ineffective clearance through cough
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 76

ANS: D
As indicated in Box 36-7, there are several reasons why tracheal tubes increase the incidence of pulmonary infection.

DIF: Recall REF: p. 768 OBJ: 8

Question 77

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?

a. Maintaining cuff pressures below 20 to 25 mm Hg
b. Using the minimal leak technique for inflation
c. Using a low-residual-volume, low-compliance cuff
d. Monitoring intracuff pressures every 1 to 2 hr

Answer 77

ANS: C
In the past, high-pressure tracheal tube cuffs were a major cause of airway damage. Since the 1970s, high-residual-volume, low-pressure cuffs have become the norm (see Figure 36-34).

DIF: Application REF: p. 768 OBJ: 10

Question 78

What is the maximum recommended range for tracheal tube cuff pressures?

a. 15 to 20 mm Hg
b. 20 to 25 mm Hg
c. 25 to 30 mm Hg
d. 30 to 35 mm Hg

Answer 78

ANS: B
The goal is to keep cuff pressures below the tracheal mucosal capillary perfusion pressure, estimated to range between 20 and 25 mm Hg to help minimize aspiration.

DIF: Recall REF: p. 768 OBJ: 10

Question 79

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following?

a. Increase cuff pressure.
b. Not affect cuff pressure.
c. Decrease cuff pressure.
d. Rupture the cuff.

Answer 79

ANS: C
Attaching the measurement system to the pilot tube evacuates some volume from the cuff (and lowers its pressure). For this reason, you should always adjust the pressure to the desired level, never just measure it.

DIF: Recall REF: p. 769 OBJ: 10

Question 80

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H2O. What is most likely the problem?

a. The tube chosen is too small for the patient.
b. The cuff pilot balloon and line are obstructed.
c. The tube is in the right main stem bronchus.
d. The cuff has herniated over the tube tip.

Answer 80

ANS: A
High pressures may be caused by the need to overinflate the cuff to seal the airway. This problem is common if the tube chosen is too small for the patient’s trachea, positioned too high in the trachea or if the patient has developed tracheomalacia which is softening of the tracheal tissue.

DIF: Recall REF: p. 774 OBJ: 10

Question 81

Which of the following is false about cuff inflation techniques (MOV = minimal occluding volume; MLT = minimal leak technique)?

a. The MLT approach negates the need for pressure monitoring.
b. The MLT allows a small leak at peak or end of inspiration.
c. At MOV, air leakage around the tube cuff should cease.
d. With MLT, secretions tend to be blown upward during inflation.

Answer 81

ANS: A
Cuff pressure measurements should be done regularly to maintain the cuff pressure in the safe range to avoid tracheal wall injury and minimize risk of aspiration of oral secretions.

DIF: Application REF: p. 766 OBJ: 12

Question 82

What is the normal range of negative pressure to use when suctioning infants?

a. –60 to –80 mm Hg
b. –80 to –100 mm Hg
c. –100 to –120 mm Hg
d. –150 to –200 mm Hg

Answer 82

ANS: B
The suction pressure should be set at the lowest effective level. Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended.

DIF: Recall REF: p. 742 OBJ: 1

Question 83

Which of the following statements are true about the potential for aspiration in patients with cuffed tracheal tubes?

1. Periodic oropharyngeal suctioning can help to minimize aspiration.
2. Aspiration is least likely in spontaneously breathing patients.
3. The methylene blue test can help detect leakage-type aspiration.
4. Aspiration is more likely with tracheostomy tubes than with endotracheal tubes.
   a. 3 only
   b. 1, 2, and 3 only
   c. 2 and 4 only
   d. 1, 3, and 4 only

Answer 83

ANS: D
Aspiration is reported to be more common in spontaneously breathing patients than in those patients receiving positive-pressure ventilation. This may be due to the movement of pharyngeal secretions around the cuff during the negative-pressure phase of a spontaneous inspiration.

DIF: Application REF: p. 770 OBJ: 9

Question 84

To minimize the problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend?

1. Position patients in semi-recumbent position.
2. Insert the feeding tube into the duodenum.
3. Suction above the tracheal tube cuff.
4. Provide continuous aspiration of subglottic secretions.
   a. 1 only
   b. 1 and 2 only
   c. 1, 2, 3, and 4
   d. 2, 3, and 4 only

Answer 84

ANS: C
Ideally, the patient should be switched to a tube that continually aspirates subglottic secretions. If this is not possible, oropharyngeal suctioning (above the tube cuff) should be performed as needed. To decrease the possibility of aspiration with feedings, the head of the bed should be elevated 30 degrees when possible. Also, the feeding tube can be inserted into the duodenum, with its position confirmed by radiograph. The use of slightly higher cuff pressure during and after feedings may also minimize aspiration.

DIF: Recall REF: p. 770 OBJ: 9

Question 85

A patient with a tracheal airway exhibits signs of tube obstruction. Which of the following are possible causes of this obstruction?

1. The tube cuff has herniated over the tip of the tube.
2. The tube is obstructed by a mucus plug or secretions.
3. The tube is kinked, or the patient is biting the tube.
4. The tube orifice is impinging on the tracheal wall.
   a. 2 and 4 only
   b. 3 and 4 only
   c. 1, 2, and 3 only
   d. 1, 2, 3, and 4

Answer 85

ANS: D
Obstruction of the tube is one of the most common causes of airway emergencies. Tube obstruction can be caused by (1) the kinking of the tube or the patient biting on the tube, (2) herniation of the cuff over the tube tip, (3) obstruction of the tube orifice against the tracheal wall, and (4) mucus plugging (Figure 36-36).

DIF: Recall REF: p. 772 OBJ: 9

Question 86

A patient with a tracheostomy tube is receiving positive-pressure ventilation through a volume ventilator. Over the past 5 min, the peak inspiratory pressure has risen, and the pressure limit alarm is now sounding. On quick examination, you notice a generalized decreased in breath sounds. Which of the following problems is most likely?

a. Partial obstruction of the tracheostomy tube
b. Complete obstruction of the tracheostomy tube
c. Development of a left-sided pneumothorax
d. Obstruction of the left bronchus by a mucus plug

Answer 86

ANS: A
A spontaneously breathing patient with partial airway obstruction will exhibit decreased breath sounds and decreased airflow through the tube. If the patient is receiving volume-controlled ventilation, peak inspiratory pressures will rise, often causing the high-pressure alarm to sound; during pressure-controlled ventilation, delivered tidal volumes will fall.

DIF: Analysis REF: p. 772 OBJ: 9

Question 87

A patient with a tracheal airway exhibits severe respiratory distress. On quick examination, you notice the complete absence of breath sounds and no gas flowing through the airway. What is most likely the problem?

a. Partial tube obstruction
b. Right-sided pneumothorax
c. Complete tube obstruction
d. Vocal cord paralysis

Answer 87

ANS: C
With complete tube obstruction, the patient will exhibit severe distress, no breath sounds will be heard, and there will be no gas flow through the tube.

DIF: Application REF: p. 772 OBJ: 9

Question 88

After determining a patient has a complete obstruction of an oral endotracheal tube, your efforts to relieve the obstruction by moving the patient’s head and neck and deflating the cuff both fail. What should be your next step?

a. Immediately extubate the patient.
b. Try to pass a suction catheter.
c. Call for an emergency tracheotomy.
d. Apply manual positive pressure.

Answer 88

ANS: A
If you cannot clear the obstruction by using the above techniques, you must remove the airway and replace it.

DIF: Application REF: p. 772 OBJ: 11

Question 89

A patient receiving mechanical ventilatory support accidentally displaces the endotracheal tube out of the trachea. What would be the most appropriate action at this time?

a. Remove the tube and provide manual ventilation or oxygenation as necessary.
b. Push the tube back into the trachea by moving the patient’s neck up and down.
c. Suction the oropharynx with a Yankauer (tonsillar) suction tip.
d. Apply manual ventilation or oxygenation directly through the endotracheal tube.

Answer 89

ANS: A
In these cases, completely remove the tube and provide ventilatory support as needed until the patient can be reintubated or the tracheostomy tube reinserted.

DIF: Analysis REF: p. 774 OBJ: 9

Question 90

What does a positive cuff leak test indicate?

a. The patient has significant upper airway edema.
b. The patient’s neuromuscular function is adequate to protect the lower airway.
c. The patient is at minimal risk for upper airway obstruction.
d. The patient’s muscle strength will provide an effective cough.

Answer 90

ANS: C
The presence of a peritubular leak during spontaneous breathing indicates no encroachment of airway (a positive test).

DIF: Recall REF: p. 768 OBJ: 13

Question 91

Which of the following indicate that a patient being considered for extubation can provide adequate clearance of pulmonary secretions?

1. The patient has a maximum inspiratory pressure of 73 cm H2O.
2. The patient is alert and cooperative.
3. The patient has a dead space-to-tidal volume ratio of 0.7.
4. The patient coughs rigorously on suctioning.
   a. 1 and 3 only
   b. 1, 2, and 4 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 91

ANS: B
Excerpts from the AARC guideline (CPG 36-4) include indications, contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring.

DIF: Recall REF: pp. 776-778 OBJ: 11

Question 92

Which of the following equipment would you gather before assisting in extubation of a patient?

1. Suctioning apparatus
2. Oxygen or aerosol therapy equipment
3. Manual resuscitator and mask
4. Nebulizer with racemic epinephrine
5. Intubation tray
   a. 1, 2, and 3 only
   b. 2 and 4 only
   c. 2, 3, 4, and 5 only
   d. 1, 2, 3, 4, and 5

Answer 92

ANS: D
Needed equipment includes suctioning apparatus, two age-appropriate suction kits with sterile suction catheters and gloves, tonsillar suction tip (Yankauer), 10 or 12 ml syringe, oxygen and aerosol therapy equipment, manual resuscitator and mask, aerosol nebulizer with racemic epinephrine and normal saline (if ordered), and an intubation tray.

DIF: Recall REF: p. 775 OBJ: 11

Question 93

A physician has requested your assistance in extubating an orally intubated patient. Which of the following should be done before the tube itself is removed?

1. Suction the orolaryngopharynx
2. Preoxygenate the patient
3. Suction the endotracheal tube
4. Confirm cuff inflation
   a. 2 and 4 only
   b. 1, 2, and 4 only
   c. 1, 2, and 3 only
   d. 1, 2, 3, and 4

Answer 93

ANS: D
Step 1: Assess Patient for Indications. Generally, a patient should never be suctioned according to a preset schedule. Although very thick secretions may not move with airflow and may not create any adventitious sounds, the patient should be assessed for clinical indicators, such as rhonchi heard on auscultation, which suggest the need for suctioning Step 2: Suction the Endotracheal Tube and Pharynx to Above the Cuff. Suctioning before extubation helps prevent aspiration of secretions after cuff deflation. After use, dispose of the first suction kit and prepare another for use, or prepare a rigid tonsillar (Yankauer) suction tip. Because patients will often cough after the tube is pulled, you may need to help them clear secretions.
Step 3: Oxygenate the Patient Well After Suctioning. Extubation is a stressful procedure that can cause hypoxemia and unwanted cardiovascular side effects. Administer 100% oxygen for 1 to 2 min to help avoid these problems.
Step 4: Deflate the Cuff. Attach the 10 or 12 ml syringe to the pilot tubing. Withdraw the air from the cuff while applying positive pressure to direct any pooled secretions above the cuff up into the oropharynx where they can immediately be suctioned with the tonsillar suction tip. Listen for an audible leak around the tube. If no audible leak is present reinflate the cuff and discuss with the physician how to proceed.

DIF: Application REF: p. 775 OBJ: 11

Question 94

Although different techniques are used to actually remove the endotracheal tube during an extubation procedure, all aim to ensure which of the following?

a. Maximal adduction of the vocal cords
b. Maximal abduction of the vocal cords
c. Maintenance of the appropriate cuff pressure
d. Elimination of the pharyngeal (gag) reflex

Answer 94

ANS: B
The technique used to remove the tube should help avoid aspiration of pharyngeal secretions and maximally abduct the vocal cords.

DIF: Recall REF: p. 778 OBJ: 11

Question 95

To minimize laryngeal swelling, a physician orders “continuous aerosol therapy” after the extubation of a patient. Which of the following specific approaches would you recommend?

a. Heated mist therapy through a jet nebulizer and aerosol mask
b. Cool mist therapy through a jet nebulizer and aerosol mask
c. Oxygen therapy through a “venti-mask” and bubble humidifier
d. Racemic epinephrine or saline through a small jet nebulizer

Answer 95

ANS: B
If humidity/aerosol therapy is indicated, most clinicians suggest a cool mist immediately after extubation.

DIF: Application REF: p. 778 OBJ: 11

Question 96

You have been asked to monitor a patient who has just been extubated. Which of the following parameters would you monitor?

1. Color
2. Breath sounds
3. Vital signs
4. Inspiratory force
   a. 1, 2, and 3 only
   b. 2 and 4 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 96

ANS: A
After extubation, check for good air movement by auscultation. Stridor or decreased air movement after extubation indicates upper airway problems. Next, assess the patient’s respiratory rate, breathing pattern, heart rate, blood pressure, and oxygen saturation.

DIF: Recall REF: p. 778 OBJ: 11

Question 97

An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend?

a. Change from cool mist to heated aerosol.
b. Re-intubate the patient immediately.
c. Administer a racemic epinephrine treatment.
d. Draw and analyze an arterial blood gas.

Answer 97

ANS: C
Because laryngeal edema may worsen with time and stridor may develop, be sure that racemic epinephrine for nebulization is available.

DIF: Application REF: p. 778 OBJ: 11

Question 98

What is a rare but serious complication associated with endotracheal tube extubation?

a. Bradycardia
b. Aspiration
c. Infection
d. Laryngospasm

Answer 98

ANS: D
A rare, but serious, complication associated with extubation is laryngospasm.

DIF: Recall REF: p. 778 OBJ: 11

Question 99

Which of the following approaches may be used in “weaning” a patient from a tracheostomy tube?

1. Using progressively smaller tubes
2. Using a fenestrated tube
3. Using a tracheostomy button
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 99

ANS: D
Weaning is accomplished by using fenestrated tubes, progressively smaller tubes, or tracheostomy buttons.

DIF: Recall REF: p. 779 OBJ: 11

Question 100

A physician asks you to assess the upper airway function of a patient with a fenestrated tracheostomy tube. How should this be accomplished?

a. Replace the inner cannula, plug the proximal opening, and inflate the cuff.
b. Remove the inner cannula, plug the proximal opening, and deflate the cuff.
c. Remove the inner cannula, plug the proximal opening, and inflate the cuff.
d. Replace the inner cannula, plug the proximal opening, and deflate the cuff.

Answer 100

ANS: B
Removal of the inner cannula opens the fenestration allowing air to pass into the upper airway. Capping or placing a peaking valve on the proximal opening of the tube’s outer cannula, accompanied by deflation of the cuff, allows for assessment of upper airway function.

DIF: Recall REF: p. 779 OBJ: 11

Question 101

What is the most common problem with fenestrated tracheostomy tubes?

a. Relative frequency of accidental extubation
b. Increased likelihood of tracheomalacia
c. Poor positioning of the tube fenestration
d. Inability to provide mechanical ventilation

Answer 101

ANS: C
One problem associated with this type of tracheostomy tube is malposition of the fenestration, such as between the skin and stoma, or against the posterior wall of the larynx.

DIF: Recall REF: p. 779 OBJ: 11

Question 102

For which of the following purposes is a tracheal button appropriate?

1. Facilitate secretion removal.
2. Protect the airways from aspiration.
3. Relieve airway obstruction.
4. Aid in positive-pressure ventilation.
   a. 1 and 3 only
   b. 2 and 4 only
   c. 3 and 4 only
   d. 1, 2, 3, and 4

Answer 102

ANS: A
Because the tracheal button has no cuff, its use is limited to relieving airway obstruction and aiding the removal of secretions.

DIF: Recall REF: p. 779 OBJ: 11

Question 103

Therapeutic indications for fiberoptic bronchoscopy include which of the following?

1. Inspect the airways.
2. Retrieve foreign bodies.
3. Obtain specimens for analysis.
4. Aid endotracheal intubation.
   a. 2 and 4 only
   b. 3 and 4 only
   c. 1, 2, and 3 only
   d. 1, 2, 3, and 4

Answer 103

ANS: D
The purposes of bronchoscopy are to inspect the airway, remove objects from the airway, collect samples from the airway, and place devices into the airway.

DIF: Recall REF: p. 783 OBJ: 13

Question 104

In which of the following conditions should fiberoptic bronchoscopy not be performed if the risks outweigh the potential benefits?

1. Uncorrected bleeding disorders
2. Presence of lung abscess
3. Refractory hypoxemia
4. Unstable hemodynamic status
   a. 2 and 3 only
   b. 2 and 4 only
   c. 1, 3, and 4 only
   d. 1, 2, 3, and 4

Answer 104

ANS: C
Excerpts from the AARC guideline, including indications, contraindications, precautions and/or possible complications, assessment of need, assessment of outcome, and monitoring, appear on pp. 784-785.

DIF: Recall REF: p. 783 OBJ: 13

Question 105

Complications of fiberoptic bronchoscopy include which of the following?

1. Hypocapnia
2. Infection
3. Hypotension
4. Hypoxemia
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 105

ANS: D
Excerpts from the AARC guideline (CPG 36-5) include indications, contraindications, precautions and/or possible complications, assessment of need, assessment of outcome, and monitoring.

DIF: Recall REF: p. 785 OBJ: 13

Question 106

Key points to consider in planning fiberoptic bronchoscopy include which of the following?

1. Equipment preparation
2. Premedication
3. Airway preparation
4. Monitoring
   a. 2 and 4 only
   b. 3 and 4 only
   c. 1, 2, and 3 only
   d. 1, 2, 3, and 4

Answer 106

ANS: D
Key points to consider in planning and conducting fiberoptic bronchoscopy include premedication, equipment preparation, airway preparation, and monitoring.

DIF: Recall REF: p. 786 OBJ: 13

Question 107

Which of the following are appropriate orders before an elective fiberoptic bronchoscopy procedure scheduled for the next morning?

1. Have patient take nothing by mouth (NPO) after midnight.
2. Establish vascular access.
3. Premedicate with a benzodiazepine.
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 107

ANS: D
To reduce the risk of aspiration due to gagging and loss of airway reflexes, the patient should refrain from food or drink for at least 8 hr prior to the start of the procedure. In addition, if the intravenous route is not already available, vascular access should be obtained prior to the start of the procedure. Bronchoscopy is an uncomfortable procedure. To decrease anxiety, the patient should be premedicated 30 to 45 min before the procedure.

DIF: Recall REF: p. 786 OBJ: 13

Question 108

For which of the following reasons is atropine often used during fiberoptic bronchoscopy?

1. To dry the patient’s airway
2. To decrease vagal responses
3. To provide topical anesthesia
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 108

ANS: A
This promotes anesthetic deposition, aids visibility, and can reduce procedure time. An anticholinergic agent, such as atropine given prior to the procedure, is used for this purpose. Atropine may also help decrease vagal responses (such as bradycardia and hypotension) that can occur during bronchoscopy.

DIF: Recall REF: p. 783 OBJ: 13

Question 109

During fiberoptic bronchoscopy, a patient receiving intravenous fentanyl exhibits signs of respiratory depression. Which of the following would you recommend?

a. Increase the oxygen flow rate and continue monitoring.
b. Immediately administer naloxone (Narcan).
c. Decrease the oxygen flow rate and continue monitoring.
d. Immediately administer neostigmine or prostigmine.

Answer 109

ANS: B
Of course, caution must be taken to avoid respiratory depression. Should it occur, naloxone (Narcan) must be available.

DIF: Application REF: p. 787 OBJ: 13

Question 110

Equipment required for patient support and monitoring during a fiberoptic bronchoscopy procedure includes which of the following?

1. Pulse oximeter
2. Oxygen cannula
3. Electrocardiographic monitor
4. Capnometer
   a. 1 and 3 only
   b. 1, 2, and 3 only
   c. 3 and 4 only
   d. 2, 3, and 4 only

Answer 110

ANS: B
Box 36-9 provides a list of needed equipment.

DIF: Recall REF: p. 786 OBJ: 13

Question 111

Which of the following are goals of airway preparation before conducting fiberoptic bronchoscopy?

1. To decrease cough and gagging
2. To decrease pain
3. To prevent bleeding
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 111

ANS: D
The goals of airway preparation are to prevent bleeding, decrease cough and gagging, and decrease pain.

DIF: Recall REF: p. 786 OBJ: 13

Question 112

Which of the following drugs can be used to prevent bleeding during fiberoptic bronchoscopy?

1. Phenylephrine
2. Dopamine HCl
3. Epinephrine
   a. 1 and 2 only
   b. 2 and 3 only
   c. 1 and 3 only
   d. 1, 2, and 3

Answer 112

ANS: C
Topical vasoconstrictors such as pseudoephedrine or dilute epinephrine (usually 1:10,000) may be used to prevent or treat bleeding.

DIF: Recall REF: p. 786 OBJ: 13

Question 113

Lower airway anesthesia for fiberoptic bronchoscopy can be achieved via which of the following routes of administration?

1. Bronchoscopic instillation
2. Intravenous administration
3. Nebulization (aerosol delivery)
   a. 1 and 2 only
   b. 1 and 3 only
   c. 2 and 3 only
   d. 1, 2, and 3

Answer 113

ANS: B
Lidocaine is commonly delivered by an atomizer to the nose, by mouthwash to the oropharynx, and by nebulizer and/or instillation through the bronchoscope to the lower airways.

DIF: Recall REF: p. 786 OBJ: 13

Question 114

During fiberoptic bronchoscopy, a patient’s SpO2 drops from 91% to 87%. Which of the following actions would be appropriate?

1. Apply suction through the scope’s open channel.
2. Give oxygen through the scope’s open channel.
3. Increase the cannula or mask oxygen flow.
   a. 1 and 2 only
   b. 2 and 3 only
   c. 1 and 3 only
   d. 1, 2, and 3

Answer 114

ANS: B
If desaturation occurs, the FiO2 should be increased with an oxygen therapy device. Alternatively, the procedure can be temporarily halted, and oxygen can be given through the scope’s open channel. The latter technique has the advantage of defogging the scope and diffusing any secretions. Suctioning for brief periods will help reduce the incidence or severity of hypoxemia.

DIF: Application REF: p. 787 OBJ: 13

Question 115

A patient exhibits persistent mild hypoxemia after a fiberoptic bronchoscopy procedure. Which of the following would you recommend?

a. Continue oxygen therapy and reassess in 4 hr.
b. Administer a benzodiazepine (e.g., Valium or Versed).
c. Administer a racemic epinephrine aerosol treatment.
d. Have the patient refrain from eating or drinking.

Answer 115

ANS: A
Hypoxemia that occurs during the procedure may persist after completion. Oxygen therapy should be maintained for up to 4 hr.

DIF: Application REF: p. 787 OBJ: 13

Question 116

To avoid the risk of aspiration after a fiberoptic bronchoscopy procedure, what would you recommend that the patient do?

a. Be placed in the supine Trendelenburg position for 2 hr.
b. Remain in a sitting position and NPO until sensation returns.
c. Receive additional aerosolized lidocaine by nebulizer.
d. Be continuously monitored for oxygenation through pulse oximetry.

Answer 116

ANS: B
The risk of aspiration persists as long as the airway is anesthetized. Therefore, patients should remain in a sitting position and refrain from eating or drinking until sensation returns.

DIF: Application REF: p. 787 OBJ: 13

Question 117

A patient exhibits persistent stridor after a fiberoptic bronchoscopy procedure. Which of the following would you recommend?

a. Aerosol therapy with albuterol (Proventil)
b. Administration of a benzodiazepine (e.g., Valium)
c. Aerosol therapy with racemic epinephrine
d. Administration of a narcotic antagonist (e.g., Narcan)

Answer 117

ANS: C
Patients should also be assessed for the development of stridor or wheezes. The physician should be notified and appropriate aerosol therapy with nebulized racemic epinephrine or bronchodilators should be instituted.

DIF: Application REF: p. 787 OBJ: 13

Question 118

The major limitations of using a laryngeal mask airway are:

1. It should not be used in conscious or semicomatose patients.
2. Gastric distention may occur if ventilating pressures greater than 20 cm H2O are needed.
3. It does not provide absolute protection against aspiration of gastric contents.
   a. 1 and 2 only
   b. 2 and 3 only
   c. 1 and 3 only
   d. 1, 2, and 3

Answer 118

ANS: D
There are two major limitations to its use. First, it cannot be used in the conscious or semicomatose patient due to stimulation of the gag reflex. Second, if ventilating pressures greater than 20 cm H2O are needed, gastric distention may occur. In addition, it may not provide absolute protection against aspiration.

DIF: Recall REF: p. 781 OBJ: 12