Pileam Test Chapter 12

Question 1

During mechanical ventilation of a patient with COPD, the PaCO2= 58 mmHg and the Vt =5.5 L/min. The desired PaCO2 for this patient is 45 mmHg. To what shoud the Vt be changed?

Answer 1

D. 7.1 L/min
5.5x58=45
319/45=7.1 L/min

Question 2

A patient with CHF is being mechanically ventilated. The patient’s current PaCO2 = 28 mm Hg, and the ventilator set rate is 16/minute. The desired PaCO2 for this patient is 40 mm Hg. To what should the set rate be changed?

Answer 2

ANS: B

Desired f = 11 min

Question 3

A patient with pneumonia and underlying COPD is being mechanically ventilated in the VC-CMV mode with VT 650 mL. The resulting PaCO2 is 62 mm Hg. What change should be made to the VT to obtain a desired PaCO2 of 50 mm Hg for this patient?

Answer 3

ANS: B

Desired VT = 800 mL

Question 4

average tidal volume range in an individual with no pulmonary problems is which of the following?

Answer 4

ANS: B

6-8 mL/Kg IBW

Question 5

A male patient (76-kg IBW) with no history of pulmonary disease is brought to the emergency department for treatment of a drug overdose. He is intubated and placed on mechanical ventilation with VC-CMV, f = 12/min, VT = 450 mL. The resulting arterial blood gas values are: pH 7.32, PaCO2 53 mm Hg, and HCO3- 25 mEq/L. The most appropriate action to correct the acid-base disturbance is which of the following?

a. Increase VT to 595 mL
b. Increase VT to 760 mL
c. Increase frequency to 16/min
d. Decrease frequency to 10/min

Answer 5

ANS: A
Desired VT =
The desired target for VT for this patient is 5 to 8 mL/kg IBW. Because the set VT of 450 mL is at 5.9 mL/kg, there is room to increase the VT. After calculating the desired VT using the formula, the new volume is at 7.8 mL/kg. A VT of 760 mL would be at 10 mL/kg IBW.

Question 6

A female patient (59-kg IBW) with no history of pulmonary disease is being invasively ventilated with VC-CMV, f = 12/min, VT = 470 mL, PEEP = 5 cm H2O, FIO2 = 0.5. ABG results with these settings are: pH 7.31, PaCO2 54 mm Hg, PaO2 92 mm Hg, SaO2 90%, HCO3- 24 mEq/L. The most appropriate action for the respiratory therapist to take is which of the following?

a. Increase f to 16/min
b. Increase VT to 635 mL
c. Decrease VT to 400 mL
d. Decrease PEEP to 3 cm H2O

Answer 6

ANS: A
The target VT for an individual without pulmonary disease is 5 to 8 mL/kg IBW. This patient’s VT range is 295 mL to 472 mL, meaning that the upper limit of this range has been reached. The f should be changed to increase this patient’s minute ventilation.

Desired f = ; desired f = 16

DIF: 3 REF: pg. 226

Question 7

A male patient (74-kg IBW) is being ventilated with PC-CMV, f = 12/min, PIP = 20 cm H2O, TI = 1.5 seconds; the resulting flow-time scalar is shown below. The patient’s measured VT is 435 mL. ABG results on these settings are: pH 7.32, PaCO2 54 mm Hg, HCO3- 25 mEq/L. The most appropriate action to take is which of the following?

a. Increase f to 16 /min
b. Increase TI to 2.5 sec
c. Increase PIP to 27 cm H2O
d. Decrease flow rate to 40 L/min

Answer 7

ANS: C
The flow-time scalar shows that TI is adequate, because it shows a time of zero flow during inspiration. Therefore, changing TI would not be appropriate. The measured VT for this patient is at 5.9 mL/kg IBW; therefore, the VT could be increased. In the PC mode, this would be done with by increasing the set PIP using the following formulas:

Desired VT = = approximately 590 mL
Desired P = = 26.8 cm H2O

DIF: 3 REF: pg. 223| pg. 225

Question 8

A 28-year-old female (55-kg IBW) is being mechanically ventilated with VC-CMV, f = 14/min, VT = 700 mL. The patient has no history of pulmonary disease. The resulting ABG values are: pH 7.55, PaCO2 27 mm Hg, HCO3- 23 mEq/L. The most appropriate action to take is which of the following?

a. Decrease VT to 600 mL
b. Decrease VT to 450 mL
c. Decrease f to 12/min
d. Decrease f to 10/min

Answer 8

ANS: B
The original volume setting exceeded the maximum VT for this patient. The VT should be set between 275 mL and 440 mL to achieve 5 to 8 mL/kg IBW. Therefore, the VT must be reduced to avoid overdistention. Using the for-mula:

Desired VT =
Desired VT = 473 mL
The VT of 450 mL is closest to the desired VT and is more in line with the acceptable range.

DIF: 3 REF: pg. 223

Question 9

A male patient (83 kg IBW) is intubated and ventilated with PC-CMV, f = 12/min, set PIP = 28 cm H2O, resulting in a VT of 430 mL. The ABG results on this setting are: pH 7.35, PaCO2 45 mm Hg, and HCO3- 23 mEq/L. Forty-eight hours later on the same settings, the ABG results are: pH 7.54, PaCO2 27 mm Hg, and HCO3- 21 mEq/L with an exhaled VT of 800 mL. The most appropriate action at this time is which of the following?

a. Decrease PIP to 25 cm H2O
b. Decrease PIP to 19 cm H2O
c. Decrease f to 10/min
d. Decrease f to 8/min

Answer 9

ANS: B
At first the patient responded appropriately to the PC-CMV settings. At that point the Cs was 15 mL/cm H2O. After 48 hours, the patient’s lungs improved and the same pressure, 28 cm H2O, resulted in a VT of 800 mL. The patient’s Cs now is 28.5 mL/cm H2O, and the combination of Cs and PIP is resulting in respiratory alkalosis. The acceptable VT range for this patient is 415 to 664 mL (5 to 8 mL/kg IBW). Because the exhaled tidal volume now exceeds this range, the volume needs to be reduced. This is accomplished by reducing the set PIP using the following formulas:

Desired VT = and Set PIP = VT/CS = 19 cm H2O.

Question 10

A patient with an IBW of 68 kg is intubated and being mechanically ventilated with VC-CMV, f = 12/min, and VT = 470 mL. The patient has a combined respiratory rate of 25/min. The ABG results are: pH 7.56, PaCO2 26 mm Hg, and HCO3- 22 mEq/L. The most appropriate action is to do which of the following?

a. Decrease the set f to 8/min
b. Decrease the set VT to 300 mL
c. Sedate and paralyze the patient
d. Change the mode to VC-IMV

Answer 10

ANS: D
The patient has ventilator-induced respiratory alkalosis, because the patient is triggering the machine breaths each time there is a spontaneous effort. Decreasing the set f will not alter the rate at which the patient is assisting. De-creasing the set VT to 300 mL will most likely result in the patient breathing at a faster rate because of the low vol-ume. The patient could be sedated and paralyzed. However, the patient is not demonstrating a need for this option (i.e., extreme agitation, increased WOB, and patient-ventilator asynchrony). Changing to the VC-SIMV mode will allow the patient to breathe spontaneously and not trigger a machine breath each time.

DIF: 3 REF: pg. 226

Question 11

Metabolic acidosis may be caused by which of the following?

a. Overdose with salicylate
b. Diuretic administration
c. Nasogastric suctioning
d. Lactate administration

Answer 11

ANS: A
Ingestion of salicylate causes the production of acid, resulting in metabolic acidosis.

DIF: 1 REF: pg. 226

Question 12

Metabolic alkalosis can be caused by which of the following?

a. Renal failure
b. Potassium deficiency
c. Carbonic anhydrase inhibitors
d. Ethylene glycol

Answer 12

ANS: B
Potassium deficiency causes acid to shift into the cells, reducing the amount of acid in the blood.

DIF: 1 REF: pg. 226

Question 13

If respiratory acidosis persists after alveolar ventilation of a patient has been increased, which of the following could be the cause?

a. Chronic obstructive pulmonary disease
b. Pulmonary embolism
c. Pulmonary edema
d. Low PEEP levels

Answer 13

ANS: B
If pure respiratory acidosis persists even after alveolar ventilation has been increased, the patient may have a problem with increased dead space. One cause of increased dead space is a pulmonary embolism or low cardiac output, resulting in low pulmonary perfusion.

DIF: 1 REF: pg. 228

Question 14

A 59-kg IBW female patient is being mechanically ventilated in the CMV mode, f = 12/min, VT = 400 mL, PEEP = 5 cm H2O, FIO2 = 0.5. The ABG results on these settings show a respiratory acidosis and severe hypoxemia. The respiratory therapist increases the set VT and increases the PEEP to 12 cm H2O. The resulting ABGs show improved oxygenation, but the patient still has a respiratory acidosis. The respiratory acidosis may be due to which of the following?

a. Tissue hypoxia
b. Increased dead space
c. Increased cardiac output
d. Continued hypoventilation

Answer 14

ANS: B
If an increase in alveolar ventilation does not correct a respiratory acidosis, the condition usually is caused by pul-monary embolism, low pulmonary perfusion, or increased dead space. The reduction in pulmonary blood flow caused by high alveolar pressures can increase dead space. In this patient’s case, the increase in PEEP is most likely the reason for the continued respiratory acidosis.

DIF: 2 REF: pg. 228

Question 15

A patient diagnosed with sepsis who is being mechanically ventilated has a combined minute ventilation of 25 L/min with a PaCO2 of 38 mm Hg. The reason for these findings is most likely which of the following?

1. Increased
2. Decreased
3. Increased VD/VT
4. Decreased VD/VT

a. 1 and 3 only
b. 1 and 4 only
c. 2 and 3 only
d. 2 and 4 only

Answer 15

ANS: A
Sepsis increases the metabolic rate and . However, given the level, the PaCO2 should be lower. The reason it is not lower is the increased and VD/VT.

DIF: 1 REF: pg. 228

Question 16

In which of the following situations should iatrogenic hyperventilation be considered?

a. Severe traumatic brain injury
b. Initial treatment for increased intracranial pressure
c. Acute head injuries with increased intracranial pressure
d. Acute neurological deterioration with increased intracranial pressure

Answer 16

ANS: D
Hyperventilation may be needed for brief periods when acute neurological deterioration is present and the ICP is elevated. Current therapeutic guidelines for head injuries with increased ICP do not recommend prophylactic hy-perventilation (PaCO2 <25 mm Hg) during the first 24 hours. Hyperventilation during the first few days after severe traumatic brain injury (TBI) may actually increase cerebral ischemia and cause cerebral hypoxemia

DIF: 1 REF: pg. 229

Question 17

Treatment for increased intracranial pressure includes all of the following except which technique?

a. Hyperosmolar therapy
b. Neuromuscular blockade
c. Iatrogenic hyperventilation
d. Cerebral spinal fluid drainage

Answer 17

ANS: C
The practice of iatrogenic hyperventilation is controversial, and it may actually increase cerebral ischemia and cause cerebral hypoxemia in certain cases (severe TBI). Treatments for increased ICP include sedation and analge-sia, neuromuscular blockade, cerebral spinal fluid drainage, and hyperosmolar therapy.

DIF: 1 REF: pg. 229

Question 18

Permissive hypercapnia would benefit patients with which of the following?

a. Cerebral trauma
b. Intracranial lesion
c. Acute lung injury
d. Cardiovascular instability

Answer 18

ANS: C
Patients with ALI benefit from permissive hypercapnia to protect the lungs from ventilator-induced lung injury. Contraindications to PHY include cerebral disorders, because CO2 is a powerful vasodilator. PHY also is contrain-dicated in patients with pre-existing cardiovascular instability, because the circulatory effects of PHY can include decreased myocardial contractility, arrhythmias, vasodilation, and increased sympathetic activity.

DIF: 1 REF: pg. 229

Question 19

A 45-year-old female (58-kg IBW) with a past medical history of asthma arrives at the emergency department short of breath, anxious, diaphoretic, and unable to perform a peak expiratory flow measurement. She also has a combined acidosis. Breath sounds reveal the patient is not moving much air. The patient is intubated, stabilized, and transported to the ICU. The ventilator settings are: PC-CMV, f = 12/min, PIP = 30 cm H2O, FIO2 = 0.6, and PEEP = 3 cm H2O. The patient is sedated and paralyzed; the resulting ABGs are: pH 7.17, PaCO2 69.3 mm Hg, PaO2 90 mm Hg, and HCO3- 21 mEq/L after continuous bronchodilator therapy. The respiratory rate is increased to 20/min, and the next ABG results are: pH 7.26, PaCO2 58 mm Hg, PaO2 96 mm Hg, and HCO3- 22 mEq/L. The respiratory therapist should suggest which of the following at this time?

a. Increase PIP to 38 cm H2O
b. Decrease PIP to 25 cm H2O
c. Continue with current therapy
d. Change to VC-CMV, f = 12/ min, VT = 700 mL

Answer 19

ANS: C
The current therapy should be continued in an effort to prevent lung injury.

DIF: 3 REF: pg. 229

Question 20

At what point during deep suctioning should negative pressure be applied?

a. Five seconds after resistance is met
b. Ten seconds after insertion of the catheter
c. After 1-cm withdrawal from the point of resistance
d. After 2-cm withdrawal from the point of resistance

Answer 20

ANS: C
During deep suctioning, once resistance is met, the catheter is withdrawn approximately 1 cm before negative pres-sure is applied.

DIF: 1 REF: pg. 231

Question 21

A suction catheter long enough to reach a mainstem bronchus should be what length?

a. 22 cm (8.7 in)
b. 25 cm (9.8 in)
c. 46 cm (18 in)
d. 56 cm (22 in)

Answer 21

ANS: D
A catheter of about 56 cm (22 inches) should be long enough to reach a mainstem bronchus.

DIF: 1 REF: pg. 231

Question 22

What size suction catheter is appropriate for use in a patient with a 7-mm ET tube?

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

Answer 22

ANS: B
Multiply the ET tube size by 3; this converts the ET size to French units (Fr). Then divide the result by 2, for a size that is half or less of the ET diameter.

DIF: 2 REF: pg. 232

Question 23

What size suction catheter is appropriate for use in a patient with a 6-mm ET tube?

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

Answer 23

ANS: A
Multiply the ET tube size by 3; this converts the ET size to French units (Fr). Then divide the result by 2, for a size that is half or less of the ET diameter. In this case, the answer is 9; therefore, round down to the lower size so as not to obstruct more than 50% of the ET tube during suctioning.

DIF: 2 REF: pg. 232

Question 24

Advantages of closed suctioning include which of the following?

1. No need to prehyperoxygenate or posthyperoxygenate
2. No need to prehyperventilate or posthyperventilate
3. Decreased risk of infection for caregiver
4. No loss of PEEP during the procedure
   a. 1 and 2 only
   b. 3 and 4 only
   c. 1, 2, and 4 only
   d. 2, 3, and 4 only

Answer 24

ANS: B DIF: 1 REF: pg. 232

Question 25

During a closed suctioning procedure, the patient’s heart rate changes from 95 beats/min to 58 beats/min. The res-piratory therapist should take what immediate action?

a. Continue the procedure until secretions are re-moved.
b. Stop the procedure and switch to the open suc-tioning method.
c. Stop the procedure and use the ventilator to hy-peroxygenate the patient with 100% oxygen.
d. Remove the patient from the ventilator and ven-tilate the person with a resuscitator bag.

Answer 25

ANS: C
Cardiac arrhythmias can occur during aggressive suctioning. Bradycardia may occur when the catheter stimulates vagal receptors in the upper airways. The procedure should be stopped and the ventilator should be used to hyper-oxygenate the patient.

DIF: 3 REF: pg. 232

Question 26

Which of the following is recommended when administering aerosols to mechanically ventilated patients with a small-volume nebulizer?

a. Make sure the flow-by is turned on during admin-istration.
b. Keep the HME in-line during the aerosol treat-ment.
c. Use the ventilator nebulizer system when appro-priate.
d. Bypass the humidifier during the aerosol treat-ment.

Answer 26

ANS: C
Use the ventilator nebulizer system if it meets the SVN flow needs and cycles on inspiration. Flow-by should be turned off, because it produces a continuous flow through the circuit during exhalation while nebulization is pro-ceeding. Remove the HME from the circuit, because it will trap the aerosol particles. Do not disconnect the humidi-fier.

DIF: 1 REF: pg. 239

Question 27

When using a SVN or pMDI with NPPV, where in the NPPV circuit should the device be placed to obtain the greatest aerosol deposition?

a. Before the leak port
b. Anywhere in the circuit
c. Between the NPPV and the humidifier
d. Between the leak port and the face mask

Answer 27

ANS: D
To achieve the greatest aerosol deposition when using a pMDI or SVN, the device should be placed close to the pa-tient, between the leak port and the face mask.

DIF: 1 REF: pg. 237

Question 28

Which of the following ventilator graphics could be used to assess the response to bronchodilator therapy for a pa-tient receiving mechanical ventilation with VC-CMV?

1. Pressure-time scalar
2. Flow-time scalar
3. Pressure-volume loop
4. Volume-time scalar
   a. 1 and 2 only
   b. 3 and 4 only
   c. 1 and 3 only
   d. 1, 2 and 4 only

Answer 28

ANS: D
With VC-CMV, the volume-time scalar will remain constant. The expiratory portion of the flow-time scalar can show improvement if there is a response to the bronchodilator. The changes in PIP can be monitored with the pres-sure-time scalar and/or the pressure-volume loop.

DIF: 2 REF: pg. 241

Question 29

A mechanically ventilated patient continues to have rhonchi after deep suctioning. The respiratory therapist should recommend which of the following?

a. Prone position
b. Vest Airway Clearance System
c. Prone position with the foot of the bed elevated 12 inches
d. Supine position with the foot of the bed elevated 18 inches

Answer 29

ANS: B
The Vest Airway Clearance System creates vibrations around the entire thorax, which helps mobilize secretions from all areas of the lungs. The prone position is used for patients with ARDS to assist with oxygenation and perfu-sion of the “good” lung areas. The head-down positions may cause an increase in ICP or BP or may increase the risk of vomiting.

DIF: 2 REF: pg. 241

Question 30

Bedside bronchoscopy of an invasively ventilated patient is being performed by a physician and respiratory thera-pist. Fentanyl and midazolam were used for conscious sedation. After the bronchoscopy, the patient is not arousa-ble. Which of the following should be done at this time?

a. Draw a sample for arterial blood gas determina-tions
b. Increase the patient’s respiratory rate
c. Administer naloxone
d. Administer atropine

Answer 30

ANS: C
The patient requires reversal of the sedation. Naloxone or flumazenil may be used to reverse sedation.

DIF: 2 REF: pg. 242

Question 31

An invasively ventilated patient with ARDS is on PC-CMV, PIP = 30 cm H2O, PEEP = 12 cm H2O, FIO2 = 1.0. The patient’s returned VT is 320 mL. The ABG results on these settings are: pH 7.3, PaCO2 53 mm Hg, PaO2 62 mm Hg. The patient is placed in the prone position, and after 1 hour, ABG results show: pH 7.38, PaCO2 46mm Hg, PaO2 83 mm Hg. The respiratory therapist should do which of the following?

a. Keep the patient in the prone position.
b. Place the patient in the supine position.
c. Keep the patient in the prone position and de-crease the FIO2.
d. Place the patient in the supine position and de-crease PEEP.

Answer 31

ANS: C
This patient has shown a positive response to the prone position; therefore, the patient can be maintained in this position for 2 to 12 hours. A reduction in the FIO2 would be appropriate, because the level is at 1.0.

DIF: 3 REF: pg. 244

Question 32

A patient with extensive infiltrates throughout the right lung should be placed in which of the following positions to improve oxygenation?

a. Left lung down laterally
b. Right lung down laterally
c. Left lung down with right lung 45 degrees from supine
d. Right lung down with left lung 45 degrees from supine

Answer 32

ANS: A
To improve oxygenation without uneven distribution of PEEP to the normal lung, the patient should be placed with the “good lung” down.

DIF: 2 REF: pg. 246

Question 33

What effect does positive pressure ventilation have on fluid balance?

a. It increases urinary output.
b. It increases renal perfusion.
c. It causes renal malfunction.
d. It increases plasma ADH levels.

Answer 33

ANS: D
Positive pressure ventilation increases the plasma antidiuretic hormone level. Renal malfunction does directly affect fluid balance, but it is not caused by PPV. PPV decreases urinary output because of the increased levels of ADH. PPV may also also decrease renal perfusion.

DIF: 1 REF: pg. 247