Practice Questions Flashcards

Question 1

Q

A respiratory therapist is assisting a physician with endotracheal intubation. Which of the following should be used INITIALLY to confirm tracheal intubation?
A.
cm marking of the endotracheal tube
B.
observable condensation in the tube
C.
pulse oximetry
D.
colorimetric capnography

Answer

A

(c) D. Colorimetric capnography assesses the presence of CO2 and provides confirmation of tracheal intubation when CO2 is detected.

Question 2

Q

A respiratory therapist is asked to review a newborn’s history. The following information is available about the first few minutes after birth:

1 minute 5 minutes

Clr acrocyanosis pink
HR 70/min 110/min
Rfx cough cough
MT weak active motion
RR 20/min 40/min

Which of the following APGAR scores should the therapist expect to see for this infant?

1-minute 5-minute

4 8
5 8
6 10
7 10

A. 1
B. 2
C. 3
D. 4

Answer

A

C. The APGAR scoring system consists of the following:

Score 0 1 2
Appearance pale or blue acrocyanosis completely pink
Heart rate absent < 100 per minute > 100 per minute
Reflex no response grimace cry, cough, sneeze
Muscle tone limp some flexion active motion
Respiratory rate absent slow, irregular good cry

The score for 1 minute is 6: acrocyanosis = 1, heart rate of 70/min = 1, cough = 2, weak activity = 1, respiratory rate of 20/min = 1.
The score for 5 minutes is 10: pink = 2, heart rate of 110/min = 2, cough = 2, active motion = 2, respiratory rate of 40/min = 2.

Question 3

Q

A 58-year-old female was diagnosed with bronchiectasis 3 years ago. She reports increased cough and difficulty clearing secretions for the past 4 weeks. A chest radiograph shows no significant changes. Which of the following should the respiratory therapist recommend FIRST?

A. transtracheal aspiration
B. airway clearance therapy
C. bronchodilator treatments
D. respiratory isolation

Answer

A

B. The history, clinical presentation, and chest radiograph findings suggest worsening bronchiectasis. The treatment of bronchiectasis includes techniques to loosen and mobilize viscid secretions. Postural drainage enhances sputum clearance.

Question 4

Q

A 24-year-old female is diagnosed with exercise-induced asthma and albuterol prn is ordered. A respiratory therapist should NEXT

A. refer the patient for allergy skin testing.

B. educate the patient on obtaining daily peak flow measurements.

C. instruct the patient to use albuterol 15 minutes before exercising.

D. suggest the patient use pursed lip breathing while exercising.

Answer

A

C. Patient understanding of their disease process and triggers is important part of patient education, as well as knowing when and which medication should be taken.

Question 5

Q

In which of the following circumstances will tracheal secretions tend to dry in an intubated patient?

A. a water vapor pressure of 47 mm Hg
B. a relative humidity of 100% at 22° C
(71.6° F)
C. a dew point of 37° C (98.6° F)
D. an absolute humidity of 44 mg/L

Answer

A

B. The absolute humidity at this temperature is inadequate.

Question 6

Q

Prior to suctioning the endotracheal tube of an adult patient who is receiving ventilation with an FIO2 of 0.40, a respiratory therapist should FIRST

A. lubricate the catheter.
B. hyperoxygenate the patient.
C. cleanse the catheter with water.
D. administer an FIO2 of 0.40 by T-piece.

Answer

A

B. The FIO2 should be increased prior to each suctioning attempt to minimize hypoxemia.

Question 7

Q

A 68-year-old patient who is post-CABG was extubated 4 hours ago and complains of increasing shortness of breath. Breath sounds are decreased over the right lung field. The following data are available while the patient receives 4-L oxygen by nasal cannula:

HR 103/min
RR 27/min
BP 155/90 mm Hg
SpO2 90%

Which of the following studies should a respiratory therapist recommend FIRST?

A. bedside spirometry
B. chest CT with contrast
C. ventilation/perfusion scan
D. chest radiograph

Answer

A

D. Based on the timing and symptoms, the dyspnea could be due to pneumothorax, chest tube malfunction, lobar collapse, or accumulation of pleural fluid. A chest radiograph can be obtained quickly to identify the issue for rapid intervention.

Question 8

Q

Which of the following medications should a respiratory therapist use to anesthetize a patient’s airway prior to a flexible bronchoscopy procedure?

A. lidocaine HCl
B. midazolam HCl (Versed)
C. ketamine (Ketalar)
D. vecuronium bromide (Norcuron)

Answer

A

A. Lidocaine HCl is a topical anesthetic and will reduce airway reflexes during the procedure.

Question 9

Q

A 25-year-old patient with apnea is receiving PC ventilation. ABG analysis results are as follows:

pH 7.20
PCO2 65 mm Hg
PO2 70 mm Hg
HCO3- 25 mEq/L
BE -4 mEq/L
SO2 (calc) 94%

A respiratory therapist should recommend increasing the

A. set inspiratory pressure.
B. expiratory time.
C. sensitivity.
D. peak flow.

Answer

A

A. In PC ventilation, increasing the inspiratory pressure will result in an increased tidal volume and minute ventilation, potentially causing a decrease in the PCO2.

Question 10

Q

A 63-year-old patient with COPD is seen in the pulmonary clinic for a routine appointment. The analysis results of an ABG sample drawn while the patient is breathing air are:

pH 7.40
PCO2 57 mm Hg
PO2 42 mm Hg
HCO3- 35 mEq/L
BE +8 mEq/L
SO2 (calc) 77%

Which of the following is the most appropriate NEXT step?

A. Schedule polysomnography.
B. Initiate supplemental oxygen.
C. Perform a 6-minute walk test.
D. Coach on deep breathing.

Answer

A

B. Administering oxygen and observing the patient is the appropriate therapy for a hypoxemic patient with COPD, as indicated by the ABG analysis.

Question 11

Q

A pulse oximeter can provide an accurate indication of a patient’s oxyhemoglobin saturation in which of the following clinical conditions?

congestive heart failure
polycythemia
pulmonary hypertension
carbon monoxide poisoning

A. 1, 2, and 3 only
B. 2, 3, and 4 only
C. 1, 2, and 4 only
D. 1, 3, and 4 only

Answer

A

A. Carbon monoxide poisoning will result in carboxyhemoglobin. Standard pulse oximetry is unable to distinguish oxyhemoglobin from carboxyhemoglobin, which will lead to a falsely elevated SpO2 reading

Question 12

Q

A respiratory therapist is evaluating a 75-kg (165-lb), 180-cm (5-ft 11-in) male who is receiving VC, SIMV. The following patient data are obtained:

FIO2 0.40
Mandatory rate 8
Total rate 8
VT 550 mL
PEEP 8 cm H2O

pH 7.27
PaCO2 55 mm Hg
PaO2 94 mm Hg
HCO3- 25 mEq/L
BE -3 mEq/L
SaO2 (calc) 97%

Which of the following should the therapist recommend?

A. Maintain current settings.
B. Increase the mandatory rate to 12.
C. Decrease the FIO2 to 0.30.
D. Decrease the tidal volume to 450 mL.

Answer

A

B. Increasing the mandatory rate will increase the V̇E. This should correct the respiratory acidosis.

Question 13

Q

A patient receiving mechanical ventilation by a portable ventilator is being transported from the ED to radiology. Which of the following is required during transport?

A. bag-valve mask resuscitator
B. point-of-care blood gas analyzer
C. demand valve respirator
D. crash cart

Answer

A

A. A bag-valve mask resuscitator is required in case of transport ventilator failure.

Question 14

Q

Mechanical ventilation was initiated for a patient, after which the PaCO2 decreased from 53 to 40 mm Hg. A respiratory therapist should expect which of the following will increase?

A. HCO3-
B. pH
C. PETCO2
D. VD/VT

Answer

A

B. Carbon dioxide and pH move in opposite directions, so a decrease in carbon dioxide will result in an increase in pH.

Question 15

Q

According to CLIA standards, quality control must be performed for blood gas analyzers every

A. 8 hours.
B. 48 hours.
C. 72 hours.
D. 24 hours.

Answer

A

A. Eight hours is the CLIA-approved time frame for quality control of blood gas analyzers.

Question 16

Q

While performing a patient-ventilator assessment, a respiratory therapist observes very little condensation in the heated wire circuit. The reservoir of the heated wick humidifier is full of water. The most likely explanation is that the

A. minute ventilation is greater than 15 L/min.
B. patient circuit is operating normally.
C. flow is set at too low of a value.
D. room temperature is lower than normal.

Answer

A

B. The heated wire circuit is designed to maintain gas temperature to prevent condensation

Question 17

Q

Which of the following devices must be used to comply with airborne precautions?

A. N95 face mask
B. vinyl gloves
C. barrier gown
D. full face shield

Answer

A

A. An N95 face mask will provide protection against airborne microorganisms.

Question 18

Q

Which of the following imaging techniques is preferred when identifying metastatic disease associated with non-small cell lung cancer?

A. PET scan
B. chest radiograph
C. ultrasound
D. ventilation scan

Answer

A

A. The metabolically active tissue of a malignant mass will be shown in a PET scan.

Question 19

Q

A patient has been receiving mechanical ventilation through a tracheostomy tube for 16 days. The patient begins to thrash about in the bed following withdrawal of a drug-induced coma. The patient’s tracheostomy tube has become dislodged. After the patient is pharmacologically sedated, a respiratory therapist should NEXT

A. obtain an ABG sample.
B. perform nasal intubation.
C. reinsert the tracheostomy tube.
D. initiate oxygen therapy.

Answer

A

C. After 16 days, the tracheostomy tract should be well established, and the tube should be easily reinserted.

Question 20

Q

Following a bariatric surgery procedure 2 days ago, a patient with a PBW of 55 kg (121 lb) remains hospitalized with signs of sepsis. The patient is intubated and receiving VC, A/C ventilation with the following settings:

FIO2 0.50
Mandatory rate 18/min
VT 350 mL
PEEP 12 cm H2O

After returning from radiology, the patient’s peak inspiratory pressure is 45 cm H2O and plateau pressure is 35 cm H2O. ABG analysis reveals:

pH 7.39
PCO2 38 mm Hg
PO2 49 mm Hg
HCO3- 23 mEq/L
BE -2 mEq/L
SO2 (calc) 84%

A respiratory therapist should recommend

A. increasing the mandatory rate.
B. decreasing the tidal volume.
C. inline bronchodilator therapy.
D. a lung recruitment maneuver.

Answer

A

D. The presentation suggests acute atelectasis. A lung recruitment maneuver can be used to reopen atelectatic lung units.

Question 21

Q

An 18-year-old male with cystic fibrosis is admitted for pneumonia and increasingly thick pulmonary secretions. The patient’s home regimen consists of albuterol and HFCWO. A physician has ordered albuterol, HFCWO, and aztreonam (Cayston). A respiratory therapist should anticipate the addition of which of the following inhaled medications?

A. dornase alfa (Pulmozyme)
B. tobramycin (TOBI)
C. pentamidine isethionate (NebuPent)
D. iloprost (Ventavis)

Answer

A

(c) A. Dornase alfa (Pulmozyme), a mucolytic, is indicated for patients with cystic fibrosis that have increasing thick secretions.

(u) B. Tobramycin (TOBI) is not indicated because the patient is already receiving an inhaled antibiotic, and it will not thin or break down thick secretions.

(u) C. Pentamidine isethionate (NebuPent) is for pneumocystis pneumonia in immunocompromised patients.

(u) D. Iloprost (Ventavis) is for pulmonary arterial hypertension.

Question 22

Q

Twenty-four hours following thoracic surgery, a 61-year-old male who is 180 cm (5 ft 11 in) tall and weighs 88 kg (194 lb) is receiving VC, A/C ventilation with the following settings:

FIO2 0.40
Mandatory rate 12
VT 600 mL
PEEP 5 cm H2O

The patient is alert and oriented. A respiratory therapist notes the following data:

SpO2 98%
MIP -32 cm H2O
Exhaled VT 420 mL
The best weaning method for this patient is

A. a spontaneous breathing trial.
B. SIMV mode, mandatory rate 14, and set tidal volume 600 mL.
C. PS ventilation at 20 cm H2O.
D. PC ventilation at 25 cm H2O and mandatory rate of 12.

Answer

A

(c) A. The patient is alert and has very good inspiratory muscle effort. A spontaneous breathing trial will provide the best method for rapid weaning.

(h) B. Increasing the mandatory rate is unnecessary and will prolong the course of mechanical ventilation.

(u) C. The patient is alert, oriented, and has adequate inspiratory muscle effort and tidal volume. High levels of pressure support may not be needed to support the patient’s spontaneous breathing.

(u) D. Data indicates weaning from mechanical ventilation is appropriate. Changing to PC ventilation at this time will not facilitate weaning.

Question 23

Q

A respiratory therapist intends to change the I:E during VC ventilation. Flow is constant during inspiration. Which of the following can be adjusted to accomplish this change?

volume mandatory rate sensitivity inspiratory flow

yes yes yes no
yes yes no yes
yes no yes yes
no yes yes yes

A. 1
B. 2
C. 3
D. 4

Answer

A

(c) B. Changing the volume or inspiratory flow will change the inspiratory time on a VC, flow-limited ventilator. Changing the mandatory rate will change the total cycle time and thus impact the I:E.

Question 24

Q

An adult patient who is spontaneously breathing and receiving an FIO2 of 0.40 by air-entrainment mask has the following ABG analysis results:

pH 7.46
PCO2 33 mm Hg
PO2 48 mm Hg
HCO3- 23 mEq/L
BE 0 mEq/L
SO2 (calc) 83%
A respiratory therapist should FIRST

A. sedate the patient.
B. intubate the patient.
C. administer 2.5 mg albuterol.
D. switch to nonrebreathing mask.

Answer

A

(h) A. Sedating the patient will depress respirations and worsen the degree of hypoxemia.

(h) B. The patient is able to maintain adequate ventilation; therefore, intubation is not indicated at this time.

(u) C. There is no indication for the administration of albuterol.

(c) D. A nonrebreathing mask will provide a higher FIO2 than the air-entrainment mask.

Question 25

Q

Following placement of a subclavian venous catheter, the high pressure alarm on a patient’s ventilator begins sounding. After 10 minutes, the patient’s peak inspiratory pressure has increased from 40 to 60 cm H2O and mean arterial pressure decreased from 80 to 40 mm Hg. A respiratory therapist should FIRST

A. increase the peak flow.
B. suggest administering a vasopressor.
C. suction the endotracheal tube.
D. recommend needle decompression.

Answer

A

D. Tension pneumothorax is a possible complication of venous catheter insertion and can result in increased airway pressure. This would sound the high pressure alarm and decrease arterial pressure. Needle decompression is indicated.

Question 26

Q

While counseling a patient during a smoking cessation session, the patient expresses concern about weight gain. A respiratory therapist should address the patient’s concern by explaining that this is partially the result of

A. decreased metabolism.
B. increased loss of self-control.
C. reliance on nicotine replacement therapy.
D. lack of available aversive conditioning.

Answer

A

(c) A. Metabolism decreases when nicotine is withdrawn. If dietary intake remains unaltered and exercise is not included, there may be a resulting weight gain.

Question 27

Q

While assessing an adult male receiving invasive mechanical ventilation, a respiratory therapist notes breath sounds suddenly are markedly decreased, the cuff pressure is 5 cm H2O, and airflow is coming from the patient’s mouth during each positive pressure breath. The tube depth remains at 22 cm at the lip. Air is added to the cuff, but the cuff pressure is not maintained. Which of the following should the therapist recommend?

A. Perform an ABG analysis.
B. Increase the tidal volume setting on the ventilator.
C. Reintubate using an endotracheal tube exchanger.
D. Advance the endotracheal tube 4 cm.

Answer

A

C. The sudden loss of cuff pressure and air noted coming from the mouth indicates a ruptured cuff and must be addressed immediately. An endotracheal tube exchanger is a safe means to reintubate successfully.

Question 28

Q

A patient with severe COPD continues to complain of dyspnea on a home regimen that includes tiotropium bromide (Spiriva) and albuterol. A respiratory therapist should recommend adding

A. fluticasone/salmeterol (Advair).
B. montelukast (Singulair).
C. n-acetylcysteine.
D. guaifenesin (Robitussin).

Answer

A

(c) A. Fluticasone/salmeterol (Advair) is a long-acting bronchodilator and inhaled steroid that is the generally accepted care for COPD.

(u) B. Montelukast (Singulair) is a leukotriene-modifying agent. There is no documented clinical basis for its use in the management of severe COPD.

(h) C. N-acetylcysteine is a mucolytic agent and may promote additional bronchospasm in the patient.

(u) D. Guaifenesin (Robitussin) is an over-the-counter expectorant. Its use will not decrease symptoms of dyspnea.

Question 29

Q

For which of the following are PEF measurements indicated?

A. Establish readiness for weaning.
B. Evaluate lung compliance.
C. Determine ventilatory reserve.
D. Monitor airways obstruction.

Answer

A

D. PEF measurements are routinely used to monitor airways obstruction in patients with asthma.

Question 30

Q

A respiratory therapist is reviewing the medical record of an infant to determine whether any respiratory care is indicated in the home. Which of the following suggests the need for home apnea monitoring?

A. albuterol aerosol every 4 hours prn
B. caffeine citrate daily
C. APGAR scores of 3 and 4
D. oxygen by cannula at 0.25 L/min

Answer

A

B. Caffeine citrate is used to treat apneic conditions and indicates the need for home apnea monitoring.

Question 31

Q

A DLCO measuring device requires evaluation after being taken out of service because of erroneous values. Which of the following is critical to evaluate?

A. linearity of pressure drops
B. verification of shutter response
C. verification of He percentage
D. linearity of analyzed gas concentrations

Answer

A

D. The integrity of the gas analysis system and its ability to return expected results are critical elements in DLCO measurement.

Question 32

Q

An adult patient is receiving PC, SIMV and the following data are observed:

FIO2 0.80
Mandatory rate 15
Spontaneous rate 32
Set inspiratory pressure 20 cm H2O
PEEP 10 cm H2O
SpO2 92%

On inspection, the patient demonstrates suprasternal retractions during spontaneous breaths. Which of the following should a respiratory therapist do NEXT?

A. Decrease the rise time setting.
B. Switch to A/C mode.
C. Increase the FIO2 to 0.90.
D. Change set inspiratory pressure to 25 cm H2O.

Answer

A

B. The suprasternal retractions are indicative of increased work of breathing and may be resolved by changing the mode to A/C. The respiratory rate may also come down.

Question 33

Q

Which of the following is the most significant factor leading to the development of tracheomalacia?

A. cuff pressure
B. trauma during intubation
C. intracuff volume
D. tube length

Answer

A

A. Excessive cuff pressure will obstruct mucosal blood flow to the tracheal wall. The resulting ischemia weakens the tracheal wall and tracheomalacia develops.

Question 34

Q

A respiratory therapist is using an oxygen-calibrated flowmeter to administer 70/30 heliox. To deliver a flow of 16 L/min, the therapist should set the oxygen flowmeter to

A. 8 L/min.
B. 16 L/min.
C. 14 L/min.
D. 10 L/min.

Answer

A

D. The correction factor for a 70/30 heliox is the oxygen flow multiplied by 1.6 (10 L/min X 1.6 = 16 L/min.)

Question 35

Q

Which of the following should a respiratory therapist recommend to aid in secretion removal for a patient with COPD who has a strong cough?

A. incentive spirometry
B. abdominal thrust
C. insufflation-exsufflation device
D. vibratory PEP

Answer

A

D. Vibratory PEP aids in secretion removal.

Question 36

Q

A 22-year-old patient with a history of intermittent wheezing has the following pulmonary function test results:

Prebronchodilator Postbronchodilator

FEV1 (% of predicted) 84 88
FVC (% of predicted) 85 86
FEV1/FVC (%) 84 86
Peak flow (% of predicted) 98
96

Which of the following should a respiratory therapist recommend?

A. lung volume measurements
B. inhalation challenge
C. DLCO testing
D. polysomnography

Answer

A

B. An inhalation challenge uses bronchoprovocative stimulus (e.g., methacholine), to test the hyperactiveness of the airway. Patients with asthma demonstrate an excessive response to various doses of this substance.

Question 37

Q

A 65-year-old patient with congestive heart failure is receiving 10 cm H2O CPAP and an FIO2 of 0.60. ABG analysis results are:

pH 7.41
PCO2 40 mm Hg
PO2 150 mm Hg
HCO3- 25 mEq/L
BE 0 mEq/L
SO2 (calc) 99%

Which of the following should a respiratory therapist conclude?

A. The patient is acidotic.
B. Hyperoxemia is present.
C. The patient is tachypneic.
D. Hypocapnia is present.

Answer

A

B. A PaO2 of 150 mm Hg is above the normal range of 75 - 100 mm Hg; therefore, hyperoxemia is present.

Question 38

Q

A respiratory therapist is evaluating a patient who has OSA. CPAP pressure is delivered at 7 cm H2O through a nasal mask. The patient complains of dryness of the mouth the next morning despite maximal humidification settings. Which of the following should the therapist recommend?

A. Initiate bi-level ventilation.
B. Change to a full face mask.
C. Increase the ramp time.
D. Switch to nasal pillows.

Answer

A

B. Changing to a full face mask will direct humidified gas from the machine through the nose and mouth.

Question 39

Q

A respiratory therapist is called to the ED for a 1 year old who is having difficulty breathing. Severe suprasternal, subcostal, and substernal retractions are observed. The child has a harsh, barking cough. Stridor is present. The therapist should anticipate treatment for

A. cystic fibrosis.
B. pneumonia.
C. croup.
D. asthma.

Answer

A

C. The patient has some degree of upper airway obstruction cause by some type of viral illness. The barky cough is a classic finding for patients experiencing croup.

Question 40

Q

Fluticasone/salmeterol (Advair Diskus) has been added to the treatment plan of a 68-year-old male who has COPD. A respiratory therapist teaches him how to use the device and asks him to demonstrate his technique. The patient pushes the lever, places the device in his mouth, exhales fully, inhales rapidly, holds his breath for 10 seconds, and rinses his mouth. Which of the following corrective instructions should the therapist provide?

A. Eliminate the breath hold.
B. Rinse your mouth before using the medication.
C. The inhalation should occur slowly.
D. Exhale before placing the device in your mouth.

Answer

A

D. Exhaling into the device will disperse the powder throughout the device and the moisture in the exhaled air can make the medication occlude the device.

Question 41

Q

An adult patient is receiving mechanical ventilation. Which of the following should be recommended to improve oxygenation and recruit collapsed alveoli?

A. PEEP
B. SIMV mode
C. mechanical dead space
D. in-line suction system

Answer

A

A. Application of PEEP minimizes the potential for end-expiratory alveolar collapse and then maintains the alveoli in an open position because it exceeds the force of surface tension.

Question 42

Q

A patient who is conscious with an intact gag reflex requires an artificial airway to prevent obstruction of the upper airway by the tongue. Which of the following types of airways is most appropriate in this situation?

A. nasopharyngeal
B. oropharyngeal
C. oral endotracheal tube
D. tracheostomy tube

Answer

A

A. A nasopharyngeal airway is the least invasive device to use to prevent upper airway obstruction in a conscious patient.

Question 43

Q

After performing tracheostomy care for a patient with a TBI, a respiratory therapist observes that the low exhaled tidal volume alarm is sounding on the ventilator and audible noises are heard coming from the patient’s mouth. The therapist should conclude that

A. the patient is experiencing bronchospasms.
B. air has been lost from the patient’s cuff.
C. the patient is agitated from the tracheostomy care.
D. the tracheostomy tube tip is lodged against the tracheal wall.

Answer

A

B. A low volume alarm with the audible noise from the mouth indicates a leak.

Question 44

Q

A respiratory therapist is caring for a 185-cm (6-ft 1-in), 85-kg (187-lb) male patient with ARDS who is receiving VC, A/C ventilation. The following data are observed:

FIO2 0.80
Mandatory rate 12
VT 600 mL
Inspiratory time 1.0 sec
PEEP 14 cm H2O
PIP 40 cm H2O
Pplat 34 cm H2O

An ABG analysis shows:

pH 7.37
PCO2 43 mm Hg
PO2 62 mm Hg
HCO3- 25 mEq/L
BE -1 mEq/L
SO2 (calc) 92%

According to ARDSnet, the therapist should

A. increase the FIO2.
B. decrease PEEP.
C. increase the inspiratory time.
D. decrease the tidal volume.

Answer

A

D. Given a plateau pressure of greater than 30 cm H2O, the next step in the ARDSnet protocol is to decrease the tidal volume in 1 mL/kg PBW increments (to a minimum of 4 mL/kg of PBW) until plateau pressure is less than 30 cm H2O.

Question 45

Q

Which of the following is a side effect of inhaled nitric oxide?

A. decreased cardiac output
B.
methemoglobinemia
C.
systemic hypotension
D.
increased WBC count

Answer

A

B. As inhaled nitric oxide breaks down, methemoglobin is formed. This may lead to methemoglobinemia.

Question 46

Q

Which of the following best reflects the adequacy of ventilation?

A. PaO2
B. PaCO2
C. vital capacity
D. FEF25-75%

Answer

A

B. The arterial level of CO2 reflects the alveolar CO2 and is the best indication of the adequacy of ventilation.

Question 47

Q

Which of the following types of nebulizer can be used to deliver aerosolized medications to a ventilator circuit without altering delivered tidal volume?

A. vibrating mesh
B. air entrainment
C. small-volume jet
D. breath actuated

Answer

A

A. Vibrating mesh nebulizers place only the aerosolized medications into the circuit.

Question 48

Q

Which of the following values for arterial carbon dioxide tension is consistent with alveolar hyperventilation?

A. 30 mm Hg
B. 40 mm Hg
C. 50 mm Hg
D. 60 mm Hg

Answer

A

A. An arterial carbon dioxide tension of less than 35 mm Hg reflects alveolar hyperventilation as it results in a decreased arterial carbon dioxide tension in the blood.

Question 49

Q

While reviewing a medical record, a respiratory therapist notes a patient has shortness of breath, pleuritic chest pain, low-grade fever, tachypnea, tachycardia, and a swollen, tender right leg. The patient has a 50 pack-year history of smoking and known coronary artery disease. These findings are MOST consistent with

A. pneumonia.
B. pulmonary embolism.
C. myocardial infarction.
D. acute exacerbation of COPD.

Answer

A

B. The signs and symptoms are consistent with pulmonary embolism.

Question 50

Q

A 58-year-old male presents to the ED with a chief complaint of acute chest pain. Which of the following diagnostic tests should be done FIRST?

A. electrocardiography
B. chest radiograph
C. CT scan of the chest
D. cardiac ultrasound

Answer

A

A. An ECG is required to rule out an acute myocardial infarction or arrhythmia before considering other diagnoses.

Question 51

Q

A respiratory therapist observes the following ventilator graphics for a 3-month-old infant with bronchiolitis who is receiving PC, A/C ventilation:

The infant has a normal pH and is hemodynamically stable. Which of the following should the therapist recommend?

A. Maintain current settings.
B. Decrease FIO2.
C. Change to VC ventilation.
D. Increase mandatory rate.

Answer

A

A. Though there is evidence of auto-PEEP in the flow-time graphic, the patient’s normal pH and stable hemodynamics indicate no intervention is currently needed.

Question 52

Q

Furosemide (Lasix) and oxygen therapy are initiated for a patient with pulmonary edema. Which of the following should a respiratory therapist recommend?

A. monitoring of electrolyte levels and a PA catheter
B. a CBC and pulse oximetry
C. pulse oximetry and monitoring of electrolyte levels
D. a PA catheter and a CBC

Answer

A

C. Pulse oximetry to monitor the SpO2 in a patient with pulmonary edema is essential to track the patient’s status. As furosemide will impact fluid levels, monitoring the patient’s electrolyte levels is essential to ensuring a correct sodium level.

Question 53

Q

Which of the following questions should a respiratory therapist ask to determine whether a patient has orthopnea?

A. “Can you climb one flight of stairs?”
B. “Do you snore when sleeping?”
C. “Have you experienced any chest pain?”
D. “Are you short of breath while lying flat?”

Answer

A

D. Orthopnea is defined as the shortness of breath while lying flat.

Question 54

Q

Moderate stridor with retractions is noted immediately after extubation of a patient. A respiratory therapist should recommend

A. cool, bland aerosol therapy.
B. inhaled steroids.
C. nebulized racemic epinephrine.
D. a nasopharyngeal airway.

Answer

A

C. Given its strong alpha-adrenergic vasoconstrictive properties, racemic epinephrine is the first choice to help reduce the glottic edema that has occurred in this patient.

Question 55

Q

A patient who is receiving mechanical ventilation requires an FIO2 of 0.70 and 10 cm H2O PEEP to maintain an acceptable PaO2. The patient is restless and has become disconnected from the ventilator circuit several times, during which she experiences cardiac rhythm disturbances. A respiratory therapist should conclude that the patient will benefit from a

A. sedative.
B. mucolytic.
C. neuromuscular blocker.
D. pulmonary vasodilator.

Answer

A

A. Sedation is required to eliminate excessive activity so the patient’s cardiopulmonary status can be properly evaluated and treated.

Question 56

Q

Three liters of air are injected into a spirometer from a certified-volume standard syringe. The measured value is 2.6 L. Which of the following should a respiratory therapist conclude?

A. The plunger was pushed too slowly.
B. The spirometer is ready for patient testing.
C. The time scale was incorrectly calibrated.
D. The calibration is outside the accepted range.

Answer

A

D. A leak is the likely cause for the difference of 400 mL and is one of the reasons for checking spirometers with a calibrated syringe.

Question 57

Q

A respiratory therapist is assessing a ventilator for readiness of use. To evaluate the integrity of the circuit, the therapist should check the

A. pressure during tidal volume delivery.
B. compressible volume of the circuit.
C. peak pressure change when the circuit is capped.
D. volume delivery distal to the exhalation valve.

Answer

A

C. Maintaining peak pressure when the circuit is capped indicates a tight circuit without leaks.

Question 58

Q

In the last 6 months, a patient with bronchiectasis who uses postural drainage at home has had three exacerbations requiring hospitalization. Which of the following should a respiratory therapist recommend?

A. insufflation/exsufflation device
B. nebulized ipratropium (Atrovent)
C. inhaled corticosteroid
D. HFCWO

Answer

A

D. HFCWO provides an effective method to loosen and mobilize airways secretions.

Question 59

Q

When calibrating a fuel cell oxygen analyzer, the analyzer should be set to

A. 40% while exposed to nitrous oxide.
B. 21% while exposed to room air.
C. 70% while exposed to oxygen.
D. 0% while exposed to carbon dioxide.

Answer

A

B. Room air is used for the low calibration of an oxygen analyzer and should be set at 21%.

Question 60

Q

An air-entrainment mask will deliver an FIO2 higher than intended when

A. the flow is set too high.
B. nebulized water is being added through the air-entrainment ports.
C. corrugated tubing was added between the air-entrainment adapter and mask.
D. the air-entrainment ports have been blocked.

Answer

A

D. Blocked air-entrainment ports prevent air from being added to the inspired gas flow and results in a higher FIO2.

Question 61

Q

Which of the following will most accurately and quickly assess a patient’s response to changes in FIO2?

A.
transcutaneous monitoring
B.
pulse oximetry
C.
capillary refill

D.
absence of cyanosis

Answer

A

B. Pulse oximetry gives a rapid response to changes in oxyhemoglobin saturation and is the most accurate of the options given.

Question 62

Q

Which of the following values is the best indicator of an individual’s response to inhaled bronchodilators?

A.
FVC
B.
FEV1
C.
FEF200-1200
D.
diffusing capacity

Answer

A

B. FEV1 is the best indicator of reversible airway obstruction in response to inhaled bronchodilators.

Question 63

Q

A patient receiving continuous heated aerosol therapy with air by a T-piece develops subcutaneous emphysema around the tracheostomy site, neck, and chest. After noting unequal breath sounds, a respiratory therapist should recommend obtaining

A.
a chest radiograph.
B.
a MIP measurement.
C.
timed forced expiratory volumes.
D.
an arterial blood gas analysis.

Answer

A

A. Subcutaneous emphysema may indicate the presence of a pneumothorax. A chest radiograph is the most appropriate initial diagnostic test when a pneumothorax is suspected.

Question 64

Q

A 188-cm (6-ft 2-in), 84-kg (185-lb) male patient who has undergone a right lower lobectomy is receiving VC, A/C ventilation with the following settings:

FIO2 0.50
Mandatory rate 12
Total rate 14
VT 500 mL

The following ABG analysis results are available:

pH 7.32
PCO2 47 mm Hg
PO2 83 mm Hg
HCO3- 24 mEq/L
BE -2 mEq/L
SO2 (calc) 96%

A respiratory therapist should recommend

A.
changing to SIMV.
B.
initiating 10 cm H2O PEEP.
C.
maintaining current therapy.
D.
increasing the tidal volume.

Answer

A

C. Although the patient has a mild respiratory acidosis, the values are acceptable for this patient.

Answer 65

A

D. These findings are consistent with a pleural effusion.

Answer 66

A

D. There has been an increase in the patient’s heart rate of greater than 20/min, signaling a tachycardic reaction to the medication. Termination of the treatment is advisable.

Answer 67

A

C. The patient has a tension pneumothorax. Inserting a needle in the chest is the quickest action based on the vital signs.

Answer 68

A

D. Diuretics may cause fluid shifts and excretion of certain electrolytes in the urine. Therefore, electrolytes should be monitored to detect electrolyte imbalances (particularly in sodium, potassium, and calcium) as these can be life threatening.

Answer 69

A

A. The patient is experiencing respiratory alkalosis. Decreasing the tidal volume will reduce the overall minute ventilation and help reduce the pH.

Answer 70

A

C. The flow to the mask is insufficient and will result in dilution of both the oxygen and helium concentrations with air. Increasing the flow will ensure the patient receives the desired gas mixture

Answer 71

A

D. Bronchitis is characterized by chronic cough and sputum production.

Answer 72

A

A. An excess in interstitial fluid can impair oxygen diffusion into the capillaries and increase the P(A-a)O2.

Answer 73

A

D. The ventilatory parameters and the accompanying ABG analysis results indicate the patient is ready for extubation.

Answer 74

A

C. Universal precautions should be used when obtaining an ABG sample.

Answer 75

A

A. An AHI of 28 is categorized as moderate to severe sleep apnea. PAP therapy is the treatment of choice.

Answer 76

A

D. Handwashing before and after use prevents contamination of equipment and transmission of microorganisms.

Answer 77

A

B. To reduce complications of trauma, the catheter should be lubricated with a water-soluble lubricant to aid catheter passage through the nostril.

Answer 78

A

A. The patient exhibits oxyhemoglobin desaturation with exercise and should have oxygen administered with activity.

Answer 79

A

D. The data suggests a low cardiac index and cardiogenic shock. An inotropic agent should be used to increase myocardial contractility, which in turn, should increase blood pressure.

Answer 80

A

D. Auto-PEEP is caused by gas trapping. Expiratory flow will not return to baseline because expiration has not completed before the next breath is delivered.

Answer 81

A

B. Changing to levalbuterol (Xopenex) may decrease the incidence of tachycardia and palpations.

Answer 82

A

D. Difficulty withdrawing blood through an arterial catheter is a sign of malfunction.

Answer 83

A

A. Mallampati score IV is characterized by the visualization of only the hard palate. None of the soft palate is visible.

Answer 84

A

B. A 40% air-entrainment mask entrains air at a ratio of 3 parts air to 1 part oxygen. To determine the total flow provided with a 40% mask and 12 L/min, use the following formula to solve for x, with x being oxygen flow in L/min:

3x = air entrained
3x + x = total flow
3(12) + 12 = total flow
= 48 L/min.

Answer 85

A

C. The most common cause of issues with the light source of bronchoscopes is the connection port.

Answer 86

A

D. For a patient who has been receiving mechanical ventilation for a long period of time, an abrupt loss of ventilation may lead to anxiety and dyspnea. Initiating pressure support is most likely to lead to successful weaning.

Answer 87

A

C. The lack of a plateau and upward sloping shape of the curves demonstrate impairment of exhalation due to an obstructive process or airways collapse.

Answer 88

A

A. A malfunctioning exhalation valve can cause a significant leak and prevent the development of normal pressures during the inspiratory phase of ventilation.

Answer 89

A

B. The FEV1 and FEV1/FVC values are within normal ranges. The patient should be able to deep breathe and cough after surgery.

Answer 90

A

B. Right heart failure inhibits venous return and results in edema in the periphery.

Answer 91

A

C. The flow control valve in conjunction with the gas flow into the bag regulates the filling of the bag. With the flow control valve open, the gas going into the bag will immediately leave the bag through the open-flow control valve.

Answer 92

A

C. MIP is an indication of respiratory muscle strength. Vital capacity provides information regarding respiratory reserve. Both provide data about the need for ventilatory support in a patient with neuromuscular disease.

Answer 93

A

B. An apnea monitor is indicated when an infant is asleep or when not being observed; therefore, it should be used during naps and at night.

Answer 94

A

A. The site must be heated for 2-5 minutes to facilitate capillary dilatation. Once dilatation occurs, transcutaneous values will stabilize.

Answer 95

A

C. To attempt to compensate by blowing off CO2, there is an increase in rate and depth of breathing. This is called Kussmaul’s breathing and is the result of diabetic ketoacidosis.

Answer 96

A

B. Keeping the current invasive procedure in mind, the diminished breath sounds over the affected area and an increased heart rate are consistent with a pneumothorax.

Answer 97

A

C. An ABG will indicate the patient’s ventilatory status. Hemoximetry (CO-oximetry) will indicate the patient’s carboxyhemoglobin level, which is essential in CO poisoning, in addition to true oxygen saturation.

Answer 98

A

B. The description suggests obstruction of the catheter due to kinking or mucous, resulting in significant back pressure causing the supply tube to pop off.

Answer 99

A

A. Based on NAEPP guidelines, the patient meets criteria for step 2 and requires the addition of an inhaled corticosteroid.

Answer 100

A

D. A right-sided pneumothorax will result in diminished breath sounds on the right and possibly a tracheal shift to the left.

Answer 101

A

B. Although a pressure-volume loop can identify the presence of air trapping by looking at the shape of the curve, the amount of air trapping cannot be determined.

Answer 102

A

D. Bag-valve-mask resuscitation is required for a patient in severe respiratory distress.

Answer 103

A

D. Intubation of the right mainstem bronchus most likely explains the asymmetrical chest movement and decreased breath sounds. The best corrective action is to assess the depth of the endotracheal tube insertion.

Answer 104

A

B. Vital capacity is performed by having the patient inhale to total lung capacity and maximally exhale to residual volume.

Answer 105

A

A. The high-pitched squeal indicates that the oxygen or air source is disconnected or below a critical point.

Answer 106

A

A. Propofol is a sedative and will not be useful for analgesia.

(u) B. Midazolam HCl (Versed) is an anxiolytic agent and will not be useful for analgesia.

(u) C. Lorazepam (Ativan) is an anxiolytic agent and will not be useful for analgesia.

(c) D. Fentanyl citrate (Sublimaze) is an analgesic agent and will be helpful to reduce musculoskeletal pain.

Answer 107

A

A. The patient appears to have an obstructed tracheostomy tube and is exhibiting respiratory distress with oxygen desaturations. The tube should be replaced immediately.

Answer 108

A

C. Right-sided atelectasis causes diminished breath sounds on the right and the trachea is pulled in the direction of the atelectasis.

Answer 109

A

C. A nonrebreathing mask with high-flow oxygen will ensure that each breath contains an FIO2 approximating 1.00, and is most likely to increase this patient’s oxygenation.

Answer 110

A

(c) A. The patient has allergic rhinitis and, at most, mild persistent asthma. A leukotriene inhibitor, such as montelukast (Singulair), are indicated to control mild asthma and allergic rhinitis.

(h) B. An IgE immunoglobulin antagonist, such as omalizumab (Xolair), is indicated for severe allergic asthma and carries significant risk.

(u) C. Beta-adrenergic agonists are rescue drugs. They should not be used to control asthma and should have no role in the treatment of allergic rhinitis.

(u) D. Anticholinergics do not play a role in the treatment of allergic rhinitis.

Answer 111

A

B. Given the tracheostomy was placed 24 hours ago, the tract has likely not epithelialized. Creation of a false tract and malposition can occur if an attempt is made to blindly reinsert the tracheostomy tube. The correct course of action is to occlude the stoma and ventilate with a bag-valve-mask resuscitator while preparations are made to reintubate by the mouth or nose.

Answer 112

A

C. A hemoximeter (CO-oximeter) can directly measure various forms of hemoglobin saturation, including oxyhemoglobin, carboxyhemoglobin, and methemoglobin. In a patient with suspected smoke inhalation, elevation in the carboxyhemoglobin level can be expected.

Answer 113

A

D. Fowler’s position elevates the head of the bed to an angle between 45 and 60 degrees. This will relieve the dyspnea and alleviate the patient’s distress.

Answer 114

A

A. The expiratory flow does not return to baseline prior to the start of the next breath. This indicates auto-PEEP is present.

Answer 115

A

B. The pH is greater than 7.45, which indicates alkalemia. The PCO2 is decreased, which indicates respiratory alkalosis. The HCO3- is normal, so no compensation has occurred. The PO2 is in the 60-80 mm Hg range, which indicates mild hypoxemia.

Answer 116

A

D. The current tidal volume is less than 6 mL/kg of PBW; increasing it to 7 mL/kg of PBW should correct the respiratory acidosis.

Answer 117

A

C. An HHFNC will provide a consistent FIO2 along with heat and humidity. This should help treat the patient’s hypoxemia.

Answer 118

A

D. A patient who demonstrates patient-ventilator dyssynchrony associated with air trapping will often benefit from an increase in the set (extrinsic) PEEP level. Increasing the set PEEP to be closer to, but slightly below, the total PEEP level minimizes the effort required to trigger the ventilator.

Answer 119

A

B. Calculation of the C(a-v̄)O2 is as follows:
C(a-v̄)O2 = CaO2 - Cv̄O2
Cv̄O2 = (Hb x 1.34) x Sv̄O2 + (Pv̄O2 x 0.003)
Cv̄O2 = (10 x 1.34) x 60% + (30 x 0.003)
Cv̄O2 = 13.4 x 0.60 + 0.09
Cv̄O2 = 8.04 + 0.90
Cv̄O2 = 8.13
CaO2 - Cv̄O2 = 12 - 8.13
C(a-v̄)O2 = 3.87

Answer 120

A

A. The patient became tachycardic, tachypneic, and hypoxic, all indicating intolerance of the SBT. The patient should be returned to the previous ventilation settings.

Answer 121

A

D. A needle thoracentesis should be performed first to help diagnose the cause of the pleural effusion.

Answer 122

A

A. Dexmedetomidine (Precedex) will sedate the patient, but will not address the patient’s pain or dyspnea postextubation.

B. Atropine is an anticholinergic that can be used to decrease secretions, but will not address the patient’s pain or dyspnea post extubation.

(c) C. Morphine will alleviate pain and dyspnea associated with a terminal extubation.

D. Furosemide (Lasix) is not indicated in this situation as it will not address the patient’s pain or dyspnea.

Answer 123

A

A. The graphic shows that the volume isn’t returning to baseline and a leak is present.

Answer 124

A

C. The patient is already on a minimal level of PSV and demonstrates acceptable ABG analysis and pulmonary mechanics results.

Answer 125

A

C. Crepitus may be associated with a pneumothorax due to the presence of subcutaneous emphysema.

Answer 126

A

C. The patient should first be placed in high Fowler’s position.

Answer 127

A

B. In an optimally exposed chest radiograph, vertebrae are visible while maintaining visible lung markings.

Answer 128

A

C. Biologic indicators, or spore tests, indicate whether a highly resistant microorganism has been killed within the package. This is the most accepted method for monitoring effectiveness of heat/stem sterilization.

Answer 129

A

D. Vital capacity is the maximum volume exhaled after a maximum inhalation.

Answer 130

A

B. Vocal fremitus is transmission of the spoken voice to the chest wall, detectable by auscultation or palpation. It is increased with lung consolidation.

Answer 131

A

A. Facial burns with oropharynx edema indicate upper airway burns and the potential for worsening edema and airway obstruction. Intubation is necessary to ensure airway patency.

Answer 132

A

C. The goal of CPAP intervention is to completely eliminate apnea and hypopnea episodes, standard protocol is to incrementally increase the CPAP level until this occurs.

Answer 133

A

A. Overnight oximetry may be considered a screening tool for a more detailed polysomnography study.

Answer 134

A

B. Coached coughing and deep breathing are the best methods for mobilizing secretions in a young healthy adult.

Answer 135

A

B. Hemoptysis is bleeding from an airway source. Bronchoscopy may help localize the site of the bleeding.

Answer 136

A

C. Air in the syringe will affect the results.

Answer 137

A

C. Continuous positive airway pressure provides constant positive airway pressure during the entire respiratory cycle.

Answer 138

A

B. Providing sedation and analgesia is standard in any protocol for discontinuing mechanical ventilation during end of life care.

Answer 139

A

B. The increase in PEEP will increase FRC, decrease the intrapulmonary shunt, and address the hypoxemia.

Answer 140

A

C. Breathing in fast and deep is the proper method of administration for umeclidinium/vilanterol (Anoro Ellipta).

Answer 141

A

D. Routine use of semi-Fowler positioning with the head of the bed elevated at an angle of 30-45 degrees has been shown to decrease rates of ventilator-associated pneumonia.

Answer 142

A

D. A Stow-Severinghaus blood gas electrode is used in transcutaneous monitors.

Answer 143

A

A. A PICC is the best choice for long-term IV access and allows for blood sampling.

Answer 144

A

(c) A. Since the PaO2 is adequate, it is now appropriate to decrease the FIO2.

(u) B. The PEEP needs to be maintained to prevent derecruitment of alveoli.

(u) C. There is no indication for changing the minute ventilation. The patient’s ventilation is appropriate.

(u) D. The FIO2 needs to be decreased to minimize oxygen-induced lung injury.

Answer 145

A

A. Pursed lip breathing is used as an expiratory maneuver to stabilize airways typically with COPD patients and not as a cough assist.

(c) B. An abdominal thrust is used to assist patients with decreased respiratory muscle function, such as quadriplegics, to more forcefully cough out secretions.

(u) C. PEP therapy is used by patients who can spontaneously take a deep breath and follow-up with a forced cough effort.

(u) D. Inspiratory muscle training is used to enhance inspiratory muscle strength typically with COPD patients and not for quadriplegic patients.

Answer 146

A

(u) A. The history, signs, and symptoms point to CHF. Prednisone will not address the cause of the patient’s symptoms.

(u) B. The history, signs, and symptoms point to CHF. Albuterol will not address the cause of the patient’s symptoms.

(c) C. Nocturnal dyspnea and coarse crackles are indications of CHF. Hypertension can be an etiologic factor for heart failure. A diuretic, such as furosemide (Lasix), is useful in controlling water retention that can lead to fluid accumulation and narrowing in airways.

(u) D. The history, signs, and symptoms point to CHF. Guaifenesin (Mucinex) will not address the cause of the patient’s symptoms.

Answer 147

A

(c) A. Yankauer suction devices are designed specifically to suction secretions from the mouth in an efficient way.

(u) B. A DeLee suction trap is common in neonatal care, but would likely be unable to adequately remove large amounts of secretions from an adult.

(a) C. While it is possible to use a 14 Fr catheter for adult suctioning of the oral cavity, the Yankauer is designed for it. A 14 Fr catheter would possibly get easily occluded by large secretions and be ineffective.

(u) D. There is no reason to use a catheter designed to enter the left mainstem bronchus selectively on an oral suction procedure. It would be costly, and just like the 14 Fr whistle-tip, not as effective as the Yankauer.

Answer 148

A

A. Subcutaneous emphysema is demonstrated by the presence of crepitus during chest wall palpation.

(u) B. Pleurisy is a symptom of pain while breathing, typically associated with inspiration. There are often no physical findings for pleurisy.

(u) C. Bronchospasm is noted as a wheezing sound from narrowed airways.

(c) D. Secretions in the airway produce low-pitched, discontinuous lung sounds described as coarse crackles upon auscultation.

Answer 149

A

A. A diagnostic tool, such as an echocardiogram, will not treat the patient’s pleural effusion.

(c) B. Thoracentesis is indicated based on the patient’s chest radiograph and clinical findings.

(u) C. A diagnostic tool, such as a V̇/Q̇ scan, will not treat the patient’s pleural effusion.

(u) D. The patient’s pleural effusion requires treatment, which cannot be addressed through a bronchoscope in the patient’s airways. A thoracentesis is required to access the patient’s pleural space and drain the effusion.

Answer 150

A

c) A. Fluffy-appearing infiltrates in both lungs are consistent with the increased interstitial and alveolar fluid in pulmonary edema.

(u) B. Neoplasm would appear more localized and mass-like.

(u) C. The increased opacification of a pleural effusion is localized to the dependent areas of the chest and generally is not described as fluffy in appearance.

(u) D. An area of hemothorax will appear as an increased opacification in the dependent regions of the chest and generally is not described as fluffy in appearance.

Answer 151

A

A. Auto-PEEP is not detected during the inspiratory phase.

(c) B. Auto-PEEP is detected at the end of the expiratory phase. Expiratory hold permits pressure to be equilibrated throughout the ventilator circuit and the patient’s airway, allowing estimation of alveolar pressure.

(u) C. Plateau pressure is an end-inspiratory measurement.

(u) D. Changing to PSV mode should not be done to determine the presence of auto-PEEP while in the VC mode.

Answer 152

A

(h) A. Cricoid pressure is used during a rapid-sequence induction where bag-mask ventilation is avoided. If attempted, cricoid pressure may impair ventilation by altering the geometry of the trachea.

(c) B. The oropharyngeal airway can help restore airway patency and maintain adequate ventilation by pulling the tongue forward in an unconscious patient, where the tongue would otherwise obstruct the oropharynx.

(h) C. Trendelenburg position will cause the tongue to move cranially, further obstructing the oropharynx.

(u) D. Neck extension, rather than flexion, is recommended to open the airway and optimize positioning for bag-mask ventilation.

Answer 153

A

(u) A. Hypoxemia, not hyperoxia, will result in an increase in PVR.

(u) B. Hypovolemia will most likely result in a decrease in PVR.

(c) C. Excessive PEEP can compress the pulmonary vessels and obstruct blood flow, resulting in an increase in PVR.

(u) D. Decreased cardiac output results in decreased circulating volume and decreased PVR.

Answer 154

A

(u) A. The oxygen concentration delivered by a pulse-dose oxygen-conserving device may be reduced when longer tubing is used.

(u) B. Pulse-dose oxygen systems synchronize gas delivery with the beginning of inspiration.

(u) C. Pulse-dose oxygen systems are effective for those patients with low FIO2 needs.

(c) D. With continuous oxygen delivery, most oxygen is delivered during the first half of inspiration with the remainder being wasted. With pulse-delivered oxygen, most of the oxygen is delivered during the first quarter of the inspiration and no waste occurs.

Answer 155

A

(c) A. VC ventilation terminates inspiration after delivering a preset volume.

Answer 156

A

(c) A. The patient is experiencing hypoxemia associated with altitude and a lower inspired alveolar PO2. Increasing the oxygen flow will increase the inspired FIO2.

(u) B. The patient does not need CPAP. An increase in the FIO2 will help alleviate the hypoxemia associated with the high altitude.

(u) C. Administration of a diuretic will delay providing appropriate care.

(h) D. A sedative may cause hypoventilation and exacerbate the hypoxemia.

Answer 157

A

B. Relative humidity increases as a gas cools. When the relative humidity is at 100%, the gas is unable to hold more water vapor and it condenses into liquid.

Answer 158

A

(c) C. PAO2 = FIO2 (PB - PH2O) - PaCO2
R

        PAO2  =  1.0 (747 - 47) - 38
                                              0.8
        PAO2  =  700 - 48
        PAO2  =  652 mm Hg
        P(A-a)O2  =  652 - 152
        P(A-a)O2  =  500 mm Hg

Answer 159

A

(u) A. Increasing the flow to 7 L/min may result in patient discomfort and may not provide a high enough concentration of oxygen.

(c) B. The patient’s SaO2 of 83% indicates that a nonrebreathing mask is needed to provide a high FIO2.

(u) C. The patient’s PaCO2 indicates adequate ventilation. There are no indications to initiate mechanical ventilation. Less invasive treatments for the patient’s hypoxemia should be attempted first.

(u) D. A CPAP level of 3 cm H2O is unlikely to improve the patient’s hypoxemia.

Answer 160

A

(u) A. Secretions is an indication for fiberoptic bronchoscopy in the mechanically ventilated patient.

(u) B. Elevated airway pressures are generally required to ventilate around the scope inside the airway.

(u) C. Loss of consciousness will not directly impact adequate ventilation if compensatory measures are taken with ventilator settings.

(c) D. Placing the scope in the artificial airway may obstruct the tube, especially if the scope is too large for the artificial airway.

Answer 161

A

(u) A. Sedating the patient will probably improve the patient’s synchrony with the ventilator, but will not resolve the problem of the excessive inspiratory time due to low flow.

(u) B. Decreasing the tidal volume may result in an inadequate minute ventilation, and the problem will not be resolved.

(h) C. Increasing the pressure limit will not address the problem of inadequate flow and may increase the possibility of pulmonary overdistention.

(c) D. Increasing the flow will more adequately meet the patient’s inspiratory flow demand.

Answer 162

A

(u) A. Increasing the set inspiratory flow will lead to an even higher resistance in the small artificial airway.

(h) B. The tidal volume is currently set at 6 mL/kg of PBW. Raising the tidal volume will not reduce the resistance of the small tube and increases the potential for barotrauma.

(u) C. Though there may be some indication for a bronchoscopy with increased peak airway pressure, it would delay replacement of too small of an endotracheal tube based on the patient’s size.

(c) D. The small size of the endotracheal tube causes an increase in airway resistance causing an increase in the work of breathing. Using a larger diameter endotracheal tube will decrease the airway resistance, which will make the work of breathing easier.

Answer 163

A

(c) A. Repositioning may have caused displacement of the tracheostomy tube. Placing the patient supine will allow better access and ability to evaluate and correct the problem.

(u) B. Tube integrity and position should be assessed before it is removed.

(u) C. Instilling normal saline will not help the patient’s respiratory distress.

(u) D. The patient should be placed supine, and the tube should be evaluated before suction is attempted.

Answer 164

A

(u) A. Progressive bradycardia may result from an acute hypoxemia clinical event.

(c) B. Stimulation of vagal receptors in the tracheobronchial tree may cause a rapid slowing of the heart rate.

(u) C. Mucosal trauma will result in bleeding and not a decrease in the heart rate.

(u) D. Hypercapnia initially causes an increased respiratory rate.

Answer 165

A

(c) D. The treatment for carbon monoxide poisoning is a high concentration of oxygen (as close as possible to 100%) administered by nonrebreathing mask.

Answer 166

A

(u) A. Protein is 7% of surfactant.

(u) B. No significant glucose content exists in surfactant.

(c) C. Phospholipid is 85% of surfactant.

(u) D. No significant independent polysaccharide exists in surfactant.

Answer 167

A

(u) A. A right-to-left shunt is an anatomic shunt and is not diagnosed with a V̇/Q̇ scan.

(c) B. This is the classic description of a pulmonary embolism where the alveolar unit is normally ventilated, but pulmonary capillary blood flow is impeded by the presence of a clot.

(u) C. The consolidated alveolar units associated with pneumonia will inhibit ventilation and perfusion will be normal.

(u) D. A hemothorax will cause compression of the alveolar units and decrease ventilation.

Answer 168

A

(u) A. A pulse oximeter will only provide the clinical team with an indication of the patient’s oxygenation status, not ventilation status.

(u) B. A colorimetric CO2 detector is used to conform tracheal placement of an ETT. It does not monitor ventilation.

(c) C. Capnometry can be performed noninvasively through a cannula to monitor the patient’s ventilatory status.

(u) D. A transcutaneous oxygen monitor will only monitor the patient’s oxygenation status, not ventilation status.

Answer 169

A

(u) A. Levalbuterol (Xopenex) is a SABA. It is not the next step in asthma treatment.

(u) B. Umeclidinium/vilanterol (Anoro Ellipta) is a LABA/LAMA. It is not the next step in asthma treatment.

(c) C. According to national asthma guidelines, a LABA/ICS, such as fluticasone/salmeterol (Advair Diskus), should be initiated as the next step in this patient’s asthma treatment.

(u) D. Azithromycin (Zithromax) is an antibiotic, and not a standard of care in asthma treatment.

Answer 170

A

(h) A. There is neither evidence of increased secretions, nor the patient’s inability to cough effectively. Therefore, suctioning this patient is not indicated.

(c) B. The treatment should be discontinued because the patient is demonstrating severe respiratory distress of unknown etiology. Determining the cause of the distress is of the utmost importance.

(h) C. Decreasing the peak pressure will not identify the cause of the distress. Continuing the treatment, even at a lower pressure, may worsen the patient’s condition.

(h) D. Temporarily stopping the treatment will not determine the cause of the respiratory distress.

Answer 171

A

(c) A. Low PCWP and CVP coupled with a low urine output is characteristic of hypovolemia.

(u) B. A fluid overloaded patient would be characterized by a high PCWP and CVP.

(u) C. The urine output value is markedly low. The expected urinary output for a clinically stable patient is 0.5 mL/kg/hr.

(u) D. There is insufficient information to make this conclusion.

Answer 172

A

(u) A. Nausea and insomnia are common side effects of nicotine replacement therapy regardless of the route of administration.

(u) B. While nausea and insomnia are common side effects of nicotine replacement therapy, they may be resolved with a lower dose.

(c) C. Switching to a lower-dose nicotine patch should be the first step to address the common side effects of nausea and insomnia.

(u) D. An antiemetic will not address the insomnia, and lowering the dose of nicotine should be tried before adding another medication to the regimen.

Answer 173

A

(u) A. Systolic and diastolic pressures will increase if the bed is raised, not lowered, relative to the transducer.

(u) B. Changes in the level of the bed relative to the transducer will make both systolic and diastolic pressures move the same direction.

(c) C. A fluid-filled transducer catheter system is zeroed to the patient’s position. Lowering the patient relative to the height of the transducer will result in both a lower systolic and diastolic blood pressure reading proportionate to the change in patient position.

(u) D. Changes in the level of the bed relative to the transducer will make both systolic and diastolic pressures move the same direction.

Answer 174

A

(u) A. In some cases, repetitive cleaning and sterilizing may shorten the life of the equipment.
(c) B. Cleaning and sterilization are essential to limiting the transmission of organisms related to reusable respiratory care equipment.
(a) C. Although cleaning and sterilizing equipment may prevent contamination of other equipment, the primary goal is to limit transmission of infection to patients.
(a) D. Although cleaning and sterilizing equipment may protect medical personnel, the primary goal is to limit transmission of infection to patients.

Answer 175

A

(c) A. Per CDC guidelines, an initial step in managing disasters is to initiate a triage process.

(u, e) B. Turning away patients with chronic disease is unethical.

(u) C. Having oxygen available for anyone to use could be problematic.

(u) D. While this could be helpful, it is not the most immediate response needed in a disaster situation.

Answer 176

A

(u) A. If an appropriate size catheter is unable to remove the secretions, a smaller catheter would be less likely to help in this situation.

(u) B. While a larger endotracheal tube may allow suctioning with a larger bore suction catheter, it is not without risk. Changing the HME to heated humidifier should be tried first.

(c) C. A heated humidifier can deliver more humidity than an HME, which may help with thick secretions.

(u) D. There is no indication for dornase alfa (Pulmozyme) at this time.

Answer 177

A

(c) C. Dishwashing soap is recommended for cleaning home CPAP masks and tubing.

Answer 178

A

(c) B. Physiological dead space is calculated from the Bohr equation [(VD/VT = (PaCO2 - PeCO2)/PaCO2]. Thus, it is necessary to know the values for the arterial and expired values for carbon dioxide.

Answer 179

A

A. Based on the oxyhemoglobin dissociation curve, an SpO2 of 75% is approximately a PaO2 of 47 mm Hg for a patient with a normal pH.

Answer 180

A

(c) A. A CBC will provide a hemoglobin value that is used to calculate oxygen delivery.

(u) B. Exhaled nitric oxide can detect an inflammatory process, but it does not measure oxygen delivery.

(u) C. A crossmatch of the patient’s blood type should be completed in the event of blood loss; however, it does not provide information about oxygen delivery.

(u) D. Serial blood pressure assessment should be completed due to volume loss; however, it does not provide information about oxygen delivery.

Answer 181

A

(a) A. Although the patient’s PaO2 is slightly high, the patient’s respiratory alkalosis should be addressed first.

(c) B. Decreasing the set inspiratory pressure should result in a decreased tidal volume and minute ventilation, resulting in an improvement of the respiratory alkalosis. Additionally, the current exhaled tidal volume is greater than 8 mL/kg of ideal body weight and may be potentially harmful.

(a) C. While decreasing the mandatory rate will potentially correct the respiratory alkalosis, the high tidal volume needs to be addressed first.

(h) D. Reducing inspiratory time will not improve the respiratory alkalosis and may worsen oxygenation.

Answer 182

A

(u) A. The patient is using HFCWO. Adding another form of airway clearance will not significantly improve the care.

(u) B. N-acetylcysteine has not been shown to be beneficial for altering airway secretions and carries significant risk of bronchoconstriction.

(u) C. The patient is using HFCWO. Adding another form of airway clearance will not significantly improve the care.

(c) D. Dornase alfa (Pulmozyme) has been shown to decrease viscosity of sputum in persons with cystic fibrosis and to decrease the frequency of exacerbations requiring hospitalization.

Answer 183

A

C. 500 mL tidal volume divided by 10 cm H2O (plateau pressure - PEEP) equals 50 mL/cm H2O static compliance.

Answer 184

A

(u) A. Percutaneous tracheostomy should only be attempted after other, less invasive strategies have failed to provide effective ventilation.

(h) B. A head-tilt maneuver is contraindicated, due to manipulation of the cervical spine in a patient with a suspected neck injury.

(c) C. An oropharyngeal airway can be inserted using a limited amount of neck movement and it moves the tongue off the posterior wall.

(u) D. Using a flow-inflating resuscitator will not relieve the tongue obstruction.

Answer 185

A

(u) A. In the presence of a left tension pneumothorax, the patient will present with the left side of the chest not moving and the trachea will be deviated to the right.

(u) B. A left mainstem intubation will result in the right side of the chest not moving, but the trachea will not be shifted toward the left.

(u) C. With right-sided atelectasis, there will be limited movement of the right side of the patient’s chest, and the trachea may be deviated to the right.

(c) D. A right tension pneumothorax will cause a decrease in movement of the right hemithorax and the increased pressure from the pneumothorax will shift the trachea to the left.

Answer 186

A

(u) A. It is important to attempt clearance of the secretions first. Administering more medication, even diluted, may not help to clear these secretions.

(c) B. Secretions have been mobilized and the airway must be cleared before continuing treatment.

(u) C. Increasing the dose of medication will not help to clear the secretions further.

(u) D. Pausing the treatment and allowing the airway to be cleared is the most appropriate first step. Notifying the physician of these findings should occur afterwards.

Answer 187

A

(h) A. VC ventilation may exacerbate a pneumothorax.

(u) B. Administration of nitric oxide will not be helpful in the management of a pneumothorax.

(u) C. An ABG analysis could be performed to assess overall gas exchange, but will not help with the resolution of the pneumothorax.

(c) D. The onset of agitation, tachycardia, oxygen desaturation, and left chest tympany are suggestive of a tension pneumothorax. Needle decompression is recommended.

Answer 188

A

(c) A. Many patients with known CHF suffer from orthopnea. Sitting them upright in the high Fowler position is the best initial intervention to decrease pulmonary venous return and improve respiratory mechanics.

(h) B. Placing a patient with CHF in Trendelenburg position may exacerbate shortness of breath.

(u) C. Prone positioning is primarily for intubated patients with refractory hypoxemia due to ARDS.

(u) D. Left lateral positioning will result in the same complications as supine positioning.

Answer 189

A

(u) A. Although the placement of a tracheostomy may be required, other possibilities should be exhausted when it appears the patient may be able to wean if anxiety is controlled.

(u) B. A new approach is required, not simply transferring the patient to long-term acute care.

(h) C. Discontinuing SBTs and initiating an infusion of midazolam HCl (Versed) will make it more difficult to liberate the patient from mechanical ventilation, exposing the patient to further potential harm.

(c) D. Dexmedetomidine (Precedex) can provide effective anxiolysis without suppressing the respiratory drive. This may be used to overcome failure of SBTs due to anxiety when the patient is otherwise physiologically ready for extubation.

Answer 190

A

(u, e) A. A PaCO2 greater than 60 mm Hg or an increase in PaCO2 of 20 mm Hg or greater from baseline with no respiratory movement supports a diagnosis of brain death.

(c, e) B. A PaCO2 greater than 60 mm Hg or an increase in PaCO2 of 20 mm Hg or greater from baseline with no respiratory movement supports a diagnosis of brain death.

(u, e) C. Criteria for a determination of brain death have been reached. It is unnecessary to extend the test for a longer period of time.

(u, e) D. Results are conclusive, and supportive of a diagnosis of brain death.

Answer 191

A

(h) A. Changes in the respiratory care plan should not be implemented without a provider’s order.

(u) B. Changes in the care plan may be discussed by all members of the patient care team; however, changes cannot be implemented without a provider’s order.

(c) C. Despite notation in the provider’s progress notes, treatment changes require a provider’s order.

(u) D. Changes in the care plan may be discussed with supervisory personnel; however, changes cannot be implemented without a provider’s order.

Answer 192

A

(u) A. Male patients experiencing acute myocardial infarction are typically hypertensive.

(u) B. Pedal edema is not an indicator of an acute myocardial infarction.

(c) C. An elevated ST interval is a classic sign that a male patient is experiencing an acute myocardial infarction.

(u) D. Cardiac murmur is not an indicator of an acute myocardial infarction.

Answer 193

A

(u) A. Cardiac tamponade will present with tachycardia and tachypnea, but should not cause a change in the exhaled volume or ventilation to the right lung.

(c) B. A pneumothorax will result in tachycardia, decreased ventilation, and decreased breath sounds on the affected side.

(u) C. Lacerating a blood vessel may result in hemorrhage; however, it should have no immediate effect on the exhaled volume or diminish breath sounds.

(u) D. Anterior displacement of the tube may result in subcutaneous emphysema or airway obstruction.

Answer 194

A

(u) A. High-frequency oscillatory ventilation may be considered for patients with refractory hypoxemia, but should not be considered the first-line treatment for this patient.

(h) B. Decreasing PEEP may worsen the patient’s hypoxemia.

(u) C. There is no indication that the ABG analysis is incorrect. Obtaining a new ABG sample may delay care.

(c) D. Patients with severe refractory hypoxemia and high plateau pressures will benefit from lung recruitment.

Answer 195

A

(c) A. An ECG is required to rule out an acute myocardial infarction or arrhythmia before considering other diagnoses.

(u) B. A chest radiograph may be an appropriate diagnostic test after an ECG is performed.

(u) C. CT scan of the chest may be an appropriate diagnostic test after an ECG is performed.

(u) D. Cardiac ultrasound may be an appropriate diagnostic test after an ECG is performed.

Answer 196

A

(h) A. Given the significant increase in heart rate, the treatment should not be continued.

(u) B. There is no need to increase the inspired oxygen concentration as the oxygen saturation is 94%.

(u) C. Having the patient take slower breaths will likely not affect the elevated heart rate.

(c) D. Given the increase in heart rate, the treatment should be terminated and the results reported to the physician.

Answer 197

A

(c) A. In the presence of a flail chest, the findings most likely indicate a pneumothorax requiring needle decompression.

(u) B. An echocardiogram does not address the issue of decreased breath sounds.

(a) C. Though analgesia is important for patient comfort, needle decompression needs to be performed emergently.

(a) D. While a chest CT scan may be helpful, due to the patient’s significant compromise, needle decompression is first indicated.

Answer 198

A

(h) A. Placing an LMA requires extubation and replacement with a less secure airway device which would not be recommended.

(h) B. Fiberoptic bronchoscopy requires complete removal of the existing endotracheal tube and then reintubation, which can result in airway loss.

(u) C. Magill forceps are typically used for nasal intubation or removal of foreign bodies from the oropharynx and would not be appropriate in this situation.

(c) D. An airway exchange catheter allows the therapist to maintain a tract while exchanging the endotracheal tube. This decreases the risk of malposition of the new endotracheal tube, especially if the intubation is difficult or if there is upper airway swelling. In addition, many exchange catheters allow oxygenation by jet ventilation or manual bag-mask ventilation if there is difficulty replacing the tube in order to temporize until a more definitive solution can be achieved.

Answer 199

A

(c) A. This is a commonly performed method for oxygen titration.

(u) B. The patient needs an increase in oxygen.

(u) C. Switching to a simple mask will not be helpful. Also, a simple mask requires a minimum oxygen flow of 5 L/min.

(u) D. There is no reason to stop the test prematurely.

Answer 200

A

(c) A. This patient has a respiratory alkalosis. Decreasing the tidal volume will reduce the overall minute ventilation and help reduce the pH.

(u) B. There is no need to change from VC to PC ventilation in this patient. A simple change of the tidal volume is the first step to normalize the pH.

(u) C. Increasing peak flow will have no effect on the arterial blood gas analysis results.

(h) D. The patient has a normal serum bicarbonate level and thus the addition of supplemental bicarbonate is not necessary and will only result in a further increase in the blood pH.

Answer 201

A

(u) A. Fistulas are abnormal connections between tissues or organs and are rarely caused by arterial punctures.

(u) B. Fistulas are abnormal connections between tissues or organs and are rarely caused by arterial punctures. A pulmonary embolism is not associated with an arterial puncture.

(c) C. Hematomas, or large extravascular blood accumulations, will result when post-puncture pressure has not been applied adequately. Vessel spasm is a common complication associated with needle trauma.

(u) D. A pulmonary embolism is not associated with an arterial puncture.

Answer 202

A

(c) A. The pH is less than 7.35, which indicates acidemia. The PCO2 is elevated, which indicates respiratory acidosis. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia.

(u) B. The pH is less than 7.35, which indicates acidemia. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia.

(u) C. The HCO3- is within the normal range, so a metabolic acidosis is not present. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia.

(u) D. The pH is less than 7.35, which indicates acidemia.

Answer 203

A

(u) A. Peripheral perfusion will not be expected to change with the addition of PEEP.

(u) B. Tachycardia, not bradycardia, may be an expected adverse effect of increased PEEP.

(u) C. Increased FRC is a desired effect of PEEP.

(c) D. Hypotension can occur with increasing PEEP as the increase in intrathoracic pressure results in decreased venous return and, in turn, decreased preload.

Answer 204

A

(c) A. The blood gas values are acceptable for initiating a spontaneous breathing trial.

(u) B. The generally accepted standard of care is to perform a spontaneous breathing trial prior to considering extubation.

(u) C. Decreasing the mandatory rate will unnecessarily prolong the course of mechanical ventilation.

(u) D. Decreasing to less than 5 cm H2O PEEP is not indicated.

Answer 205

A

(c) A. The evidence suggests a pneumothorax. A chest radiograph is a quick test to identify the presence of pneumothorax.

(u) B. The evidence suggests a pneumothorax; a fiberoptic bronchoscopy is not indicated.

(u) C. A CT scan of the chest with contrast would be useful to identify pulmonary embolism. The data suggest pneumothorax as the cause of the changes.

(u) D. A ventilation/perfusion scan cannot be easily completed on a patient who is receiving mechanical ventilation.

Answer 206

A

(u) A. Oxygen desaturation may transpire if the patient’s ventilator drive and minute ventilation are reduced. The change from VC to PC ventilation increased the patient’s minute ventilation.

(u) B. Ventilator dyssynchrony can occur if the trigger sensitivity, inspiratory time, or flow make it more difficult for the patient to trigger a mechanical breath, or make it so easy that it will contribute to auto-triggering. This clinical scenario does not provide information that should lead the respiratory therapist to conclude dyssynchrony will occur.

(u) C. The risk for atelectasis can occur with hypoventilation. The change from VC to PC ventilation may contribute to hyperventilation, not hypoventilation.

(c) D. The increased VT will increase the patient’s minute ventilation and may decrease the PaCO2. Respiratory alkalosis may result.

Answer 207

A

(u) A. Increased conditioning usually results in a lower resting pulse rate.

(c) B. An important part of physical conditioning is an increase in exercise tolerance, easily measured by increased walking distance.

(u) C. Pulmonary function results do not normally improve with pulmonary rehabilitation.

(a) D. See explanation C.

Answer 208

A

(c) A. With increasing oxygen requirements and the recent administration of surfactant, a chest radiograph will aid in determining the cause of deterioration.

(u) B. Two hours is too early for a second dose of surfactant.

(u) C. High-frequency ventilation should not be initiated before obtaining a chest radiograph.

(u) D. Inhaled nitric oxide is indicated for persistent pulmonary hypertension. There is inadequate information to make this diagnosis.

Answer 209

A

(u) A. A tracheostomy button will not provide a patent airway for ventilatory support.

(u) B. A foam cuff tracheostomy tube is not designed to have the cuff collapsed for prolonged periods of time. A leak in the system may cause a foam cuff to reinflate, blocking the patient’s ability to exhale.

(c) C. When using a speaking valve, the cuff can be deflated and then reinflated for mechanical ventilation.

(h) D. A cuffless tracheostomy tube will not provide a closed system for periods of volume ventilation between ventilatory support.

Answer 210

A

(u,e) A. Initiating invasive mechanical ventilation is unethical as the patient has a DNI directive.

(u) B. Continuously nebulized albuterol will not provide adequate support for the patient while waiting until her family arrives.

(c, e) C. Noninvasive positive pressure ventilation is preferred as an initial mode for treating an acute respiratory failure in patients with acute exacerbations of COPD. As the patient has indicated she does not want to be intubated, this would provide the necessary ventilation while also respecting her wishes.

(u) D. Nutritional supplementation may improve respiratory muscle strength in malnourished patients. As the patient is near the end of life, this is not indicated.

Answer 211

A

(u) A. An HME should be discouraged for NPPV use as it may hamper triggering and increase deadspace.

(u) B. An HME should be considered for short-term mechanical ventilation. A patient with ARDS will require long-term mechanical ventilation and humidification.

(c) C. An HME should be considered for short-term mechanical ventilation like that used for a patient in PACU.

(h) D. An HME is contraindicated in a bronchopleural fistula. The air leak will not allow the HME to collect adequate moisture from the decreased volume exhaled to humidify the inhaled gas.

Answer 212

A

(c) A. An adequate oxygen supply is necessary to complete the trip.

(u) B. The endotracheal cuff should be inflated rather than deflated.

(u) C. There is no clinical indication to increase the FIO2. Increasing the FIO2 will affect the O2 supply available for the transport.

(u) D. Heated humidification is not necessary in this situation and adds cumbersome equipment to the transport.

Answer 213

A

(u) A. Condensation in the circuit is likely causing auto-triggering. Decreasing the mandatory rate will not correct the auto-triggering.

(u) B. Individuals with congenital central hypoventilation syndrome do not initiate ventilation during sleep and would most likely be unable to trigger the ventilator.

(c) C. The patient is dyssynchronous with the ventilator likely due to condensation in the circuit causing auto-triggering. No ventilator setting changes are indicated without having more details.

(u) D. Some children with a tracheostomy have cuffed tubes to help compensate for a leak, but information related to this is not known given the information provided.

Answer 214

A

(u) A. The patient’s blood gas values are acceptable. Switching to PC ventilation is not indicated.

(u) B. The patient’s blood gas values do not indicate the need to increase the spontaneous tidal volume.

(h) C. There is insufficient evidence to indicate the patient is ready for extubation.

(c) D. With the information provided, this patient qualifies for a spontaneous breathing trial.

Answer 215

A

(u) A. Nothing in this scenario indicates the titration should be prematurely terminated.

(u) B. There is no need for continued observation before modifying the patient’s CPAP settings.

(u) C. The patient’s AHI of 15 will not be corrected by adding 2 L/min of supplemental oxygen.

(c) D. Airway patency needs to be re-established by increasing the CPAP level.

Answer 216

A

(u) A. A nasogastric tube is not necessary for cardioversion.

(c) B. A bag-valve-mask resuscitator is required for patient safety as the patient will be sedated and may have a post-event that requires resuscitation.

(a) C. The end-tidal CO2 monitor may be helpful to monitor sedation, but is not an integral part of the procedure.

(u) D. Blood gas sampling is not a standard of care with cardioversion.

Answer 217

A

(c) A. Air contains essentially no helium; therefore, it should read zero.

(u) B. There is 79% nitrogen in air.

(u) C. This implies there is 100% helium in air.

(u) D. There is 21% oxygen in air.

Answer 218

A

(u) A. The patient has chronic respiratory acidosis with an acute process causing further CO2 retention. Noninvasive ventilation is a reasonable first step before a more aggressive step of invasive ventilation.

(u) B. Measuring vital capacity will not address the patient’s ventilation problem and may result in a delay of care.

(u) C. Performing airway clearance will not improve minute ventilation or provide ventilator assistance.

(c) D. Blood gas analysis results indicate a need to provide ventilatory assistance. NPPV will address the ventilation problem.

Answer 219

A

(u) A. A CBG sample only provides an accurate evaluation of ventilation status, not of oxygenation status.

(c) B. Pulse oximetry will provide the most rapid assessment of oxygenation status.

(a) C. ABG analysis will provide accurate assessment of oxygenation status, but will not provide the most rapid turnaround time for results.

(u) D. Transcutaneous monitoring will not provide rapid assessment of oxygenation status due to required calibration and equilibration.

Answer 220

A

(c) A. A patient with obstructive sleep apnea typically has an irregular breathing pattern.

(u) B. Evaluation of peripheral perfusion would not be helpful in this patient’s assessment.

(u) C. Evaluation of breath sounds would not be helpful to assess for sleep-disordered breathing.

(u) D. While the cardiac rate will likely vary with obstructive sleep apnea, it is not diagnostic.

Answer 221

A

(c) A. The APGAR scoring system consists of the following:

Score 0 1 2
Appearance pale or blue acrocyanosis completely pink
Heart rate absent < 100 per minute > 100 per minute
Reflex irritability no response grimace cry, cough, sneeze
Muscle tone limp some flexion active motion
Respiration absent slow, irregular good cry

The score for 1 minute is 6: central cyanosis = 0, pulse of 105 = 2, sneeze = 2, some flexion = 1, irregular respiratory rate = 1.
The score for 1 minute is 3: central cyanosis = 0, pulse of 80 = 1, grimace = 1, limp = 0, slow respiratory rate = 1.

Answer 222

A

(c) A. Albuterol is a fast-acting beta2-agonist and is the appropriate treatment for acute bronchospasm.

(u) B. Ipratropium (Atrovent) is useful only as an adjunct to albuterol and only in the early phases of treatment.

(u) C. Salmeterol (Serevent) is a long-acting beta2-agonist that has a long onset of action and will not be useful for an acute exacerbation.

(u) D. Tiotropium (Spiriva) is a long-acting bronchodilator and is not useful for an acute asthma exacerbation.

Answer 223

A

(u) A. The patient’s SpO2 is adequate at rest, so he does not require O2 when not exercising or exerting himself.

(u) B. The patient needs more than 1 L/min because 86% is not a sufficient SpO2.

(u) C. The patient’s SpO2 is adequate at rest. He does not require O2 when not exercising or exerting himself.

(c) D. The patient’s SpO2 is adequate with 2 L/min during exercise, and is adequate at rest without O2 supplementation.

Answer 224

A

(u) A. The device should be calibrated at the site of use before proceeding to quality control assessment.

(u) B. Changes in barometric pressure can introduce measurement errors.

(u) C. Electrodes do not need to be replaced prior to use of a new analyzer.

(c) D. Regardless of where they are manufactured, new blood gas analyzers must be calibrated at the site of use before analyzing blood.

Answer 225

A

(u) A. The right radial artery should not be punctured when there is insufficient collateral circulation through the ulnar artery.

(u) B. Procedures should be avoided on a shunted extremity when alternative sites are available to protect the patency of the shunt for dialysis.

(c) C. The right brachial artery is the appropriate alternative site from which to obtain an arterial blood gas sample.

Answer 226

A

(c) A. FIO2 is impacted by both the flow into the bag and the presence of a reservoir. With oxygen flow set at 15 L/min and a reservoir attached, the concentration approaches 100%. When a reservoir is not attached, the concentration is approximately 40% less.

(u) B. A PEEP valve is a threshold resistor and has no effect on oxygen concentration.

(u) C. Bag size does not have a primary impact on oxygen concentration. A PEEP valve is a threshold resistor and has no effect on oxygen concentration.

(u) D. Bag size does not have a primary impact on oxygen concentration.

Answer 227

A

(u) A. Breath-holding will not decrease the trapped air causing the auto-PEEP.

(h) B. Adding mechanical deadspace will not affect the time available for exhalation and may increase the arterial carbon dioxide.

(c) C. Decreasing the mandatory rate will increase expiratory time. Allowing more time to exhale will reduce air trapped in the lungs at the end of exhalation, or the auto-PEEP.

(h) D. Decreasing the inspiratory flow will decrease expiratory time, allowing less time for air to escape. This will not reduce auto-PEEP and has the potential to worsen air-trapping.

Answer 228

A

(c) A. This patient is alert and ready for extubation.

(a) B. Assessing pulmonary mechanics will provide additional clinical information; however, it is unnecessary in this patient.

(u) C. There is no reason to titrate the FIO2 in this instance as the oxygen saturation is adequate at this level of support.

(h) D. The patient is alert and ready for extubation. Maintaining mechanical ventilation exposes the patient to nosocomial infections and delays discharge.

Answer 229

A

(u) A. 5 cm H2O PEEP will not result in either the best SpO2 or static compliance.

(u) B. 10 cm H2O PEEP may lead to a marginally acceptable SpO2, but not the best compliance.

(c) C. This change will lead to the highest compliance with acceptable systemic blood pressure and SpO2. In the absence of cardiac output measurements; compliance, blood pressure, and SpO2 are the only useful data for determining optimal PEEP.

(u) D. The application of 20 cm H2O PEEP will decrease the static compliance and blood pressure, suggesting the lung is overexpanded.

Answer 230

A

(c) A. Due to the allergic component to this patient’s disease, NAEPP guidelines recommend the addition of a leukotriene receptor antagonist, such as montelukast (Singular), as part of the step-up approach to therapy in an uncontrolled patient, especially those with an allergic component.

(u) B. A short-acting anticholinergic is not part of the NAEPP guidelines for stepwise therapy, and is unlikely to improve the patient’s long-term control of her asthma symptoms.

(u) C. Antibiotic therapy is not a standard of care for the treatment of asthma.

(u) D. If the patient’s symptoms do not improve, a systemic corticosteroid may be needed to gain control of the patient’s asthma symptoms. However, a leukotriene modifier should be used first due to the patient’s history of moderate, persistent asthma with an allergic component.

Answer 231

A

(c) A. Cisatracurium (Nimbex) is a nondepolarizing skeletal muscle relaxant that may be administered to patients prior to endotracheal intubation or during mechanical ventilation.

(h) B. Morphine is an opioid that acts upon receptors in the brain and spinal cord to reduce the feeling of and emotional response to pain.

(a) C. Midazolam HCl (Versed) is a benzodiazepine that can be used as an anxiolytic and amnestic. It does not have any significant neuromuscular-blocking effects.

(u) D. Succinylcholine chloride (Anectine) is a depolarizing skeletal muscle relaxant whose onset of paralysis is very rapid (less than 1 minute after IV administration) and effects are very short (approximately 4 to 6 minutes). It is not an effective agent for skeletal muscle paralysis because it will not sustain paralysis.

Answer 232

A

(u) A. Hypertonic saline is used for mucus clearance. It will not treat the lung infection.

(c) B. Tobramycin (TOBI) is an inhaled antibiotic, and is the standard of care to treat lung infections in patient with cystic fibrosis.

(u) C. Budesonide is an inhaled steroid used to decrease inflammation. It will not treat the lung infection.

(u) D. N-acetylcysteine is a mucolytic and is not indicated for patients with cystic fibrosis.

Answer 233

A

(u) A. Increased oxygen requirements and an elevated PaCO2 indicate a need to change therapy.

(c) B. The patient’s condition continues to deteriorate, based on increased oxygen requirements and an elevated PaCO2, indicating the need for assisted ventilation.

(u) C. The patient continues to be hypoxemic despite increased supplemental oxygen. Decreasing the FIO2 does not address the ventilatory failure.

(u) D. There is no indication for vibratory PEP.

Answer 234

A

(h) A. Sedating the patient will depress respirations and worsen the degree of hypoxemia.

(h) B. The patient is able to maintain adequate ventilation; therefore, intubation is not indicated.

(c) C. In the presence of CHF and subsequent pulmonary edema, mask CPAP can be used to recruit collapsed alveoli, increase lung volumes by increasing transpulmonary pressure, and correct hypoxemia.

(h) D. Administering an FIO2 of 1.0 may transiently improve oxygenation; however, it places the patient at risk for oxygen toxicity and absorption atelectasis.

Answer 235

A

(u) A. Although a larger endotracheal tube may be indicated when high cuff pressures are needed to obtain minimum occlusion volume, the recurrent aspiration and abdominal distention indicate a possible connection between the trachea and the esophagus.

(h) B. Cuff pressures of 30-34 cm H2O are above the recommended range, and use of a higher cuff pressure may cause tissue necrosis.

(c) C. Long-term use of high cuff pressures can increase the risk of developing a tracheoesophageal fistula. The recurrent aspiration and abdominal distention indicate a possible connection between the trachea and the esophagus.

(u) D. There are no indications of upper or lower airway inflammation, so a glucocorticosteroid should be not administered.

Answer 236

A

(h) A. A nonrebreathing mask is not indicated and may produce hyperoxygenation resulting in respiratory depression in a patient with chronic hypercarbia and hypoxemia.
(u) B. There is no indication for NPPV for a patient in a compensated acid-base state.
(h) C. Excessive oxygen may suppress the patient’s respiratory drive.
(c) D. A nasal cannula provides a variable oxygen concentration.

Answer 237

A

(u) A. Mallampati score I is characterized by complete visualization of the soft palate, uvula (including the tip), fauces, and tonsillar pillars.

(u) B. Mallampati score II is characterized by visualization of the soft palate, fauces, and most of the uvula (but notably with the tip obscured).

(c) C. Mallampati score III is characterized by the visualization of the soft palate, including the base of the uvula only.

(u) D. Mallampati score IV is characterized by the visualization of the hard palate only. None of the soft palate is visible.

Answer 238

A

(u) A. Although the patient’s PaO2 is high and decreasing the FIO2 is warranted, the swelling of the patient’s lips and burns on the face and neck increases the risk of a compromised airway. Emergency intubation is indicated.

(u) B. Although aerosolized racemic epinephrine may reduce the patient’s upper airway swelling, emergency intubation is indicated due to the patient’s swollen lips and burns on the face and neck.

(c) C. The burns on the patient’s face and the swelling of her lips indicate the need for emergency intubation to protect the patient’s airway.

(u) D. Emergency intubation is indicated due to the patient’s swollen lips and burns on the face and neck.

Answer 239

A

(u) A. Clubbing does not involve the joints.

(c) B. Clubbing causes an increased angle between the nail bed and the finger, as well as an increase in the diameter of the terminal portion of the finger.

(u) C. Discoloration does not occur with clubbing of the digits.

(u) D. The symmetry of the fingers is not an accurate assessment of digital clubbing.

Answer 240

A

(c) A. The therapist should suspect the regulator setting has been switched to continuous mode rather than pulse dose.

(u) B. These units do not have an oxygen sensor to calibrate.

(u) C. Replacing the nasal cannula may be considered after confirming the regulator setting is set to pulse dose.

(u) D. Increasing the flow does not affect the pulse mode selected.

Answer 241

A

(u) A. End-tidal CO2 tensions will not rise until the ventilatory impairment is severe.

(u) B. While PaCO2 provides data regarding ventilation, vital capacity measurements are less invasive and can provide trending information earlier in the progression of the disease.

(c) C. Guillain-Barré syndrome is a neurological disease that causes weakness of respiratory muscles and ascending paralysis. Serial measurements of vital capacity will reveal progressive neuromuscular ventilatory impairment.

(u) D. Peak flow is used to monitor airways obstruction in patients with asthma, not neurological diseases, like Guillain-Barré syndrome.

Answer 242

A

(c) A. Peak flow is the maximum flow during a forced exhalation.

(u) B. Vital capacity is the volume measured from maximal inhalation to maximal exhalation.

(u) C. FEV1 is the volume exhaled in the first second of a forced vital capacity maneuver.

(u) D. V̇E is the volume exhaled from a person’s lungs per minute.

Answer 243

A

(c) B. AASM guidelines classify obstructive sleep apnea by an AHI of 5 or greater.

Answer 244

A

(u) A. Allergic rhinitis is often associated with nasal symptoms of runny nose and congestion, not fever and sputum production.

(u) B. A viral respiratory tract infection is often associated with a nonproductive cough.

(u) C. Congestive heart failure is often associated with shortness of breath and nonproductive cough.

(c) D. These signs and symptoms are often associated with bacterial pneumonia.

Answer 245

A

(u) A. There is no indication for nasal CPAP in a well-oxygenated patient.

(c) B. The FIO2 should be decreased to minimize the risk of retinopathy of prematurity.

(u) C. There is no evidence of neonatal RDS; therefore, surfactant is not indicated.

Answer 246

A

(u) A. The patient is showing signs of excess fluid, which cannot be treated by changing the patient’s IV fluid to D5W.

(h) B. The patient is showing signs of fluid overload. Administering an additional bolus of normal saline may increase the risk of respiratory distress and cause harm to the patient.

(h) C. Administering albumin will increase the volume of blood, which could be harmful to a patient showing signs of fluid overload.

(c) D. The faint crackles heard in the lung bases and the increase in CVP show that the patient is fluid overloaded. Minimizing the administration of IV fluids will prevent the patient’s condition from worsening.

Answer 247

A

(u) A. Although ABG analysis can evaluate arterial oxygen content, analysis of a mixed venous sample is the best evaluation of tissue oxygenation.

(c) B. Analysis of a mixed venous sample from the pulmonary artery catheter is the best method to evaluate tissue oxygenation.

(u) C. Serum lactate level is a measure of anaerobic metabolism and does not evaluate tissue oxygenation.

(u) D. Cardiac output is used to assess oxygen delivery, but does not provide information regarding the oxygen content of the blood to evaluate tissue oxygenation.

Answer 248

A

(a) A. Alveolar ventilation can increase without significantly involving accessory muscles.

(u) B. The use of accessory muscles is often associated with decreased lung compliance.

(c) C. Increased airways resistance requires the use of accessory muscles to move air.

(u) D. Increased cardiac output is not associated with the use of accessory muscles.

Answer 249

A

(u) A. The flow to the mask is too low and should be increased to 15 L/min. Removing the one-way valve will not increase the amount of flow to the mask.

(u) B. A simple mask will provide a lower concentration of oxygen. The nonrebreathing mask should continue to be used, but the flow should be increased to 15 L/min.

(u) C. The use of a bubble humidifier is not appropriate with a nonrebreathing mask.

(c) D. A flow of 10-15 L/min should be used with a nonrebreathing mask. A flow of less than 10 L/min may cause the reservoir bag to deflate during inspiration, reduce the concentration of oxygen delivered to the patient, and may worsen the patient’s work of breathing due to inadequate flow to the mask.

Answer 250

A

(u) A. The third intercostal space in the mid-clavicular is more appropriate for a pneumothorax.

(c) B. The fifth intercostal space in the mid-axillary line is appropriate for draining fluid from the chest. A tube placed any higher than the thorax may not adequately drain the fluid.

(u) C. The second intercostal space in the mid-clavicular line is more appropriate for a pneumothorax.

(u) D. The fourth intercostal space in the mid-axillary line is too high to drain a hemothorax.

Answer 251

A

(u) A. A liquid oxygen system is expensive and requires regular refills.

(u) B. E cylinders require regular replacement and supply can be depleted.

(c) C. An oxygen concentrator is the most cost-effective option as it does not require refills or replacements.

(u) D. Delivering transtracheal oxygen has no impact on the economics of the delivery system.

Answer 252

A

(c) A. The correct negative pressure to use when suctioning the airway of a infant is -80 to -100 mm Hg.

(h) B. A negative pressure of -120 mm Hg is likely to damage airway mucosa.

(h) C. A negative pressure of -150 mm Hg is likely to damage airway mucosa.

(u) D. It is the therapist’s responsibility to know the recommended safe suction pressures for the various patient populations.

Answer 253

A

(u) A. The resulting minute ventilation of 2.4 L/min is inadequate for this patient.

(c) B. Using the predicted or PBW formula for women (45.5 kg + 2.3 kg for each inch over 5 ft), the patient’s PBW is 50 kg (110 lb). Tidal volume is 8 mL/kg of PBW, which is appropriate.

(a) C. This tidal volume is 12 mL/kg of PBW, which is too large.

(u) D. This tidal volume is 10 mL/kg of PBW, which is too large.

Answer 254

A

(u) A. No causal relationship between the use of aerosolized pentamidine isethionate (NebuPent) and tachycardia has been established.

(u) B. No causal relationship between the use of aerosolized pentamidine isethionate (NebuPent) and bradycardia has been established.

(c) C. Bronchospasm is the most frequently reported adverse effect associated with the use of aerosolized pentamidine isethionate (NebuPent.)

(u) D. Hypotension is associated with the use of IV or IM pentamidine isethionate (Pentam). It has not been shown to be a problem when the drug is aerosolized.

Answer 255

A

(u) A. Dornase alfa (Pulmozyme) is not available in DPI form.

(u) B. Dornase alfa (Pulmozyme) is not available in MDI form.

(u) C. An ultrasonic nebulizer may alter the configuration of the medication.

(c) D. A vibrating mesh nebulizer will not alter the configuration of the medication and will not increase volume delivery to patient.

Answer 256

A

(c) D. Minute ventilation = VT x RR = 450 mL/breath x 12 breath/min = 5400 mL/min = 5.40 L/min.

Answer 257

A

(u) A. The conversion factor for a 60/40 heliox mixture is 1.4.

(u) B. The conversion factor for a 70/30 heliox mixture is 1.6.

(c) C. The conversion factor for an 80/20 heliox mixture is 1.8.

(u) D. This conversion factor does not exist for a heliox mixture.

Answer 258

A

(c) A. Evaluation of MIP is to determine the strength of the muscles used for inspiration.

(u) B. Evaluating a patient’s MIP does not provide information about a patient’s oxygenation status. Evaluation of maximum inspiratory pressure is to determine the strength of the muscles used for inspiration.

(u) C. Although a poor MIP measurement may be a result of poor ventilation, evaluation of MIP does not provide information about a patient’s ventilation status.

(u) D. An abnormally low MIP measurement may result in an abnormal V̇/Q̇ ratio by altering a patient’s ability to ventilate. However, evaluation of MIP does not determine a patient’s V̇/Q̇ ratio.

Answer 259

A

(u) A. The set inspiratory time will not directly impact the work of breathing, and lengthening it may make the patient less comfortable.

(u) B. Ramp time is designed to slowly increase CPAP as the patient falls asleep for increased comfort.

(a) C. Increasing PEEP may help with work of breathing, but it more directly impacts oxygenation.

(c) D. Increasing pressure support directly impacts the patient’s work of breathing.

Answer 260

A

(u) A. A chest radiograph provides only anatomic abnormality information, not evaluation of functional status.

(u) B. Furosemide (Lasix) is a diuretic and administration will not treat the increased airways resistance or bronchospasm.

(h) C. Information from an ABG analysis will not assist in the treatment of the increased airways resistance or bronchospasm.

(c) D. Ipratropium (Atrovent) treats bronchoconstriction by a mechanism different from albuterol and should decrease airways resistance or bronchospasm.

Answer 261

A

(u) A. There is no indication that the treatment needs to be terminated.

(u) B. See explanation A.

(c) C. The heart rate response is within normal limits, so continuing the treatment as ordered is appropriate.

(u) D. Normal saline has no pharmacological value in this situation.

Answer 262

A

(a) A. NPPV is effective in improving ventilation, but it is unlikely that it will be sufficient to meet oxygenation and ventilation requirements of a patient with severe ARDS.

(h) B. Drug overdose patients are prone to aspiration. NPPV can lead to gastric insufflation, thus increasing the risk of aspiration. These patients require intubation for airway protection.

(h) C. NPPV can lead to gastric insufflation, thus increasing the risk of further aspiration.

(c) D. NPPV may lead to reduced mortality in patients with COPD.

Answer 263

A

(c) A. Albuterol is a quick-relief medication. It should be used as needed, not at a scheduled frequency.

(u) B. Peak flow monitoring will not address the need to reeducate the parents on the indications and use of a quick-relief inhaler.

(u) C. The route of administration does not need to be addressed. Rather, education on the indications and use of a quick-relief inhaler is warranted.

(u) D. An exercise regimen will not address the family’s educational needs.

Answer 264

A

(u) A. The most likely explanation is a right mainstem intubation that can be resolved by withdrawing the endotracheal tube until bilateral breath sounds are heard.

(u) B. While a chest radiograph can assist with diagnosing a right mainstem intubation, ventilating only one lung while waiting for a radiograph may compromise the patient’s oxygenation. A chest radiograph should be obtained to confirm placement or to diagnose alternative etiologies of unilaterally decreased breath sounds if withdrawing the endotracheal tube fails to resolve the issue.

(c) C. This patient most likely has a right mainstem intubation due to advancing the endotracheal tube too deep during intubation. This is easily resolved by withdrawing the endotracheal tube until bilateral equal breath sounds are heard. Diagnosing and resolving this issue early is imperative as a delay in recognizing right mainstem intubation can result in compromised oxygenation from ventilating only one lung.

(u) D. While a left pneumothorax is possible, given the timing immediately after intubation makes malposition of the endotracheal tube in the right mainstem more likely.

Answer 265

A

(u) A. MIP is a measurement that reflects inspiratory muscle strength.

(c) B. Spirometry provides detail of a patient’s lung condition as well as the patient’s ability to cough.

(u) C. While a CBC may be obtained prior to surgery, it does not reflect the patient’s ability to avoid respiratory complications.

(u) D. An ABG analysis may indicate a potential pre-existing lung condition; however, it will not reflect the patient’s ability to deep breathe and cough postoperatively.

Answer 266

A

(u) A. There is insufficient data to indicate increased air trapping.

(c) B. An increase in the difference between peak airway pressure and plateau pressure is indicative of increased airways resistance.

(u) C. A decrease in inspiratory flow will result in decreased peak airway pressure.

(u) D. Based on an unchanging VT and a constant plateau pressure, static compliance has not changed.

Answer 267

A

(u) A. An N95 mask is required when following CDC airborne precautions.

(c) B. According to CDC droplet isolation precautions, a surgical mask is required if the distance between the patient and others is 3 feet or less.

(u) C. An air-purifying respirator is required when following CDC airborne precautions.

(u) D. A full-face respirator is not needed for droplet precautions.

Answer 268

A

(h) A. Since the patient continues with refractory hypoxemia, a decrease in the FIO2 setting would be detrimental.

(u) B. Given the patient’s normal PCO2, increasing the mandatory rate to 20 will not improve the patient’s oxygenation.

(u) C. There is no indication that changing the mode to SIMV will be beneficial.

(c) D. Prone positioning has been shown to improve oxygenation and mortality in patients with severe ARDS by improving V̇/Q̇ mismatch.

Answer 269

A

A. In the presence of normal vital signs, the SpO2 value may be inaccurate. Therapy should not be initiated before confirming this value.

B. The SpO2 value may not be accurate. Recording the value in the medical record may result in unnecessary interventions.

(h) C. Obtaining an arterial blood gas sample based on an inaccurate SpO2 value may cause unnecessary harm to the patient.

(c) D. The saturation may not be accurate, and should be measured at a different site.

Answer 270

A

(c) A. A 3-liter syringe provides accurate volumes for calibration and is the gold standard for assessing the volume accuracy of a spirometer.

B. A pneumotachometer measures flow and does not directly measure volume.

C. A vortex sensor spirometer measures flow integrated with time and is not sufficiently accurate for calibration.

D. A Wright respirometer is not sufficiently accurate to be used as a volume standard

Answer 271

A

A. Thoracentesis is useful to diagnose the origin of a pleural effusion; however, that is not what is indicated in this situation.

(c) B. Microbiologic analysis of material obtained during a bronchoscopy with BAL will differentiate between hydrostatic pulmonary edema associated with fluid overload or left ventricular failure, and non-hydrostatic pulmonary edema associated with ARDS.

C. Transthoracic needle biopsy is useful in obtaining lung tissue in the diagnosis of lung cancer; however, that is not what is indicated in this situation.

D. Transbronchial needle aspiration is useful in the diagnosis of lesions on the periphery of the lung; however, that is not what is indicated in this situation.

Answer 272

A

(u) A. Radiographic aspects of a pneumothorax are not evident, including the absence of visible lung markings.

(u) B. A chest tube is not present on this radiograph.

(u) C. A chest tube is not present on this radiograph. Radiographic aspects of a pneumothorax are not evident, including the absence of visible lung markings.

(c) D. The entire tracheostomy tube is visible at the clavicles ending in the trachea. Pleural effusion is present in the lower zone of the radiograph noted by obscuring of the heart border, costophrenic angle, and hemidiaphragm.

Answer 273

A

(c) A. An increase and slant in CO2 are characteristic of emphysema due to prolonged expiration and air trapping.

B. Morbid obesity will not have an impact on a capnograph.

C. Pulmonary embolism will cause an increase in alveolar dead space resulting in a decrease in the expired CO2 level.

D. Mainstem intubation will not have the slant shape to the capnograph.

Answer 274

A

A. An expiratory flow would not return to zero flow baseline, but vary breath to breath.

(c) B. The sawtooth pattern of the flow-volume waveform indicates secretions in the airway.

C. In the presence of a system leak, the flow would not return to zero on most if not all breaths.

D. An inadequate inspiratory flow rate would be indicated by a scalloping pattern of the flow-volume waveform.

Answer 275

A

A. A patient in cardiac arrest will have an absent PETCO2.

B. Normal exhalation will produce a rectangular waveform that has an abrupt rise in CO2 during phase II followed by a plateau.

C. An air leak around the tracheal tube or tracheostomy will result in a waveform with a peaked, triangular appearance.

(c) D. Obstructive lung disease shows impaired expiratory air flow with a more rounded ascending phase that never reaches the plateau.

Answer 276

A

(h) A. Decreasing the mandatory rate will not resolve the “bird-beak” pattern caused by excessive tidal volume.

(h) B. The lungs are already being hyperinflated with each breath. Decreasing PEEP will potentially exacerbate the hyperinflation.

(c) C. “Bird-beak” patterns are a result of hyperinflation. Decreasing the tidal volume will correct the hyperinflation.

(h) D. Decreasing the expiratory time will cause an increase in tidal volume and exacerbate the hyperinflation (auto-PEEP).

Answer 277

A

A. Adjusting the PEEP is not indicated and does not address the dyssynchrony.

B. A flow rate that is too low is represented by a scooped inspiratory flow curve. There are no indications to adjust the flow rate.

C. There are no indications that the tidal volume is inadequate. The patient’s trigger sensitivity should be adjusted so less negative force is needed to trigger a breath.

(c) D. The patient is having difficultly triggering the breath, which is shown by the significant negative force created before the breath is delivered. The trigger should be adjusted to be more sensitive to improve the patient’s ability to trigger a breath.

Answer 278

A

(c) A. Though there is evidence of auto-PEEP in the flow-time graphic, the patient’s normal pH and stable hemodynamics indicate no intervention is currently needed.

B. There is no indication of a need to decrease the FIO2.

C. There is no indication to change to VC ventilation.

(h) D. An increase in mandatory rate will cause a decrease in expiratory time and will result in increased auto-PEEP.

Answer 279

A

A. Given the improvement in the flow-volume loop after bronchodilator administration, there is no indication for bronchoscopy.

B. NPPV is not useful for reversible airways disease.

(c) C. The flow-volume loop obtained after bronchodilator administration demonstrates a significant improvement in expiratory flow.

D. This flow-volume loop indicates reversible airway obstruction, and there is no information regarding the presence of hypoxemia to justify the use of supplemental oxygen therapy.

Answer 280

A

A. The curve is not indicative of a malfunctioning exhalation valve.

B. The tracing does not provide data indicating the need for a change in the mode of ventilation.

(c) C. The lack of a plateau and upward sloping shape of the curves demonstrate impairment of exhalation due to an obstructive process or airways collapse.

D. Calculating the gradient between PaCO2 and PETCO2 will not explain the abnormal shape of the curve.

Answer 281

A

(c) A. The expiratory flow does not return to baseline prior to the start of the next breath. This indicates auto-PEEP is present.

B. A small leak would likely not show up in this graphic.

C. If the exhalation valve were faulty (i.e., stuck open), there would be no exhalation flow because the inspiratory flow would travel directly through the circuit.

D. An expiratory hold would result in a period of no flow, and the duration of expiration would be extended until the end of the hold. This is not present in the graphic.

Answer 282

A

(c) A. The graphic shows that the volume isn’t returning to baseline and a leak is present.

B. The graphic does not show an airway obstruction.

C. If the tidal volume is too high, the graphic will show overdistension, i.e. “birds’ beak.”

D. The graphic does not represent secretions in the airway.

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