TMC Module 1

Question 1

During the assessment of 60-year-old female patient, you note the following signs:

dyspnea, hypotension, reduced chest expansion on the left side, hyperresonant percussion note and tactile fremitus on the left side, absent breath sounds on the left side, and a tracheal shift to the right.

These findings suggest which of the following?

A. A pleural effusion on the left side
B. A pneumothorax on the left side
C. Atelectasis on the left side
D. Consolidation on the left side

Answer 1

B. A pneumothorax on the left side

To get this one correct, you needed to be able to interpret the signs that were given about the patient in the question.

This is a common type of question for the TMC Exam.

The question tell us that the patient has reduced chest expansion, a hyperresonant percussion note, absent breath sounds, and tactile fremitus all on the left side.

That to go along with a tracheal shift to the right. This indicates that the patient has a pneumothorax on the left side.

Remember that, when a pneumothorax is present, the trachea will shift away from the affected side.

That means you can rule out left-sided atelectasis because the trachea would shift to that side.

A pleural effusion and consolidation would cause a dull
percussion note, not a hyperresonant note, so we can rule out those two as well.

The correct answer is: B. A pneumothorax on the left side

Question 2

A 39-year-old male patient was admitted to the emergency department with a fever and an SpO2 of 87% on room air.

Upon auscultation, rhonchi is heard and the patient has a productive cough. Which of the following would you recommend?

A. Intubate and provide mechanical ventilation with 40% oxygen

B. Provide noninvasive positive pressure ventilation using a full face mask

C. Implement postural drainage and percussion with
directed coughing

D. Provide oxygen therapy and obtain a sputum sample for culture and sensitivity

Answer 2

D. Provide oxygen therapy and obtain a sputum sample for culture and sensitivity

To get this one correct, you needed to be able to recognize that the patient has some type of infection, like pneumonia.

You know this because the question states that the patient is hypoxemic, has a fever, and rhonchi breath sounds.
So in this case, you would want to obtain a sputum sample for culture and sensitivity in order to identify the type of organism.

Oxygen therapy is indicated for the hypoxemia.
Intubation and NPPV would not be indicated in this case.

Postural drainage and percussion are not recommended either.
So by breaking down the question, the best answer clearly is D.

Question 3

A 50-year-old male patient is intubated with a size 8
endotracheal tube and is receiving volume-controlled A/C ventilation.

Upon assessment, you note that the patient’s cuff
pressure is measured at 38 cm H2O.

Which of the following would you recommend?

A. Withdraw the tube 1-2 cm and reassess the patient’s
breath sounds

B. Recommend reintubation with a smaller endotracheal tube

C. Lower the cuff pressure to < 30 cm H2O

D. Recommend ventilation via a tracheostomy instead

Answer 3

In order to get this one right, you needed to know the normal values for cuff pressure. And in this case, you needed to recognize that 38 cm H2O is way too high and could potentially be dangerous for the patient’s trachea.

So your first action should be to lower the cuff pressure to < 30 cm H2O and then check to make sure that there are not any leaks.

For the TMC Exam, you need to remember that the cuff pressure normal range is between 20-30 cm H2O.

There is no indication to withdraw the tube and using a smaller tube would only cause the patient’s peak pressure to increase which is something that we do not want.

Also, nothing in the question indicates that a tracheostomy is needed, so we knowthat the correct answer has to be C.

The correct answer is: C. Lower the cuff pressure to < 30 cm H2O