Lindsey Jones TMC

For the following pulmonary function graphic, the known volumes include TLC 6.0 L VC 4.8 LVT 0.5 LERV 1.8 LIRV 2.5 L How much is the estimated FRC? A. 3.0 L B. 2.3 L C. 3.6 L D. 4.3 L

A

Which of the following should NOT be included in the initial assessment of a comatose patient in the intensive care unit? A. General appearance B. Breath sounds C. Symptoms D. Vital signs

A comatose patient is not cable of self-reporting problems. Therefore, subjective information, or symptoms cannot be determined. Signs, however, which are objective, can be determined by the caregiver, independent of the patient's ability to communicate.

IPPB therapy is CONTRAINDICTED in wich of the following conditions? A. Untreated pneumothorax B. alveolar hypoventilation C. myoplasma pneumonia D. asthma

A. IPPB therapy is contraindicated when an untreated pneumothorax is present. Active tuberculosis and current bleeding of the pulmonary tree (pulmonary hemorrhaging) are also reasons to avoid IPPB therapy.

A patient has a diagnosis of post-operative left lower lobe pneumonia three days after cesarean section surgery. The respiratory therapist should recommend A. postural drainage and percussion B. Albuterol metered dose inhaler (MDI) with spacer C. bronchoscopy of the left lobe D. blow bottles

A. For a patient with pneumonia, a key consideration is mobilization and removal of secretions. Of the options offered only postural drainage and percussion would accomplish this.

Hemoximetry can be used to determine which of the following levels? A. Hb B. PECO2 C. PaO2 D. pH

A. Hemoximetry assesses hemoglobin levels and the presence of oxygen attached to hemoglobin. It does not report PaO2, but it does report SAO2. It is not used to determine pH or exhaled CO2 levels.

While adjusting the cuff pressure of an oral endotracheal tube on a patient who has a Mallampati classification of 4, the respiratory therapist discovers that the cuff is perforated and unable to maintain pressure. Because the patient is receiving mechanical ventilatory support, tube replacement is scheduled. The therapist should recommend A. use of an airway exchange catheter (AEC) B. use of a laryngeal mask airway (LMA). C. placement of a tracheostomy tube. D. use of a Combitube?

A. A Mallampati classification of 4 suggests that the patient is a difficult intubation. As such, reintubation could be difficult. This should be considered when planning for re-intubation. Use of an AEC will help ensure proper, quick replacement of the ET tube.

A homeless patient reports to a clinic with hemoptysis and emaciation, as well as other symptoms consistent with tuberculosis. Which of the following exams would be most appropriate to further assess the patient? A. Mantoux test B. eosinophil count C. FeNO exhaled gas analysis D. serum creatinine blood level

A. A Mantoux test (also called a TB test) is helpful in determining the patient's exposure to the tubercle bacilli. Although not diagnostic for TB, it is a quick screening method that is appropriate.

The respiratory therapist obtains the following blood gas data on a patient breathing spontaneously on room air: pH 7.35 PaCO2 45 torrPaO2 50 torrHCO3- 27 mEq/LBE +2 mEq/L The therapist could accurately estimate the patient's SaO2 to be which of the following? A. 80% B. 75% C. 90% D. 85%

A. A PaO2 of 50 mmHg most closely correlates with an oxygen saturation of about 80% on the oxygen dissociation curve.

A respiratory therapist observes a decreased plateau pressure compared to previous measurements. This is most indicative of A. improved static compliance. B. worsening gas distribution in the lungs. C. decreased airway resistance. D. an increase in dynamic compliance.

A. A decrease in plateau pressure is associated with improved pulmonary compliance (lessening in the stiffness of the lungs).

A patient with confirmed Guillain-Barre' Syndrome is being monitored every 4 hours. The following data is available: 10 am 2 pm 6 pm VC (L) 1.6 1.4 0.8VT (mL) 500 485 260MIP (cm H2O) -48 -35 -24 The respiratory therapist should recommend A. intubate and initiate mechanical ventilatory support B. administer systemic steroid medication C. continue to monitor the patient closely D. check the protein level in the spinal fluid

A. A patient with Guillain-Barre' Syndrome experiences a slow onset of paralysis of the ventilatory muscles and will ultimately require mechanical ventilatory support. The point at which ventilatory support is needed is when vital capacity falls below 1 L. In this case, vital capacity is 0.8 L indicating the patient should be intubated and receive mechanical ventilatory support.

One hour after performing quality control on a blood gas analyzer, a respiratory therapist obtains arterial blood from a patient breathing supplemental oxygen at 2 L/min by nasal cannula. The following blood gas results are available: pH 7.41 PaCO2 39 torrPaO2 190 torrHCO3- 25 mEq/LBE -1 mEq/L The respiratory therapist should A. perform a two-point calibration and repeat the analysis B. recommend discontinuing supplemental oxygen based on these results C. report the blood gas results D. replace the Sanz electrode, repeat the analysis

A. An estimation of the alveolar oxygen tension reveals that on 2 L/min the maximum oxygen tension in the alveolo is about 147 mmHg. However, the oxygen tension in the blood is high at 190 mmHg, according to the blood gas results. This would be impossible. Arterial oxygen tension cannot exceed the maximum possible oxygen tension in the alveoli. The blood gas instrument should be recalibrated and the analysis should be repeated.

A postoperative patient for abdominal surgery is to perform sustained maximum inspiration therapy with an incentive spirometer. Prior to surgery the patient achieved 1400 mL. With significant coaching the patient is unable to reach an initial goal of 700 mL but is able to achieve 500 mL. For future coaching, the therapist should A. Set the goal to 600 mL B. Switch to IPPB C. Instruct the patient to try to comply with instruction to achieve 1400 mL D. Remind the patient the goal is 1400 mL

A. An initial goal for incentive spirometry postoperatively is one half of the patient's achievement prior to surgery. In this case the patient was able to achieve 1400 mL prior to surgery. The initial goal would be 600 mL if the patient is unable to obtain that amount or comes far from that goal, the goal should be lowered to a volume that is closer to the patient's achievement. This will incentivize the patient keep trying.

After performing minimum seal technique on an 80-kg (175-lb) patient who is orally intubated with an 8.0-mm ET tube, the cuff pressure is measured by manometer and found to be 36 cmH2O. Which of the following can best explain this? A. transesophageal fistula B. tracheal stenosis C. ruptured cuff D. tracheomalacia

A. Because the minimum seal technique was used (also called minimum occluding volume), we know that the cuff is touching the tracheal tissues. However, the pressure required to do so is far above the normal pressure. This would indicate that the space inside the trachea is larger than normal. The cause of this is most likely a transesophageal fistula.

A patient presents in the emergency department (ED) with fever, chills, general malaise, and mild ventilatory distress. The patient has been in a long-term care center for the past 6 months and is currently producing thick, yellow sputum. Which of the following should the respiratory therapist do? A. order a CBC B. determine PAO2 C. request an echocardiogram D. check electrolyte levels

A. Clinical evidence, including a febrile condition, suggests the possibility of a bacterial infection. A CBC (complete blood count) will help confirm the presence of an infection by examining the white blood cell count.

While transporting a patient in a non-pressurized fixed-wing aircraft for a 3-hour flight, the respiratory therapist notices the fluidic ventilator being used to provide mechanical ventilation to the patient is delivering less-than-set tidal volume. Additionally, the delivered rate is less that the set rate. The therapist should A. change the compressed gas cylinder. B. change the batteries in the ventilator. C. provide manual ventilation for the duration of the flight. D. change to a different ventilator.

A. Fluidic ventilators, often used in air transport, work by gas pressure. In addition to providing the ventilator air and oxygen, the same compressed gas drives the function of the ventilator, including rate and tidal volume. As compressed gas pressure falls to nearly empty, the function of the ventilator will begin to decrease and fail. In such a case, the solution is to replenish the source gas (to change to a full cylinder).

A decreasing CvO2 while CaO2 remains constant is most closely associated with A. increasing tissue oxygen consumption B. decreasing SVR C. increasing PVR D. decreasing oxygen consumption

A. If CvO2 is decreasing while CaO2 remains the same, there is a widening between the arterial and venous oxygen content difference C(a-v)O2. A bigger gap between these numbers, or an increase in the C(a-v)O2, is associated with decreasing tissue oxygen consumption which is also associated with a decrease in cardiac output.

Physicians at the hospital have been increasingly ordering improper mixtures and combinations of similar class bronchodilators, causing significant delays in patient treatment. Which of the following would be MOST helpful at improving patient care with regard to bronchodilator therapy? A. establish a bronchodilator protocol B. place educational posters in various areas in the hospital C. communicate with each physician personally on proper ordering D. administer medications as ordered, but notify the medical director

A. In this question, there is an obvious indication that there is a broad problem among physicians to incorrectly order bronchodilator therapy. Although physicians could be spoken to individually, a more efficient method is to create a bronchodilator protocol. This is a documented set of instructions that allows a physician to order bronchodilator therapy, without having to provide the specifics of how the therapy is given or what drug or dosage is used. This approach helps to standardize care and avoid problems with physician orders.

For which of the following conditions is inhaled nitric oxide used? A. pulmonary hypertension B. pulmonary emphysema C. pulmonary embolus D. pleural effusion

A. Inhaled nitric oxide (NO therapy) is used to treat extreme cases of pulmonary hypertension.

Immediately after extubation of an adult male, the respiratory therapist auscultates mild stridor in the upper airway. SpO2 is 98% with FIO2 0.4 by air-entrainment mask. Spontaneous tidal volume is 450 mL and minute ventilation is 6.3 L. The respiratory therapist should recommend which of the following? A. administration of cool aerosol by large-volume nebulizer B. immediately reintubate the patient C. provide heated mist D. administration of aerosolized epinephrine

A. Mild stridor may be addressed by administering a cool aerosol or racemic epinephrine. Do not be tempted to administer epinephrine. "Racemic epinephrine" is half-strength epinephrine.

A patient with status asthmaticus has been intubated and sedated for prolonged mechanical ventilation. Which of the following drugs would be most appropriate to provide paralysis? A. rocuronium bromide (Zemuron) B. flumazenil (Romazicon) C. diazepam (Valium) D. succinylcholine chloride (Anectine)

A. Normally, paralysis for the purpose of intubation is best achieved by administering Anectine (succinylcholine chloride). The other paralytic medication listed is rocuronium bromide. Anectine is considered better because of its short half-life. However, in this case Anectine is contraindicated with status asthmaticus and therefore rocuronium is most appropriate. Diazepam (Valium) is a sedative that cannot provide a neuromuscular blockade. Romazicon is a benzodiazepine reversal drug and does not provide paralysis.

Which of the following represents the most effective method of preventing nosocomial infections in a hospital setting? A. diligent hand washing B. use of alcohol wipes on equipment C. use of sterile gloves D. use of N-95 respirators

A. Nosocomial infections are those that are spread in hospitals among patients. The most common cause of nosocomial infection is poor handwashing among healthcare givers. Thus, the most effective method at preventing nosocomial infections is to encourage diligent and proper handwashing techniques.

What is the objective for using a pressure/volume loop to determine optimal PEEP on a mechanically ventilated patient? A. ensure increase in volume with any rise in pressure B. eliminate PEEP when the FIO2 is 1.0 C. ensure increase in pressure with any rise in volume D. determine how high one can adjust the PEEP

A. Pressure/volume loops are used to determine optimal PEEP for mechanically ventilated patients to make sure that increases in peak pressure result in increases in volume while in the pressure control mode.

Which of the following chest PA radiograph results would suggest the patient was rotated improperly? A. the apecies are different sizes B. tops of the lungs are not level C. heart shadow exceeds 1/2 the chest cavity laterally D. there is a mediastinal shift

A. The apexes (apecies) of the lungs are the very top triangular, cone-shaped aspects of each lung. When one apex is larger than the other on a radiograph, this is likely due to inappropriate patient rotation. This happens because one lung ends up closer to the film than the other and therefore appears smaller. If this is observed, the radiograph should be redone.

A patient reports to the emergency room (ER) following an accident while playing football. Paramedics on the scene report a sudden on-set of tachypnea. The following chest radiograph is taken. What is the most likely diagnosis? A. pneumothorax B. pulmonary interstitial emphysema C. pleural effusion D. pulmonary contusion

A. The chest radiograph shows hyperlucency on the right. This is consistent with a pneumothorax.

An air-oxygen blender is being used to provide 40% oxygen to a newborn. Suddenly the blender begins to emit a high-pitched sound. The respiratory therapist should A. ensure the blender is adequately attached to 50 psi source gas. B. cancel the alarm and analyze oxygen near the patient. C. perform a two-point calibration on the blender. D. adjust the blender to 100%, analyze oxygen at the source.

A. The high-pitched sound emitted by a blender is an alarm the sounds automatically when there is a loss of gas pressure or a significant decrease in pressure below 50 PSI.

While assisting a physician during a bronchoscopy procedure, the therapist notices bright red blood in the specimen tube. The therapist should prepare which of the following NEXT? A. epinephrine B. Atropine C. Heparin D. cold normal saline

A. The installation of epinephrine down the bronchoscope to an actively bleeding site will help to immediately stop the bleeding. This should be the first step in treating a bleed in the bronchial tree. The next step should be to compress the site with the bronchoscope followed by the insertion of the Fogarty catheter to tamponade the bleeding site.

Which of the following questions or directives would be most helpful in determining a patient's ability to understand procedural instructions given in English? A. "Please explain the procedure back to me." B. "Do you speak English?" C. "Nod your head if you understand me." D. "Are you able to understand what I am saying?"

A. The key in ascertaining a patient's ability to understand instruction is to ask open-ended questions. An open-ended question is one that cannot be answered simply with 'Yes' or 'No'. In many cultures and languages, people are likely to respond with 'Yes' when they do not understand what is being communicated.

The respiratory therapist records a patient's blood pressure to be 120/80 mmHg as measured by a sphygmomanometer. Simultaneously, the therapist notes the blood pressure measured by an indwelling radial artery catheter and transducer is reading 145/90 mm Hg. Which of the following could explain the difference in these results? A. the transducer is lower than the level to which it was originally zeroed and calibrated B. erratic movement of the arm with the arterial catheter C. the transducer is 8 inches or more above the level of the heart D. the sphygmomanometer is likely in error

A. The transducer associated with an indwelling arterial catheter should be level with the heart in order to produce an accurate blood pressure reading. If the transducer is lower than the heart, increased blood pressure will be demonstrated on the monitor and the reported pressure will be erroneously high. If the transducer is above the level of the heart, the reported blood pressure on the monitor will be erroneously low, or less than the actual blood pressure of the patient.

While transporting at patient from the emergency department (ED) to the intensive care unit (ICU), the respiratory therapist suspects the oral endotracheal tube has changed position. The quickest way to assess the ET tube position would be to A. auscultate breath sounds B. obtain a chest x-ray C. analyze end-tidal CO2 D. visualize diaphragmatic excursion

A. There are many ways to determine the location or position of the ET tube. The question is asking for the quickest way. Of the options offered, auscultation of breath sounds would provide the most immediate pertinent data. If an option such as examination of equal and bilateral chest rise were offered, that option would be even better because it is visual in nature and therefore quicker.

A respiratory therapy supervisor is responsible for making suggestions in the initial development of a smoking cessation program. Which of the following would be part of an effective smoking cessation program? A. nicotine replacement therapy B. removing pulmonary irritants from the house C. daily COHb analysis D. daily completion of an asthma action plan

A. To stop smoking, both physiological and emotional barriers must be addressed. The patient may be helped best through nicotine replacement therapy and emotional support. Routine monitoring of the patient's progress is also helpful. Removing irritants from the house will not help the patient stop smoking.

A respiratory therapist notices the reservoir bag on a nonrebreathing mask collapses completely every time the patient inspires. The respiratory therapist should A. increase flow to the mask B. obtain a larger mask C. switch to a high-flow Venturi mask D. switch to a partial rebreather mask

A. When a patient is using a non-rebreather mask, the reservoir should collapse slightly with each breath. The collapse indicates that the seal between the mask and the patient's face is adequate. If the reservoir collapses completely, this indicates there is not enough flow of oxygen to the reservoir bag to keep up with the patient's inspiratory demand. Increasing flow to the reservoir, or mask, is most appropriate.

A patient with a tracheostomy is receiving supplemental oxygen via tracheostomy collar connected to a large volume nebulizer set at 40%. The respiratory therapist analyzes the FIO2 at the tracheostomy collar with a galvanic fuel cell analyzer. The analysis shows the FIO2 to be 55%. Which of the following could be the cause of the increase in FIO2? A. too much water in the circuit B. calibration error in the galvanic fuel cell C. the aerosol tubing is too short D. clogged jet orifice in the nebulizer

A. When administering oxygen by any device that has a venturi mechanism, back pressure on the venturi will slow the speed of gas, decrease room air entrainment, and result in an increase in FIO2. Of the options offered, only excess water in the tubing would cause this type of back pressure.

The disk fails to rise on a volume-oriented incentive spirometer in spite of a forceful exhalation into the device. The therapist should A. instruct the patient to inhale through the device B. switch to a flow-oriented device C. switch to IPPB by mask D. examine the device for a leak

A. With incentive spirometers, patients commonly confuse the maneuver and exhale into the device rather than inhale. When this happens the respiratory therapist must instruct the patient on the proper use of the device, which is to perform inhale deeply through the device.

A 55-year old male is receiving VC, SIMV ventilation. The following parameters are observed: f 4/min Total rate 32/minVT (set) 500 mLVT (spont) 180 mLFIO2 0.45 Which of the following would be an appropriate change? A. administer Narcan (naloxone) B. add pressure support C. increase rate to 12/min D. begin a spontaneous breathing trial (SBT)

B

A patient with a fenestrated 8.0-mm tracheostomy tube in place suddenly demonstrates difficulty breathing with an oxygenation saturation of 89%. The respiratory therapist attempts to pass a suction catheter down the trach tube and notes significant resistance after advancing the catheter 2 cm. The therapist should immediately A. extubate the patient. B. remove the inner cannula. C. activate the rapid response team. D. instill mucomyst (acetylcysteine) into the trach tube.

B

A respiratory therapist is providing homecare education to family members who will be acting caregivers to a patient on a home-use ventilator at least 50% of the time and who requires tracheal suctioning from time to time. To encourage aseptic technique, the therapist will include which of the following in the teaching? A. Suction the patient with at least one sterile hand. B. Use a closed system suction catheter. C. Rinse the suction catheter after each use with sterile water. D. Utilize disposable, sterile suction catheter kits each time.

B

A patient is intubated in the field by first responders with a CombitubeÒ. After connecting the patient to positive pressure ventilation, the respiratory therapist notices the sound of gas escaping around the tube at the top of each inspiration. The patient is receiving a Propofol drip IV. The following data is available: Vent settings FIO2 0.6PEEP 5 cm H2OVT (set) 500 mLVT (return) 220 mLRate (set) 14/minRate (total) 14/min The respiratory therapist should A. withdraw the tube by 2 cm B. inject air into the tube's white port C. advance the tube by 2 cm D. remove air from the blue port

B. A Combitube? is an airway with two lumens. It allows for blind insertion of an airway and is usually used by first responders. Because the delivered tidal volume is so much less than the set tidal volume, it must be assumed that gas is escaping around the cuff during inspiration. Insertion of air into the white pilot valve would be most appropriate.

A respiratory therapist is asked to assist a physician for a diagnostic bronchoscopy on a mechanically ventilated patient. What special equipment should be brought to the room? A. Wrights respirometer B. ventilator circuit bronchoscopy adapter C. ventilator circuit endotracheal tube wedge D. laryngoscope and blade

B. A bronchoscopy can be done on an intubated patient with the use of an adapter that permits the entrance of the bronchoscope while maintaining assisted ventilation around the scope.

Which of the following tracheostomy tubes would be most appropriate for a patient who frequently experiences mucus plugs in the airway. A. silver metal B. fenestrated C. Kamen-Wilkinson D. single-bore

B. A fenestrated tracheostomy tube includes a removable (and disposable) inner cannula. This is especially helpful for patients who have a propensity for mucus plugging. If a plug develops in the airway, the inner cannula can be removed immediately. The inner cannula can be cleaned or replaced with a new one.

A home care patient is ventilator dependent for more than 50% of the time. Which of the following is necessary to have? A. H-tank manifold with a bank of oxygen cylinders B. back up ventilator C. non-rebreathing mask with an E-cylinder D. bulk liquid oxygen supply

B. A homecare patient who is ventilator-dependent more than 50% of the time should have a backup ventilator. A bag/valve is also important but does not qualify as a backup ventilator.

A ventilator-dependent male patient with a size 8.0 mm tracheostomy tube requires general instructions including infection control procedures prior to being discharged home. Which of the following would not be an appropriate part of the teaching plan? A. use of acetic acid for cleaning equipment B. patient should not be encouraged to clear airway by direct cough C. method for performing suctioning of self D. proper handwashing before and after airway clearance procedures

B. A patient should be encouraged to clear their airway by direct cough. This is the most effective airway clearance technique and maintains the patient's strength. Handwashing, cleaning with vinegar (acetic acid), and suctioning oneself as needed are also appropriate aspects of a teaching plan for a homebound tracheostomy patient.

A patient with COPD is receiving mechanical ventilation on the following settings: Mode Assist/control Mandatory rate 12VT 450 mLFIO2 0.40PEEP 5 cm H2OTotal rate 14I:E 1:1.8 The physician is concerned about air trapping and development of auto PEEP. The therapist should recommend which of the following? A. Increase I:E ratio B. Increase inspiratory flow C. Switch to control mode of ventilation D. Decrease mandatory rate

B. A patient with COPD has difficulty exhaling gases and can easily have air trapping. To prevent this, the normal ventilator I:E ratio of 1:2 should be prolonged to 1:4 or 1:5. This is done by allowing more time for expiration which is accomplished by decreasing inspiratory time. Inspiratory time may be decreased by increasing the inspiratory flow rate.

A respiratory therapist is caring for a 68 year old female who has been receiving mechanical ventilation via tracheostomy tube for 6 weeks. After adjusting the cuff pressure using the minimum seal technique, the therapist measures the cuff pressure and notes it is 35 cm H2O. Which of the following could explain this finding? A. leaky cuff B. presence of a transesophageal fistula C. tracheostomy tube too large D. herniation of the cuff

B. After performing a minimum seal technique, also called minimum occluding volume, the therapist can be sure that the ET tube cuff is touching the wall of the trachea. If, subsequently, the ET tube cuff pressure is found to be excessive, it must mean that the space in the trachea has been enlarged. This can be caused from a transesophageal fistula.

A 60 kg (132 lb) postoperative cholecystectomy patient is receiving mechanical ventilatory support on the following settings: Mode SIMV Mandatory rate 10Total rate 12FIO2 0.40Tidal volume (VT) 450 mLInspiratory flow 50 L/min Corresponding blood gases show: pH 7.48 PaCO2 32 torrPaO2 92 torrHCO3- 24 mEq/LBE +1 mEq/L Which of the following should the respiratory therapist decrease? A. FIO2 B. tidal volume C. mandatory rate D. inspiratory flow

B. Arterial blood gases show this patient is hyperventilating just slightly. To correct hyperventilation, rate may be increased, tidal volume may be decreased, or dead space may be added. In this case, because CO2 is off by only 3 torr compared to the target range, decreasing tidal volume is most appropriate. This is also the most appropriate option because the current tidal volume is at the top of the range for the patient and the patient would benefit from having a tidal volume closer to the center of the range.

A patient who was ready to be extubated inadvertently removed the endotracheal tube prior to the extubation procedure. Immediately after the ET tube was extracted, the patient began to exhibit moderate stridor. The respiratory therapist should A. schedule for surgical placement of a tracheostomy. B. administer aerosolized racemic epinephrine. C. re-intubate the patient using a video-assist device. D. administer Albuterol and monitor the patient.

B. Because the patient self-extubated, it is likely that the ET tube cuff was not deflated completely or at all. This could cause tissue injury during the extraction and could promote the development of stridor. While severe stridor should be addressed by immediate re-intubation, moderate stridor is less urgent and may be first treated with aerosolized racemic epinephrine.

What is the complication of most concern associated with the use of a self-inflating infant resuscitator with mask? A. inability to ventilate through the nose B. gastric insufflation C. difficulty creating a seal between the mask and the infant's face D. inability to assess pulmonary compliance

B. Both major types of resuscitators, the flow-inflating anesthesia bag and self-inflating bag have a common complication of gastric insufflation, which means that air can easily enter into the esophagus and overinflate the stomach. This complicates resuscitation efforts by reducing lung expansion potential and increasing the chance of emesis in the airway.

Cardioversion is considered for which of the following on a conscious patient? A. unstable bradycardia B. non-lethal arrhythmias C. pulseless ventricular tachycardia D. ventricular flutter

B. Examples of conditions that may require cardioversion are (1) atrial fibrillation, (2) atrial flutter, and (3) ventricular tachycardia with a pulse. This is done with low voltage (50-100 joules) and must be done with the synchronization set to ON.

A patient had an oxygen index of 35, determined one day prior. Which of the following could be stated accurately about the patient, given the following current data? mPAW 25 cm H2O FIO2 0.60PaO2 50 mm Hg A. PAO2 is increasing. B. The patient is improving. C. V/Q mismatching is increasing. D. CaO2 is decreasing.

B. Given the present data, the currently calculated oxygen index (OI) is 30. The previous oxygen index was higher. This indicates the patient is improving generally as it relates to the resulting PaO2 under the current FIO2 and mPAW conditions. V/Q mismatching is likely decreasing and CaO2 is likely increasing. The status of PAO2 cannot be determined directly.

A patient with a history of hyper-reactive airway disease is having difficulty expectorating because the sputum is thick and tenacious. Which of the following medications should the respiratory therapist recommend? A. Solu-Mederol B. Acetylcysteine (mucomyst) C. Spiriva (tiotropium bromide) D. Beclamethasone (Beclovent)

B. Hyperactive airway disease is associated with diseases such as asthma and consist of bronchoconstriction and inflammation. This patient appears to have difficulty with bronchoconstriction and thick secretions. Therefore, a mucolytic, such as acetylcysteine, and Solu-Medrol are appropriate.

Multiple wavelength spectrophotometry oxygen saturation is 97% on a patient with a respiratory rate of 14/min, heart rate 80/min, and clear breath sounds. Arterial blood gas results are as follows: pH 7.42 PaCO2 37 torrPaO2 125 torrHCO3- 25 mEq/LFIO2 0.21 What should the respiratory therapist recommend? A. Conduct proficiency testing on the Clark electrode. B. Run a two-point calibration on the ABG analyzer, then repeat the sample. C. Discontinue supplemental oxygen. D. Check the most recent quality control values.

B. In this example, the PaO2 is not possible while breathing on room air, which can be seen more easily after calculating the alveolar air equation. A multiple wavelength spectophotometer (oximeter) is a non-invasive way to measure oxygen saturation, metHb, COHb, etc. The ABG analyzer should be recalibrated and the sample repeated.

A 24-year-old Caucasian male has suffered a spontaneous pneumothorax on the right side. Upon inspection, which of the following would most likely be observed? A. a "batwing" pattern on a chest radiograph B. accessory muscle use C. pronounced vascular markings over the left lung field D. concave interface border on a chest radiograph

B. Of the options listed, only accessory muscle use would likely be observed. A 'batwing' pattern is related to pulmonary embolism and a concave interface border is related to a pleura effusion. Pronounced vascular markings are not associated with a pneumothorax.

Regarding patient safety while performing a heel stick on a newborn, the most important thing to consider is A. level of the capillary tube while filling. B. location of the puncture. C. depth of skin puncture. D. warming the heel for one minute prior to puncture.

B. One might be tempted to select the depth of the puncture, but actually more concerning is the location. Heel sticks should not be performed on a neonate in an area of their foot that they will walk on in the future as they grow. Damage to this area of the foot can result in difficulty with future ambulation. Therefore, heel sticks are performed on the lateral area of the heel.

Oral-pharyngeal suctioning is appropriate for which of the following? A. clear nasal passages B. Immediately following extubation C. To facilitate sputum specimen collection for analysis D. Deep suctioning for a cachectic patient with a weak cough

B. Oropharyngeal describes the location for the tip of the catheter, which is the oral-pharynx, or back of the mouth. This is as far as one would need to apply suction for patients with a strong, productive cough. This is also common following extubation as secretions above the cuff of the endotracheal tube are often accumulated in the oropharynx. It is also common to apply oropharyngeal suctioning prior to intubation. Deep suctioning would be performed in the trachea itself.

If a patient's static compliance increases while receiving PCV, which of the following will also occur? A. plateau pressures will increase. B. tidal volume will increase. C. low-volume alarms would likely be triggered. D. dynamic compliance will be unchanged.

B. Pressure-control ventilation (PCV), does not have a constant set tidal volume. VT is a result of set peak inspiratory pressure and inspiratory time in this mode. If the lung has low compliance and is difficult to ventilate, the returned volumes will diminish. If the lung becomes easier to ventilate, the tidal volumes will increase.

Which of the follow data obtained from a pulmonary artery catheter would suggest impeded blood flow through the pulmonary vasculature? A. elevated CVP, normal mPAP and PCWP B. elevated mPAP, normal or low PCWP C. decreased C.O. with high PCWP D. increased CVP, mPAP, PCWP, and C.O.

B. Problems related to blood flowing through the pulmonary vasculature can be identified by examining the pressures immediately before and after the lungs - mPAP and PCWP. In the case of poor or impeded blood flow through the pulmonary vasculature, mPAP would likely be elevated while PCWP would be normal or low.

After replacing the three-chamber chest tube drainage system, the respiratory therapist notices significant bubbling in the water-seal compartment. The therapist should A. monitor closely as this is a normal finding B. examine the system for leaks C. decrease suction pressure D. reposition the chest tube in the pleural space

B. Significant or excessive bubbling in the water-seal chamber of a chest tube drainage system is usually associated with a leak somewhere between the patient's lung and the waterseal compartment. The system should be examined for leaks.

Following a complete sleep study, it is determined that a 45-year-old male requires bi-level therapy at home, with supplemental nocturnal oxygen. Which of the following is indicated? A. arterial blood gas B. oxygen bleed-in device C. blood pressure monitoring D. nocturnal oximetry study

B. The best device for home oxygen therapy is a molecular sieve device, commonly known as an oxygen concentrator. This device is powered with electricity, which makes it appropriate for home use.

A patient reports to the emergency room (ER) following an accident while playing football. Paramedics on the scene report a sudden on-set of tachypnea. The following chest radiograph is taken. What is the most likely diagnosis? A. pulmonary interstitial emphysema B. pneumothorax C. pulmonary contusion D. pleural effusion

B. The chest radiograph shows hyperlucency on the right. This is consistent with a pneumothorax.

To facilitate drainage of secretions consolidated in the bases of the lungs, the respiratory therapist should anticipate placing the patient in which of the following positions? A. supine position. B. head-of-bed down 30 degrees C. prone position. D. semi-Fowler's position

B. The head of bed is placed down 30 degrees to drain the basilar segments.

The following clinical information is documented after assessment of a home care COPD patient's SpO2 with varying levels of activity. What is the appropriate supplemental oxygen recommendation for this patient? SpO2 #1: room air, resting: 88% SpO2 #2: room air, slow walk for 5 minutes on room air: 86% SpO2 #3: 1 L/min nasal cannula at rest: 90% SpO2 #4: moderate walk for 5 minutes on 1 L/min nasal cannula: 88% SpO2 #5: 2 L/min nasal cannula at rest: 94% SpO2 #6: moderate walk for 5 minutes on 2 L/min nasal cannula: 91% A. 1.5 L/min pulse-dose delivery device B. 2 L/min continuously C. oxygen PRN - liquid oxygen source D. 1 L/min by oxygen-conserving device

B. The level of supplemental oxygen that maintains an acceptable SpO2 during a moderate walk is 2 L/min.

A 35-year old that is receiving VC, SIMV ventilation has the following parameters: f 6/min Total rate 28/minVT (set) 450 mLVT (spont) 160 mLFIO2 0.45PS 5 cm H2O Which of the following would be an appropriate change? A. increase set VT to 500 mL B. increase PS to 10 cm H2O C. increase rate to 10/min D. decrease set VT to 400 mL

B. The presence of a low spontaneous VT (likely well below 5 mL/kg) suggests that the patient requires additional pressure support. This will help to lower total rate and generally decrease the work of breathing.

While performing a routine ventilator a check on a patient with a balloon-tipped flow-directed pulmonary artery catheter in place, the respiratory therapist notices the inflection points on the waveform indicate the tip of the pulmonary artery catheter is improperly placed in the right ventricle. To correct this problem, the therapist should recommend A. recording the pulmonary artery pressure as shown on the waveform B. inflating the balloon and advancing the catheter C. twisting the catheter until pulmonary artery pressures are observed D. removing the catheter and inserting a new one

B. The pulmonary catheter should be terminated in the pulmonary artery, which is beyond the right ventricle. Therefore, advancing the catheter is appropriate. The catheter may be advanced by sailing it into position, which is done by inflating the catheter balloon and allowing blood flow to carry the catheter into position and then deflating the balloon once it is in the proper position.

A patient is receiving volume-controlled ventilation in the assist/control mode. The following data are available: Peak pressure Plateau Pressure Exhaled VT 2 PM 35 cm H2O 22 cm H2O 696 mL5 PM 53 cm H2O 24 cm H2O 702 mL7 PM 55 cm H2O 23 cm H2O 700 mL The respiratory therapist would categorize the most significant problem noted from this data as A. decreasing static compliance B. decreasing dynamic compliance C. increasing static compliance D. increasing dynamic compliance

B. This data shows a significant increase in peak airway pressures but plateau pressures are remaining nearly steady. An increase in peak airway pressures with steady plateau pressures is associated with a decrease in dynamic compliance and is caused from such temporary conditions as bronchoconstriction, secretions in the airway, and occlusion of the endotracheal tube, to name a few.

Which of the following is most accurately descriptive of VC ventilation? A. pressure is constant for a specified period of inspiratory time B. the inspiratory phase terminates after delivery of a preset volume C. inspiration ends when a preset pressure setting is reached D. flow is constant until a preset volume is delivered

B. VC ventilation, also called volume-controlled ventilation, is a mode of ventilation that is characterize by the ending of inspiration through delivery of a predetermined tidal volume.

During palpation of a patient's chest, the respiratory therapist notes vibrations during inspiration that clear when the patient coughs vigorously. This is consistent with A. pneumonia B. pulmonary secretions in the large airways C. allergic asthma D. pulmonary tuberculosis

B. Vibrations felt during inspiration and/or expiration are associated with secretions in the larger way. When secretions are in a larger way, oftentimes coughing will cause expectoration and clearing a secretions.

A patient's PEEP has been increased by 8 cm H2O while static compliance has remained steady. The respiratory therapist should expect the plateau pressure to A. decrease by the level of the previous PEEP B. increase by approximately 8 cm H2O C. exceed the peak pressure D. remain steady

B. When PEEP is increased both plateau and peak pressures will increase by the same amount. In this case an increase of PEEP by 8 cm H2O is likely to cause an increase in plateau pressures by about 8 cmH2O.

Which of the following statements would be helpful in determining a patient's location of pain? A. "Please describe your pain on a scale of 1 to 10" B. "Tell me or point to the location of any pain you are feeling" C. "Is your pain above or below the waist?" D. "Are you having chest pain?"

B. When questioning a patient to determine the location of pain, it is appropriate to use open-ended questions. Using a close-ended question, or a question that can be answered simply by "yes" or "no", the patient may answer without understanding the question. Thus, asking the patient to point to or describe the location of pain will help to determine any language barriers that may exist.

A 30 weeks-of-gestation infant is being monitored transcutaneously for PO2 and CO2. The respiratory therapist notices a sudden increase in the PO2 value from 68 mm Hg to 110 mm Hg. The therapist should A. calibrate the PO2 electrode with zeroing solution. B. move the PO2 electrode to a new site. C. suspect a disconnected PO2 electrode. D. decrease FIO2.

C

A patient undergoes a V/Q scan to rule out pulmonary embolism after evidence of a decreasing PetCO2 with a steady arterial CO2 value. The V/Q scan results come back as inconclusive. What should be recommended? A. obtain a new PetCO2 value B. ultrasound with contrast material C. pulmonary angiography D. lateral decubitus chest radiograph

C

Which of the following is an example of an advanced directive? A. inheritance specifications B. verbal instructions to caregivers C. a living will D. funeral preferences

C. A living will is a document that specifies issues related to life-supporting healthcare before a patient is in a situation where they are unable to communicate or make decisions during a life-threatening condition.

A 55-kg (121-lbs), 157-cm (5 ft, 2 in) patient with ARDS is receiving PC A/C ventilation on the following settings: PIP 50 cm H2O PEEP 12 cm H2OI-time 1.1 secondsRate 16/minFIO2 0.55VT (return) 532 mL On these settings, ABGs are pH 7.38 PaCO2 42 torrPaO2 87 torr The respiratory therapist should recommend A. decreasing PEEP. B. decreasing rate. C. decreasing PIP. D. increasing FIO2.

C. A patient with ARDS should receive tidal volumes of 4 to 6 mL/kg. Though tidal volume is not set directly with pressure control ventilation, it is largely determined by the peak inspiratory pressure (PIP) setting. The patient currently has a return tidal volume of 532 mL. This is equivalent to 8.2 mL/kg, which is much higher than the recommended 4 - 6 mL/kg. PIP should be lowered to decease delivered tidal volume.

Which of the following may assist an ARDS patient receiving volume control ventilation and who has markedly decreased lung compliance? A. increased inspiratory flow rate B. increased expiratory time C. high frequency jet ventilation D. expiratory retard

C. A patient with ARDS suffers from markedly decreased pulmonary compliance. Providing the patient positive pressure breathing at high peak airway pressures is risky as it may cause barotrauma and other problems. One of the primary strategies in the treatment of ARDS is to keep airway pressures as low as possible. One strategy for this is to use a high-frequency jet ventilator.

Which of the following conditions should result in patient instructions to decrease inspiratory time and increase expiratory time? A. sarcoidosis B. asbestosis C. COPD exacerbation D. CHF

C. A patient with COPD, chronic obstructive pulmonary disease, suffers with the inability to exhale gas from the lung. This results in air-trapping during a COPD exacerbation. Pursed-lips breathing, along with an extension of expiratory time is helpful. One may also decrease I-time or increase E-time to resolve air-trapping created by COPD.

A pulmonary rehabilitation patient is having difficulty complying with a smoking cessation program. A physical and psychological screen reveals a heavy physiological dependence and a low psychological dependence on smoking. Which of the following is appropriate? A. Versed B. psychological counseling C. nicotine replacement therapy D. Valium

C. A physiological dependence on nicotine can be overcome slowly by having the patient use nicotine replacement therapy. This may include chewing gum with nicotine or transdermal preparations.

A forced expiratory spirogram can reveal which of the following? A. FRC and FVC B. TLC and FEV1 C. FEV1 and FVC D. RV and FEV1/FVC

C. Although an FEV1 is a flow, its data is achieved by performing a maneuver called FVC, or a forced expiratory spirogram. TLC, FRC, and RV cannot be determined through this method. They require more indirect procedures such as nitrogen washout and helium dilution.

Which APGAR score necessitates the delivery of basic and/or advanced cardiac life support for a newborn? A. 5 B. 7 C. 2 D. 10

C. An APGAR score is a 10-point scoring system that helps to know what kind of intervention for a newborn is appropriate. An APGAR score between 0-3 indicates immediate cardiopulmonary resuscitation. A score between 4-6 suggests that supplemental oxygen and general stimulation of the infant is required. A score between 7-10 indicates a normal, healthy infant, which means routine care is appropriate.

A patient is receiving supplemental oxygen therapy at FIO2 0.60 with heated humidity by large volume air-entrainment nebulizer. What can the respiratory therapist expect to occur with FIO2 as excessive water develops in the aerosol tubing? A. will remain unchanged B. will rise to 1.0 C. increase D. decrease

C. Anytime an entertainment device encounters back pressure that develops in the device as a result of a kinked tube or water in the tubing, the result will be an increase in FIO2. This is because back pressure on the air-entrainment device will cause the gas passing through the device to slow. The slowing of gas causes the relative pressure to increase. When the pressure increases, less room air is entrained. This results in an increase in FIO2.

Which of the following do NOT contribute to total airway resistance for a mechanically ventilated patient with an endotracheal tube? A. endotracheal tube B. main bronchi C. upper half of the trachea D. bronchoconstriction

C. Because the upper half the trachea is not communicating with the airway when an endotracheal tube is in place, it does not contribute to total airway resistance. The endotracheal tube cuff is inflated in the lower half of the trachea.

A patient in full cardiopulmonary arrest is intubated with an 8.0-mm endotracheal tube. Although multiple attempts have been made, neither a peripheral nor central line have been successfully placed. The following ECG waveform is observed. The respiratory therapist should recommend which of the following medications? A. Dobutamine B. Intal C. epinephrine D. Lidocaine

C. Epinephrine is a medication used during cardiac arrest that may be administered directly down the endotracheal tube in lieu of intravenous access.

A victim with COPD is rescued from a house fire and is brought to the emergency department. Upon arrival, the respiratory therapist notes the patient is comatose. After determining the airway is patent, the therapist's next action should be to A. transport the patient to a hyperbaric chamber B. obtain an SpO2 reading C. start oxygen at 100% D. perform arterial puncture for blood gas analysis

C. Even though COPD patients are supposed to avoid the use of high oxygen concentrations, in emergency settings, 100% is always appropriate

Which of the following is an appropriate goal for a patient in pulmonary rehabilitation who is in the advance stages of pulmonary emphysema? A. return the patient to normal life B. normal pulmonary function values C. reduced hospitalizations D. reduction of ADLs

C. For a patient in pulmonary rehabilitation, appropriate goals include: increasing the quality of life from the patient's point of view, reducing incidence of infections and hospitalizations, and increasing the ability to perform activities of daily living. Because most lung disease is not reversible, returning the patient to "normal life" or "normal pulmonary function values or blood gas values" is not considered a goal of pulmonary rehabilitation.

The disposable biological indicator found in a package of non-disposable mouthpieces shows the presence of viable spores. The respiratory therapist should A. Place the mouthpieces into service B. Soak the mouthpieces in Cidex for 10 minutes C. Send the equipment to be resterilized D. Wipe mouthpieces with alcohol, let air dry before use

C. When equipment is sterilized, there should be no evidence of living or potentially living organisms in the package or on the equipment. The presence of viable spores indicates the equipment should be re-sterilized.

A patient has just been diagnosed with obstructive sleep apnea and obesity hypoventilation syndrome. In addition to nasal nocturnal CPAP, on what else might the therapist educate the patient with regard to treatment options? A. respiratory stimulating medication such as Dopram (doxapram) B. smoking alternatives C. weight loss surgery D. neutrally adjusted ventilatory assist devices

C. For a patient with obstructive sleep apnea, likely due to obesity, there are several options that can help treat the issue. One is weight loss, which can be done surgically through bariatric surgery. Another surgical procedure, though not offered here, consists of resection of various soft tissue structures in the oropharynx.

Which of the following is a central goal of pulmonary rehabilitation on a patient diagnosed with advanced stage COPD? A. achieving normal pulmonary function B. improving physical activity performance C. maintenance of ADLs D. returning the patient to normal life

C. Goals of pulmonary rehab include: 1) ensuring the patient can continue to perform activities of daily living (ADLs), which can affect their quality of life. 2) minimizing illness and hospitalization. 3) improving the quality of the patient's life from the patient's point-of-view. Not included in pulmonary rehab goals are such things related to returning the patient to normal life or other normal physiological states. Pulmonary diseases, such as COPD, do not heal. Therefore, the patient will never experience a complete reversal, nor will they return to normal life.

Which of the following alarms would be most important for a patient receiving positive pressure ventilation by a pressure-cycled ventilator? A. low FIO2 B. high pressure C. low volume D. I:E ratio

C. If the patient is on a pressure cycle ventilator, that means the ventilator is going to deliver a certain pressure regardless of how much volume is achieved. If the ventilator does not care about volume, the practitioner must. Thus, the most important alarm for a pressure-cycled ventilator is low-volume. The opposite is also true. The most important alarm on a volume-cycled ventilator would be the high pressure alarm.

While attempting to suction a patient intubated with a 7.0-mm oral endotracheal tube, the respiratory therapist meets significant resistance while inserting a size 12 Fr, whistle-tip suction catheter. The respiratory therapist should do which of the following? A. instill 10.0 cc of normal saline prior to insertion B. lubricate the catheter with water-soluble lubricant prior to insertion C. obtain a size 10 Fr catheter D. reintubate the patient with a larger endotracheal tube

C. In this case the source of the resistance when inserting the suction catheter must be determined. It can either be casued by secretions or a suction catheter that is too large relative to the size of the ET tube. The suction catheter should not be more than 1/2 of the internal diameter of the tube. To determine the maximum suction catheter size we first take the ET tube size and divide it by 2. In this case, we get 3.5 mm. To then put this number in French units we multiply it times three. We get 10.5 Fr. Suction catheters come in increments of two, i.e. 8 Fr., 10 Fr., 12 Fr., 14 Fr., etc. therefore, the maximum suction catheter size is 10 French. The suction catheter being used is 12 French and is therefore too large. This is the most likely cause of the resistance found during suctionin. The best answer is to switch to a 10 Fr. catheter.

A 5-year-old child is brought to the emergency room (ER) with a fever and difficulty breathing. The patient is drooling but is making no vocal sounds. Which of the following procedures should the respiratory therapist recommend? A. inspection of the pharyngeal area with a tongue depressor B. bronchoscopy C. lateral neck radiograph D. CBC

C. In this situation, the five-year-old child has a fever and difficulty breathing. A key indicator is the fact that the patient is drooling, meaning they are unwilling to swallow their own oral secretions. This should make the practitioner suspect acute epiglottis. This can be confirmed diagnostically by obtaining a lateral chest radiograph.

While observing a PA chest radiogram, the respiratory therapist notices that the apices of the lung are not level with one another. The right is higher than the left while the clavicle structure remains level. What is the most likely reason for this? A. The patient is leaning to the left. B. The x-ray camera is tilted to the left. C. The patient is improperly rotated. D. Over-exposure is projecting a shadow.

C. Level clavicles rule out any leaning of the patient or tilting of the camera. This is mostly likely caused from the patient being rotated improperly, causing one side the lungs to be closer to the film than the other. This would account for the apparent difference in lung size and/or height.

A physician asks the respiratory therapist to evaluate the effectiveness of PEP therapy on a patient with cystic fibrosis. The therapist can conclude the therapy is effective if A. improved arterial blood gas values are observed B. increased inspiratory capacity is observed C. the patient develops rhonchi that clears with coughing D. increased oxygen saturation during treatment is noted

C. Of the options listed the development of rhonchi, which means secretions in the large upper airways, is the best evidence that secretions are being mobilized by the PEP therapy. The other options offered are either too indirect or are not related.

What would occur on a time-cycled ventilator with a fixed rate if the inspiratory flow rate were increased? A. decrease in tidal volume B. decrease in inspiratory time C. increase in tidal volume D. increase in inspiratory time

C. On a time-cycled ventilator inspiratory time is predetermined. So, if the flow rate is increased while the mandatory rate is unchanged, the result would be an increase in tidal volume.

An infant on a time cycled, pressure limited ventilator is showing signs of distress. Inspiratory pressure is set to 30 cm H2O with a pop-off set at 35 cm H2O. Close observation reveals the pressure manometer on the ventilator is only rising to 20 cmH2O with each breath. Which of the following changes should the therapist recommend? A. switch to a volume-cycled ventilator B. decrease I:E ratio C. increase the flow D. decrease the pressure pop-off

C. On a time-cycled ventilator, when the set inspiratory pressure is not being reached it is likely due to an inadequate flow.

High-frequency chest wall oscillation device is being used on a patient with pneumonia. The oscillation setting is measured in which of the following units? A. CPM B. cm H2O C. Hertz D. RPM

C. Oscillations are set in Hertz.

A patient indicates he has been smoking an average of 1.5 packs per day for 30 years. Which of the following accurately summarizes the patient's history of smoking? A. 60 pack-years B. 30 pack-years C. 45 pack-years D. 10 pack-years

C. Pack-years are calculated by: Average packs per day X number of years.

The respiratory therapist responds to an adult patient on a ventilator whose low pressure alarm is sounding. The therapist determines the 6.0 mm ET tube is in proper position according to the markings. Gas escaping around the ET tube is audible. The therapist should A. switch to a cuffless ET tube B. schedule the patient for a tracheotomy C. switch to a larger ET tube D. add air to the cuff

C. The first, most obvious problem in this question is that an adult patient has a 6.0 mm ET tube. For a normal sized adult, this endotracheal tube size is likely too small. Further evidence indicates gas escaping around ET tube. This is also likely due to a small endotracheal tube.

A male postoperative patient has physician orders to receive incentive spirometry therapy. His preoperative inspiratory capacity was 2800 mL. The respiratory therapist will set which of the following as an initial goal? A. 500 mL B. 700 mL C. 1400 mL D. 1100 mL

C. The initial incentive spirometry goal after surgery should be about one half of the inspiratory capacity achieved prior to surgery. In this case, 1400 mL is an appropriate goal.

A 52-year-old patient has the following ECG rhythm immediately after suctioning with a 14 Fr catheter. The respiratory therapist should recommend which of the following strategies to prevent this in the future? A. bolus of Atropine B. utilizing a smaller suction catheter C. hyperoxygenation D. administration of epinephrine

C. The rhythm strip demonstrates several PVCs. The most effective treatment and prevention strategy for PVCs is oxygenation.

A patient in the emergency room is in respiratory distress. The report indicates the patient was stable one moment, but suddenly became short of breath with a respiratory rate of 30/min. Which of the following could be the cause of the change in the patient's condition: A. congestive heart failure B. carbon monoxide inhalation C. pulmonary embolus D. chronic bronchitis

C. The sudden development of shortness of breath is brought on by a pneumothorax or pulmonary embolism. Most other disease processes or conditions cause changes to occur more slowly.

Prior to the removal of chest tubes, which of the following should be done? A. suction pressure should be increased temporarily B. the chest tube should be exposed to normal atmospheric pressure C. clamp the chest tube for 24 hours D. flush the chest tube with normal saline

C. There is a specific procedure that must be followed to discontinue chest tubes. Prior to removing the tubes the first step is to clamp the chest tubes for 24 hours and observe if drainage has adequately ceased.

During the weaning process of a 70 year-old patient, the respiratory therapist notes the following ventilator settings and clinical information: Mode SIMV Mandatory rate 8Total rate 28VT 500 mLVT(spont) 220 mLFIO2 0.4PEEP 5 cm H2O The respiratory therapist should do which of the following? A. increase set VT B. discontinue PEEP C. add pressure support D. increase rate

C. This patient appears to be weaning from mechanical ventilation. To determine the ventilatory ability of the patient, it is helpful to first look at the patient's total rate compared to the set rate, and the patient's spontaneous tidal volume. In this case the total rate is 28/min which is excessive. This high rate can be explained by the patient's spontaneous tidal volume which is 220 mL. This volume is far below the 5 mL per kilogram required to sustain life. Together, with the high respiratory rate, this patient will ultimately tire and be unable to sustain independent ventilation. One way that we can help this patient is to add pressure support. This will cause an increase in spontaneous tidal volumes and thus decrease total rate.

Arterial Venous pH 7.40 7.38PCO2 40 torr 42 torrPO2 85 torr 48 torrHCO3- 24 mEq/L 24 mEq/LBE 0 mEq/L 0 mEq/LSAT 96% 80%Hb 14 g/dL 14 g/dL A patient receiving mechanical ventilator support in the intensive care unit has the follow blood gas results: The respiratory therapist should record which of the following C(a-v)O2 values in the patient's medical record? A. 5.1 vol% B. 1.6 vol% C. 3.1 vol% D. 6.2 vol%

C. To answer this question, one must complete two calculations. First, CaO2 and CvO2 must be determined. Once CvO2 is subtracted from CaO2, 3.1 vol% is the closest answer.

What is the static compliance in mL/cm H2O, given the following data on a patient receiving VC AC ventilation? Plateau pressure 15 cm H2O Peak pressure 25 cm H2OVT 500 mLPEEP 5 cm H2O A. 25 B. 20 C. 50 D. 33

C. To determine static compliance, tidal volume is divided by plateau pressure after subtracting any PEEP. In this case, (500/(15-5) = 50 cm H2O.

What is the minute ventilation (L/min) of a 200-lb (91-kg) male who has a tidal volume 400 mL and a respiratory rate of 15? A. 7.2 B. 4.6 C. 6.0 D. 3.0

C. To determine the minute ventilation of the patient, one should multiply the tidal volume by the rate. In this case, tidal volume is expressed in mL. Because minute ventilation is expressed as L/min, tidal volume must be translated to liters. Thus, .400 x 15 is equal to him 6.0 L.

The respiratory therapist should recommend which of the following to help evaluate a patient with suspected vocal cord paralysis? A. maximum voluntary ventilation for 12 seconds B. slow vital capacity maneuver C. flow volume loop maneuver D. complete inhalation followed by completed forced exhalation

C. Vocal cord paralysis and other fixed upper airway obstructions are best diagnosed by doing a flow-volume loop pulmonary function test. If present, the flow-volume loop will be described as "round" in shape. This is because a fixed obstruction causes an equal amount of resistance on both inhalation and exhalation.

A 14-year old patient with asthma is in the emergency department (ED) with shortness of breath. Two treatments with Albuterol have been given, but the patient is still wheezing and peak flow measurements have not changed. The respiratory therapist should recommend? A. administering cromolyn sodium (Intal) B. ordering a chest radiograph C. administering ipratropium bromide (Atrovent) D. drawing arterial blood for gas analysis

C. When a patient is not responsive to a particular bronchodilator medication, it is appropriate to attempt bronchodilation with a different medication. In this case, Atrovent is a good alternative medication because it is also a short term rescue medication, like albuterol, but with a different mode of action.

A patient is engaged in a smoking cessation program. During a routine visit to the counseling clinic, the patient expresses a concern about recent weight-gain with cessation of smoking. The respiratory therapist should explain that the reason for the weight gain is most likely due to A. hypothyroidism B. lack of self control due to compensation for the loss of tobacco C. decreased metabolism D. nicotine withdrawal

C. When a patient stops smoking, their body experiences a decrease in metabolism and therefore can experience weight gain.

A patient receiving oxygen by nasal cannula at 5 L/min complains of dryness of the nasal passages. The respiratory therapist notices the patient is using a bubble humidifier and that the reservoir is one quarter full. The respiratory therapist should help the patient by A. Switching to a Venturi mask B. Utilizing a heated cascade humidifier C. Adding sterile water to the reservoir D. Applying a petroleum based ointment to the patient's nares

C. When receiving flows greater than 1-2 liters per minute by nasal cannula, patients have a tendency to experience a drying of the nasal mucosal tissues. To combat thi,s humidification of the delivered gas by a bubble humidifier is appropriate. In this case, the patient's humidifier reservoir is nearly empty. As the bubble humidifier loses water its effectiveness decreases significantly because there is less distance from the bubbles to travel from the bottom of the humidifier to the top water level. Ensuring an adequate level of sterile water in the reservoir is important.

A respiratory therapist suspects a patient has significant atelectasis following abdominal surgery. Which of the following methods could be used to immediately evaluate the patient for this finding? A. A-aDO2 determination B. obtain a chest radiograph C. P/F ratio determination D. observe symmetry of chest rise

D

Who would benefit most from the administration of dornase alpha? A. a patient with pneumococcal pneumonia B. a patient with a pseudomonas infection C. a pulmonary emphysema patient D. a cystic fibrosis patient

D

While performing routine tracheostomy tube care on a patient who breathes spontaneously during the day but requires positive-pressure ventilation in the night, the respiratory therapist notices that the cuff will not maintain pressure when air is injected through the pilot valve. The therapist should recommend A. inserting an oral airway. B. clamping the pilot line immediately after injecting air. C. cutting the pilot line and inserting a blunt needle. D. exchanging the airway.

D. If the cuff is ruptured or is faulty, the tube should be exchanged for a new one. Other methods may provide temporary assistance, but a faulty device should not be maintained.

When determining a patient's readiness to wean from mechanical ventilation, a respiratory therapist calculates the rapid shallow breathing index. This is done by which of the following calculations? A. Vd / VT B. mPAW / PaO2 C. PaO2 / FIO2 D. RR / VT (L)

D. RSBI is calculated by RR / VT (L). The patient is eligible for weaning and ventilator liberation when RSBI is less than 106.

A CHF patient with decreased left ventricular filling pressure would benefit from which of the following medications? A. Pronestyl B. Osmitrol C. Anectine D. Lasix

D. A patient with CHF can benefit from two things - diuresis and an increase in the cardiac contraction strength. Lasix will diurese the patient while digitalis increase the stength of contraction of the left ventricle.

A mal-positioned tracheostomy tube is detected by chest radiograph for a patient who is still receiving partial ventilation through the tube. Subcutaneous emphysema is present in the upper chest. Palpation of the affected area would produce A. air accumulation below the skin. B. soft tissue hyperlucency. C. dry crackles. D. popping or crackling sensations.

D. A patient with an inappropriately positioned tracheostomy tube may experience air in the dermal and subdermal spaces of the skin around the neck and upper chest. Upon palpation air bubbles below this may move around or may burst, causing crackling or popping sensations during palpation.

A respiratory therapist auscultates expiratory wheezing on a patient with COPD who has a 75 pack-year history of smoking. The therapist should recommend A. Theophylline by pill. B. Aerosolized Lidocaine, 3.0 mL. C. Pulmicort (budesonide) by MDI, 2 puffs. D. Unit dose of Albuterol by small volume nebulizer.

D. Albuterol is most appropriate for treating bronchoconstriction.

The respiratory therapist assesses a 78-year-old COPD patient who has a history of chronic carbon dioxide retention and has a 90-pack-year smoking history. The patient is placed on a 40% air-dilution mask. Twenty minutes after the placement of oxygen the patient seems more relaxed but ventilations are becoming shallow. The respiratory therapist should A. Switch to a 4 L/min nasal cannula B. Change to a partial rebreathing mask C. Place on a non-rebreathing mask D. Switch FIO2 to 0.28 via an air-dilution mask

D. Because this patient is COPD, oxygen delivery greater than 28% is inappropriate. When excessive oxygen is delivered to a COPD patient the result can be reduced depth and rate of respiration. The appropriate action is to decrease FIO2 to 28% or below or 1-2 L/min by nasal cannula.

A radiographic image shows an upper lobe cavitation. Which of the following conditions is most closely associated with this finding? A. Asbestosis B. Bronchiectasis C. Pneumonia D. Tuberculosis

D. Cavitations in the upper lobes are generally associated with tuberculosis. Bronchiectasis is a condition affecting the bronchioles or airways and is seen throughout the lung. Pneumonia is not a cavitation and can also be seen throughout the lung on X-ray. Asbestosis is seen throughout the lung with reduced lucency.

Upon discovering a patient in the step-down intensive care unit who appears to have lost all ventilatory drive and is therefore experiencing a complete cardiopulmonary arrest, the respiratory therapist intubates the patient and places an infrared end-tidal CO2 detector on the ET tube before providing manual ventilation with a resuscitator bag and beginning chest compressions. What initial end-tidal CO2 trend will the therapist expect to observe? A. fluctuating CO2 as resuscitation efforts continue B. high CO2 followed by a steady decrease C. no CO2 reading until within range of the infrared device D. low CO2 followed by a steady rise

D. For a patient who has not been ventilating or circulating (no pulse), initial end-tidal CO2 values will be low (if not zero) but will then steadily rise as circulatory efforts expose CO2-filled blood to the alveoli. When a patient is neither circulating nor ventilating, there is no appreciable CO2 in the alveoli initially, and thus the value is low (close to zero) at first but climbs with resuscitative efforts.

The chest radiograph of a post-operative abdominal surgery patient shows pneumonia in the lower right lobe. The respiratory therapist should recommend which of the following? A. diagnostic chest percussion B. Albuterol and Atrovent (Ipratropium Bromide) metered dose inhaler C. pulmonary rehabilitation D. PEP therapy

D. For a patient with pneumonia, a key consideration is mobilization and removal of secretions. Of the options offered only PEP therapy would accomplish this.

Which of the following would be increased in a patient diagnosed with COPD? TLC FRC RV VT 1. YES NO YES NO2. YES YES YES NO3. NO YES NO YES4. NO NO NO YES A. 4 B. 3 C. 1 D. 2

D. With COPD, air-trapping causes an increase in RV, FRC, and TLC. Tidal volume does not increase as a result of the obstructive defect.

A respiratory therapist notices the waveform of a pulmonary artery catheter is repeatedly rising and descending from 25 mmHg to 8 mmHg. However, a closer observation reveals there is no dicrotic notch in the waveform. Which of the following can the respiratory therapist do with the pulmonary artery catheter to correct the situation? A. withdraw the the catheter B. advance the catheter C. jiggle the catheter D. aspirate the catheter

D. The absence of a dicrotic notch in a pulmonary artery pressure waveform is called "pressure dampening". This does not harm the patient. However, it is an indication of a poor signal and should be resolved. This may be remedied by: First, aspirating from the catheter; second, flushing the catheter; and third, rotating the catheter. Advancement or withdraw of the catheter is not an appropriate remedy for pressure dampening.

During the administration of an IPPB treatment, the patient becomes unresponsive and develops the ECG rhythm as shown below. Which of the following is the best initial action? A. Connect a pacemaker B. Defibrillate at 50 joules C. Arterial blood gas analysis D. Begin CPR

D. The best option in this case is to begin CPR. This is because the ECG rhythm is consistent with the absence of cardiac contraction. Combined with the fact that the patient has suddenly become unresponsive, this is adequate data indicating the need to intervene with cardiopulmonary resuscitation.

A respiratory therapist is performing a routine patient/ventilator check on a mechanically ventilated patient. Returned tidal volume is 150 mL less than delivered. A high-pitched audible leak is auscultated through the neck. What is the appropriate response? A. reposition the patient B. advance the endotracheal tube 1 cm C. increase delivered tidal volume D. add air to the cuff

D. The high-pitched audible leak auscultating over the neck in conjunction with a low returned tidal volume is most likely an indication of insufficient pressure in the endotracheal tube cuff. Adding air to the cuff is most appropriate.

Which of the following questions would help a healthcare practitioner assess the mental awareness of the patient? A. "Can you think clearly?" B. "Do you feel aware and awake?" C. "Do you know where you are right now?" D. "Where are you right now?"

D. The key to ascertaining a patient's awareness of time, person, and place is to ask open-ended questions. Open-ended questions are those than cannot be answered with 'yes' or 'no'.

The most common cause of nosocomial infections in a hospital setting is A. breaking the sterile field with suctioning B. improper equipment cleaning C. poor use of gloves D. poor hand washing

D. The most common cause of nosocomial infection is poor handwashing among healthcare staff.

Parents of a newborn are complaining of sleep deprivation due to a frequently alarming apnea monitor at night. They indicate that when the apnea monitor alarms, the infant appears to have been breathing adequately. Which of the following should the respiratory therapist investigate? A. the internal battery level of the monitor B. the parent's understanding of true apnea C. the electrical outlet into which the monitor is plugged D. the contact surfaces between the metal snaps on the leads and the electrode patch

D. The most common source of erroneous alarming on an apnea monitor is the connection between the lead wire and the electrode patch. Often, the female portion of the snap does not maintain adequate contact with the male portion of the snap on the patch.

During the placement of a pulmonary artery catheter, the respiratory therapist observes the waveform on the monitor and notices it is repeatedly rising and falling from 0 mmHg to 25 mmHg, which is an indication that the tip of the catheter is in the right ventricle of the heart. Based on this information, the respiratory therapist will recommend A. suture the catheter in place B. rotate the catheter to achieve a dicrotic notch in the waveform C. withdraw the catheter back to the upper vena cava D. inflate the catheter balloon to sail the tip to the proper location

D. The pulmonary catheter should be terminated in the pulmonary artery, which is beyond the right ventricle. Therefore, advancing the catheter is appropriate. The catheter may be advanced by sailing it into position, which is done by inflating the catheter balloon and allowing blood flow to carry the catheter into position and then deflating the balloon once it is in the proper position.

Prior to beginning patient pulmonary function testing, a respiratory therapist uses a 3-L calibrated and certified syringe to confirm proper function of the pulmonary function testing equipment. The measurements are: 2.85 L, 2.99 L, 3.14 L. Which of the following should the therapist conclude? A. The PFT equipment requires calibration or maintenance B. Room temperature should be lowered before retesting C. The syringe requires recalibration or recertification D. The equipment is acceptable for patient testing.

D. The three-liter calibrated syringe should be trusted above the pulmonary function equipment. Therefore, after injecting air into the pulmonary function machine and finding these values, it can be concluded that the machine is inaccurate and requires maintenance or calibration. Although the syringe used to calibrate is 3 L, some deviation is allowed. That deviation is 2.85 to 3.15 or plus +/- 5%. In this case, all values obtained are within the margin of error and are acceptable enough to proceed with patient testing.

The respiratory therapist is determining the proper size of an oropharyngeal airway on a patient who is orally intubated. Which of the following methods will be helpful in properly estimating the appropriate size of the airway? A. determine the patient's ideal body weight in kilograms B. determine the age and sex of the patient C. examine the distance between the earlobe and nasal septum D. examine the distance between the angle of the jaw and tip of the chin

D. The way to determine the proper length of an oral pharyngeal airway is to measure and match the distance between the angle of the jaw and the tip of the chin.

The following arterial blood gas results are available for a patient receiving volume controlled ventilation. pH 7.21 PaCO2 53 torrPaO2 72 torrHCO3- 23 mEq/LBE -2 mEq/L Current ventilator settings are: Mode Assist/control VT 550 mL Mandatory rate 12Total rate 12FIO2 1.0PEEP 20 cm H2O The respiratory therapist should recommend: A. increasing PEEP B. decreasing tidal volume C. decreasing FIO2 D. increasing mandatory rate

D. This patient's blood gas reveals hypoventilation and hypoxemia. Of these two problems, ventilation should be addressed first. Because PaCO2 is off target by more than 4 mmHg the best option would be to increase mandatory rate.

A victim of a multiple trauma motorcycle accident is receiving mechanical ventilation and has chest tubes inserted in the right lung. The respiratory therapist notices gentle bubbling in the water-seal bottle and a small amount of fluid dripping into the fluid collection bottle. The following data is also available: Mode Assist/control Mandatory rate 18Total rate 18VT (set) 550 mLVT(exhaled) 534 mLPeak pressure 28 cm H2OPlateau pressure 18 cm H2O The therapist should A. troubleshoot the chest tube drainage system B. suction the patient C. clamp the chest tube(s) near the patient D. continue current therapy

D. This question indicates that gentle bubbling is noticed in the water-sealed bottle or compartment of the chest tube drainage system. Although this may sound like something is wrong, this is actually a normal finding. In this case. Therapy should be continued. Profuse bubbling is an indication of leak in the tubing or a bronchopleural fistula in the lung tissue.

A 150-lb (68-kg), 5-ft 6-in (168 cm) female patient is receiving mechanical ventilation as follows: Mode Assist/control Alveolar minute ventilation 7.5 L/minTotal Rate 15PB 734 mm Hg What is the patient's set tidal volume? A. 550 mL B. 350 mL C. 700 mL D. 500 mL

D. Tidal volume is calculated by dividing the minute ventilation by the respiratory rate. By knowing any two of these three data, one can calculate the third. For example, to calculate minute ventilation, multiply the tidal volume by the respiratory rate. To calculate respiratory rate, divide minute ventilation by tidal volume.

Immediately following oral endotracheal intubation, the respiratory therapist should confirm proper placement by doing which of the following? A. Assess end-tidal CO2 with a colorimetric capnometer B. Auscultate the neck C. Ensure tube markings are between 20-24 at the teeth D. Obtain a anterior-posterior chest radiograph

D. To determine the location and placement of an endotracheal tube a chest x-ray is appropriate. Because the patient is intubated it is not likely that the patient is ambulatory and therefore must undergo a chest x-ray in bed. When shooting a chest x-ray bed, the proper technique is called an AP chest radiograph, or anterior-posterior x-ray.

In preparation for pulmonary function testing, the respiratory therapist interviews the patient to investigate use of tobacco products. The patient reports smoking 5 packs a day for 10 years and 1.5 packs a day for 20 years. What is the pack-year history of smoking for this patient? A. 30 B. 110 C. 195 D. 80

D. To determine the pack-year history of smoking, one must take the average packs per day and multiply it by the years smoked. In this case, however the patient has had two separate segments of their life where they have smoked different amounts. Thus, five multiplied by 10 is 50 pack years and that must be added to 1.5 multiplied by 20 years for a total of 80 pack years.

A respiratory therapist auscultates a 3-year-old child in respiratory distress in the emergency department (ED). Auscultation reveals unilateral wheezing on the right and vesicular breath sounds on the left. The therapist should prepare which of the following to help the patient? A. aerosolized racemic epinephrine B. aerosolized Ipratropium Bromide (Atrovent) C. a small volume treatment with Albuterol D. a bronchoscope

D. Unilateral wheezing in a small child is usually associated with foreign body aspiration. When the patient wheezes, normally, bilateral bronchoconstriction is present. Therefore, unilateral wheezing is more likely caused from an object or food in the airway on the affected side. To resolve this, a bronchoscope will both diagnose the problem and facilitate extraction of the object.

After making the universal sign of choking, a person collapses. The observer should FIRST A. administer 2 rescue breaths B. call for help C. check for a pulse D. perform abdominal thrusts

D. When a person indicates the universal sign of choking, they are unable to verbalize because there is likely something caught in their airway. The person responding must first focus on removing the obstruction, which is done by performing abdominal thrusts. Administering rescue breaths would not be appropriate because the airway is obstructed. Calling for help is tempting but is only related to two-man CPR. The patient is not yet at that point. Performing abdominal thrusts is a one-man maneuver and therefore obtaining additional help is not the first concern.

A patient in the intensive care unit has an arterial catheter in place. The respiratory therapist notices the blood pressure from the arterial line is 95/70 mmHg. Blood pressure taken by a sphygmomanometer reads 110/78 mmHg. The patient is asymptomatic. The therapist should A. discard the blood pressure cuff B. calibrate the blood pressure cuff C. record the arterial line blood pressure D. record the sphygmomanometer blood pressure

D. When blood pressure by sphygmomanometer (cuff) differs from the blood pressure obtained from an indwelling arterial line, the blood pressure taken by cuff is considered more accurate and reliable. Problems that may occur in the yard line include a clots in the line or bubbles in the transducer dome.

A patient will be receiving short-term mechanical ventilatory support after surgery. Which of the following methods of humidification is appropriate? A. large volume nebulization B. cool, passover humidification C. centrifugal nebulizer D. HME

D. When providing humidity to the patient on a ventilator, because the natural humidification processes of the body are bypassed, 100% humidity must be provided through the ventilator. Only heated humidification can accomplish this. Non-heated passover humidification is inadequate. An HME is meant for short-term use only (a few hours). A centrifugal and large volume nebulizers are not devices used with the mechanical ventilation.

A 38-week gestational age infant delivered 4 hours prior shows signs of hypoxemia. In preparation for oxygen administration at 30% by oxygen hood, the therapist should utilize which of the following devices? A. high-flow hydrator B. bubble humidifier C. heat-moisture exchanger D. blender

D. When using an oxygen hood, it is appropriate to premix gases by use of an oxygen-air blender. Use of a large-volume nebulizer at low FIO2 could cause excessive noise transmitted to an oxygen hood which could promote hearing damage and restlessness of the infant. For this reason use of blender is more appropriate.

Which of the following could cause a false exhaled CO2 reading on a capnograph placed in a ventilator circuit? A. excessive gas temperatures in the circuit B. high ambient light in the room C. polycythemia D. soiled infrared detector

D. While in the ventilator circuit, an infrared sensor may become easily soiled with secretions and excess condensation. This can cause erroneous exhaled CO2 readings. Gas temperature does not make an appreciable difference and the presence of excessive hemoglobin is not relevant.

Which of the following are needed to assess a patient's pulmonary compliance while receiving VC ventilatory support? 1. peak pressure 2. plateau pressure 3. tidal volume 4. I:E ratio A. 2 and 3 only B. 1 and 2 only C. 1 and 3 only D. 3 and 4 only

Pulmonary compliance can be determined by this calculation - VT / Press(plat).

A 74-year-old male in the intensive care unit has the following arterial blood gas results while receiving volume-controlled ventilation at an FIO2 of 1.0 with PEEP of 10 cm H2O. pH 7.33 PaCO2 50 torrPaO2 220 torrHCO3 - 22 mEq/LBE -2 mEq/L The respiratory therapist should conclude which of the following regarding the patient's condition? A. venous admixture B. metabolic acidosis C. ventilation/perfusion mismatch D. increased systemic vascular resistance

The alveolar oxygen tension for a patient on 100% should be about 650 mmHg. When you subtract the PaO2, the A-a gradient is 430 mmHg. A gradient greater than 300 mmHg is called pulmonary shunting or venous admixture. A gradient greater than 65 but less than 300 mmHg is considered ventilation/perfusion mismatch.