TMC Practice Exam 1

A 48-year-old male is orally intubated, receiving mechanical ventilation with an 8.0 mm endotracheal (ET) tube secured in place. Cuff pressure is measured at 36 cm H2O. You should: Select one: A. Recommend reintubation with a smaller ET tube B. Withdraw the tube 1-2 cm and reassess breath sounds C. Recommend a percutaneous tracheotomy D. Lower cuff pressure to < 30 cm H2O and assess for leaks

36 cm H2O is excessive and could cause tracheal damage. You should first lower cuff pressure to < 30 cm H2O and assess for leakage. If leakage is present at the safer pressure, recommend an ET tube with a port for aspirating subglottic secretions. Replacing the ET tube with a larger size is an alternative. The correct answer is: Lower cuff pressure to < 30 cm H2O and assess for leaks

Sputum induction is performed on a trach patient to gather a sample for microbiological identification. The sample is collected using a Lukens trap. When applying suction after entering the airway, the mucus should Select one: A. pass into the trap and then move on into the collection jar B. pass through the wall tubing and then into the Lukens trap C. pass through the suction catheter and then enter the Lukens trap D. pass into the Lukens trap and then enter the suction catheter

A Lukens trap is used to collect sputum samples during suctioning or bronchoscopy. To use the trap, the therapist places it between the suction catheter and the suction system's connecting tubing, while maintaining its internal sterility. When suction is applied, secretions should then pass through the suction catheter and enter the Lukens trap. After gathering the desired specimen, the trap is sealed (with its own connecting tubing) and processed for laboratory study. The correct answer is: pass through the suction catheter and then enter the Lukens trap

Which of the following methods could be used to assess the intensity of pain being experienced by an elderly, confused patient who is unable to express himself? Interview a family member Observe patient for grimacing Use a numeric rating scale A. No Yes Yes B. Yes No Yes C. Yes Yes No D. Yes Yes Yes Select one: A. A B. B C. C D. D

A numeric rating scale is not useful for young children or patients who are confused or unable to express themselves. As an alternative, interviewing family members may help provide information about pain history, typical behaviors when the patient has pain, and activities that may cause or aggravate pain. Lacking such information, the health professional may have to rely on overt patient behaviors (e.g., groaning/moaning, 'doubling over,' etc.) and/or facial expressions indicative of severe pain (e.g., grimacing, eye tearing, etc). The correct answer is: C

Which of the following would most adversely affect the accuracy of pulse oximetry measurement? Select one: A. coma B. fever C. tachycardia D. shock

Accurate SpO2 readings depend on the adequacy of circulation to the monitored area. For this reason, vasoconstrictor drugs, shock, and placement over areas with poor perfusion (e.g., a bony area) may adversely affect the accuracy of pulse oximetry. The correct answer is: shock

Based on the results of cardiopulmonary exercise testing, which of the following patients most likely has a ventilatory limitation to exercise? Patient VO2max Anaerobic Threshold Breathing Reserve A. Decreased Decreased Normal B. Decreased Normal Normal C. Normal Increased Increased D. Decreased Normal Decreased Select one: A. Patient A B. Patient B C. Patient C D. Patient D

All patient with poor exercise capacity have a reduced VO2max. In addition, patients with a pulmonary limitation to exercise tend to have a normal anaerobic threshold (if it can be reached), but a decreased breathing reserve. Patients with a cardiovascular limitation to exercise typically have a reduced anaerobic threshold, but normal breathing reserve. In the presence of a low VO2max, poor effort is revealed by both a normal anaerobic threshold and breathing reserve. The correct answer is: Patient D

When using a resuscitation mask for mouth-to-mask ventilation, which of the following will protect you from exposure to the patient's secretions? Select one: A. face shield B. rubber seal C. one-way valve D. HEPA filter

All resuscitation masks incorporate a one-way breathing valve. In addition to separating the inspired (you) and expired gas streams (allowing the patient to exhale without removing the mask), these valves protect you from contacting the patient's secretions or vomitus The correct answer is: one-way valve

In clinical practice, positive identification of medical gas cylinder contents is made by: Select one: A. noting the color of the cylinder B. reading the cylinder label C. inspecting the cylinder's threaded connection D. collecting and analyzing a gas sample

Although color codes for medical gases are specified by the National Institute of Standards & Technology of the US Dept of Commerce, these codes are not yet accepted world-wide (O2 cylinders are white in many other countries). For this reason, a cylinder's color should be used only as a rough guide. As with any medicinal agent, the therapist must always positively identify the cylinder contents by carefully reading its label. The correct answer is: reading the cylinder label

Which of the following would cause an increase in a patient's peak airway pressure while receiving volume control ventilation? Select one: A. resolving pulmonary edema B. bronchospasm C. blown ET tube cuff D. ventilator circuit leak

An increase in peak airway pressure during volume control ventilation indicates either an increase in airway resistance or a decrease in lung and/or thoracic compliance. Bronchospasm, increased secretions and obstruction of the ET tube would all increase airway resistance. As pulmonary edema resolves lung compliance INCREASES, which would decrease peak pressure. A blown ET tube cuff or any other type of leakage will cause the airway pressure to fall. The correct answer is: bronchospasm

You note in the chart of a patient's who is receiving volume control ventilation that the plateau pressure has been increasing over the last 6 hours, while the PEEP levels remains constant. Which of the following would be the most likely cause of this change? Select one: A. development of pulmonary edema B. water accumulation in the ventilator circuit C. partial obstruction of the endotracheal tube D. development of bronchospasm

An increase in the plateau pressure relative to baseline (Pplat-PEEP) indicates a decrease in the patient's lung and/or thoracic compliance. Common causes of a decrease in lung compliance are pneumothorax, pulmonary edema, atelectasis and ARDS. Partial obstruction of the ET tube and development of bronchospasm would increase airway resistance and thus increase PIP and the PIP-Pplat pressure difference, but not affect Pplat. The correct answer is: development of pulmonary edema

In order to assure a stable FIO2 under varying patient demands, an oxygen delivery system must: Select one: A. provide all the gas needed by the patient during inspiration B. have a reservoir system at least equal to the tidal volume C. maintain flows at least equal to the patient's peak flows D. automatically change its flow in response to patient demands

As long as a device provides all the inspiratory gas needs of the patient, a stable FIO2 is assured. This need can be met either by providing a volume of gas equal to the inspired volume, or by matching the patient's inspiratory flow with an equal flow of the prescribed mixture. Devices supplying all a patient's inspired gas needs at a given FIO2 are called fixed-performance delivery systems. The correct answer is: provide all the gas needed by the patient during inspiration

When asking a patient who he is, where he is, and the time of day, you are trying to assess the patient's: Select one: A. level of consciousness B. reaction to chronic illness C. understanding of the language D. ability to cooperate

Asking patients the time of day, where they are, and who they are is a quick way to assess their level of consciousness or "sensorium." Alert patients are well-oriented as to time, place, and person, or "oriented ×3." The most common reasons for a patient not being well-oriented to time, place, and person are neurologic injury, pharmacologic sedation and severe hypoxemia or hypercapnia. In general, only alert patients can be expected to cooperate and fully participate in their own care. The correct answer is: level of consciousness

A home care patient needs 8 L/min oxygen bled into an air nebulizer system. Which of the following would you recommend as the most efficient and cost-effective way to provide the oxygen? Select one: A. large cylinder (H/K) gas B. liquid oxygen system C. single O2 concentrator D. dual O2 concentrators

At the desired flow (8 L/min), large gas cylinders and liquid oxygen systems would be very inefficient and costly, due to the need for frequent deliveries. Because most concentrators cannot deliver more than 5 to 6 L/min, higher flows can only be achieved by running two systems together in parallel. The correct answer is: dual O2 concentrators

A patient admitted to the ED exhibits wheezing and hypoxemia on room air. Lab tests indicate a normal B-type natriuretic peptide (BNP) level. Which of the following conclusion can you draw from these findings? Select one: A. renal function likely is normal B. a myocardial infarction is likely C. congestive heart failure is unlikely D. liver function likely is normal

B-type natriuretic peptide (BNP) is a cardiac neurohormone secreted from membrane granules in the cardiac ventricles as a response to ventricular volume expansion and pressure overload. BNP levels that are less than 100 pg mL (normal is < 20 pg/mL) tend to rule out diagnosis of CHF, while values exceeding 500 pg/mL help rule in this diagnosis. Intermediate values are less helpful and may occur in conditions with similar symptoms, including renal insufficiency, cor pulmonale, and acute pulmonary embolism. The correct answer is: congestive heart failure is unlikely

In which of the following situations would you expect the SpO2 provided by a standard pulse oximeter provide inaccurate data? Select one: A. acute pulmonary edema B. carbon monoxide poisoning C. chronic bronchitis D. bacterial pneumonia

Because standard 2-wavelength pulse oximeters cannot detect the presence of carboxyhemoglobin (HbCO), their saturation readings (SpO2) in carbon monoxide poisoning are usually falsely high and thus provide inaccurate information regarding patient oxygenation. To accurately measure HbCO levels requires at least 3 wavelenghts of light, as provided by a laboratory CO-oximeter and some newer multi-wavelength pulse oximeters. The correct answer is: carbon monoxide poisoning

The most likely cause of bilateral fluffy infiltrates on a chest x-ray is: Select one: A. pulmonary edema B. neoplasm C. pleural effusion D. hemothorax

Bilateral infiltrates indicate a global (lung-wide) as opposed to local pulmonary problem. "Fluffy" infiltrates usually indicate an alveolar condition. Only pulmonary edema is a global condition affecting the alveolar region (fluid transudation). Typically neoplasms, effusions and hemothoraces are revealed as a localized areas of increased radiopacity. The correct answer is: pulmonary edema

During capnography monitoring of a mechanically ventilated patient, you note that the end-tidal PCO2 (PetCO2) has dropped to 0 mm Hg. This finding may indicate: Select one: A. increased cardiac output B. decreased body temperature C. complete airway obstruction D. hyperventilation

Causes of a PetCO2 of zero mm Hg include 1) a system leak/disconnection, 2) esophageal intubation, 3) cardiac arrest, and 4) a totally obstructed/kinked artificial airway. The correct answer is: complete airway obstruction

Which of the following changes will cause a patient's peak inspiratory pressure delivered during volume controlled ventilation to increase? Increased set VT Increased Patient Compliance Increased set insp flow Increased set PEEP A. No Yes No Yes B. Yes No Yes No C. Yes Yes Yes Yes D. Yes No Yes Yes Select one: A. A B. B C. C D. D

During volume controlled ventilation (VC), the peak inspiratory pressure increases if 1) set VT increases, 2) set inspiratory flow increases, 3) set PEEP increases, 4) patient compliance decreases, or 5) patient airway resistance increases. Peak pressure also increases during VC if the airway is occluded by secretions or obstructed by compression due to biting or tube misplacement. The correct answer is: D

Equipment/supplies required to perform an arterial puncture include which of the following? Select one: A. local anesthetic B. anticoagulant C. sterile gloves D. lancet

Equipment needed to obtain an arterial puncture includes a syringe, anticoagulant, transport container with label (and ice if not analyzed immediately), antiseptic swabs, tape, clean exam gloves, and a sterile gauze or bandage. A local anesthetic is optional. A lancet is used for capillary sampling, not arterial puncture. The correct answer is: anticoagulant

Based on overnight oximetry results, a COPD patient receiving continuous long-term oxygen therapy at 1 L/min exhibits a drop in SpO2 from 90% to 84% at night. Which of the following would you recommend for this patient? Select one: A. have the patient undergo polysomnography to determine the cause of the desaturation B. titrate the patient's nocturnal O2 flow upward until the SpO2 remains above 88% C. change the continuous oxygen therapy prescribed flow from 1 to 2 L/min D. titrate the patient's nocturnal O2 flow upward until the SpO2 remains above 92%

For COPD patients already certified for continuous long-term oxygen therapy who also exhibit nocturnal desaturation, the liter flow can be titrated upward in 1 L/min increments until the nighttime SpO2 consistently exceeds 88% and no further desaturation events occur. The correct answer is: titrate the patient's nocturnal O2 flow upward until the SpO2 remains above 88%

A patient is receiving volume controlled ventilation at a rate of 10/min. The percent inspiratory time (%I) control is set at 25%. What is the inspiratory time? Select one: A. 1.00 sec B. 1.25 sec C. 1.50 sec D. 1.75 sec

Given the rate (f) and percent inspiratory time (%I), the inspiratory time (I) is computed as:I = %I x (I + E)In this case (I + E) = 60/10 = 6 sec; I = 0.25 x 6 = 1.50 sec The correct answer is: 1.50 sec

Which of the following would provide the best bedside assessment of the need for mechanical ventilation in a patient with Guillain-Barre syndrome? Select one: A. FRC B. VC C. airway resistance D. TLC

Guillain-Barre syndrome is a restrictive neuromuscular disorder that results in hypoventilation. Airway resistance measures are not useful in diagnosing restrictive ventilatory impairments. Restrictive ventilatory impairments are characterized by low lung volumes. Of the volumes listed, only the vital capacity (VC) can be measured at bedside The correct answer is: VC

A patient is admitted with signs and symptoms and a history consistent with bronchiectasis. Which of the following tests would you recommend to confirm or rule out this diagnosis? Select one: A. fiberoptic bronchoscopy B. high-resolution CT scanning C. pulmonary function testing D. standard chest X-ray

High-resolution computed tomography (HRCT) scanning has replaced traditional contrast media bronchography as the imaging modality of choice for diagnosing bronchiectasis and evaluating its extent. HRCT scanning also helps clinicians evaluate the status of the surrounding lung tissue and exclude other lesions such as foreign bodies or tumors. For patients who may need repeated follow-up imaging, magnetic resonance imaging (MRI) can provide useful information without the hazard of X-ray exposure. The correct answer is: high-resolution CT scanning

When checking a nondisposable steel laryngoscope blade prior to intubation, you note that the bulb does not light when connected to the handle. Your first step should be to Select one: A. recheck the handle/blade connection B. replace the blade C. replace the batteries D. check/replace the bulb

If the bulb does not light when checking a laryngoscope blade prior to intubation, the first thing you should do is to recheck the handle/blade connection. If this does not work then replace the blade, check/replace the bulb, or replace the batteries The correct answer is: recheck the handle/blade connection

You are gathering a sputum specimen from a patient in isolation. In addition to applying appropriate transmission-based precautions, which of the following procedures should be followed in processing this specimen? Select one: A. mix the specimen with a fixative before sending it to the lab B. leave the specimen container at the nursing station for transport C. disinfect outside of specimen container if contaminated D. have the specimen undergo sterilization before processing

In addition to applying appropriate transmission-based precautions, when gathering a sputum specimen, great care should be taken to prevent external contamination of the container. If the outside of the container gets contaminated, it must be disinfected or placed in an bag. To minimize leakage during transport, specimens should always be placed in a sturdy container with a secure lid. When a specimen comes from a patient in isolation, the container should be placed in an impervious bag and labeled before removal from the room. Fixing or sterilizing the specimen makes no sense because it would prevent valid laboratory analysis. The correct answer is: disinfect outside of specimen container if contaminated

You are gathering a sputum specimen from a patient in isolation. In addition to applying appropriate transmission-based precautions, which of the following procedures should be followed in processing this specimen? Select one: A. mix the specimen with a fixative before sending it to the lab B. place the specimen cup in a sturdy container with a secure lid C. leave the specimen cup at the nursing station for transport D. have the specimen undergo sterilization before processing

In addition to applying appropriate transmission-based precautions, when gathering a sputum specimen, great care should be taken to prevent external contamination of the container. If the outside of the container gets contaminated, it must be disinfected or placed in an bag. To minimize leakage during transport, specimens should always be placed in a sturdy container with a secure lid. When a specimen comes from a patient in isolation, the container should be placed in an impervious bag and labeled before removal from the room. Fixing or sterilizing the specimen makes no sense because it would prevent valid laboratory analysis. The correct answer is: place the specimen cup in a sturdy container with a secure lid

A comprehensive environmental history needs to include information on: Select one: A. the jobs of all household members B. home/apartment temperature settings C. commuting distance to/from work D. approximate hours per day spent on feet

In addition to work-related exposures, a comprehensive environmental history should include information on present and previous home locations, jobs of household members, home insulating and heating/cooling system, home cleaning agents, pesticide exposure, water supply, recent renovation/remodeling, air pollution (indoor and outdoor), hazardous wastes/spill exposure, and hobbies (e.g., painting, sculpting, ceramics, welding, woodworking, automobiles, gardening, etc.) The correct answer is: the jobs of all household members

Results of an overnight oximetry test of a 62-year-old male with complaints of daytime sleepiness reveal an Oxygen Desaturation Index (ODI) of 5 desaturations per hour. Which of the following would you recommend? Select one: A. a full polysomnography exam B. nocturnal O2 therapy C. an O2 titration with exercise D. nocturnal CPAP therapy

In general, an ODI of 15 or more desaturation events (a 3-4% or greater drop in SpO2) per hour indicates the presence of sleep apnea-hypopnea syndrome. When this occurs, a follow-up polysomnography exam is not needed to confirm the diagnosis or begin therapy, except as may be required to titrate CPAP treatment. On the other hand a patient like this one suspected of sleep-disordered breathing but with and ODI < 15 per hour should undergo full laboratory polysomnography to help determine its cause. The correct answer is: a full polysomnography exam

In individuals with disorders causing an increased ELASTIC work of breathing, such as pulmonary fibrosis, which of the following breathing patterns results in the minimum work? Select one: A. slow and deep breathing B. slow and shallow breathing C. rapid and deep breathing D. rapid and shallow breathing

Individuals with disorders characterized by an increased elastic work of breathing, such as pulmonary fibrosis, tend to assume a rapid and shallow breathing pattern. For these patients, such a pattern results in the minimum mechanical work necessary to effectively ventilate the lungs. The correct answer is: rapid and shallow breathing

For which of the following situations would you recommend transcutaneous monitoring of PO2 or PCO2? Select one: A. assessing oxygenation status in suspected CO poisoning B. titrating FIO2 levels in patients receiving oxygen therapy C. spot checking blood oxygen levels in postoperative patients D. monitoring ventilation during noninvasive support (NPPV)

Monitoring the adequacy of ventilation during noninvasive support (NPPV) is one of the good indications for transcutaneous (TC) PCO2 monitoring. This is because obtaining accurate PCO2 data by capnography during NPPV is technically difficult. TC blood gas monitoring also is indicated when the need exists to continuously monitor oxygenation and/or ventilation in patients who either lack arterial access or for whom frequent blood draws are to be avoided. Likewise, TC monitoring can be used to quantify in real-time a patient's response to diagnostic or therapeutic interventions. Because pulse oximetry (SpO2) is not particularly sensitive in detecting hyperoxia (higher than normal PO2s), TC PO2 monitoring is the best way to continuously monitor for this problem in neonates (a potential cause of retinopathy). Last, TC PO2 monitoring is used in wound care to assess tissue perfusion status (a TC PO2 of 30-40 torr over the affected area indicates adequate perfusion). Because it measures PO2 and not HbO2, TC monitoring is not useful for assessing oxygenation in suspected CO poisoning. And due to its technical complexity and requisite warm-up time, using TC blood gas monitoring (vs. pulse oximetry) to titrate patients' FIO2s or spot check their O2 levels make no sense. The correct answer is: monitoring ventilation during noninvasive support (NPPV)

Which of the following types of breathing circuits would you select when assembling a noninvasive positive pressure/BiPAP ventilator? Select one: A. dual-limb "Y" circuit B. single-limb circuit with expiratory balloon valve C. single-limb circuit with leakage-type exhaust valve D. single-limb circuit without any valve

Most noninvasive positive pressure (NPPV) ventilators/BiPAP devices use single-limb circuit with a leakage-type exhaust valve. These circuits consist of a single section of large-bore tubing and an open exhaust port, usually either a small orifice or a set of slotted vent holes. The continuous flow that noninvasive positive pressure ventilators provide through the circuit forces expired gas out this exhaust port during exhalation. The correct answer is: single-limb circuit with leakage-type exhaust valve

Which of the following would provide the best bedside assessment of the need for ventilatory assistance in a patient with myasthenia gravis? Select one: A. functional residual capacity B. vital capacity C. closing volume D. total lung capacity

Myasthenia gravis is a neuromuscular disease that affect muscle strength. Of the tests listed, the vital capacity requires the most muscular effort from the patient and would be the first of the listed tests to decrease in a neuromuscular disorder. The correct answer is: vital capacity

A doctor wants you to assess whether a patient with a progressive neuromuscular condition will likely need mechanical ventilation. Which of the following measures would you recommend obtaining? Max expiratory pressure (MEP) Vital capacity Max inspiratorypressure (MIP) A. Yes Yes No B. Yes No Yes C. No Yes Yes D. Yes Yes Yes Select one: A. A B. B C. C D. D

Neuromuscular disorders typically cause respiratory muscle weakness, which can lead to respiratory failure. You can assess respiratory muscle strength by measuring the patient's maximum inspiratory and expiratory pressures. Measurement of the patient's vital capacity also can be useful as a global measure of respiratory mechanics. The correct answer is: D

Normal lung compliance is approximately: Select one: A. 0.1 - 0.4 L/cm H2O B. 0.4 - 0.8 L/cm H2O C. 10 - 15 L/cm H2O D. 15 - 20 L/cm H2O

Normal compliance of the adult lung ranges from 0.1 to 0.4 L/cm H2O, with an average value of about 0.2 L/cm H2O. The volume component of the compliance is measured as the inhaled volume at any given pressure change. The pressure component represents the difference between the alveolar and pleural pressures (the transpulmonary pressure gradient). The correct answer is: 0.1 - 0.4 L/cm H2O

The normal range of adult blood pressure (systolic/diastolic) is about: Select one: A. 80-100/40-70 mm Hg B. 100-140/60-90 mm Hg C. 120-140/90-100 mm Hg D. 130-150/100-110 mm Hg

Normal systolic pressure range from 100 to 140 mm Hg, with an average of 120 mm Hg. Normal diastolic pressures range from 60 to 90 mm Hg, with an average of 80 mm Hg. The blood pressure is recorded with systolic listed over diastolic; i.e., 120/80 mm Hg. The correct answer is: 100-140/60-90 mm Hg

Which of the following observations during inspection of the extremities indicate poor peripheral circulation? Digital Clubbing Peripheral Cyanosis Impaired Capillary Refill Skin Warm to Touch A. Yes No Yes Yes B. Yes Yes No No C. Yes Yes Yes Yes D. No Yes Yes No Select one: A. A B. B C. C D. D

Observations during inspection of the extremities that indicate poor peripheral circulation include peripheral cyanosis (acrocyanosis) or pallor, slow capillary refill, pitting edema and cool skin temperature. Digital clubbing is associated with a variety of clinical conditions, including bronchiectasis, pulmonary fibrosis, cyanotic congenital heart disease, lung cancer, and cirrhosis of liver. However, clubbing does not indicate poor peripheral circulation. The correct answer is: D

To validate patient readings obtained from a transcutaneous blood gas monitor, you should: Select one: A. measure and compare the PtcO2 and PtcCO2 at three or more different sites B. compare the monitor's readings to a concurrent pulse oximetry reading C. compare the monitor's readings to those obtained via a concurrent ABG sample D. compare the patient reading to those obtained when calibrating the sensor

Once properly set-up, the clinician should compare the transcutaneous blood gas monitor's readings to those obtained via a concurrent arterial blood gas. Good consistency between values validates monitor performance under the existing conditions. The correct answer is: compare the monitor's readings to those obtained via a concurrent ABG sample

An adult male patient on ventilatory support has just been intubated with a 7.0 mm oral endotracheal tube equipped with a high residual volume low pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H2O. What is the most likely problem? Select one: A. the cuff pilot balloon and line is obstructed B. the pressure manometer is out of calibration C. the tube chosen is too small for the patient D. the tube is in the right mainstem bronchus

Overinflation of a high volume, low pressure cuff changes its performance to a high pressure cuff. This problem is common if the tube chosen is too small for that patient's trachea. The correct answer is: the tube chosen is too small for the patient

A doctor asks your advice on the best way for his home care asthma patient to assess changes in her airway tone over time. You would recommend: Select one: A. peak expiratory flow rate monitoring B. methacholine challenge (provocation) test C. carbon monoxide diffusing capacity (DLco) D. pre/post bronchodilator spirometry

Peak expiratory flow rate monitoring is the primary means by which asthma patients can assess their airway tone over time, as well as changes in tone in response to bronchodilator therapy. Pre/post bronchodilator spirometry is used primarily to determine the effectiveness of bronchodilator therapy or the need for a change in the drug dose or frequency of administration. Methacholine challenge testing is used mainly to assess the severity of airway hyperresponsiveness or evaluate occupational asthma The correct answer is: peak expiratory flow rate monitoring

A patient is being considered for participation in a pulmonary rehabilitation program. Which of the following pulmonary function tests would you recommend be performed as a component of the preliminary evaluation? Lung Volumes Diffusing Capacity FEV pre/post bronchodilator Lung + thorax compliance A. No Yes No Yes B. Yes Yes Yes No C. Yes Yes Yes Yes D. Yes No Yes Yes Select one: A. A B. B C. C D. D

Prior to enrollment in a pulmonary rehabilitation program, patients should undergo evaluation of their cardiopulmonary status and exercise capacity. The evaluation should include both pulmonary function testing and a cardiopulmonary exercise evaluation. The pulmonary function testing should include lung volume determinations (e.g., FRC, TLC), diffusing capacity (DLco), and pre- and post-bronchodilator spirometry. Measures of lung or thoracic compliance are not necessary for either placement or followup. The correct answer is: B

Which of the following is a complication of pulmonary artery catheter angiography? Select one: A. hypoxemia B. myocardial infarction C. cerebral artery occlusion D. cardiac arrhythmias

Pulmonary artery catheter angiography previously was the gold standard for diagnosis of pulmonary embolism. However, due to the many complications and hazards of this invasive procedure, it has largely been replaced by the minimally invasive CT pulmonary angiography (CTPA). Immediate hazards or complications of PA catheter angiography include contrast media reaction (shared with CTPA), bleeding or hematoma formation at the puncture site, vessel dissection or occlusion, distal (pulmonary) embolization of catheter-associated clots, and potentially serious cardiac arrhythmias (as the catheter passes through the right ventricle). The correct answer is: cardiac arrhythmias

A patient breathing 100% at sea level has a PaO2 of 350 torr and a PaCO2 of 40 torr. What is her A-a gradient or P(A-a)O2? Select one: A. 663 torr B. 360 torr C. 563 torr D. 313 torr

Sea-level PB = 760 mm Hg. PAO2 = 1.0 (760 - 47) - 1.25 × 40 = 663 mm Hg (torr). P(A-a)O2 = 663 - 350 = 313 mm Hg (torr). The correct answer is: 313 torr

An infant is receiving 55% O2 via an isolette's built-in O2 controller. A doctor orders the FIO2 increased to 65%. The most appropriate action at this time would be to: Select one: A. provide additional O2 to the infant via the 'blow-by' method B. recommend intubation and initiate mechanical ventilation C. provide additional O2 to the infant via a simple mask D. setup an O2 blender/heated humidifier oxyhood system

Supplemental O2 is required for any neonate with signs/ symptoms of hypoxemia and/or a SpO2 < 90%. Isolettes provide control over the FIO2 up to approximately 0.60 (60% O2). However, the need for frequent access/opening of the isolette ports makes it difficult to maintain a stable FIO2, especially at the higher levels. For this reason, the best way to assure a stable FIO2 for infants in both isolettes and radiant warmers is via the use of an oxyhood. In either case, careful monitoring of the infant's SpO2 and PaO2 are required to prevent both hypoxemia and the toxic effects of too much oxygen. The correct answer is: setup an O2 blender/heated humidifier oxyhood system

Which of the following observations indicate that an infant's work of breathing may be abnormally high? Select one: A. palor B. digital clubbing C. acrocyanosis D. nasal flaring

Tachypnea, nasal flaring, grunting, and chest wall retractions are the most common signs of increased work of breathing in infants. Pallor or acrocyanosis are associated with circulatory problems insufficiency. Digital clubbing is associated with a variety of clinical conditions, including bronchiectasis, pulmonary fibrosis, cyanotic congenital heart disease, lung cancer, and cirrhosis of liver. However, clubbing does not indicate increased work of breathing. The correct answer is: nasal flaring

Which of the following clinical findings would increase the probability that a patient with some perfusion defects on a V/Q scan has a pulmonary embolism? Deep venousthrombosis Recent history of cancer Prolonged immobilization A. Yes No Yes B. Yes Yes Yes C. No Yes Yes D. Yes Yes No Select one: A. A B. B C. C D. D

The accuracy of V/Q scans in diagnosing pulmonary embolism (PE) can be improved by combining a set of clinical risk factors with the V/Q results. These factors (known as the Wells criteria) include signs and symptoms of deep venous thrombosis (DVT), prior diagnosis of DVT or PE, tachycardia, immobilization for three or more days or surgery during the prior month, hemoptysis and recent history of cancer. The correct answer is: B

The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the: Select one: A. cerebral perfusion pressure B. cerebral vascular resistance C. blood-brain barrier pressure D. jugular venous pressure

The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the cerebral perfusion pressure (CPP); CPP = MAP - ICP. As this equation makes clear, any factor that increases ICP and/or lowers MAP will decrease CPP and thus potentially cause brain damage or death. In general perfusion is adequate if the CPP can be maintained between 60 to 100 mm Hg. The correct answer is: cerebral perfusion pressure

A patient receiving ventilatory support with 10 cm H2O PEEP has a C(a-v)02 of 7.9 mL/dL. Which of the following is the most likely cause of this finding? Select one: A. PEEP has impaired cardiac output B. This is the optimum PEEP level C. PEEP has caused hyperventilation D. The PEEP level is too low

The goal of PEEP is to achieve adequate oxygenation, with a safe FIO2, without compromising cardiovascular function. In principle, optimum PEEP occurs when O2 delivery to the tissues is maximized. This point is reached when the CO x CaO2 and PvO2 peak, and the C(a-v)O2 is at its MINIMUM. Here the C(a-v)O2 is higher than the normal 5 mL/dL, indicating compromised cardiovascular function. The correct answer is: PEEP has impaired cardiac output

While conducting a fluoroscopic exam, a doctor has a patient perform a short, sharp inspiratory effort through his nose. During this maneuver, the right hemidiaphragm rises, while the left descends. The most likely problem is: Select one: A. right phrenic nerve paralysis B. atrophy of the diaphragm C. left phrenic nerve paralysis D. bilateral phrenic nerve paralysis

The maneuver being performed by the patient is a 'sniff' test, used to identify phrenic nerve dysfunction. During this maneuver, if one or the other hemidiaphragm moves upinstead of down, the likely problem is unilateral phrenic nerve paralysis/palsy. In this case it is the right phrenic nerve that is not functioning. The correct answer is: right phrenic nerve paralysis

The normal apical impulse (PMI) usually is identified where? Select one: A. 3rd right intercostal space, left sternal border B. 3rd left intercostal space, anterior axillary line C. 5th right intercostal space, midclavicular line D. 5th left intercostal space, midclavicular line

The normal apical impulse is produced by the thrust of the contracting left ventricle and usually is identified near the midclavicular line in the left fifth intercostal space. This systolic thrust, referred to as the point of maximal impulse, or PMI, may be felt and visualized in most normal individuals. The correct answer is: 5th left intercostal space, midclavicular line

Within one second after initiating a forced vital capacity (FVC) maneuver, a patient with normal lungs should be able exhale what percent of the FVC? Select one: A. 35-50% of the FVC B. 50-70% of the FVC C. 70-83% of the FVC D. 84-93% of the FVC

The normal range for the FEV1 as a percent of the FVC (FEV1%) is 70-83%. Patients with obstructive pulmonary disease will show a reduction in timed FEV% values, while patients with restrictive disorders will generally exhibit normal (or sometimes high) FEV% values. The correct answer is: 70-83% of the FVC

Which of the following studies would be most helpful in confirming whether a patient has a pneumothorax? Select one: A. arterial blood gas analysis B. chest X-ray C. forced vital capacity D. static compliance

The only answer that will allow you to "see" the pneumothorax is a chest X-ray. This makes it the most helpful. The correct answer is: chest X-ray

On the physical assessment of a patient who appears acutely ill, you note the following: severely labored breathing, accessory muscle use, and stridor. These findings suggest: Select one: A. acute tension pneumothorax B. acute upper airway obstruction C. pneumonia with consolidation D. chronic airway obstruction

The patient with an acute upper airway obstruction is usually in acute distress and exhibits labored breathing. Accessory muscles commonly are used during inhalation. Breath sounds may be clear but can be difficult to discern through the characteristic stridor. The lungs may be normal to percussion and palpation. Since ventilation is at risk, the patient should not be left alone, and the assessment must be quick and accurate to allow proper treatment. The correct answer is: acute upper airway obstruction

During auscultation of a patient's chest, you hear intermittent "bubbling" sounds at the lung bases. Which of the following chart entries best describe this finding? Select one: A. "bronchial sounds heard at lung bases" B. "wheezes heard at lung bases" C. "rhonchi heard at lung bases" D. "crackles (rales) heard at lung bases"

The preferred term for short, discontinuous adventitious lung sounds that are crackling or bubbling in nature is crackles. Many clinicians still use the term râles for these sounds. Crackles are caused either by movement of excessive secretions in the airways (course crackles), or by collapsed airways opening during inspiration (fine crackles). The correct answer is: "crackles (rales) heard at lung bases"

The primary indication for apnea monitoring is to: Select one: A. prevent sudden infant death syndrome (SIDS) B. identify life-threatening events in neonates C. warn of ventilator disconnection or malfunction D. assess neonates for obstructive sleep apnea

The primary indication for apnea monitoring is to identify life-threatening events in neonates at risk of recurrent apnea, bradycardia and hypoxemia. Prevention of sudden infant death syndrome (SIDS) is NOT an indication for apnea monitoring, and it cannot be used to diagnose obstructive sleep apnea. The correct answer is: identify life-threatening events in neonates

The radial site is preferred for arterial puncture or cannulation because: Select one: A. the radial artery is the most superficial artery available B. other available arteries are too small to easily puncture C. the radial artery has the highest systolic pressure available D. collateral circulation is provided through the ulnar artery

The radial site is preferred for arterial puncture or cannulation because of the extra safety provided by collateral circulation through the ulnar artery. The correct answer is: collateral circulation is provided through the ulnar artery

When making routine equipment checks you hear the relief valve of a patient's bubble humidifier sounding. Which of the following is the most likely cause of this problem? Select one: A. clogged bubble/diffuser B. high wall outlet pressure C. excessive oxygen input flow D. decreased patient compliance

The relief valve of a humidifier sounds when the pressure in the reservoir container exceeds the valve's threshold pressure (usually between 1-2 psig). The most common reasons for this to occur are 1) excessive oxygen input flow, and 2) downstream obstruction to outflow. In bubble humidifiers that use a diffuser plate to break up the gas stream, clogging of this element would prevent gas from entering and pressurizing the system. Flowmeter restriction prevents high wall outlet pressures (> 50 psig) from affecting pressure in the humidifier. And changes in patient mechanics (e.g., compliance or resistance) would have no effect on pressure in the humidifier. The correct answer is: excessive oxygen input flow

To prevent heated wires from melting ventilator circuit tubing, you would: Select one: A. decrease the humidifier setting to 28° C B. avoid covering the circuit with linens C. add deadspace to cool the circuit D. reverse the airway/humidifier sensors

There are incident reports of heated wires actually melting the delivery tubing and causing dangerous circuit leaks and even fires. To avoid these potentially serious problems, you should (1) never use reusable wires with disposable breathing circuits; (2) ensure that heating wires are threaded evenly along the tubing and not bunched-up; and (3) never let a heated-wire circuit be covered with towels or linens. The correct answer is: avoid covering the circuit with linens

You observe the following on the bedside capnograph display of a patient receiving ventilatory support. What is your interpretation of this display data? Select one: A. the capnogram indicates ventilator disconnection B. the capnogram indicates partial expiratory obstruction C. the capnogram indicates a leak around the ET tube D. the capnogram indicates hypoventilation or decreased metabolism

This capnogram shows disconnection, indicated by the immediate transition from normal pattern to PCO2 = 0 torr baseline. The correct answer is: the capnogram indicates ventilator disconnection

While performing a maximal expiratory pressure (MEP) test using a valved T-piece, the patient blows out against the manometer, but no positive pressure is registered. What should be done to troubleshoot this problem? Select one: A. make sure both the inspiratory and expiratory valves are blocked B. make sure the inspiratory valve is patent and the expiratory valve is blocked C. make sure the inspiratory valve is blocked and the expiratory valve is patent D. make sure both the inspiratory and expiratory valves are patent

To measure the maximal expiratory pressure (MEP) with a valved T-piece, the inspiratory valve should be open/patent (allowing the patient to inhale to TLC), while the expiratory valve should be blocked (allowing air to move only from the patient to the measuring manometer). The correct answer is: make sure the inspiratory valve is patent and the expiratory valve is blocked

Which of the following describes the correct procedure for performing a modified Allen's test? Select one: A. compress both the radial and ulnar arteries then release the radial artery B. compress both the radial and ulnar arteries then release the ulnar artery C. compress both the radial and ulnar arteries then release both arteries at once D. compress the brachial artery only and observe circulation to the hand

To perform the modified Allen's test, 1) the patient clenches his hand into a tight fist while you apply pressure to both the radial and ulnar arteries; 2) the patient then opens his hand without fully extending it (the palm and fingers are blanched); 3) you maintain pressure on the radial artery while removing pressure on the ulnar artery. At this point you should observe flushing of the entire hand, indicating the presence of collateral circulation. The correct answer is: compress both the radial and ulnar arteries then release the ulnar artery

CO-oximetry analysis should be performed whenever the following information is needed: Select one: A. total CO2 content B. acid-base status C. HCO3 concentration D. abnormal Hb levels

Unlike the SpO2 and PaO2, CO-oximetry measures the total hemoglobin in a blood sample and fractions of the total (percent saturations) bound to O2 and other chemicals. Measures include total hemoglobin (THb in g/dL), % oxyhemoglobin (HbO2% or SaO2), % carboxyhemoglobin (HbCO%), % methemoglobin (metHb%), and % sulfhemoglobin (SHb%). In addition, total O2 content (CaO2 in mL/dL) of the sample is calculated (total Hb x 1.36 x HbO2%). The correct answer is: abnormal Hb levels

During an interview, a patient complains about coughing. What further information would you seek regarding this symptom? Onset (e.g. what brings it on?) Characteristics (e.g. productive?) Course (e.g. progress over time) A. No Yes Yes B. Yes No Yes C. Yes Yes Yes D. Yes Yes No Select one: A. A B. B C. C D. D

When exploring a patient's symptoms, you should use probing questions to elaborate on the onset, characteristics, and course of each subjective complaint. Since a patient's subjective evaluation of a symptom is related to factors such as pain tolerance and perception, you also should evaluate the intensity or severity of a symptom in terms of it's observable interference with the patient's ability to function. The correct answer is: C

A large volume jet nebulizer is operating at the 100% O2 setting with an input flow of 12 L/min. What effect will changing the entrainment port setting from 100 to 70% have on the system? Select one: A. the input liter flow will increase by 30% B. the total output liter flow will decrease C. the aerosol weight density will increase D. the total output liter flow will increase

When the air-entrainment port of a large volume jet nebulizer is opened, room air is entrained, and total flow through the system increases (in direct proportion to the size of the opening). This increased output flow increases total aerosol output per minute, but actually lowers aerosol density. The correct answer is: the total output liter flow will increase

You would recommend continuous SpO2 monitoring (versus short-term assessment or spot checks) for which of the following? Select one: A. child requiring twice daily postural drainage B. neonate being screened for congenital heart disease C. stable postop adult started on O2 therapy D. patient undergoing diagnostic bronchoscopy

Whether SpO2 monitoring should be continuous or 'spot checked' only depends on the clinical status of the patient and the monitoring needs of the situation at hand. For example, continuous SpO2 monitoring is usually indicated for all critically ill patients and for detecting desaturation on those undergoing procedures such as bronchoscopy, exercise testing and sleep studies. On the other hand, a spot check usually suffices for evaluating the efficacy of O2 therapy on stable patients. And screening for congenital heart disease via dual oximetry (pre/post-ductal) is a single test that is repeated up to 3 times, but not applied continuously. The correct answer is: patient undergoing diagnostic bronchoscopy

Immediately following intubation of a patient's trachea, which of the following would yield the best information regarding ET tube position in the trachea? Select one: A. arterial blood gas analysis B. chest X-ray C. exhaled volume D. PETCO2

While the PETCO2 can help determine lung vs esophageal placement of an ET tube, only a chest X-ray can confirm its proper placement in the trachea. On an adult A-P chest X-ray, the ET tube tip should be positioned about 4 to 6 cm above the carina or between T2 and T4. This position minimizes the chance of the tube moving down into the mainstem bronchi (endobronchial intubation) or up into the larynx (extubation). The correct answer is: chest X-ray

After attaching a yoke connector regulator to an E cylinder and opening the cylinder valve, you notice a leak at the regulator-cylinder connection. Which of the following is the most likely cause for this leak? Select one: A. missing safety system pins B. yoke screw not properly tightened C. cylinder pressure < 500 psig D. flowmeter not fully turned off

Yoke connectors for cylinders A-E use a hand screw to hold the yoke on the valve stem. If not tightened properly, a leak could result. In addition, the small receiving nipple on the yoke is normally sealed to the gas outlet with a nylon or hard rubber washer. For this reason, a missing or damaged washer could also cause a leak. Missing PISS pins would not cause a leak, nor would low cylinder pressure. And were the flowmeter not turned completely off, gas would escape from the regulator outlet, not from the regulator-cylinder connection. The correct answer is: yoke screw not properly tightened

A patient is receiving oxygen via a nonrebreathing mask set at 12 L/min. You notice that the mask's reservoir bag does not deflate at all during inspiration. Which of the following is the most likely cause of this problem? Select one: A. the patient is nose-breathing B. the mask is too loose on the face C. the flowmeter setting is too low D. the patient is mouth-breathing

You know that a nonrebreathing O2 mask is operating properly when the bag partially deflates as the patient inhales. Too low a flow (< 10 L/min) would cause the bag collapse, not remain inflated. The most likely cause for the bag not deflating is a large leak, which would allow the patient to draw air from the room instead of O2 from the bag. This would occur if the mask were too loose on the face or if the exhalation valves were missing. Assuming no major leakage, a 'sticky' one-way valve between the bag and mask also could prevent the patient from easily drawing gas from the reservoir, and the bag would remain inflated. Whether the patient breathes through the nose or mouth will have no impact on bag inflation. The correct answer is: the mask is too loose on the face