boards 7
41. A patient receiving pressure controlled SIMV develops progressive atelectasis in the lower lobes and now requires 70% O2 to keep his SaO2 above 80-85%. Comparison chest X-rays indicate a generalized decreas in lung volume. What would you recommend to help correct the problem? A. add CPAP/PEEP to the circuit B. increase the FIO2 to 80% C. suction the patient more frequently D. switch to volume controlled A/C
A
89. For which of the following conditions causing acute respiratory failure would you recommend noninvasive positive pressure ventilation (NPPV)? A. cardiogenic pulmonary edema B. smoke/fire inhalation injuries C. acute respiratory distress syndrome D. opiate drug overdose
A
91. Which of the following drugs would you NOT consider recommending for the long-term management of mild persistent asthma in an adult patient? A. levalbuterol (Xopenex) B. beclomethasone (Vanceril) C. zafirlukast (Accolate) D. cromolyn sodium (Intal)
A
97. After bronchodilator therapy, you record the following PFT data on a 67 year- old male COPD patient with chronic cough and sputum production: FEV1/FVC = 65%; FEV1 = 82% predicted. You would characterize the stage of the patient's COPD as: A. mild B. moderate C. severe D. very severe
A
39. A 6-year-old child is intubated and being mechanically ventilated. Pertinent data are below. Ventilator Settings Blood Gases Mode SIMV Vol Ctrl pH 7.46 VT 200 mL PaCO2 33 torr Rate 25/min HCO3 23 mEq/L FIO2 0.90 PaO2 54 torr PEEP 0 cm H2O SaO2 87% Based on these data, which of the following changes would you initially recommend? A. Initiating 5 cm H2O PEEP B. Decreasing the rate to 20/min C. Increasing the FIO2 to 1.0 D. Increasing the inspiratory time
A
4. Which of the following is associated with the administration of aerosolized epinephrine? A. tachycardia B. bradycardia C. laryngospasm D. bronchospasm
A
100. Which of the following is the most common indication for home CPAP therapy? A. sleep apnea-hypopnea syndrome (SAHS) B. bronchospasm associated with asthma C. chronic hypoxemia D. neuromuscular disorders
A
22. You would consider modifying any head-down positions used for postural drainage for a patient with: A. brain trauma B. ciliary dyskinesia C. bronchiectasis D. cystic fibrosis
A
23. A 58-year-old patient in the open heart unit had cardiopulmonary bypass surgery with significant blood loss. On physical exam the patient presents with tachypnea and tachycardia and the SpO2 is 85% on 4 L/min nasal cannula. You should now recommend: A. non-rebreathing mask at 12 L/min B. CPAP with 5 cm H2O pressure C. nasal cannula at 6 L/min D. 60% air-entrainment mask
A
28. While given an adrenergic aerosol bronchodilator treatment to an adult patient, you notice an increase in pulse rate from 85/min (pre-treatment) to 125/min. Which of the following would be the correct action in this case? A. terminate the treatment and record adverse response in chart B. use half the standard dosage listed in the package insert C. add more diluent (e.g., saline) to the nebulizer chamber D. temporarily stop the treatment and let the patient calm down
A
30. An 90 kg (198 lb) patient with ARDS is receiving volume controlled A/C ventilation. The ventilator settings are as follows: Mode Vol ctrl A/C FIO2 0.60 Mandatory rate 15 Total rate 15 Tidal volume 500 mL PEEP 10 cm H2O Inspiratory flow 30 L/min Inspiratory pause 1.5 sec Waveform Decelerating The pressure time graphic display indicates the presence of auto-PEEP . Which of the following changes would you recommend to help reduce auto-PEEP in this patient? A. decrease the pause time B. change to a square waveform C. increase the tidal volume D. increase the mandatory rate
A
42. A patient with a neuromuscular disorder who is breathing through an intact upper airway is receiving external (vest) oscillation to help mobilize secretions into the large airways, but is having difficulty clearing them. Which of the following techniques would you recommend to facilitate clearance of this patient secretions? A. manually assisted ("quad") cough B. postural drainage, percussion and vibration C. positive expiratory pressure (PEP) therapy D. acetylcysteine (Mucomyst) via aerosol
A
48. You are called to the bedside of a patient receiving volume controlled ventilation by her ICU nurse concerned about the ventilator's function. You note that both the low volume and high pressure limit alarm are sounding on each breath. Your first action should be to: A. disconnect patient and manually ventilate with 100% 02 B. call the attending physician for further patient information C. check the patient's chart for the original ventilator orders D. ask the nurse about how recently the patient was suctioned
A
49. A physician wants to apply high PEEP levels (30 cm H2O) to a patient receiving volume control ventilation (assist-control). Which of the following would you recommend in order to minimize the effect of the high level PEEP on this patient's cardiovascular system? A. switch the patient to the SIMV mode B. increase the inspiratory time C. decrease the expiratory time D. use inverse ratio pressure control ventilation
A
50. A nurse complains to you that a neuromuscular patient under her care cannot develop a good cough. Which of the following would you recommend as best able to aid this patient in clearing secretions? A. combining mechanical insufflation/exsufflation with suctioning B. applying forward waist flexion to aid expiratory flow C. using short, expiratory bursts or the 'huffing' method D. employing the forced expiration technique (FET)
A
52. A 59-year-old postoperative man who weighs 77 kg (169 lb) is receiving volume control A/C ventilation at a rate of 14/min with a tidal volume of 650 mL and an FIO2 of 0.4. Results of arterial blood gas analysis are as follows: Blood Gases pH 7.51 PaCO2 30 torr HCO3 23 mEq/L BE -1 PaO2 117 torr SaO2 99% Based on this information, you should recommend which of the following? A. decrease the minute ventilation B. discontinue mechanical ventilation C. increase the peak flow setting D. administer IV bicarbonate
A
56. Following extubation, a nurse places a patient on a heated nebulizer with an FIO2 of 35%. Soon thereafter, the patient begins to exhibit mild stridor. Which of the following specific changes would you recommend? A. switch to cool mist therapy via jet nebulizer B. increase the heat setting on the nebulizer C. switch to O2 therapy via nasal cannula @ 3 L/mn D. provide O2 therapy via a 35% venti-mask
A
65. You observe the following pressure-volume loop display on a patient receiving volume-control ventilation. Which of the following actions would be appropriate? A. decrease the delivered volume B. increase the inspiratory flow C. decrease the I:E ratio D. increase the PEEP level
A
68. A patient is admitted to the Emergency Department with severe upper airway trauma. Attempts to intubate the patient fail and you cannot ventilate him using a bag-mask resuscitator. Which of the following actions would you recommend at this time? A. surgical cricothyrotomy B. nasotracheal tube insertion C. laryngeal mask airway insertion D. esophageal-tracheal tube insertion
A
7. Which of the following describes the ventilatory pattern that is best suited for maximum aerosol deposition in the small airways? A. slow inhalation, pause, slow exhalation B. slow inhalation, pause, rapid exhalation C. rapid inhalation, pause, slow exhalation D. rapid inhalation, pause, rapid exhalation
A
74. Theophylline therapy would tend to increase the risk of exacerbating which of the following conditions? A. sinus tachycardia B. chronic asthma C. emphysema D. chronic bronchitis
A
75. At follow-up in a disease management program, a patient with severe (Stage IV) COPD is diagnosed with pulmonary hypertension and cor pulmonale. Which of the following would you recommend the doctor consider for this patient? A. long-term O2 therapy B. oral corticosteroids C. systemic vasodilators D. a long-acting beta agonist
A
78. A patient is receiving aerosol treatments with albuterol (Proventil) q4h following an uneventful cholecystectomy. Patient assessment reveals clear breath sounds bilaterally. The patient has no history of smoking and takes deep breaths with strong coughs voluntarily throughout the day. What should you recommend? A. discontinuing the aerosol treatment B. continuing the treatment as ordered C. postural drainage and percussion D. a MDI with albuterol
A
79. Which of the following airway clearance techniques would you recommend as the best way to help mobilize retained secretions in a 6 month-old infant with cystic fibrosis? A. postural drainage & percussion B. positive expiratory pressure C. autogenic drainage D. intrapulmonary percussive ventilation
A
84. A COPD patient receiving volume control SIMV with a VT = 500 mL, rate = 8/min, pressure support = 10 cm H2O and PEEP = 5 cm H2O undergoes a spontaneous breathing trial (SBT) via T-tube. After 5 minutes the patient has to be placed back on the ventilator due to severe tachypnea. What approach would you recommend for the next SBT? A. provide pressure support + CPAP via ET tube B. extubate the patient then provide nasal BiPAP C. provide pressure support only via ET tube D. provide sedation prior to ventilator withdrawal
A
85. A patient is receiving pressure control SIMV with an FIO2 of 0.35, a set rate of 18, and a pressure limit of 25 cm H2O. Results of an arterial blood gas analysis are below. pH 7.45 PaCO2 34 mm Hg HCO3 23 mEq/L SpO2 83% On the basis of these results, the most appropriate action would be to A. increase the FIO2 B. add mechanical dead space C. increase the ventilator rate D. decrease the pressure limit
A
88. While assessing a patient receiving volume controlled A/C ventilation, you notice that the peak pressure has increased 10 cm H2O over the last hour. The plateau pressure has not changed. You also notice that the patient has significant wheezing in both lungs that was not present earlier. You would recommend: A. nebulizing a bronchodilator B. nebulizing a corticosteroid C. suctioning the patient D. increasing the VT by 100 mL
A
98. A doctor institutes volume control ventilation for a 70 kg ARDS patient with a targeted tidal volume of 420 mL. To maintain adequate ventilation with this tidal volume, you would allow a machine respiratory rate as high as: A. 20/min B. 25/min C. 30/min D. 35/min
D
1. A patient who is receiving an aerosol treatment with acetylcysteine (Mucomyst) and hypertonic saline via a SVN suddenly becomes dyspneic. The most likely cause of this problem is: A. hypercapnia B. bronchospasm C. pneumothorax D. fluid overload
B
10. An increase in a patient's heart rate during aerosolized bronchodilator therapy is primarily a result of which of the following effects of the drug? A. Alpha only B. Beta1 only C. Beta2 only D. Beta1 and beta2 only
B
11. Which of the following represents the primary indication for and approved use of inhaled nitric oxide? A. hypoxemia associated with obstructive sleep apnea B. hypoxemia in neonates with persistent pulmonary hypertension C. ventilatory failure in premature neonates D. hypoxemia associated with hyaline membrane disease
B
15. You are about to start a patient on a new regimen of therapy. The patient is irritable, has difficulty focusing, and exhibits mild trembling of his hands. You should: A. request that the physician discontinue the therapy B. postpone therapy until the patient's anxiety is resolved C. request that the nurse be present during the therapy D. proceed as quickly as possible with the therapy
B
16. An 80 kg (176 lb) patient is receiving volume control A/C ventilation with 35% oxygen at a rate of 12/min and a VT of 600 mL. The following information is available (blood gases obtained while on ventilator): MIP/NIF -10 cm H2O pH 7.38 Spon VT 175 mL PaCO2 35 mm Hg Spon VE 7.0 L/min HCO3 21 mEq/L VC 600 mL PaO2 110 mm Hg Which of the following actions would be appropriate at this time? A. place the patient on a 40% T-tube and monitor closely B. maintain current ventilator settings and re-evaluate later C. switch the patient to SIMV at a rate of 4/minute D. place the patient on 5 cm H2O CPAP and monitor closely
B
17. After weaning and extubation, a patient on a cool aerosol mask at 40% O2 develops moderate hypoxemia and hypercapnia, with a falling pH. Which of the following actions would you recommend at this time? A. increase the nebulizer oxygen concentration to 60% B. apply bi-level positive airway pressure via mask C. administer 50 mEq IV sodium bicarbonate D. re-intubate and apply volume control ventilation
B
18. Which of the following pulmonary function study results indicate that bronchodilator therapy should be initiated? Parameter Predicted Pre Post 1 FVC (L) 2.6 1.8 1.9 2 FEV1 (L) 1.9 1.9 1.4 3 FEV1% 73% 53% 69% 4 Peak Flow (L/sec) 7.4 6.2 7.1 A. 1 and 2 only B. 3 and 4 only C. 1, 2 and 4 only D. 2, 3 and 4 only
B
2. A physician orders a 70% He/30% O2 mixture to be delivered to a patient having an acute asthmatic attack. Which of the following systems would be most appropriate to deliver this mixture? A. nebulizer set at 100% oxygen with aerosol mask B. tight-fitting nonrebreathing mask with competent valving C. simple oxygen mask set to deliver 15 L/min oxygen D. tight-fitting partial rebreathing mask at 12 L/min
B
20. A patient with a neuromuscular disorder who is breathing through an intact upper airway is receiving external (vest) oscillation to help mobilize secretions into the large airways, but is having difficulty clearing them. Which of the following techniques would you recommend to facilitate clearance of this patient secretions? A. postural drainage, percussion and vibration B. mechanical insufflation-exsufflation C. positive expiratory pressure (PEP) therapy D. acetylcysteine (Mucomyst) via aerosol
B
21. A COPD patient has the following arterial blood gas results in room air: pH 7.33 PaCO2 65 torr PaO2 49 torr HCO3 33 mEq/L BE +7 The patient complains of shortness of breath and lightheadedness, has bilateral bronchial breath sounds with inspiratory crackles and exhibits cyanosis around his lips. Which of the following would you recommend for this patient? A. 10 L/min nonrebreathing mask B. 28% air-entrainment mask C. albuterol (Proventil) by SVN D. 4 L/min nasal cannula
B
24. While monitoring a patient during a spontaneous breathing trial via T-tube, you note the following: an increase in heart rate from 85 to 103/min; an increase in respiratory rate from 19 to 26/min; an increase in PetO2 from 44 to 52 mm Hg; and a decrease in SpO2 from 94 to 90%. Which of the following actions would be appropriate at this time? A. restore the patient to full ventilatory support B. encourage the patient to relax and continue monitoring C. request that the patient be given a mild sedative D. measure the patient's vital capacity and MIP/NIF
B
27. A 90-kg male patient with a traumatic chest injury is receiving volume control ventilation (assist/control) with an FIO2 of 0.5, a set rate of 18, and a tidal volume of 600 mL. Due to patient triggering of machine breaths, the total respiratory rate is 28-30 breaths/min. Results of an arterial blood gas analysis are as follows: pH 7.52 PaCO2 28 torr HCO3 22 mEq/L BE -2 PaO2 81 torr SaO2 96% On the basis of these results, the most appropriate action is to: A. increase the FIO2 B. add mechanical deadspace C. increase the ventilator rate D. increase the tidal volume
B
29. A 45-year-old patient with asthma is prescribed 0.3 mL of albuterol (Proventil) in 3 mL normal saline via small volume nebulizer. Before initiating therapy, you note from chart review that the patient is severely hypertensive and has been experiencing episodes of superventricular tachycardia. You should do which of the following? A. administer the treatment as ordered B. postpone the treatment and consult the physician C. dilute the albuterol with extra normal saline D. decrease the amount of albuterol administered
B
3. A doctor orders aerosol therapy for a patient receiving mechanical ventilation who is being provided humidification with a heat and moisture exchanger (HME). To assure effective therapy you must: A. place the aerosol device proximal to the HME in the stream of flow B. remove the HME before aerosol therapy and replace it afterward C. place the aerosol device distal to the HME in the stream of flow D. switch from an HME to an active heated the humidification system
B
32. A 65-year-old male patient with COPD is in the emergency department is receiving oxygen therapy by nasal cannula at 6 L/min, with an SpO2 of 98%. He was talkative on admission, but is becoming sleepy after 1 hour of O2 therapy. The most appropriate action is to: A. discontinue the O2 therapy B. switch to a 24% air-entrainment mask C. decrease the cannula flow to 5 L/min D. switch to a nonrebreathing mask @ 10 L/min
B
44. While administering an IPPB treatment to a post-op abdominal surgery patient, you note that her neck veins become distended and her heart rate increases and becomes a bit irregular. What action would you take at this time? A. decrease the pressure setting B. stop the treatment/monitor the patient C. increase the delivered FIO2 D. increase the sensitivity setting
B
47. A physician prescribes incentive spirometry for a postoperative patient who complains of dizziness when performing five inspiratory maneuvers in a row. What action should you take? A. recommend that the therapy be discontinued B. coach the patient to pause before each maneuver C. begin CPR on the patient D. begin oxygen therapy via protocol
B
53. After a patient has been inhaling an aerosol from an ultrasonic nebulizer for 8 min, she begins to wheeze. What should be done at this time? A. recommend that the patient be given IV epinephrine B. stop the treatment, monitor the patient, and notify the doctor C. add 0.5 mL (2.5 mg) of albuterol to the nebulizer solution D. switch the ultrasonic nebulizer source gas to 100% O2
B
67. You are assisting in the treatment and evaluation of an opiate narcotic overdose patient in the ER who is hypoventilating. The physician asks you to recommend a drug to help reverse the effects of the narcotic and enable the patient's breathing to return to normal. Which of the following drugs would you recommend? A. indomethacin (Indocin) B. naloxone (Narcan) C. vecuronium (Norcuron) D. fentanyl (Sublimaze)
B
71. The following results of a PEEP study are obtained: A.Time B.PEEP cm H2O C.PaO2 mm Hg D.CompliancemL/cm H2O E.Cardiac Output (L/min) A.6:00 B.5 C.44 D.22 E.5.5 A.6:20 B.8 C.65 D.44 E.5.6 A.6:40 B.11 C.74 D.35 E.4.8 A.7:00 B.14 C.90 D.30 E.4.1 Which of the following PEEP levels is indicated? A. 5 cm H2O B. 8 cm H2O C. 11 cm H2O D. 14 cm H2O
B
86. A spontaneously breathing premature infant is placed in a 70% oxygen hood. ABG results are as follows: pH 7.38 PaCO2 37 torr HCO3 21 mEq/L PaO2 40 torr SaO2 73% Based on these data, you should change to which of the following? A. mist tent B. nasal CPAP C. double-walled Isolette D. mechanical ventilator
B
90. An adult patient with cystic fibrosis cares for himself at home. The patient's doctor has ordered postural drainage, percussion and vibration. Which of the following would your recommend to assist this patient in clearing his retained secretions during postural drainage? A. a pneumatically powered percussor/vibrator B. a high frequency chest wall oscillation vest C. an electrically powered percussor/vibrator D. properly sized percussion cups or wand
B
93. A physician orders supplemental O2 for a patient via nasal cannula at a flow of 12 L/min. When you ask her what goal she has in mind, she states that she wants the patient to receive about 60% oxygen. Which of the following should you recommend? A. that the cannula flow be set to 15 L/min instead of 12 L/min B. that the O2 be given via a partial rebreathing mask at 10 L/min C. that a nasal catheter at 12 L/min be used instead of the cannula D. that the O2 be given via an air entrainment mask set at 60%
B
94. A patient whose asthma was well-controlled using a short-acting beta-agonist inhaler PRN and low dose inhaled corticosteroid BID reports that she recently has been experiencing shortness of breath almost daily and is awakened at night with wheezing episodes. Her peak flow, which had been 83% of her predicted normal is now at 66% of the predicted value. Which of the following would you recommend to the patient's doctor as possible changes to the current drug regimen? A. discontinue the short-acting beta agonist inhaler B. add a leukotriene modifier to the regimen C. switch the short-acting beta agonist from PRN to Q4H D. switch from inhaled to oral corticosteroid therapy
B
99. Any sudden occurrence of pulmonary or cardiac distress in older, bed-ridden patients and those having undergone extensive abdominal or pelvic surgery suggest a diagnosis of: A. coronary artery disease B. pulmonary thromboembolism C. anaphylatic shock D. acute left ventricular failure
B
35. A home care patient with chronic bronchitis who lives alone is having difficulty clearing secretions via simple coughing. Which of the following should you recommend? A. incentive spirometry B. postural drainage and percussion C. vibratory PEP therapy D. albuterol (Proventil) via SVN
C
26. Clinical signs and a chest X-ray confirm that a patient receiving volume control SIMV has suffered a tension pneumothorax. Which of the following actions would you recommend to treat this problem? A. lowering the peak inspiratory pressure B. obtaining a stat arterial blood gas C. performing a needle thoracostomy D. switching to pressure control SIMV
C
33. A doctor orders suctioning PRN of a conscious patient who is having some difficulty clearing secretions. Which of the following devices would you recommend to aid in suctioning this patient? A. endotracheal tube B. oropharyngeal airway C. laryngeal mask airway D. nasopharyngeal airway
D
34. Prior to beginning an adrenergic aerosol bronchodilator treatment on an adult patient, you record a resting heart rate of 132/min. Which of the following would be the correct action in this case? A. double the drug diluent and prolong the administration time B. have the patient self-administer the aerosol treatment C. postpone therapy until able to contact the ordering physician D. use half the standard dosage listed in the package insert
C
13. Which of the following drug would you recommend for a patient with acute bronchospasm? A. racemic epinephrine B. acetylcysteine (Mucomyst) C. albuterol (Proventil) D. cromolyn sodium (lntal)
C
19. You are administering chest physical therapy in the Trendelenburg position to a 68-year-old male patient with chronic bronchitis. The patient starts to cough up a small amount of fresh blood. What action should you take? A. continue the therapy and provide supplemental oxygen B. continue the therapy but report the problem to the nurse C. stop the therapy, stabilize the patient up and contact a physician D. immediately call a code and begin resuscitation
C
25. A patient has been on a high-flow nasal cannula for 2 days following abdominal surgery. The patient's atelectasis has improved and the arterial blood gas results on a flow of 20 L/min and FIO2 of 0.70 (via blender) are as follows: pH 7.37 PaCO2 43 torr PaO2 155 torr SaO2 99% HCO3 24 mEq/L BE +2 Which of the following would you recommend? A. Decreasing the flow B. Decreasing the flow and FIO2 together C. Decreasing the FIO2 D. Changing to standard nasal cannula
C
37. Data for a 63-kg (140-lb.) patient receiving ventilatory support with 8 cm PEEP are as follows: Ventilator Settings Blood Gases Mode SIMV vol ctrl pH 7.46 VT 500 mL PaCO2 36 torr Rate 12 HCO3 25 mEq/L FIO2 0.70 PaO2 55 torr PEEP 8 cm H2O SaO2 100% Which of the following changes should you recommend at this time? A. lower the VT B. increase the rate C. increase PEEP D. decrease the FIO2 Respiratory Therapy Zone | 219 MODULE 7
C
38. A 150 lb female patient is receiving volume controlled SIMV with a volume of 600 mL, a mandatory rate of 12/min with 5 cm H2O pressure support. You note that her total rate of breathing is 45/min, and that she is using her scalene muscles during most spontaneous breaths. Which of the following is the most appropriate action at this time? A. increase the set tidal volume B. increase the inspiratory flow C. increase the pressure support level D. decrease the mandatory breath rate
C
46. The intracranial pressure (ICP) of a patient with closed head trauma receiving volume control A/C ventilation has risen from 18 mm Hg to 26 mm Hg despite aggressive treatment with osmotic diuresis, CSF fluid drainage, sedation and neuromuscular blockade. Which of the following short-term ventilatory strategies would you recommend to help manage this patient? A. decelerating flows B. inspiratory hold C. hyperventilation D. high PEEP
C
51. A college student involved in a automobile accident sustains closed head trauma. The patient has just been intubated and is breathing synchronously on pressure control A/C ventilation at a rate of 10/min and peak pressure of 30 cm H2O. Based on the following blood gas results, what should you recommend? pH 7.39 PaCO2 38 torr SaO2 96% HCO3 22 mEq/L BE -2 mEq/L A. change to CPAP B. increase the rate C. make no change D. increase the FIO2
C
54. A 52 year-old male is admitted to the hospital emergency room with a chief complaint of severe radiating chest pain and signs of central cyanosis. The attending physician orders STAT O2 therapy. Which of the following would you recommend? A. simple oxygen mask at 8 L/min B. air entrainment mask at 40% O2 C. partial rebreathing mask at 10 L/min D. nasal cannula at 5 L/min
C
58. You are monitoring a mechanically ventilated patient 36 hours post-craniotomy who has an ICP of 20 mm Hg but is otherwise stable. The latest ABG results are as follows: pH 7.38 PaCO2 44 mm Hg HCO3 25 mEq/L BE 0 PaO2 89 mm Hg SaO2 96% Based on this information, which of the following is the most acceptable action? A. increase the minute ventilation B. decrease the tidal volume C. maintain the current settings D. add 10 cm H2O PEEP
C
6. A physician orders 2.5 mL ipratropium bromide (Atrovent) 0.2% TID for a COPD patient with recurrent bronchospasm. Which of the following methods would you use to deliver this drug? A. small volume nebulizer with mask B. ultrasonic nebulizer with mask C. small volume nebulizer with mouthpiece D. MDI
C
61. A 154 lb (70 kg) patient who had just had thoracic surgery is being mechanically ventilated in the SIMV mode. Ventilator settings and arterial blood gas results 1 hour after surgery are below: FIO2 0.45 pH 7.42 Mandatory rate 10 PaCO2 39 torr Total rate 31 PaO2 95 torr VT 600 mL HC03 24 mEq/L PEEP 5 cm H2O BE +1 mEq/L The patient's spontaneous breaths are rapid and shallow and he appears anxious and is complaining of chest pain. Which of the following changes would be appropriate? A. increase the FIO2 to 0.60 B. increase the PEEP to 10 cm H2O C. add pressure support D. increase the tidal volume to 800 mL
C
63. A doctor wants an outpatient with idiopathic pulmonary hypertension to self- administer an inhaled pulmonary vasodilator. Which of the following drugs would you recommend? A. epoprostenol (Flolan) B. diltiazem (Cardizem) C. iloprost (Ventavis) D. bosentan (Tracleer)
C
66. A doctor orders an increase in PEEP from 8 to 12 cm H2O for a patient receiving mechanical ventilation. After you adjust the PEEP setting, you note a rapid drop in the patient's blood pressure and a significant rise in heart rate. Which of the following actions would be appropriate? A. increase the FIO2 by 10% B. start a nitroprusside infusion C. lower the PEEP back to 8 cm H2O D. obtain a stat electrocardiogram
C
72. A premature 1850 g newborn infant is receiving 40% oxygen in an oxyhood. A chest X-ray shows a ground-glass appearance bilaterally, with air bronchograms. An arterial blood gas reveals the following: pH 7.36 PaCO2 44 torr PaO2 45 torr HCO3 24 mEq/L BE 0 mEq/L Which of the following actions is appropriate at this time? A. intubate and initiate 10 cm H2O CPAP B. intubate and initiate mechanical ventilation C. administer 5 cm H2O nasal CPAP with an FIO2 of 0.50 D. place the neonate in an Isolette with an FIO2 of 0.60
C
77. Before giving your patient an aerosol treatment with racemic epinephrine for laryngeal edema, you check his vital signs. His pulse rate is 85/min and respiratory rate is 16/min. Five minutes into the treatment, his pulse rate climbs to 135/min and his respiratory rate rises to 29/min. What is the best action in this case? A. continue the treatment as ordered to completion B. switch to albuterol (Proventil) and continue the treatment C. stop the treatment, monitor the patient and contact the physician D. ask the nurse what action she would recommend
C
8. A doctor orders a metered dose inhaler (MDI) bronchodilator for a patient receiving mechanical ventilation via a dual-limb breathing circuit. To maximize aerosol deposition, you would: A. place the MDI directly in-line on the inspiratory side of the circuit B. recommend that a small volume nebulizer be used instead of the MDI C. place the MDI plus a spacer in-line on the inspiratory side of the circuit D. place the MDI directly in-line on the expiratory side of the circuit
C
80. A 42 year old (50 kg) patient is admitted to the emergency department after overdosing on heroin. The patient is unconscious and is making minimal respiratory efforts. Blood gases on a nonrebreathing mask @ 12 L/min are as follows: pH 7.29 PCO2 75 torr HCO3 21 mEq/L PaO2 320 torr What should you recommend? A. intubate/apply SIMV, VT 600 mL, rate 6/min, FIO2 0.40 B. apply mask BiPAP, IPAP 20 cm H2O, EPAP 5 cm H2O, FIO2 0.30 C. intubate/apply A/C ventilation, VT 400 mL, rate 12/min, FIO2 0.50 D. apply 10 cm H2O mask continuous positive airway pressure, FIO2 1.00
C
81. A 75-year-old patient with fracture of the pelvis and femur will have limited mobility and be bedridden for at least a week. Currently, the patient has clear breath sounds and normal pulmonary function. Which of the following should you recommend? A. frequent nasotracheal suctioning B. O2 via high flow nasal cannula C. turning, deep breathing and coughing D. bronchodilator therapy via IPPB
C
83. A doctor orders a spontaneous breathing trial (SBT) for a 80 kg (176 lb) male patient intubated with a 6.5 mm endotracheal tube. Which of the following weaning strategies would you recommend? A. CPAP B. simple T-tube C. pressure support D. SIMV
C
87. A patient on mechanical ventilation is improving, and the physician wants to begin weaning her. Originally, she was on pressure controlled A/C with a rate of 12/min and a tidal volume of 600 mL. For weaning the doctor orders a switch to pressure support ventilation at 10 cm H2O. Initially, the patient seems comfortable on pressure support, but after 45 minutes she is moderately tachypneic and is starting to use her accessory muscles. Which of the following would you recommend to alleviate this problem? A. giving her 10 mg of Valium for anxiety B. putting her back on pressure control ventilation C. increasing the pressure support level to 15 cm H2O D. adding 5 cm H2O of PEEP
C
92. Signs of sudden upper airway obstruction include which of the following? 1.Intercostal retractions 2.Agitation/ anxiety 3.Accessory muscle use 4.Inspiratory crackles A. 1.Yes 2.No 3.Yes 4.No B. 1.Yes 2.Yes 3.Yes 4.Yes C. 1.Yes 2.Yes 3.Yes 4.No D. 1.No 2.Yes 3.No 4.Yes A. A B. B C. C D. D
C
95. In assessing a patient receiving ventilatory support, you note that her white blood cell count is 18,000/mm3 and her temperature is 102 °F. In addition, her secretions have become more tenacious and yellow over the past 24 hours. Which of the following would you suggest to the attending physician? A. that her humidifier temperature be lowered to below 30 °C B. that a regimen of aerosolized carbenicillin be started ASAP C. that a sputum sample be obtained for culture and sensitivity D. that the frequency of suctioning be increased to every half hour
C
40. The settings below are ordered for an 80 kg (176 lb) man who has undergone a pneumonectomy Mode Vol Ctrl A/C FIO2 0.5 Rate 12/min VT 1000 mL On the basis of this information, your most appropriate action would be to: A. suggest the IMV mode B. suggest using PEEP C. suggest a decrease in rate D. suggest a decrease in tidal volume
D
36. A patient is being mechanically ventilated in the IMV mode with spontaneous breaths supported by continuous flow through the circuit. The FIO2 is 0.4, the set rate is 5/min, and +7 cm H2O PEEP is being applied. The airway pressure drops to +1 cm H2O whenever the patient takes a spontaneous breath. On the basis of this information, it would be appropriate to increase the A. PEEP B. mandatory rate C. FIO2 D. circuit flow
D
12. A postoperative patient develops bilateral wheezing. Which of the following is the most appropriate therapy for this condition? A. incentive spirometry B. mucolytic agent C. chest physiotherapy D. bronchodilator
D
14. Which of the following are possible side effects associated with the administration of beta-adrenergic bronchodilators? 1.Tachycardia/ palpitations 2.Skeletal muscle tremor 3.Nervousness/ insomnia A. 1.Yes 2.Yes 3.No B. 1.Yes 2.No 3.Yes C. 1.No 2.Yes 3.Yes D. 1.Yes 2.Yes 3.Yes A. A B. B C. C D. D
D
31. You would consider modifying any head-down positions used for postural drainage for a patient with: A. cystic fibrosis B. ciliary dyskinesia C. bronchiectasis D. orthopnea
D
43. A surgeon writes an order for "hyperinflation therapy" for a 28 year old 110 lb female patient having undergone lower abdominal surgery. In evaluating this patient at the bedside, you obtain a vital capacity of 800 mL and an inspiratory capacity of 50% predicted. In addition, her chest X-ray indicates basal atelectasis. What hyperinflation treatment regimen would you recommend? A. incentive spirometry, 4-6 breaths TID B. IPPB q4h at 30 cm H2O with albuterol C. volume-oriented IPPB q2h, VT=800 mL D. incentive spirometry with 8-10 breaths/hr
D
45. Which of the following medication you would recommend to help quiet an ICU patient who is breathing asynchronously on a ventilator? A. dextroamphetamine (Dexedrine) B. cisatracurium (Nimbex) C. fluoxetine (Prozac) D. midazolam (Versed)
D
5. After completing an aerosol drug treatment, which of the following is the most appropriate chart notation for you to make? A. Treatment given as ordered B. Aerosol therapy given; pulse stable, no changes during therapy; well tolerated C. Aerosol therapy given with 0.5 mL albuterol and 3 mL normal saline; vital signs stable; well tolerated D. Aerosol therapy given with 0.5 mL albuterol and 3 mL normal saline; pulse stable at 72/min during therapy; B.P. stable at 120/80; respiratory rate 10/min; therapy well tolerated; chest clear on auscultation
D
55. When 15 cm H2O PEEP is initiated, a patient's cardiac output decreases from 4 to 2 L/min. Which of the following actions would be appropriate? A. maintain the present settings and check the ABGs in one hour B. decrease the respiratory rate to extend cardiac filling time C. increase PEEP level slightly to reach the "optimal" PEEP D. decrease PEEP to 10 cm H2O and recheck the cardiac output
D
57. An 18-year-old patient presents to the emergency room with bilateral expiratory wheezing. Which of the following treatments would you recommend? A. aerosolized cromolyn sodium B. aerosolized normal saline solution C. IV furosemide (Lasix) D. aerosolized bronchodilator
D
59. As part of a weaning protocol, you switch a 85 kg (187 lb) patient from SIMV at 4/min to 5 cm H2O CPAP and an FIO2 of 0.45. Twenty minutes after switching to CPAP, you obtain the following data: pH 7.24 Spon Resp Rate 36/min PaCO2 53 torr MIP/NIF -23 cm H2O PaO2 49 torr Tidal Volume 275 mL HCO3 22 mEq/L Vital Capacity 1.2 L Which of the following actions would you recommend at this time? A. administer sodium bicarbonate B. continue CPAP, but raise the FIO2 to 0.55 C. increase the CPAP to 8 cm H2O D. put the patient back on SIMV
D
60. A trauma patient has been receiving volume controlled SIMV via an endotracheal tube for two days. The attending surgeon anticipates that the patient will likely be on the ventilator for another 3 to 4 days. Which of the following actions would you recommend? A. switch from ET intubation to tracheostomy B. switch to noninvasive positive pressure ventilation C. switch to pressure control ventilation (PSV) D. maintain the endotracheal tube in place
D
62. The nurse calls you over to examine the arterial blood gas results of a 50-kg (110 lb) patient who is receiving volume control A/C ventilation. Currently the patient has a VT of 400 mL, rate of 10/min, and 35% O2. Her blood gas results are as follows: pH 7.30 PaCO2 48 torr HCO3 23 mEq/L BE -2 mEq/L PaO2 73 torr SaO2 94% Based on these values, which of the following changes is appropriate? A. increase the VT B. increase the FIO2 C. mantain settings D. increase the set rate
D
64. A 65 kg (143 lb) postoperative patient is receiving volume controlled SIMV. Pertinent data are below Ventilator Settings Blood Gases Mode Vol Ctrl SIMV pH 7.29 VT 325 mL PaCO2 51 torr Set Rate 12 HCO3 24 mEq/L Spon Rate 3 PaO2 86 torr FIO2 0.35 SaO2 96% Which of the following changes is appropriate? A. add/increase PEEP B. add mechanical dead space C. increase the set rate D. increase the tidal volume
D
69. A patient with congestive heart failure is coughing up large quantities of pink, frothy sputum. ABG values on simple mask O2 at 7 L/min are as follows: pH 7.44 PaCO2 29 mm Hg HCO3 20 mEq/L BE -3 mEq/L PaO2 46 mm Hg SaO2 76% Which of the following treatments would you recommend? A. nonrebreathing mask at 12 L/min and postural drainage therapy B. intermittent positive pressure breathing (IPPB) with compressed air C. start intrapulmonary percussive ventilation to clear secretions D. mask continuous positive airway pressure (CPAP) with 80% O2
D
70. Data for a 80 kg (176 lb) patient receiving ventilatory support are: Ventilator Settings Blood Gases Mode Vol Ctrl A/C pH 7.57 VT 600 mL PaCO2 25 torr Set Rate 12/min HCO3 22 mEq/L Actual Rate 18/min PaO2 106 torr FIO2 0.50 SaO2 98% Which of the following changes would be appropriate at this time? A. increasing the tidal volume B. decreasing the set (machine) rate C. adding 5 cm H2O PEEP D. adding mechanical deadspace
D
73. Continuous bland aerosol therapy would pose the greatest risk for a patient with: A. post-extubation edema B. a bypassed upper airway C. laryngotracheobronchitis D. airway hyperresponsiveness
D
76. An 16-hour-old, 28-week gestational age neonate is being maintained in an O2 hood with an FIO2 of 0.5. The neonatologist believes that the patient has infant respiratory distress syndrome (IRDS). The following blood gas results are from an umbilical artery sample: pH 7.35 PaCO2 37 mm Hg HCO3 24 mEq/L BE 0 mEq/L PaO2 47 mm Hg Based on this information, what should you recommend?: A. increase the O2 hood concentration to 100% B. intubate and begin mechanical ventilation with PEEP C. get a chest X-ray to look for a pneumothorax D. start nasal CPAP at 5-8 cm H2O
D
82. You are working the night shift and receive an order from a new resident to provide an albuterol treatment via SVN to a CHF patient with acute pulmonary edema who is wheezing. What should you do? A. perform the therapy as ordered B. recommend ethyl alcohol instead of albuterol C. perform the therapy with supplemental oxygen D. recommend diuresis and O2 therapy
D
9. Which of the following patient instructions for using a dry powder inhaler (DPI) is correct? A. hold device vertically after loading B. perform slow (3-4 sec) deep inhalation C. exhale back into the device D. seal lips tightly around mouthpiece
D
96. A clinical condition characterized by a history of a productive cough for at least three months a year for two consecutive years best describes: A. panlobular emphysema B. status asthmaticus C. centrilobular emphysema D. chronic bronchitis
D