Certified respiratory therapist exam 3-8

The ratio of lecithin to sphingomyelin, or L/S ratio, is a test to determine fetal lung maturity. Such a test may be done in the later stages of pregnancy, and the values will initially be noted in the lab results section of the mother's medical record. Approximately what ratio is associated with the onset of mature surfactant production?

A). 2:1 The lecithin to sphingpmyelin ratio, or L/S ratio, is used to determine fetal lung maturity. Generally, this ratio reaches 2:1 (twice as much lecithin as sphingomyelin) near week 35 of gestation, which corresponds to the onset of mature surfactant production. The L/S ratio will generally be noted in the lab results section of the mother's medical record.

You need to measure the forced vital capacity (FVC) of an adult patient at the bedside. What device should be used to make this measurement?

A). A computerized electronic spirometer with flow sensor. If you need to measure a patient's forced vital capacity or related measures (e.g., peak flow, FEV1, FEV25-75%) at the bedside, you should choose a portable electronic spirometer that incorporates a flow sensor (pneumotachometer) and computer analysis module. Mechanical turbine-type volumeters like the Wright respirometer are used to measure tidal volume, minute volume, inspiratory capacity, and slow vital capacity. Because the Wright respirometer can be damaged by flows greater than 60 L/min, it should not be used to measure forced inspiratory or expiratory volumes.

While a patient is being ventilated with a bag-valve resuscitator, the bag fills rapidly and collapses on minimal pressure, although little chest movement by the patient is noted. The cause may be.

A). Absence of the inlet valve. If a bag-valve resuscitator fills rapidly but collapses on minimal pressure and delivers little volume, the likely problem is a missing, torn or malpositioned inlet valve. In this case, when you squeeze the bag, gas follows the path of least resistance and escapes out the inlet port (instead of going to the patient). Can be avoided by performing an operational check on the bag before applying it to the patient.

The best way to avoid arterial blood gas analysis errors associated with blood metabolism is to:

A). Analyze the sample immediately. ABG errors caused by blood metabolism are time and temperature dependent. It is important to analyze all ABG samples immediately on receipt in the lab after transport with minimal delay. If this is not possible, the sample should be kept in an ice/water bath and analyzed as soon as possible.

In the lab results section of a patient's medical record, the overall WBC count is shown as 22,000 for a febrile patient who appears acutely ill in moderate respiratory distress. Which of the following is this patient's most likely diagnosis?

A). Bacterial pneumonia The elevated WBCs suggest a bacterial infection. The respiratory distress further points to a respiratory infection such as bacterial pneumonia. In addition, the other choices are not infectious processes, and therefore you would not likely see elevated WBCs.

A PET scan would be most useful in the diagnosis of which of the following conditions?

A). Bronchogenic carcinoma A PET scan is a nuclear imaging technique used in the diagnosis/staging/management of tumors and cancer. The answer choice bronchogenic carcinoma describes lung cancer.

A fuel cell oxygen analyzer is reading 18% when exposed to ambient air. The initial corrective action should be to:

A). Calibrate the sensor. If a galvanic cell oxygen analyzer reads 18% when exposed to ambient air, it should first be recalibrated to 20.9%. Replace the sensor only if an analyzer fails to calibrate at 21% and 100% oxygen.

Which of these conditions is associated with jugular venous distension?

A). Cor pulmonale Cor pulmonale is right heart failure due to chronic lung disease. Right heart failure occurs when chronic hypoxemia elevates the pulmonary vascular resistance and puts a strain on the right ventricle to pump blood through the constricted pulmonary capillaries. Right heart failure causes venous blood to back up into the neck veins.

An AP x-ray of a 3-year-old child with wheezing and stridor shows an area of prominent subglottic edema, but lateral neck x-ray appears normal. What is the most likely problem?

A). Croup Croup is the most likely problem. On an AP x-ray. croup is characterized by the "steeple sign"-i,e, a narrowed and tapered airway below larynx due to subglottic edema. Typically, the lateral neck x-ray in these patients is normal (showing little or no evidence of supraglottic involvement).

To evaluate and follow the course of a patient with interstitial lung disease, which of the following pulmonary function testing procedures would you recommend?

A). Diffusing capacity (DLCO). The primary indication for the carbon monoxide diffusing capacity (DLCO) test to evaluate and follow the course of parenchymal and interstitial lung diseases such as pulmonary fibrosis, pneumoconiosis, and sarcoidosis. In addition, the DLCO test can be used to differentiate among the various patterns of airway obstruction (emphysema patients typically have a low DLCO) and is helpful in following the course of emphysema and cystic fibrosis. The DLCO test also can help predict arterial desaturation during exercise in patients with lung disease.

How often should a Ptco2 electrode be relocated in a neonate?

A). Every 2 hours. Both transcutaneous PcO2 and PO2 electrodes are heated to 44 degree celcius to "arterialize" the capillary blood. As a result of the increased temperature at the site the electrodes must be moved frequently, every 2 hours for neonates and every 2-4 hours for adults.

To apply vibrations to a patient when using an electrically powered percussor during postural drainage, you should use the ______ available frequency and apply during _______ only.

A). Highest; exhalation To provide vibration with a mechanical percussor, you should use the higher available frequencies (20-30 Hz) and apply during exhalation only.

A patient has a pulmonary capillary wedge pressure (PCWP) of 18 mm Hg. All of the following are potential causes for this finding except:

A). Hypovolemia A pulmonary capillary wedge pressure (PVWP) of 18 mm Hg is higher than the normal pressure of 4-12 mm Hg. All of the causes listed except hypovolemia can increase PCWP. Hypovolemia tends to lower all vascular pressures.

An apnea monitor on a premature infant indicates an abnormal decrease in respiratory rate and an abnormal increase in heart rate. What is the most likely cause of this problem?

A). Hypoxemia A decreased respiratory rate in combination with an increased heart rate in a neonate most likely indicates hypoxemia, which should be confirmed by pulse oximetry or an ABG.

What would indicate an obstruction in the ET tube of a patient who is being mechanically ventilated by a volume-cycled ventilator?

A). I. High pressure is required to deliver the volume. & III). A suction catheter cannot be passed. An obstruction in the ET tube of a patient who is being mechanically ventilated increases flow resistance and thus the peak pressure needed by a volume-cycled ventilator to deliver its preset volume. In addition, you could detect the obstruction by trying to pass a suction catheter through the ET tube. Failure to pass a suction catheter through a tracheal airway indicates tube obstruction.

Upon exam of an acutely dyspneic and hypotensive patient, you note the following (all to the left hemithorax): reduced chest expansion, hyperresonance to percussion, absence of breath sounds and tactile fremitus, and a tracheal shift to the right. These findings suggest:

A). Left-sided pneumothorax An acutely ill patient with dyspnea, hypotension, unilateral findings of reduced chest expansion, a hyperresonant percussion note, absence of breath sounds and tactile fremitus, and a tracheal shift to the right has most likely suffered a large pneumothorax on the affected side. If the pneumothorax is severe enough to disrupt cardiac function, blood pressure will also fall.

A patient with pneumonia has her noninvasive ventilatory support discontinued. Which of the following should be used to disinfect the device's nondisposable breathing circuit before it is placed back into service?

A). Pasteurization. Reusable breathing circuits are semicritical items. According to CDC recommendations, reusable semicritical equipment should be sterilized or undergo high-level disinfection. Only pasteurization meets this standard.

All of the following are associated with a patient being at risk for malnutrition except:

A). Recent weight gain Any patient who (1) is significantly underweight; (2) has recently lost a significant amount of weight; (3) has poor dietary habits or inadequate food intake; or (4) is impoverished, isolated, or unable to prepare hie or her own food is at high risk for malnutrition. Weight gain is not normally associated with malnutrition.

To continuously monitor the adequacy of ventilation of a patient in the ICU being supported by mask BIPAP, you would recommend which of the following?

A). Transcutaneous PCO2 analysis. Although traditionally used only with infants and children, recent research indicates that the transcutaneous PCO2 is an accurate measure of ventilation in hemodynamically stable adults, making it a good choice for continuous monitoring of ventilation when capnography is unavailable or impractical (e.g., during noninvasive ventilation).

To provide a low to moderate concentration of oxygen to a patient receiving nasal BIPAP via a device that uses a turbine or blower to generate pressure, you should:

C). Bleed supplemental O2 from a flowmeter into the circuit. Most NPPV ventilators and BIPAP devices use a simple air blower to generate pressure. In order to provide supplemental oxygen with devices, you place a small-bore tubing adapter at either the patient interface or machine outlet. After connecting this adapter to a flowmeter via O2 delivery tubing, you bleed O2 into the circuit until he desired level is confirmed by O2 analysis. Note that high supplemental O2 flows can interfere with the proper triggering or cycling of some NPPV ventilators.

Your patient in the ICU is suspected of having developed a bacterial ventilator-associated pneumonia. Which of the following procedures would you recommend as best able to diagnose the cause of this problem?

C). Bronchoalveolar lavage A sputum culture and sensitivity could help diagnose this problem. However, bronchoalveolar lavage (BAL) is one of the best tools avaible to diagnose bacterial ventilator-associated pneumonia (VAP) and is thus the better choice for this patient. According to the American Thoracic Society, bronchoalveolar lavage (BAL) is indicated in patients with nonresolving pneumonia, unexplained lung infiltrates (interstitial and/or alveolar), and suspected alveolar hemorrhage.

To estimate the metabolic rate of a patient receiving mechanical ventilation, you would recommend:

C). Capnography Capnography (expired CO2 analysis) is used primarily to noninvasively monitor the effectiveness (PETCO2) and efficiency (PaCO2-PETCO2) of ventilation, usually during mechanical ventilation. Most capnographs can also compute the accumulated volume of CO2 over time if the expired minute ventilation is known or measured. CO2 production per minute is one measure of metabolic activity, the other being O2 consumption.

You measure an oxygen concentration of 55% being delivered by an air-entrainment mask set to deliver 31% oxygen.

C). Check the entrainment ports. Because air-entrainment masks mix air and oxygen at a constant ratio, an alteration in the delivered oxygen concentration could result only from an alteration in the mixing ratio. Since jet size (for a given adapter) is fixed, the problem must be with the entrainment ports. Obstruction of the entrainment ports will decrease air entrainment and raise the delivered oxygen concentration.

You observed that the reservoir bag on a patient receiving O2 at 10 L/min does not deflate at all when the patient inspires. What to do first.

C). Check the mask for a snug fit. If a nonrebreathing mask reservoir bag does not deflate at all when the patient inspires, either the flow is higher than needed, there are large inspiratory air leaks (around the mask or through the exhalation valves), or the inspiratory valve is jammed. The most common cause is large air leakage, which can easily be corrected by making sure that the mask is fit comfortably tight to the patient,s face.

The best way to determine whether or not a patient has learned the information needed to understand how her disease impacts on lung function would be to:

C). Have her "teach" the information back to you. Teach-back is the best way to determine whether a patient has learned critical information related to his or her care. A return demonstration is appropriate for procedural skills, whereas discussion is the best method for assessing attitudinal change.

Which of the following hemoximeter measurements are affected by air contamination?

C). HbO2 levels. Levels of HbO2 values for samples contaminated with air bubbles should be questioned. Levels of HbCO, metHb, SHb, and total Hb are unaffected by air contamination. Additionally, inadequate mixing of either a syringe or capillary sample just prior to analysis will result in erroneous total hemoglobin measurements.

If sterilization is not feasible, what are acceptable alternatives for processing a specialized reusable plastic airway?

C). I.Exposure to a high-level chemical disinfectant III. Pasteurization at 63C for 30 minutes. It directly comes in contact with mucous membranes, a reusable airway is categorized as semicritical equipment. If sterilization of a semicritical item is not feasible the alternatives are high-level disinfection or pasteurization.

ALL of the following help minimize the risk of cross-contamination during suctioning.

C). Instilling 10 mL sterile saline before the suctioning attempt. To decrease the risk of patient contamination during suctioning, you should use a fresh serile single-use catheter on each patient and use only sterile water or saline to clear the catheter. In addition, both the suction collection tubing and collection canister should be changed between patients, except in short term care units (where only the collection tubing should be changed)

A 2-year-old child is admitted to the emergency department with severe asthmatic symptoms. The attending physician orders a bronchodilator that is available in both solution and MDI preparations. What is the best delivery system for this drug?

C). MDI with holding chamber and a mask. Most infants and small children should receive aerosolized drugs via an MDI with a valved holding chamber and a mask. If tolerated by the patient, an SVN with a mask could be considered as an alternative. Avoid using the "blow by" technique (i.e., holding the mask or open tube near the infant's nose and mouth) with small-volume nebulizers.

You hear bronchial breath sounds over the patient's right middle lobe. What condition is probably present?

C). Pneumonia Bronchial breath sounds normally are heard only over the trachea. When heard over the lung periphery, consolidation (due to pneumonia) is present. Consolidation of the lung allows the turbulent flow sounds of the larger airways to pass directly through the lung as attenuation is reduced.

The wife of a patient receiving postoperative incentive spirometry asks if this therapy will help get rid of his snoring, daytime sleepiness, and morning headaches. In communicating this information to the patient's surgeon, you would recommend which of the following diagnostic procedures?

C). Polysomnography. You should recommend polysomnography for patients who complain of or exhibit signs or symptoms associated with sleep-disordered breathing (e.G., daytime somnolence and fatigue, morning headaches, pulmonary hypertension, and polycythemia).

To assess gas exchange at the tissues you would sample blood from which of the following?

C). Pulmonary artery. To assess gas exchange at the tissues, you need to assess blood after it leaves the capillaries. For the body as a whole, you need to wait until after all the blood from all the capillary beds mixes together, which is complete only in the pulmonary artery.

Prior to intubation in an emergency, injection of air into the pilot line fails to inflate the cuff. You should:

C). Replace the endotracheal tube. A cuff that fails when injected with air has a large leak. The faulty ET tube should be replaced and the new tube tested in the same manner.

Negative inspiratory force (NIF) is useful in the determination of which of the following?

C). Respiratory muscle strength Negative inspiratory force (NIF) or maximal inspiratory pressure (MIP) is used for the bedside assessment of respiratory muscle strength. You probably know that it is a measurement of pressure only. Since airway resistance is a measurement of pressure divided by flow, and sine functional residual capacity and sustained maximal inspiration are measurements of volume, the process of elimination leaves muscle strength as the only correct answer.

You note on inspection of an anterior-posterior (AP) chest radiograph that the left hemidiaphragm is elevated above normal. Which of the following is the most likely cause of this abnormality?

C). Right phrenic nerve paralysis. An elevated hemidiaphragm indicates phrenic nerve paralysis on the affected side or hepatomegaly (generally right side only). Pleural effusions blunt the costophrenic angles, whereas hyperinflation tends to flatten the hemidiaphragms, as does tension pneumothorax (on the affected side).

After attaching a yoke connector to an E-size cylinder and opening the cylinder valve, you notice a leak at the gas outlet. What are the possible causes of the leak?

C). The gas outlet bushing is missing & The yoke hand screw is not tight enough. Yoke connectors for cylinders A-E use a hand screw to hold the toke 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 bushing. A missing or damaged bushing could also cause a leak.

After setting up a 12-lead ECG on a patient, you note a noisy and unstable signal. What will help to resolve the problem.

C). Turning off filtering of extraneous electrical activity. The two most common problems in obtaining a good 12-lead ECG recording are absent or "noisy" signals. In either case you should check and confirm that: 1) the ECG snaps and connectors are clean and corrosion-free; 2) the lead electrodes are connected properly to the patient; 3) the electrode gel is not dry (replace ant suspect electrodes); 4) the main lead cable is undamaged; 5) the patient is motionless; and 6) the device's filter settings (if available) are properly set to eliminate extraneous electrical activity.

To assess the level of pain that a 2-year-old child is experiencing during a procedure, you would do all of the following except:

C). Use a numeric pain scale a numeric pain scale is not useful for young children or patients who cannot express themselves. The best way to assess the pain level of a young child to get the input of a family member. Without such information, you may have to rely on observing patient behaviors that indicate severe pain, such as moaning, crying, or grimacing.

Which of the following specialized imaging tests would be most useful in diagnosing a pulmonary emboli?

C). Ventilation-perfusion scan (V/Q scan) A chest x-ray and an ABG might be useful in detecting an abnormality, but not specifically a pulmonary emboli. Pulmonary function tests (PFTs) may reveal abnormal flows and volumes/capacities but no perfusion problems inherent in a pulmonary emboli. A ventilation-perfusion scan would show a lack of blood flow due to emboli (a clot) in the blood pulmonary circulation. Ventilation to lung regions would be shown as well.

Based on the results of cardiopulmonary exercise testing, which of the following patients most likely has a ventilatory limitation to exercise?

D). Patient D = decreased / normal / decreased All patients 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 a normal breathing reserve. in the presence of a low VO2max, poor effort is revealed by a normal anaerobic threshold and breathing reserve.

On reviewing the results of the attending physician's physical examination of a patient's chest, you note "a dull percussion note and bronchial breath sounds- LLL." All of the following are potential problems except:

D). Pneumothorax A patient with a dull percussion note and bronchial breath sounds on chest examination most likely has either pulmonary infiltrates, atelectasis, or consolidation of the affected area. A pneumothorax normally results in a hyperresonant note.

What device would assess the output accuracy of a Bourdon gauge regulator used for O2 transport?

D). Precision flowmeter. To assess the output of flow accuracy of a Bourdon gauge regulator used for O2 transport, you would use a precision (calibrated) flowmeter.

To spot check a patient's oxygen saturation at the bedside, you would select what?

D). Pulse oximeter. If you need to spot check, monitor, or obtain trend data on a patient's oxygen saturation (SpO2), you should select a pulse oximeter. You would select a laboratory hemoximeter if you needed precise measures of both normal and abnormal hemoglobin saturations. A transcutaneous monitor would be your best choice to continuously and noninvasively monitor arterial blood gases (PO2 and PCO2) in infants.

You can use a fluid column pressure manometer for what?

D). To measure rapid pressure changes. Fluid pressure manometers are used to measure 1) atmospheric pressure (barometer); 2) static or slowing changing pressures- e.g. CVP; 3) systolic/diastolic blood pressures (occlusion method); and also to calibrate other pressure measuring devices. They are not suited for measuring rapidly changing pressures, thier accuracy depends on position, and they can be messy or hazardous (if mercury is used).

Cultures taken from a respirometer that has been used in the surgical intensive care unit to monitor several patients indicate that it is contaminated. The most practical way to prevent cross-contamination is to:

D). Use a disposable HEPA filter and one-way valve for each patient. The best way to prevent the contamination of a Wright respirometer used on several different patients is to use a one-way valving system, preferably with an in-line HEPA filter. Such an approach can ensure that patients only breathe out through the device, thus preventing cross-contamination.

To avoid the preanalytical errors that are associated with air contamination of a blood gas, what is appropriate?

D). Using the minimum amount of heparin. To avoid pre-analytical errors associated with air contamination of a gas sample, yo should fully remove any air bubbles, cap the syringe quickly, and mix the sample only after all air has been removed.

As you are fitting him with a nonrebreathing mask, a 62-year-old patient in the emergency department complains of severe chest pain. Which of the following tests would you first recommend for this patient?

B). Electrocardiogram (ECG) You should recommend obtaining an electrocardiogram to screen for heart disease, rule out heart disease in surgical patients, evaluate patients with chest pain, follow the progression of patients with CAD, and evaluate heart rhythm disorders.

A patient with a chronic neuromuscular condition requires nocturnal positive pressure ventilation over the long term. What airway would you recommend for this patient?

B). Fenestrated tracheostomy tube. A fenestrated tracheostomy tube is the best choice to support patients needing intermittent (e.g. nocturnal) ventilatory support. For positive pressure ventilation, the inner cannula is inserted to close the fenestration and the cuff inflated to provide a seal. When the patient is not on the ventilator, the inner cannula is removed (to open the fenestration), the cuff is deflated, and the tube is plugged. This allows normal use of the upper airway.

Which of the following tests of lung mechanics would you recommend to detect the presence of auto-PEEP on a patient receiving ventilatory support?

B). Flow -volume loop Of the tests, only the flow-volume loop would help detect the presence of auto-PEEP on a patient receiving ventilatory support. When viewing the flow-volume loop of a patient with auto-PEEP, you will note that the expiratory flow does not return to baseline before the start of the next breath.

A patient who was hospitalized with ARDS of unknown etiology recently traveled to an area with a documented outbreak of severe acute respiratory syndrome (SARS). What infection control precautions should you recommend for this patient?

B). I.Airborne precautions II. Contact precautions III. Droplet precautions If either of the suspicion of SARS is strong or laboratory evidence confirms a SARS-CoV infection, the CDC recommends a combination of standard, contact and srtict airborne precautions to manage these patients.

When performing bedside spirometry on a 46-year-old man who is six feet tall, you obtain a peak flow measurement of 3.3 L/sec. Which of the following are possible explanations for this finding?

B). II. the patient is not exerting full effort, III. The patient has expiratory flow obstruction Normal adult male peak flows range between 8 and 12 L/sec, while adult female normal peak flows range between 6 and 9 L/sec. This patient's peak flow is considerably below normal, which generally indicates an expiratory flow obstruction. However, the peak flow test is highly effort dependent. For this reason, poor effort should always be considered when peak flow results are below predicted norms.

You come upon an elderly patient who is unresponsive and is not breathing, You had heard from her nurse that she had discussed with her physician whether or not to a have a do-not-resuscitate (DNR) order in her chart. You should:

B). Immediately call a code and begin resuscitation efforts If there is any doubt regarding a DNR order or if written orders are not present, start resuscitation efforts. Formal or informal directives such as "slow code" or "code gray" bypass the patient's rights and are generally inappropriate.

An alert 55-year-old patient who has two days earlier had abdominal surgery has moderate basilar crackles on the left side, a respiratory rate of 13 breaths/min, and an SpO2 of 96% on nasal cannula at 2L/min. The surgeon is concerned that the patient may be developing atelectasis, What approach can manage this patient?

B). Incentive breathing therapy. Incentive spirometry is the first choice for treating suspected or confirmed atelectasis in an alert patient who does not have evidence of bronchospasm or secretion clearance problems.

A patient undergoing CPAP titration during sleep exhibits three obstructive apnea events during a 5-minute observation interval at a pressure of 8 cm H2O. What would be the appropriate action at this time?

B). Increase the CPAP to 10 cm H2O for 5 minutes and continue observation. If any of the following events occur during a CPAP titration observation interval (up to the maximum protocol pressure, typically 20 cm H2O), you should increase the CPAP level by at least 1 cm H2O: > 2 obstructive apneas, > 3 hypopneas, >5 RERAs, > 3 min of loud snoring.

During CPR, the oxygen reservoir bag of a bag-valve manual resuscitator collapses during the refill phase. You can correct this problem by:

B). Increasing O2 flow to the bag. Think of the reservoir bag of a bag-valve manual resuscitator as equivalent to the bag on a reservoir mask. If the reservoir bag collapses during the resuscitator's refill phase (equivalent to patient inspiration), the flow is inadequate and should be increased until the bag does not empty.

A physician specifies in her respiratory orders the following objective for a patient with an artificial airway: " to overcome the patient's humidity deficit." Aerosol generator to be used for this patient.

B). Large -reservoir heated jet nebulizer. The large-reservoir air-entrainment jet nebulizer is the primary gas-powered aerosol generator used to provide humidification to the respiratory tract.

You palpate the patient's neck and notice that the trachea is shifted to the patient's left. Which of the following conditions could explain this finding?

B). Left upper lobe collapse Volume loss in the upper lobe will pull the trachea toward the collapsed lung. In this case the trachea has shifted to the left indicating that either volume loss has occurred on the left or a tumor on the right is pushing the trachea to the left.

The label of a disinfectant indicates that it does NOT inactivate or kill either Mycobacterium tuberculosis or bacterial spores. What class of disinfectant is this?

B). Low-level. A low-level disinfectant inactivates most bacteria, some viruses, and fungi but cannot destroy resistant microorganisms such as Mycobacterium tuberculosis or bacterial spores.

During an interview with your patient you discover that he gets short of breath at night when he lays down so he often sleeps with several pillows propping his head up. What symptom is present?

B). Orthopnea Orthopnea is present when the patient has difficult breathing upon lying down. In most cases this is due to pulmonary edema filling the lungs when the patient assumes a horizontal position. Keeping the patient's head up during sleep with the use of pillows reduces the collection of fluid in the lungs.

You conduct a 6-minute walk test (6MWT) on four patients before and after participation in a pulmonary rehabilitation program. Based on the 6-minute walking distance (6MWD) data provided below, for which of these patients has the program been effective in improving their functional capacity?

B). Patient B, pre-program 6MWD; 150m & Post-program 6MWD; 200m. When using the 6MWT to assess medical or surgical interventions, you should expect at least a 10-20% improvement in the 6MWD to consider the treatment effective. only patient B has more than a 10% improvement in this measure of functional capacity [(200-150)/150 = 33% improvement].

While obtaining an arterial sample for analysis using a point-of-care analyzer, you should do what?

B). Place the sample in an ice slush. When obtaining an arterial sample for analysis using a point-of-care analyzer, the equipment performed are essentially the same as when preparing the sample for central lab analysis. Exceptions = 1) sample to be analyzed within 3 minutes, & 2) sample should not be placed in ice.

Assessment of a 28-year-old trauma patient reveals diminished breath sounds, asymmetrical chest expansion, severe chest pain, and an SpO2 of 90%, despite receiving oxygen via cannula at 5 L/min. These findings are most consistent with what diagnosis?

B). Pneumothorax Both viral pneumonia and pleural effusion can be ruled out as correct answers as they are related to trauma. Breath sounds, though diminished, can be heard, and chest expansion, though asymmetrical, is present; both of these are not consistent with a complete airway obstruction. The physical assessment is consistent with the correct answer, pneumothorax.

After setting up a flow-resistor expiratory airway pressure (PEP) device for a patient with postoperative atelectasis, you note that the system does not generate any pressure during active patient expiration. Your first action in this case should be to:

B). Recheck and tighten all connections. If a PEP device fails to generate pressure during patient expiration, the most likely problem is a leak, either in the device itself or in the connecting tubing (including any connection to a pressure manometer,

Which of the following physical findings would you expect to see in an alert but anxious asthmatic who has just been admitted to the emergency department?

B). Respiratory alkalosis Asthmatics typically present with respiratory alkalosis. Shortness of breath and accompanying hypoxemia cause the patient to increase his rate of breathing and alkalosis occurs. It is important to note here that once hypoxemia is relieved by the administration of supplemental oxygen, patient's PaCO2 and pH will normalize.

During an interview with your patient you determine that she is disoriented to time, place, and person. What may explain this finding?

B). Severe hypoxemia An abnormal sensorium is often caused by a lack of adequate oxygenation to the brain. Severe hypoxemia reduces the oxygen available to the brain and leads to confusion. An abnormal sensorium in any patient should be assumed to be caused by hypoxia until proven otherwise.

What type of breathing circuit would you use when assembling a home-care ventilator.

B). Single-limb circuit with expiratory balloon valve. Most home-care ventilators use a single-limb circuit with expiratory balloon valve. Single-limb circuits have a separate pneumatic line running from the ventilator to the expiratory valve that pressurizes the expiratory valve during inspiration in order to block gas outflow during the application of positive pressure. An expiratory valve can also be used to control or retard expiratory flow or provide CPAP/PEEP.

Which of the following is the preferred delivery method for cromolyn sodium to young children?

B). Small-volume nebulizer. A small-volume nebulizer (SVN) is the method of choice for administering cromolyn sodium to young children. You should use a tightly fitting face mask for any child unable to use a mouthpiece.

As measured on the Borg scale, which of the following exertion levels is appropriate for titrating a COPD patient's O2 flows to support exercise?

B). Somewhat strong exertion (rating of 4). For patients continuing on, you have them initiate walking and slowly increase their activity until it replicates the highest intensity they will likely perform in the home environment, usually equivalent to a 3 to 4 on the Borg rating of perceived exertion.

You obtain a bedside vital capacity (VC) of 400 mL on a cooperative 50-kg female patient receiving ventilatory support in the CMV mode. Which of the following conclusions can you draw from this finding?

B). The patient cannot sustain prolonged spontaneous ventilation. The patient has a VC of about 8 mL/kg (400 mL/50 kg). A normal VC is about 65-75 mL/kg. Values below 65-75 mL/kg indicate a restrictive disorder, which may be due to neuromuscular weakness, acutely decreased lung volumes, or interstitial lung disease. When the VC drops below 10-15 mL/kg it is unlikely that a patient can support prolonged spontaneous ventilation.

After performing comprehensive pulmonary function testing on a patient, you note the following results: Test %Predicted FEV1% 50 RV 150 TLC 135 DLCO 60 Which of the following interpretations is most consistent with these findings?

B). The patient has pulmonary emphysema. The low FEV1% and higher than normal TLC and RV confirm an obstructive disorder with hyperinflation (emphysema, chronic bronchitis, acute asthma, etc.) Among these obstructive disorders, only patients with emphysema exhibit a low DLCO, due to the destruction of the alveolar capillary membrane.

What is the primary reason for using chemical indicators in equipment sterilization processing?

B). To show that a package has been through a sterilizing process. Chemical indicators are usually impregnated on packaging tape. These indicators change color when exposed to specific conditions, telling the user that the package has been processed via appropriate sterilizer cycle. Chemical indicators can't ensure that the contents are actually sterile. Only biological indicators can provide that information.

Resistance is encountered while suctioning through a size 6-mm ID ET tube with a 14-Fr catheter. What is the most appropriate action to take?

B). Use a 10-Fr catheter. The catheter is too large for the ET tube. In general, the outside diameter of a suction catheter should not be more than about 1/2 as large as the inside diameter of the airway through which it passes. To quickly estimate the correct catheter size in french units (Fr), simply multiply the internal diameter (ID) of the tracheal tube (in mm) by 2 and select the next smallest catheter size.(e.g. 6.0-mm tube, 2 x 6 = 12, next smallest catheter size = 10 Fr. 10Fr is the best size to use for this patient.

An intubated adult patient with severe expiratory airway obstruction requires ventilatory support. Which of the following factors is most important in selecting a ventilator for this patient?

B). Variable flow control and adjustable I:E ratios. Of the functions listed, the most important capability when selecting a ventilator for an intubated adult patient with severe expiratory airway obstruction would be variable flow control and adjustable I:E ratios. This will allow clinicians to make sure the expiratory time is sufficiently long to prevent air trapping / auto-PEEP

Upon inspection of a portable spirometer's FVC curve obtained on an adult outpatient, you determine that the back extrapolated volume is excessive. Prior to repeating the maneuver, what instruction should you provide to the patient.

A). "Don't hesitate" In adults, a back extrapolated volume greater than 150 ml, indicates patient hesitation at the beginning of the breath, which will invalidate the results.

A 23-year-old firefighter is admitted with suspected smoke inhalation. You place him on a nonrebreathing mask. What is the most appropriate method of monitoring his oxygenation?

B). CO-oximetry In the case of smoke inhalation, carbon monoxide (CO) binds to the hemoglobin molecule in place of oxygen. Neither ABGs, pulse oximetry, or calculation of A-a gradient will indicate how much oxygen is bound to hemoglobin. Any victim of suspected smoke inhalation must be monitored with CO-oximetry.

A patient complains that she has a chronic cough usually accompanied by sputum production. This information indicates that the patient probably has which of the following conditions?

B). Chronic bronchitis Chronic bronchitis is defined primarily by is symptoms: chronic cough and sputum production

The first step in processing reusable equipment is:

B). Cleaning. The fist step in equipment processing is cleaning. Equipment is cleaned by removing dirt and organic material from its surfaces, usually by washing. If equipment is improperly cleaned, subsequent processing efforts may be ineffective.

What can cause suctioning stop suddenly during tracheobronchial aspiration.

B). Clearence of secretions. Conditions that could cause suctioning to stop suddenly during tracheobronchial aspiration include: 1) disconnected tubing (leak: loss of vacuum), 2). a full suction reservoir (ball-valve shutoff), and 3) plugging of the catheter (system obstruction).

Under ideal conditions, electrochemical oxygen analyzers have an accuracy of:

B). +/- 2% There are two common types of electrochemical oxygen analyzers: the polargraphic (Clark) electrode and the galvanic fuel cell. Under ideal conditions of temperature, pressure, and relative humidity, both types are accurate to within 2% of the actual concentration.

According to ATS recommendations, diagnostic spirometers should be calibrated to within:

B). 3% or 50 mL, whichever is greater, using a 3-liter syringe. American Thoracic Society (ATS) recommendations for diagnostic spirometers are that calibration checks should be within 3% or 50 mL, whichever is larger.

Which of the following is the approximate total output flow delivered from a 35% air-entrainment mask operating at 8L/min?

B). 48L/min To compute the total output flow delivered by an air-entrainment device, multiply the sum of its ratio parts by the input flow. A 35% air-entrainment mask mixes air and oxygen at a fixed 5:1 ratio; thus (5+1) x 8 = 48 L/min

A 150-lb patient is breathing at a frequency of 20 breaths/min, with a tidal volume of 550 mL. What is his estimated alveolar ventilation per minute?

B). 8.00L/min. The formula for alveolar minute ventilation is Ve=f x (Vt-Vd). In this case the physiologic deadspace is estimated at 1 mL/lb ideal body weight, or 150 mL. Substituting the patient's values for f, Vt, and estimated Vd, we compare an alveolar minute ventilation of 20 x ( 550 - 150) = 8000 mL/min, 8.00 L/min.

To assess tissue oxygenation in a patient with ARDS, you would recommend which of the following?

B). A pulmonary artery catheter. To assess how well the tissues are getting oxygenated, we need to know how much oxygen is left over after the blood leaves the capillaries. This measure, called the mixed venous oxygen content (CVO2), can be obtained only from the distal port of a pulmonary artery catheter.

You would recommend consideration of all of the following imaging modalities for diagnosing a patient suspected of having a pulmonary embolism except:

B). AP chest X-ray A standard chest x-ray is not useful in detecting a pulmonary embolism. Pulmonary angiography has been the gold standard, along with V/Q scanning. However, more recently, CT angiography and transthoracic ultrasound have become accepted noninvasive tools for diagnosing pulmonary embolism.

Sputum culture and sensitivity would be indicated in the evaluation of which of the following clinical conditions?

B). Bacterial pneumonia Sputum culture and sensitivity are used to identify microorganisms and their most appropriate drug therapy. Bacterial pneumonia is the obvious infectious process in the choice of answers.

How often should ventilators be tested to verify their performance?

B). Between patient uses. All ventilators should be tested after each use to verify performance before the unit is used on another patient. A complete operational verification procedure, based on the manufacturer's recommendations, should be performed each time. these procedures should be detailed in the health care facility's policies and procedures manual.

A patient has a vital capacity (VC) of 3200 mL, a functional residual capacity (FRC) of 4500 mL, and expiratory reserve volume (ERV) of 1200 mL. What is her residual volume (RV)?

C). 3300 mL The functional residual capacity (FRC) equals the sum of the residual volume and the expiratory reserve volume (FRC = RV + ERV). Rearranging this equation (to solve for RV) yields Rv =FRC - ERV. In this case, RV = 4500 - 1200, or 3300 mL.

In analyzing overnight oximetry data, a desaturation event represents a decrease in SpO2 of what amount?

C). 4% or more Most sleep disorder specialists agree that a desaturation event represents a decrease in saturation of 4% or more. The total number of these desaturation events per hour is the oxygen desaturation index (ODI).

About how many hours will an H-cylinder of oxygen last if it has 1100 psig and is emptying at a flow of 8L/min?

C). 7.2 hours Duration of flow = (cylinder factor x psig)/flow. The factor for an H cylinder is 3.14 Thus duration of flow = (3.14 x 1100)/ 8 = 432 minutes. 432/ 60 = 7.2 hours.

A patient's bedside spirometry results (as compared to normal) are as follows: FVC decreased, FEV1 normal, and FEV1% increased. What is the most likely problem?

C). A restrictive disorder. A patient with a decreased FVC, normal FEV1, and increased FEV1% is exhibiting the classic pattern of a restrictive pulmonary disorder-i.e., decreased volumes and normal (or increased) flows.

Which of the following aspects of a patient's social history is most important in the diagnosis of lung disease?

D). Occupational history Of the items listed, occupational history is most important in the diagnosis of lung disease. Many lung diseases are associated with inhalation of dust or toxic chemicals in the work setting.

Which of the following is the most probable cause of insufficient mist in a croup tent)?

D). A clogged capillary tube in the nebulizer. Since most croup tents use large-volume jet nebulizers to generate mist, insufficient mist indicates malfunction of the nebulizer. The most common cause of nebulizer malfunction is clogging of the capillary tube that feeds liquid water to the jet.

A neonatal intensive care unit (NICU) nurse calls you to check an infant on a transcutaneous PO2/PCO2 monitor due to a rapid rise in PtCO2 and concurrent fall in PtCCO2 to below 10 torr. The most likely cause of this problem is:

D). Air leak around the sensor's adhesive ring. The most common problem with transcutaneous monitoring is air leaks around the adhesive ring. Air leaks always cause a dramatic fall in Ptcco2. If the leak is large, the Ptco2 and Ptcco2 values will mimic those in room air (PO2 ~ 150 torr/ PCO2 ~ 0 torr). In these cases, reapply the sensor using a new adhesive ring.

On reviewing an ECG printout you note widened QRS complexes. Which of the following is the most likely cause of this problem?

D). Bundle branch block. QRS complexes appear wider than normal (>0.12 sec) in PVCs, bundle branch block, ventricular fibrillation, and hyperkalemia.

What will reduce the incidence of ventilator-acquired pneumonia (VAP) on your patient?

D). Changing ventilator circuits every 48 hours: The key components recommended by the CDC to reduce the incidence of VAP include elevating the head of the bed at least 30 degree implementing a daily "sedation vacation" and spontaneous breathing trial, and providing peptic ulcer and deep venous thrombosis disease prophylaxis. Airway management techniques that can help decrease the incidence of VAP include: 1) avoiding intubation when possible (using noninvasive ventilation instead); 2) intubating via the oral as opposed to nasal) route; 3) maintaining proper ET tube cuff pressures; 4) aspirating subglottic secretions; and 5) using only sterile water or saline to flush suction catheters.

To periodically confirm the validity of blood gas analyzer results, you would perform:

D). Control media calibration verification. To periodically confirm the validity of a blood gas analyzer, you would perform a calibration verification using control media. Calibration verification requires analysis of at least three materials with known values (controls) spanning the entire range of results expected for clinical samples. At least one control should be analyzed every 8 hour shift. All three levels of the control media are analyzed at least once every 24 hours.

A patient admitted to the emergency department is suspected of having suffered pulmonary injury due to inhalation of toxic fumes. To determine the location and extent of potential injury you would recommend which of the following procedures?

D). Fiberoptic bronchoscopy Injury from toxic inhalation or aspiration most immediately affects the airways. In these patients the location and extent of injury is best determined initially using fiberoptic bronchoscopy

For patients receiving bronchodilator therapy via small-volume nebulizer (SVN) what precautions would be beneficial in preventing nosocomial infection?

D). I. Use a different SVN for each patient II. Change the nebulizer and tubing every 24 hours III.Perform thorough handwashing prior to each therapy session To minimize the likelihood of infection in patients receiving bronchodilator therapy via SVN, you should 1) use a different SVN for each patient, 2) change the SVN and tubing every 24 hours, and 3) perform thorough handwashing prior to each therapy session. It is also recommended that the nebulizer NOT be rinsed with tap water but rather rinsed with sterile water and blown dry between uses.

What alarm conditions indicates a potential system leak when delivering volume-oriented ventilatory support?

D). Low volume + low pressure. When delivering volume-oriented ventilatory support, potential system leaks are indicated by a low-volume and low-pressure alarm condition. Check for and correct any loose circuit connections.

While examining a patient in the ICU, you note that he appears somewhat edematous, and the nurse has indicated that the patient's urine output is "minimal". In what section of the medical record would you check to determine the patient's fluid balance (intake vs. output)?

D). Nurses' notes and flow sheet A patient's fluid balance is the relationship between fluid intake and outputs primarily from urination. It is normally noted in the nurses' notes or 25-50 ml/hour. A positive fluid balance results from excessive intake and/or decreased output and may contribute to pulmonary or peripheral edema and hypertension. A negative fluid balance is generally due to insufficient hydration and/or excessive urination from medications such as diuretics or theophylline and may lead to hypotension and low cardiac output.