THERAPIST MULTIPLE-CHOICE EXAMINATION: PRACTICE TEST

A peripheral lung mass is to be biopsied. Which of the following procedures should be recommended to obtain the tissue sample? A. Electromagnetic navigational bronchoscopy (ENB) B. Fiberoptic bronchoscopy C. Bronchoalveolar lavage (BAL) D. Rigid bronchoscopy

. A, ENB is diagnostic tool that combines conventional bronchoscopy with virtual bronchoscopy that allows bronchoscopic instruments to reach peripheral lung areas that traditional fiberoptic bronchscopes can't reach. (Analysis)

Which of the following ventilator parameters, when changed, will alter the inspiratory time during volume-controlled ventilation? A. Rate control B. Peak flow C. PEEP D. FiO2

. B, When flow is increased, inspiratory time decreases and vice versa. When VT is increased, inspiratory time increases and vice versa. Respiratory rate alters the expiratory time. The FIO2and PEEP do not affect inspiratory or expiratory time.

To minimize an increased airway resistance produced by high-density aerosol inhalation, the respiratory therapist should A. Use a bronchodilator in conjunction with the aerosol B. Instruct the patient to breathe through the nose C. Use a heated aerosol D. Perform chest physical therapy after the aerosol treatment

A) A bronchodilator should be administered with the aerosol to any patient who is susceptible to bronchospasm, such as patients with hyperactive airway disease (asthma).

Which value indicates that a patient is most likely ready to be weaned from mechanical ventilation? A. VD/VT of 50% B. MIP of 16 C. RSBI of 145 D. Spontaneous VT of 3 mL/kg

A, A VD/VT of less than 0.60 indicates weaning should be attempted. For weaning to be attempted, RSBI needs to be less than 105, MIP of at least -20 cm H2O and a spontaneous VT of at least 5-6 mL/kg

A patient has been paralyzed with vecuronium (Norcuron) and is receiving mechanical ventilation. Which of the following ventilator monitoring alarms would be the most important? A. Low pressure B. High pressure C. Inspired gas temperature D. I:E time

A, Because the patient will not be able to breathe on his or her own, it is essential that the therapist is aware of when the patient is disconnected. The low-pressure alarm is activated if this occurs.

A patient on a PEEP of 6 cmH2O has a PvO2 of 43 mm Hg. The respiratory therapist receives an order to increase the PEEP level to 9 cm H2O, and after doing so, the PvO2 drops to 34 mm Hg. The therapist should recommend which of the following at this time? A)Increase the PEEP to 12 cm H2O and get ABGs in 1 hour B)Increase the FiO2 C)Decrease the PEEP to 6 cm H2O D) Discontinue PEEP

C, A drop in the PVo2 after the increase in the PEEP level indicates the cardiac output dropped as a result of an excessive PEEP level. The PEEP needs to be returned to the PEEP level before the drop in cardiac output to improve the cardiac status

After setting up a simple O2 mask, you kink the O2tubing and the humidifier produces a high-pitched whistling sound. This indicates which of the following? A. There are no leaks in the setup B. The O2 flow to the mask is too low C. There may be a crack in the O2 tubing D. The capillary tube in the humidifier may be loose

. A, After an O2 delivery device is attached to the humidifier, the tubing should be kinked to check for leaks in the system. When the O2tubing is kinked, back pressure enters the humidifier. When the pressure builds to 2 psi, the pressure pop-off valve opens to release the built-up pressure. That is the whistling noise heard. This indicates the setup has no leaks. If, after kinking the tubing, the pop-off valve fails to open, there is a leak somewhere in the setup. The most common leak occurs when the humidifier bottle is not screwed on tight to the top. Other sources are small holes in the tubing or loose-fitting tubing on the humidifier outlet.

The following ABG results are obtained from a patient recently removed from a house with a gas leak from a faulty furnace receiving O2 with a non- rebreathing mask. pH 7.23 PaCO2 25 torr PaO2 250 torr HCO3 15mEq/L BE 10 SaO2 65% This patient's acidosis is most likely the result of A. Severe hypoxia B. Hyperventilation C. Hypocapnia D. Airway obstruction

. A, Severe hypoxia is indicated by the 65% SaO2. The PaO2, which indicates the amount of oxygen dissolved in the tissues, appears high, but for the tissues to receive an adequate level of oxygen, there must be more oxygen carried by hemoglobin. The acidosis occurs as a result of anaerobic metabolism, whereby the body produces lactic acid as a byproduct rather than carbon dioxide. The increased lactic acid production results in a drop in the blood pH

The respiratory therapist is called to the bedside of a patient who is receiving volume-controlled ventilation. Upon entering the room you notice the high-pressure limit is alarming with every breath and the low-volume alarm is activated. The nurse informs you that the patient had a pulmonary artery catheter inserted in the right subclavian vein 34 minutes prior. Upon assessment the therapist notes unilateral expansion and diminished breath sounds in the right upper lobe. There is no tracheal deviation present. Heart rate is 102/min, RR 20/min, and BP 120/64. What is the most appropriate recommendation at this time? A)CXR and possible chest tube insertion B)Emergency needle decompression C)Monitor the patient for improvement in condition for the next 30 minutes. D)STAT ABG

. A, This scenario suggests a pneumothorax has most likely occurred during the insertion of the subclavian line. Since the question states there is no tracheal deviation, which would indicate a tension pneumothorax corrected with needle decompression, getting a CXR and possible chest tube insertion is the best choice.

The physician writes an order for a patient to receive 15 L/min of an 80:20 helium/O2 mixture from a premixed Heliox cylinder via a nonrebreathing mask. For the patient to receive this flow through an O2 flowmeter, the flow must be set at approximately: A. 8 L/min B. 12 L/min C. 15 L/min D. 24 L/min

. A. An 80:20 mixture of Heliox diffuses through an O2flow meter 1.8 times faster than 100% O2. To determine the correct flow rate setting, divide the desired flow (15 L/min) by 1.8.

The data below pertain to an adult receiving mechanical ventilation: PIP 50 cm H2O Plateau pressure 40 cm H2O VT 600 mL PEEP 10 cm H2O On the basis of this information, this patient's static lung compliance is approximately which of the following? A. 16 mL/cm H2O B. 20 mL/cm H2O C. 27 mL/cm H2O D. 37 mL/cm H2O

. B Compliance = VT/plateau pressure - PEEP 600/30= 20 mL/cm H2O

All of the following are low-flow O2 devices EXCEPT the A. Nasal cannula B. Air-entrainment mask C. Partial rebreathing mask D. Simple O2 mask

. B, An air entrainment mask is considered a high-flow oxygen delivery device because it is capable of delivering flows that can meet or exceed the patient's inspiratory flow demands. Its ability to deliver high flows is the result of entrainment of large volumes of air, which mix with the oxygen flow to deliver fairly precise and consistent oxygen percentages

A patient with a peak inspiratory flow of 40 L/min is to be given O2 with a 30% air-entrainment mask. What is the minimum O2 flow required to meet the patient's inspiratory flow demands? A. 3 L/min B. 5 L/min C. 8 L/min D. 10 L/min

. B, The air/O2ratio for 30% is 8 : 1. Add the two ratio parts together and multiply by the lowest choice of the flow rates given that results in a total flow are at least 40 L/min.

While suctioning through a patient's 7.0 ET tube us- ing a 10-Fr catheter, the respiratory therapist begins having difficulty removing the thick secretions. Which of the following is the appropriate measure to take? A)Increase the suction pressure to 140 torr B)Switch to a 12-Fr catheter C)Apply continuous suction while withdrawing the catheter D)Instill saline down the ET tube before suctioning

. B; To determine the appropriate suction catheter size, multiple the ET tube size by 2 and use the catheter size just below that number. In this case, 7 × 2 = 14; 12 is the closest number just below 14.

an apnea-hypopnea index (AHI) of 22 indicates which of the following? A. Normal result B. Mild sleep apnea C. Moderate sleep apnea D. Severe sleep apnea

. C AHI interpretation a. < 5 normal b. 5-15 mild sleep apnea c. 15-30 moderate sleep apnea d. > 30 severe sleep apnea

A patient arrives in the emergency department. The respiratory therapist obtains an SpO2 reading of 98%. Blood for ABG analysis is drawn, and the SaO2 analyzed by CO-oximetry is 76%. Which of the following is the most likely reason for the discrepancy in the two saturation readings? A. The oximeter needs to be calibrated B.The CO-oximeter electrode is out of calibration C. There is an elevated HbCO level D. The pulse oximeter probe is loose

. C, A pulse oximeter does not read accurately when HbCO is present in the blood. The pulse oximeter cannot determine whether O2or CO is bound to Hb. The reading may be 100% when the actual oxygen saturation level is much lower. A pulse oximeter should never be used to determine the oxygenation status of a patient who has sustained smoke inhalation because it will give a false high reading.

Tracheal secretions tend to dry out in an intubated patient when inspired air has which of the following characteristics? A. A water vapor pressure of 47 mm Hg B. 50 mg of particulate water/L of gas C. An absolute humidity of 24 mg/L of gas D. 44 mg of particulate water/L of gas

. C, When air that is not fully saturated at body temperature is delivered to an intubated patient, a humidity deficit exists and secretions get thicker because of lack of inspired water. The inspired air must contain 44 mg H2O per liter of gas or exert a water vapor pressure of 47 mm Hg to be fully saturated at body temperature. (Analysis)

Which one of the following sets of ABG measure- ments would indicate compensated respiratory acidosis? A. pH 7.26, PCO2 60 torr, PO2 68 torr, HCO326 mEq/L, BE 0 B. pH 7.42, PCO2 39 torr, PO2 87 torr, HCO322 mEq/L, BE 1 C. pH 7.25, PCO2 61 torr, PO2 75 torr, HCO326 mEq/L, BE 1 D. pH 7.37, PCO2 58 torr, PO2 60 torr, HCO331 mEq/L, BE 8

. D, A blood gas level is considered compensated when both the PaCO2and HCO3−are abnormal and the pH level is normal. Respiratory acidosis is caused by an elevated PaCO2, which drops the pH to below normal levels. If the patient's lungs are not ventilated better to decrease the PaCO2, the HCO3−levels in the blood begin to increase (renal compensation), which increases the pH toward normal. When the pH reaches the normal range, it is called fully compensated. The most common example of this type of blood gas level is the patient with severe COPD who has chronic retention of CO2and remains in a constant state of compensation. (Application)

After a ventilator patient's PEEP level is increased from 8 cm H2O to 12 cm H2O, the PvO2 drops from 37 torr to 33 torr. This indicates which of the following? A. Venous return has increased B. Tissue oxygenation has increased C. Static CL has increased D. QT has decreased

. D, A drop in mixed venous PO2is indicative of a decreased QT. This drop in PvO2occurs because the tissues extract O2from the blood at the same rate, even though the blood is flowing slower past the tissues (decreased QT). Therefore, more O2is extracted and by the time the blood reaches the pulmonary artery, which is where PvO2is measured, there is less O2is in the blood.

A patient with bronchiectasis has been receiving postural drainage and percussion for 2 days. The patient's chest radiograph has not shown improve- ment, and he still is having difficulty expectorating sputum. Which of the following therapies may be of benefit in the treatment of this patient? A. Heliox therapy B. CPAP C. Nasotracheal suctioning every 2 hours D. HFCWO

. D, High frequency chest wall oscillation (HFCWO) is beneficial in removing difficult to mobilize secretions. The other choices would not be helpful in this situation

A 43-year-old male patient is brought to the ED with benzene exposure as a result of an industrial accident. Which of the following should the respiratory therapist suggest? A. Bronchoscopy B. Capnometry C. Administration of atropine D. Hemoximetry

. D, Inhalation of benzene results in methemoglobin as it combines with hemoglobin. This makes less oxygen being able to combine with hemoglobin and oxygenation decreases. Assessing hemoximetry (CO-oximetry) will help determine the severity of the condition.

Which of the following will decrease delivered VT during pressure-control ventilation? A. Increasing flow B. Increasing PIP C. Decreased airway resistance D. Decreased lung compliance

. D, With pressure-control ventilation, PIP remains constant. Therefore, if lung compliance decreases PIP is unable to increase to deliver the same tidal volume, so tidal volume will decrease. Changes in resistance and compliance will alter the delivered tidal volume

We determine the plateau or static pressure by holding the volume in the patient's lungs for? what is the formula for static compliance ?

1 to 2 s. This pressure closely relates to alveolar pressure. PEEP (if used) is subtracted from the plateau pressure and this number is divided into the VT. The results determine how compliant the lungs are.

The pressure limit alarm should be set at ?

10 to 15 cm H2O above the average peak inspiratory pressure.

The initial ventilator rate on the exam should be?

10/min to 16/min.

how far should The ET tube should be positioned to the main carina? That means the ET tube should be at the ______ to ________-cm mark at the teeth.

2 to 6 cm above the level of the carina. 21- to 25

what is COPD pt PaO2 normally ?

50- to 65-mm Hg range

The respiratory therapist is assessing the patient's spontaneous ventilatory variables. The PaCO2 is 50 torr, the PETCO2 is 30 torr, and the VT is600 mL. What is the patient's dead space volume? A. 150 mL B. 240 mL C. 360 mL D. 480 mL

50-30/50 = 0.40 600 * 0.40=240

what is normal PaO2 for infant ?

50-70 torr.

Exhaled air contains around ____ to _________ CO2. If the tube is in the airway, exhaled gas passing through the airway and on through the CO2 detector should read approximately ______%

6% to 7% 7

If the respiratory therapist chooses an E cylinder to transport a patient within the hospital and it contains 650 psig of O2, how long will the cylinder last if the flow is set at 10 L/min? A. 18 minutes B. 35 minutes C. 56 minutes D. 1 hour, 45 minutes

650 * 0.28/10 = 18min

B, B-type natriuetic peptide (BNP) is a biomarker used to help diagnose congestive heart failure. BNP is a cardiac neurohormone that is secreted in response to increased ventricular blood volume and pressure caused by heart failure. A level ___________ pg/mL indicates CHF

> 500

what is the PaO2 must be to avoid Retinopathy of prematurity (ROP)?

>80 mm Hg it is the high PaO2 that leads to blinding not the FIO2 .

A premature 3-week-old infant is receiving 1 L/min of O via a nasal cannula and has a PaO of 43 torr22 and a PaCO2 of 40 torr. The respiratory therapist should recommend which of the following? A. Increase the cannula flow to 2 L/min. B. Intubate and institute mechanical ventilation C. Initiate CPAP of 4 cm H2O and 50% O2 D. Increase the cannula flow to 5 L/min.

A, A PaO2 of 43 torr represents hypoxemia. The normal PaO2 for an infant is 50-70 torr. Increasing the cannula flow by 1 L/min is the most appropriate choice to return the PaO2 to normal. With a normal PaCO2 of 40 torr, mechanical ventilation is not indicated. (Analysis)

The following ABG result is obtained from a patient breathing room air: pH 7.38 PaCO2 64 PaO2 55 HCO3 36 These values are consistent with which of the following conditions? A. Chronic respiratory acidosis B. Chronic metabolic alkalosis C. Acute respiratory acidosis D. Acute metabolic alkalosis

A, A blood gas level is considered compensated when both the PaCO2and HCO3−are abnormal and the pH level is normal. Respiratory acidosis is caused by an elevated PaCO2, which drops the pH to below normal levels. If the patient's lungs are not ventilated better to decrease the PaCO2, the HCO3−levels in the blood begin to increase (renal compensation), which increases the pH toward normal. When the pH reaches the normal range, it is called fully compensated. The most common example of this type of blood gas level is the patient with severe COPD who has chronic retention of CO2and remains in a constant state of compensation.

During CPR, the physician is preparing to administer lidocaine intravenously and discovers that the IV is infiltrated. The most appropriate action to take at this time is to A. Instill the lidocaine down the ET tube B. Administer the lidocaine using a handheld nebulizer C. Place a new IV line and administer the lidocaine D. Administer the lidocaine sublingually

A, Although lidocaine is normally given intravenously to counteract arrhythmias during CPR, it is permissible to instill it directly down the ET tube.

The physician has ordered O2 to be administered to an active 3-year-old with an SpO2 of 86%. Which of the following delivery devices would you recommend for this patient? A. 1- to 2-L nasal cannula B. Air-entrainment mask C. Simple O2 mask D.O2 hood

A, An active 3-year-old generally tolerates a cannula much better than any kind of mask and is too large for an O2hood. (Application)

The respiratory therapist is using a 12-Fr suction catheter to suction a female patient who is intubated with a 6.5-mm ET tube and is having difficulty re- moving the thick secretions. The suction pressure used is 120 mm Hg. Which of the following should be recommended? A. Increase the suction pressure to 140 mm Hg. B. Instill 5 mL of normal saline down the ET tube. C. Change to a 14-Fr suction catheter .D. Change to a coude-tipped suction catheter.

A, An appropriate suction pressure level on an adult should be less than -150 torr. Therefore, increasing the pressure to -140 torr is acceptable to better enhance the removal of the secretions. Normal saline should not be instilled down the ET tube since it doesn't help thin lower airway secretions and it increases the risk of ventilator-associated pneumonia by washing bacteria in the ET tube down into the lower airway

If a patient's PaCO2 decreases to 27 torr, all of the following could have increased EXCEPT A. Physiologic dead space B. Alveolar ventilation C. Respiratory rate D. VT

A, Be sure to read these questions carefully. This question is asking for "all of the following EXCEPT." When physiologic dead space increases, it indicates less air is getting to the normally functioning alveoli for gas exchange, while more is occupying the anatomic dead space. This would result in increased, not decreased, PaCO2levels.

A patient's PaO2 increases after mechanical ventila- tion is initiated at 21% O2. What accounts for the improved oxygenation status? 1. Increased distribution of ventilation 2. Increased VD/VT ratio 3. Decreased venous return to the heart 4. Increased P(A-a)O2 gradient A. 1 only B. 1 and 4 only C. 1, 2, and 3 only D. 1, 3, and 4 only

A, Even with room air, positive pressure to the lungs will increase PaO2 as a result of increased distribution of ventilation. Positive pressure ventilation will increase the diameter of the alveoli, which will provide a larger surface area for the diffusion of gases at the alveolar-capillary membrane. This will decrease P(A-a)O2 and VD/VT.

During ventilator checks 6 hours later, you notice the PIP has been gradually increasing. What could be the cause of this occurrence? A. Bronchospasm B. Decreasing plateau pressure C. Decreasing airway resistance D. Increasing CL

A, Increasing plateau pressures with volume-controlled ventilation indicate decreasing lung compliance (stiffer lungs). Increasing airway resistance is indicated when PIP increases but plateau remains unchanged. Increased airway resistance results as the gas meets a resistance to flow caused by H2O in the tubing circuit, secretions in the airway, bronchospasm, or coughing

Failure to hyperoxygenate a patient on a ventilator before ET suctioning may result in A. Hypoxemia B. Hypocapnia C. Bradycardia D. Hypertension

A, It is important during ET suctioning that the PaO2 be maintained within a normal range. This requires increasing the oxygen percentage during the procedure. Failure to hyperoxygenate may cause hypoxemia, resulting in cardiac arrhythmias. Bradycardia may occur as a result of vagal stimulation. (Application)

A diabetic patient enters the emergency department breathing deeply at a respiratory rate of 32/min. This type of breathing pattern is referred to as A. Kussmaul respiration B. Biot respiration C. Cheyne-Stokes respiration D. Hypopnea

A, Kussmaul respirations are a deep and rapid breathing pattern encountered in patients with severe metabolic acidemia (low pH, low HCO3−). The lungs are making an effort to increase the pH back toward normal by removing CO2 from the blood, which results in an increased pH.

It is important to monitor plateau pressure in a patient receiving mechanical ventilation because it best reflects A. Lung compliance B. PaO2 C. PaCO2 D. ICP

A, Lung compliance is determined by dividing the VT by the plateau pressure.

Which of the following values will best indicate airway inflammation in asthmatics? A. FENO B. PCO2 C. PO2D. HbCO

A, Measuring fractional concentration of exhaled nitric oxide (FENO) can be helpful in determining airway inflammation. Normal FENO levels in adults is less than 25 parts per billion (ppb) and less than 20 ppb in children. FENO levels begin to rise with airway inflammation. Levels of greater than 50 ppb may indicate the patient needs to increase their normal medication. The FENO level is commonly increased as a result of the patient's noncompliance with their corticosteroid use.

After the intubation of a patient, the respiratory therapist is assessing the chest x-ray for proper tube placement. The tip of the tube is at the level of the fourth rib. This indicates which of the following? A. The tube position is too low B. The tube is too high C. Radiograph indicates esophageal intubation D. Proper tube position is indicated

A, On an inspiratory chest film, the carina is located at the level of the fourth rib and the fourth thoracic vertebra. The ET-tube tip should rest about 2 to 5 cm above this level.

A patient receiving volume-controlled ventilation is ordered to have PEEP initiated. Observation of which of the following values will best determine the optimal level of PEEP? A. Cardiac output B. PaO2 C. PaCO2 D. VD/VT

A, Optimal PEEP is the level of PEEP that improves lung compliance without decreasing the cardiac output. When a PEEP study is done, the cardiac output is measured at different PEEP levels. When the cardiac output drops after an increase in PEEP, the PEEP should be decreased to the previous level. In other words, use the PEEP level that renders the best cardiac output. Or, if measuring the static lung compliance at various PEEP levels, use the level that produces the best lung compliance.

A 70-kg (154-lb) male patient is receiving mechanical ventilation. The respiratory therapist notes the patient's SpO2 drops from 97% to 86%. The right lung is expanding more than the left, with clear breath sounds on the right but absent breath sounds on the left. The patient's ET tube is taped at the 29-cm mark at the lip. Which of the following should the respiratory therapist do at this time? A. Withdraw the tube to the 24-cm mark B. Recommend an immediate chest x-ray C. Advance the ET tube 2 cm D. Obtain immediate ABG levels

A, The ET tube should be positioned 2 to 6 cm above the level of the carina. That means the ET tube should be at the 21- to 25-cm mark at the teeth. In this question, the tube is at the 29-cm mark and the patient has decreased breath sounds in the left lung, which indicates the tube is in the right mainstem bronchus and must be withdrawn.

A patient receiving O2 via concentrator at 2 L/min at home complains he can't feel O2 coming out the prongs of the cannula. Which of the following should the respiratory therapist do first? A. Place the cannula under water and see if bubbling occurs B. Attach the cannula to a cylinder/flowmeter setup C. Increase the flow to 5 L/min D. Replace the concentrator with a new one

A, The first step is to check to make sure there is flow passing through the cannula by having the patient remove the cannula and place it in a cup of water. Bubbling will occur if there is flow. If no bubbling occurs, the patient should make sure the cannula is attached to the flowmeter outlet and the flowmeter is turned on. If there's any doubt, the patient should connect the cannula to the cylinder back-up and call the home care company

Heavy smokers can have HbCO levels as high as A. 10% B. 20% C. 30% D. 40%

A, The level of HbCO in heavy smokers may be as high as 10%-12%. Normal value is < 1%.

After a cardiac arrest, a 48-year-old female begins receiving mechanical ventilation. A pulmonary artery catheter is in place. The following data are obtained: BP 94/52 pulse 116 PCWP 6 PAP 40/20 QT 3.5 Based on these data, which of the following has increased? A. Pulmonary vascular resistance B. Left atrial pressure C. Stroke volume D. Systemic vascular resistance

A, The patient is hypotensive, which is indicated by a decreased SVR. PCWP, a measure of left atrial pressure, is normal; therefore, left atrial pressure cannot be increased. Because QT is decreased, SV would also be decreased. The PAP is elevated, which indicates an increased resistance to blood flow in the pulmonary vasculature

The following day, the patient begins a spontaneous breathing trial. During the trial, the patient's respiratory rate increases to 30/min and her blood pressure begins to drop. What is the appropriate measure to take at this time? A. Initiate SIMV at a rate of 12/min B. Obtain an immediate chest film C. Initiate CPAP D. Institute control mode at a rate of 10/min

A, The patient was not ready for T-tube weaning and should have SIMV initiated to allow for spontaneous breathing along with ventilator breaths. A postoperative patient such as this one should not be receiving mechanical ventilation for long unless unforeseen problems arise; therefore SIMV is indicated

The respiratory therapist is having difficulty calibrating a transcutaneous O2 monitor. This is most likely because of which of the following? A)The membrane is damaged B)The sensor will not stick to the infant's skin properly

A, The transcutaneous O2monitor is calibrated to room air while off the infant. Therefore, the cause could not be related to the infant's hemodynamic status. The problem must be with the monitor itself.

A 6 ft 5 in. male patient is intubated with an 8.0-mm ET tube that is taped at the lip at the 20-cm mark. The respiratory therapist hears a gurgling sound during inspiration and observes that the pa- tient's exhaled tidal volume is 250 mL less than the inhaled tidal volume. The therapist increases the cuff pressure from 18 cm H2O to 27 cm H2O with no change in the sound or exhaled volume. The therapist should A)advance the tube to the 24-cm mark on the tube. B)increase the cuff pressure to 35 cm H2O. C)change to a 9.0-mm ET tube. D)deflate the cuff and suction the ET tube.

A, The tube taped at the 20 cm mark is too high for this patient. This results in a leak and the tube must be advanced. It should rest at the 21-25 cm mark for males

A 34-year-old female patient enters the emergency department complaining of severe chest pain. The patient is placed on a 50% air-entrainment mask. Thirty minutes later, ABGs are drawn and the results are as follows: pH 7.50 PaCO2 31 torr PaO2 253 torr HCO3 24mEq/LBE1 Which of the following is a true statement regarding these ABG results? A)The results appear to be accurate and consistent with the FiO2 B)The PaO2 is not possible on this FiO2 C)The PaCO2 is not consistent with the pH D)The results represent a metabolic alkalosis

A, To approximate the normal PaO2on a given O2percentage, multiply the Percentage times 5. This patient is using 50% O2, so 50 × 5 = 250; therefore, the PaO2of 253 mm Hg is consistent with the FiO2that the patient is receiving.

A patient recovering postoperatively is receiving ventilation in the SIMV mode. The patient has normal ABG levels with the use of 35% O2 but is still drowsy. The respiratory therapist should recommend decreasing the A. SIMV rate B. Inspiratory time C. VT D. Flow rate

A, To facilitate weaning this postoperative patient from the ventilator, the SIMV rate should be reduced. This will stimulate the patient to begin breathing more on his or her own.

The most reliable method of determining whether the lungs of a patient receiving mechanical ventila- tion are getting stiffer and harder to ventilate is by measuring the A. Static lung compliance B. Dynamic lung compliance C. Spontaneous VT D. PaO2

A, When lungs get stiffer and harder to ventilate, greater pressure is required to move the same volume of air. Because peak inspiratory pressure increases when RAW increases (e.g., when airway secretions are present or water is in the ventilator tubing), this pressure does not reflect how stiff the lungs actually are. We determine the plateau or static pressure by holding the volume in the patient's lungs for 1 to 2 s. This pressure closely relates to alveolar pressure. PEEP (if used) is subtracted from the plateau pressure and this number is divided into the VT. The results determine how compliant the lungs are. (Application)

The respiratory therapist is assisting the physician in the insertion of a pulmonary artery catheter. The patient is hemodynamically stable at the time. The therapist would know the catheter tip has entered the pulmonary artery when which of the following pressures is observed? A.12/4mmHg B. 24/10 mm Hg C. 40/0 mm Hg D. 110/75 mm Hg

B, 24/10 mm Hg is a normal value for PAP; therefore, when this value is observed during the insertion of a pulmonary artery catheter, you would know it was in the pulmonary artery.

A tall, thin, otherwise healthy 24-year-old man enters the emergency department complaining of chest pain with mild respiratory distress. A chest radiograph reveals a spontaneous pneumothorax of approximately 10%. Which of the following should the respiratory therapist recommend? A. Needle decompression B. O2 therapy C. Chest tube insertion D. NPPV

B, A 10% pneumothorax is relatively small. A chest tube is not indicated; a needle aspiration is indicated only when a tension pneumothorax is present, which is not the case here on the basis of the patient's respiratory status. O2therapy is indicated because the patient is in mild respiratory distress, and O2will help absorb the air in the pleural space. Pulse oximetry should be employed to continuously monitor the SpO2level and help determine the patient's oxygenation status.

The following data are obtained from a 32-year-old patient with pneumonia in the ICU on a 60% aerosol mask: RR 28 , pulse 108 PH 7.47 PaCO2 32 PaO2 55 Which of the following would you recommend at this time? A. Intubate and institute mechanical ventilation B. Initiate CPAP C. Increase to 80% aerosol mask D. Change to a nonrebreathing mask at 15 L/min

B, A PaO2of 55 mm Hg on 60% oxygen indicates refractory hypoxemia. Increasing the FIO2most likely won't improve the PaO2. Applying CPAP to help recruit alveoli and allow for more surface area for oxygen to be able to enter the blood is more appropriate

ET tube cuff pressure should be maintained at which of the following levels? A. 5-10 cm H2O B. 20-30 cm H2O C. 35-45 cm H2O D. 40-50 cm H2O

B, A cuff exerting a pressure of more than 30 cm H2O will increase the potential of obstructing blood flow to the tracheal wall resulting in damage to the mucosa. Cuff pressures should be kept between 20-30 cm H2O to avoid tracheal damage. (Recall)

While performing chest physical therapy on a ventilator patient, the respiratory therapist percusses an area of hyperresonance. This assessment is consistent with which of the following conditions? A. Pleural effusion B. Pneumothorax C. Atelectasis D. Consolidation

B, A hyperresonant percussion note is heard over areas of the lung that contain a higher proportion of air than tissue. When a pneumothorax is present, air enters and collects in the pleural space away from normal blood flow or tissue. Another instance in which a hyperresonant note is heard is over a hyperinflated chest, such as with emphysema.

To begin the weaning process from the ventilator, a patient should be able to obtain an MIP of at least A. -10 cm H2O B. -20 cm H2O C. -30 cm H2O D. -40 cm H2O

B, Although a normal MIP level is -50 to -100 cm H2O, an MIP of at least -20 cm H2O is an indication that the patient can take deep enough breaths to produce an adequate cough and maintain secretion clearance. MIP is also referred to as negative inspiratory force (NIF).

A 36-year-old, 65-kg (143-lb) unconscious male is admitted to the emergency department. His respira- tory rate is 8/min and very shallow. A drug overdose is suspected. 132. To maintain a patent airway, what type of device should be employed? A. King tube B. Oropharyngeal airway C. Nasopharyngeal airway D. Esophageal tracheal combitube

B, An oropharyngeal airway is indicated for unconscious patients to prevent the tongue from falling back against the back of the throat and obstructing the airway.

The respiratory therapist is reviewing a patient's chart that shows the following arterial blood gas results on a 40% air-entrainment mask: pH 7.41 PaCO2 42 torr PaO2 275 torr HCO3 23 mEq/L BE 1 mEq/L What is the most appropriate recommendation? A. Decrease oxygen to 30%. B. Repeat the blood gas due to lab error. C. Discontinue oxygen. D. Decrease flow to the mask.

B, As a general rule of thumb, the PaO2 can be no higher than approximately 5 times the oxygen level being breathed. So on 40% oxygen, the highest the PaO2 could be is approximately 200 torr. Therefore, this PaO2 is not possible and a lab error exists.

Which of the following is assessed to help diagnose CHF? A. CPK B. BNP C. WBC D. Troponin

B, B-type natriuetic peptide (BNP) is a biomarker used to help diagnose congestive heart failure. BNP is a cardiac neurohormone that is secreted in response to increased ventricular blood volume and pressure caused by heart failure. A level > 500 pg/mL indicates CHF.

While assessing a patient with chest trauma in the ICU, the respiratory therapist observes that the patient's chest tube, which is connected to an underwater seal drainage system, is outside the chest wall. Which of the following statements are correct about this situation? A. The tube should be clamped immediately B. A complete pneumothorax is possible C. The tube should be disconnected from suction D. Suction pressure should be increased

B, Because the chest tube is no longer in the pleural space, air in the space cannot be removed. Therefore, a pneumothorax is most likely present.

The patient becomes apneic, and mechanical ventilatory support is required. How would the airway best be maintained at this time? A. CPAP mask B. Cuffed ET tube C. Uncuffed ET tube D. Fenestrated tracheostomy tube

B, Cuffed ET tube should be used to help prevent aspiration and prevent volume leaks around the tube.

A patient has just been intubated, and the CO2 detector on the proximal end of the ET tube reads near-zero. Which of the following is true? A. The tube is in the trachea B. The tube is in the esophagus C. The tube should be withdrawn 2 cm D. The tube is in the right mainstem bronchus

B, Exhaled air contains around 6% to 7% CO2. If the tube is in the airway, exhaled gas passing through the airway and on through the CO2detector should read approximately 7%. If it reads near zero, it must be in the esophagus because no air is flowing through this area. The CO2 detector does not indicate where in the airway the tube is located, only that it is in the airway. There is one exception: In a full cardiac arrest in which blood pressure is very low, gas exchange is extremely compromised; therefore, there may be little CO2 in the exhaled air. Even if the tube is in the airway, the detector would not indicate that it is.

Administration of high O concentrations to a neonate2 for a prolonged period of time may result in which of the following? A)Pneumothorax B)Retinopathy of prematurity (ROP) C)Persistent pulmonary hypertension of the new- born (PPHN) D)Tetralogy of Fallot

B, If the high O2 concentration results in high PaO2 levels (>80 mm Hg), retinal detachment may occur, leading to blindness in the premature neonate. Remember, it is the high PaO2 that causes the damage, not the FIO2. In other words, a neonate using 100% oxygen with a PaO2 of 60 mm Hg will most likely not develop retinopathy of prematurity because the PaO2 is below 80 mm Hg. High FIO2 levels, on the other hand, will lead to atelectasis because of nitrogen washout of the lung and the suppression of surfactant production by the alveolar type 2 cells.

The ability of the patient to follow instructions would be indicated by which of the following? A. Orientation to person B. Performance of tasks when asked C. Ability to feed himself D. Awareness of time

B, If the patient is able to perform simple tasks when asked, this best determines his or her ability to follow instructions. This is important before administering an incentive spirometry or IPPB treatment, which requires the patient to be able to follow instructions well or the treatment will not be effective. (Recall)

The physician has ordered instruction on the use of a dry powder inhaler (DPI). You would emphasize to the patient that A. the DPI must be used with a spacer. B. the DPI is dependent on inspiratory flow. C. inhalation should be done as slowly as possible. D. exhalation should be made back into DPI device.

B, In order for optimal deposition of powdered medication delivery to occur, the patient must have an inspiratory flow of at least 50 L/min

The following ABG levels are collected from a patient on a 50% air-entrainment mask: pH 7.37 PaCO2 40 torr PaO2 70 torr If the barometric pressure is 747 torr, which of the following represents this patient's P(A-a) O2? A.170torr B. 230 torr C. 300 torr D. 350 torr

B, P(A-a)O2, or the A-a gradient, is the difference between alveolar PO2(PAO2) and arterial PO2(PaO2). PAO2= (PB- 47 mm Hg) × FIO2- (PaCO2+ 10) Short cut equation: (7 x O2%) - (PaCO2 + 10) Note: 47 mm Hg represents water vapor pressure. PAO2= (7 x 50) - (40 + 10) = 7 x 50 = 350 - 50 = 300 mm Hg PAO2 - PaO2= 300 - 70 = 230 mm Hg

The reduction in urinary output caused by mechanical ventilation may be the result of A. Increased renal blood flow B. Increased production of ADH C. Decreased CVP D. Decreased airway resistance

B, Positive pressure ventilation has the potential for decreasing venous blood return to the heart. This results from this pressure being transferred to the superior and inferior vena cavae, which restricts blood flow back into the heart. Baroreceptors (pressure receptors) sense this lower pressure in the right atrium and send signals to the brain, which causes an increased production of ADH by the pituitary gland. This causes the body to hold on to more fluid as a compensatory mechanism because the right side of the heart is sensing a low pressure. The decreased cardiac output results in decreased perfusion to the kidneys, which can also reduce urine output.

A patient with ARDS is receiving volume-controlled ventilation with a PEEP of 15 cm H2O and an FiO2 of 1.0 but remains hypoxemic. The PIP is 53 cm H2O. Which of the following ventilator modifications is the most appropriate recommendation at this time? A. Increase the PEEP to 20 cm H2O B. Initiate pressure control ventilation C. Increase the PEEP to 25 cm H2O D. Begin in-line bronchodilator therapy using an MDI

B, Pressure control ventilation is a useful mode for patients with noncompliant (stiff) lungs, such as those seen in patients with ARDS. Volume ventilation for ARDS patients leads to high peak pressures and an increased potential of barotrauma by overdistention of the alveoli. Using inspiratory pressures that deliver lower VT (4 to 6 mL/kg) and maintaining plateau pressures at 30 cm H2O or less will reduce the risk of overdistention of alveoli.

A 60-kg (132-lb) 52-year-old man is admitted to the ICU for the treatment of refractory hypoxemia. He is currently on VC-SIMV and pressure support of 10 cm H2O with an FiO2 of 0.60. Other pertinent data are below: pH 7.49 PaCO2 30 torr PaO2 59 torr Heart rate 120min Respiratory rate 12 Spontaneous VT 400 ml Ventilator VT 500 mL PEEP 5 cm H2O Total respiratory rate 22/min Which of the following should the respiratory therapist recommend at this time? A. Increase the pressure support level to 15 cm H2O B. Increase PEEP to 8 cm H2O C. Increase the FiO2 to 0.70 D. Decrease VT to 400 mL

B, Refractory hypoxemia typically results from atelectasis, pneumonia, or pulmonary edema, whereby increasing oxygen levels do not correct the hypoxemia. Although the patient is hyperventilating, VT should not be decreased. The hyperventilation is a result of the low PaO2, therefore it should be increasing the PaO2 first is necessary. We should not exceed 60% oxygen to try to correct hypoxemia, so increasing the PEEP level is most appropriate. (Analysis)

The respiratory therapist is instructing a patient about the proper procedure for using an MDI. The patient should be told to activate the medication in the inhaler A. Just before inspiration B. Just after inspiration has begun C. At the end of exhalation D. After inhaling as deeply as possible

B, Studies show that a better distribution of the aerosol will be delivered if the MDI is activated shortly after the patient has begun the deep breath

Which one of these drugs would be best to use to temporarily paralyze a patient to facilitate tracheal intubation? A. Atropine sulfate B. Succinylcholine (Anectine) C. Midazolam (Versed) D. Pancuronium bromide (Pavulon)

B, Succinylcholine is a fast-acting, short-term muscle relaxant used to aid in the intubation of combative patients. The patient will be paralyzed for only about 5 min.

Which of the following can be determined from a forced expiratory spirogram? A. FRC B. FEV1 C. DLCO D. RV

B, The FVC maneuver is used to obtain FEV1, FEF200-1200, and FEF25%-75%.

The physician orders a 35% aerosol mask to be set up for a patient who requires an inspiratory flow of 42 L/min. What is the minimum flow rate to which the flowmeter must be set to meet this patient's in- spiratory flow demands? A. 6 L/min B. 8 L/min C. 10 L/min D. 12 L/min

B, The air/O2ratio for a 35% oxygen mixture is 5 : 1. To calculate total flow output from this device, add the ratio parts together and multiply by the liter flow: 6 ×6 = 36 L/min, 6 ×8 = 48 L/min, 6 × 10 = 60 L/min, 6 ×12 = 72 L/min. Total flow needed: 42 L/min. The minimum flow necessary is 8, giving a total flow of 48 L/min. (Analysis)

You suspect a patient may have a pulmonary embolism. Which of the following would be the most appropriate recommendation for diagnosis of this condition? A. Bronchoscopy B. V/Q lung scan C. Coagulation studies D. Shunt study

B, The best diagnostic test to determine whether a pulmonary embolism is present is the V/Q lung scan. (Application)

A 75-kg (165-lb) male patient is receiving mechanical ventilation in the SIMV mode and has the following ABGs: pH 7.29 PaCO2 59 torr PaO2 75 torr HCO3 27 mEq/L BE 2 The ventilator settings are as follows: FIO2 0.35 SIMV rate 8 Spontaneous rate 24 Vt 500 The ventilator settings are as follows: Which of the following could be increased to correct this acid-base abnormality? A. Inspiratory flow B. VT C. FiO2 D. PEEP

B, The blood gases indicate hypercapnia (increased PaCO2), and this condition can be corrected by increasing the patient's minute ventilation. This is done by increasing the respiratory rate or volume. Notice also the patient's VT in relation to weight. Remember to use 6-8 mL/kg of ideal body weight for the VT setting.

A patient is receiving volume-controlled ventilation in assist-control mode. The low-pressure alarm is sounding. Which of the following may be the cause of the alarm activation? A. Water in the tubing B. Patient disconnected from the ventilator C. Secretions in the patient's airway D. Kink in the ventilator tubing

B, The low-pressure alarm on volume-controlled ventilation will be activated if the patient becomes disconnected from the circuit or if leaks are present in the system. Choices A, C, and D could result in the high-pressure alarm being activated as a result of increased airway resistance.

A patient with severe COPD is on a 28% air-entrain- ment mask and has a PaO2 of 61 torr. Which of the following should the respiratory therapist recom- mend at this time? A. Initiate CPAP B. No changes are required at this time C. Increase O2 to 40% D. Place the patient on a nonrebreathing mask

B, The normal PaO2for a patient with severe COPD is 50 to 65 mm Hg. This ABG level indicates normal oxygenation for this patient; therefore, no change in therapy is necessary

Which of the following represents the normal value for potassium? A. 1.5 to 3.0 mEq/L B. 3.5 to 5.0 mEq/L C. 5.5 to 7.0 mEq/L D. 7.0 to 8.5 mEq/L

B, The normal value for potassium is 3.5-5.0 mEq/L

While delivering a bronchodilating agent to a patient using a small-volume nebulizer, the respiratory therapist notes the pulse increases from 72/min to 90/min over the first 5 minutes of therapy. Which of the following is the most appropriate action to take? A)Stop the treatment immediately and notify the physician B)Continue the treatment as ordered C)Increase the flowrate for the remainder of the treatment D)Give the remainder of the treatment with saline only

B, The pulse rate increased only 16 beats/min. If the pulse increased 20/min or more, the treatment should be stopped and the physician notified

A 28-year-old male with pneumonia is placed on a 50% aerosol mask. Arterial blood gases reveal a PaO2 of 62 torr and a PaCO2 of 44 torr. His blood pressure is 74/50. The respiratory therapist should recommend which of the following? A. Place the patient on CPAP. B. Increase the O2 to 60%. C. Place the patient on a nasal cannula at 2 L/min. D. Place the patient on a nonrebreathing mask.

B, There are two choices to correct the hypoxemia in this question, increase the FiO2 or place the patient on CPAP. CPAP, while often indicated to increase PaO2 when a patient is receiving 50%-60% oxygen, is not indicated in this scenario because of the patient's hypotension. Placing the patient on CPAP may reduce the BP even more. Therefore, increasing the FiO2 is more appropriate.

A COPD patient is being weaned from mechanical ventilation using SIMV. Which of the following arte- rial blood gas results indicates the SIMV rate should be decreased? A. pH 7.34 , PaO2 45 torr PaCO2 60 B. pH 7.47 , PaCO2 60 PaO2 64 C. pH 7.51 , PaCO2 58 PaO2 42 D. pH 7.29 PaCO2 65 PaO2 85

B, This ABG indicates an alkalotic pH resulting from a lower than normal PaCO2 for this COPD patient. In other words, the patient is hyperventilating, but not because of hypoxemia observed in choice C. This patient is "over-ventilating" on the ventilator indicating the SIMV rate should be decreased.

you are asked to deliver a low percentage of O2 to a patient whose respiratory rate is 30/min with an irregular breathing pattern. Which device would be the best choice? A. Nasal cannula at 2 L/min B. Air-entrainment mask at 28% C. Simple O2 mask at 5 L/min D. Partial rebreathing mask at 8 L/min

B, This question appears to not give adequate information to answer the question. However, the idea is that a low-flow O2device should not be set up for a patient who has an irregular breathing pattern or a respiratory rate of more than 25/min because of inconsistent O2concentrations. A high-flow device (air-entrainment mask) is indicated in this situation because more consistent O2concentrations are delivered, regardless of the patient's ventilatory pattern.

A patient arrives in the emergency department after being pulled from a burning house. The respiratory therapist should recommend obtaining which of the following measurements to best determine the sever- ity of the patient's smoke inhalation? A. SpO2 B. HbCO C. PaO2 D. Hb

B, To best determine the severity of smoke inhalation, an HbCO level should be determined with a co-oximeter. The SpO2 value should never be evaluated on a patient suspected of CO poisoning because a pulse oximeter is not capable of determining what is bound to hemoglobin. Pulse oximeters work on the principle of spectrophotometry where lightweight probes direct filtered light of specific wavelengths through the skin or digit. The light absorbed differs for saturated and desaturated blood, whether it's saturated with oxygen or a combination of oxygen and carbon monoxide. Therefore the reading will be erroneously high when HbCO is present. (Analysis)

What is the most appropriate ventilator VT setting on a 75-kg (165-lb) drug overdose patient? A. 400 mL B. 500 mL C. 700 mL D. 900 mL

B, Ventilator VT should be set at 6 to 8 mL/kg of ideal body weight. The most appropriate volume would be 500 mL.

The respiratory therapist has received an order for postural drainage and percussion for a 34-year-old patient whose chest x-ray film indicates atelectasis of the posterior basal segment of the right lower lobe. The patient should be placed in which of the follow- ing positions to help drain this segment? A. Lying on left side with bed flat B. Prone, with head of bed down C. Lying on left side with head of bed down D. Supine, with head of bed down

B, While you may be tempted to pick C in this question, that position will not drain the posterior segment of the lower lobe. Posterior segments drain anteriorly; therefore the patient must be placed on his or her stomach (prone) and in the Trendelenberg (head down) position to drain the lower lobe. (

The following data have been collected on a patient receiving continuous mechanical ventilation: 1:00pm 3:00pm Delivered VT 600 600 Peak airway pressure 44 52 Static airway pressure 25 33 Inspiratory flow 40 40 PEEP 5 5 Which of the following is the best interpretation of these data? A)The peak airway pressure increased as a result of increased airway resistance. B)The peak airway pressure increased as a result of decreased lung compliance. C)The patient's lung compliance is improving. D)The patient's dynamic compliance is increasing.

B. Notice that while peak inspiratory pressure increased, the static airway pressure increased as well. Static pressure closely resembles alveolar pressure. An increasing static pressure is a sign that it is taking more pressure to ventilate the lung; therefore, lung compliance is decreasing. In this question, if the PIP would have increased with no increase in the static pressure, then choice A would have been the correct answer. When airway resistance increases because of airway secretions, water in the ventilator tubing, or bronchospasm, PIP increases, but static pressure remains unchanged.

To most effectively increase a sedated, paralyzed patient's alveolar minute ventilation while the patient is on volume-controlled ventilation in the assist-control mode, you would recommend increasing which of the following? A. PEEP B. Inspiratory flow C. VT D. Ventilator rate

C Alveolar minute ventilation = (VT - VD) × respiratory rate It represents the volume actually reaching the alveoli per minute. It takes into account anatomic dead space (VD), which is approximately 1 mL/lb of body weight. Anatomic VD is that portion of the airway where no gas exchange occurs. If a patient's alveolar minute ventilation is to be increased, the VT must be increased. If only the ventilator rate is increased, the same VT is delivered, even though the minute ventilation (VT × RR) increases. (Recall)

The respiratory therapist is setting up a portable liquid O2 system for a patient with COPD. The patient ison a 2-L/min nasal cannula, and the portable O2container holds 4 lb of O2. The therapist should explain to the patient that the O2 supply will last for approximately what length of time? A. 4.5 hours B. 8 hours C. 11.5 hours D. 14 hours

C, 4*860/2.5 = 3440/2.5 =1376L 1376 /2 = 688/60= 11.5

A patient with COPD on a 50% air-entrainment mask becomes drowsy and unresponsive. The patient's reaction most likely is the result of A. Insufficient oxygenation B. Decreased venous return C. Increased PaCO2 D. Excessive ventilation

C, A patient with severe COPD who has chronic retention of CO2and chronic hypoxemia breathes on a different drive than other patients. When any person's PaO2drops below 60 to 65 mm Hg, peripheral chemoreceptors located in the carotid arteries and aortic arch sense this low PaO2and trigger responses that increase the heart rate and respiratory rate to improve oxygenation. Once O2 is administered and PaO2levels increase above 65 mm Hg, these receptors stop triggering and the patient returns to his or her normal central respiratory centered breathing stimulus. However, in a patient with COPD and constant hypoxemia, with PaO2levels below 65 mm Hg, the primary breathing stimulus is from the peripheral chemoreceptors. If oxygen is given and results in a PaO2above 65 mm Hg, the potential of reducing drive increases. The patient's respiratory rate or VT will begin to diminish, which would result in a decreased and lead to increased PaCO2 levels. As CO2increases, it causes a narcotic effect, known as "CO2narcosis," causing the patient to become drowsy. This is best treated by simply decreasing the delivered O2concentration. Some studies are questioning the validity of the "hypoxic drive" phenomenon, but you should still understand its characteristics for this examination. (Application)

While performing postural drainage and percussion, the respiratory therapist palpates subcutaneous emphy- sema in the patient. The therapist should postpone the therapy and recommend which of the following? A. Measure ABG levels B. Initiate IPPB therapy C. Obtain a chest radiograph D. Perform bedside spirometry

C, Air leaking from the lung often finds its way into the subcutaneous tissues. It is common after a tracheotomy is done to observe subcutaneous emphysema in the neck area. Observing subcutaneous emphysema indicates a pulmonary air leak, and a pneumothorax should be suspected. A chest film should be ordered for confirmation while the therapist assesses the patient for asymmetrical chest movement, tracheal deviation, diminished breath sounds, tachycardia, tachypnea, and SpO2value.

You have just obtained blood from the patient's radial artery to determine ABG results. As you run the blood through the blood gas analyzer, you notice you failed to remove an air bubble from the sample. The blood gas results will most likely reflect values with a A. High pH and low PO2 B. Low PCO2 and low PO2 C. Low PCO2 and high PO2 D. High PCO2 and high PO2

C, Because air contains little CO2and a much higher amount of O2, these values will be reflected if an air bubble is in the sample.

The patient's condition has deteriorated, and mechanical ventilation is initiated. What ventilation parameters should the respiratory therapist determine at this time? 1. VT required by patient2. Patient's FVC3. Patient's MIP4. Minute ventilation required by patient A. 1 and 2 only B. 2 and 3 only C. 1 and 4 only D. 1, 2, and 3 only

C, Because mechanical ventilation is to be initiated, it is not important to determine the patient's FVC or MIP. Most important is to determine the required minute ventilation (rate and VT) necessary for the patient.

A 26-year-old patient has been experiencing a mod- erate asthmatic attack for 30 minutes. Which of the following ABG results would you expect to observe if the patient was breathing room air? B)7.08 , 24 PaCO2 , 50 PaO2 C)7.51 , 27 ., 60 D)7.27 , 52 , 63

C, Because the attack has been for only 30 min, the patient will most likely be hyperventilating as a result of hypoxemia. If this condition is not reversed, the patient will begin to tire, which will result in decreasing minute ventilation accompanied by rising PaCO2 levels.

Which of the following situations would result in the high-pressure alarm being activated during volume- controlled ventilation? A. ET tube cuff leak B. Excessive cuff pressure C. Increased airway resistance D. Increased lung compliance

C, Decreasing lung compliance and increased RAW result in higher inspiratory pressures. If the pressure increases enough to reach the high-pressure limit, an alarm sounds and inspiration ends at that time. The pressure limit should be set 10 to 15 cm H2O above the average peak inspiratory pressure.

the respiratory therapist notes the following data while reviewing the patient's chart: Dynamic compliance 42 mL/cm H2O Static compliance 32 mL/cm H2OThe therapist should conclude which of the following? A. Airway resistance is 10 cm H2O/L/sec. B. A pneumothorax has likely developed. C. The data is erroneous .D. The patient has severe obstructive disease.

C, Dynamic compliance can never be higher than static compliance. To determine static compliance the plateau pressure (a lower number than PIP) is divided into the VT, whereas when calculating dynamic compliance the PIP ( a higher number than plateau) is divided into the VT. Therefore, the dynamic compliance is always be lower than static compliance, so this data is inaccurate. (Analysis)

A patient's pulmonary function study shows an FRC of 127% of predicted. The patient most likely has which of the following conditions? A. Pulmonary fibrosis B. Atelectasis C. Emphysema D. Pneumonia

C, FRC is the amount of air remaining in the lungs after a normal exhalation. Because patients with emphysema trap air during exhalation, more air stays in the lungs after exhalation and FRC increases.

If a patient has an ideal breathing pattern, what is the approximate percentage of O2 delivered with a nasal cannula at 5 L/min? A. 28% B. 36% C. 40% D. 45%

C, Generally, to calculate the approximate percentage of O2 delivered by a nasal cannula, add 4% for each liter of oxygen flow (e.g., 1 L, 24%; 2 L, 28%, etc.).

The respiratory therapist is asked to assess a 30-week-gestational-age infant with persistent pulmonary hypertension of the newborn (PPHN). Which of the following would you recommend to help treat this condition? A. Permissive hypercapnia B. Maintain PaO2 at 40 torr C. Nitric oxide D. Hypoventilation

C, In order to decrease the high pulmonary artery pressure, nitric oxide may be used since it's a potent pulmonary vasodilator. By hyperventilating and decreasing the PaCO2 level, pulmonary vasodilation occurs which decreases pulmonary hypertension. Hypercapnia (high PaCO2level) causes pulmonary vasoconstriction which increases pulmonary hypertension. Maintaining the PaO2 at 40 torr is too low for an infant and will be detrimental. (Application)

An 80-kg (176-lb) patient with ARDS is intubated and is receiving mechanical ventilation with the following settings: SIMV rate 10 VT 400 PEEP 10 FIO2 0.50 The respiratory therapist notes that the patient's SpO2 has dropped from 98% to 85% over the past 2 hours. The therapist notes the PIP has increased from 36 cm H2O to 46 cm H2O, and the plateau pressure has increased from 18 cm H2O to 28 cm H2O. Which of the following should the therapist recommend? A. Increase the FiO2 to 1.0 B. Suction the patient C. Increase the PEEP to 12 cm H2O D. Administer aerosolized albuterol

C, Looking at the data, you will notice the SpO2 is dropping, along with an increasing plateau pressure. The increasing plateau pressure indicates lung compliance is decreasing; the lungs are getting stiffer and harder to ventilate and oxygenate. This most likely is the result of atelectasis. This can be corrected by increasing the PEEP level, which should improve oxygenation. (Analysis)

While assessing a patient's chest radiograph, you observe an area of hyperlucency. This may be the result of which of the following? A. Atelectasis B. Consolidation C. Pneumothorax D. Pulmonary edema

C, Lucency is defined as black areas on a chest film. Hyperlucency indicates excessive black areas. Air is black on chest x-rays; therefore, more air is present than normal. This is caused by hyperinflation, emphysema (due to air-trapping), and a pneumothorax. When a pneumothorax is present, the lung collapses and air enters into the pleural space. The excessive air in the pleural space results in hyperlucency.

You are monitoring a patient with Guillain-Barré syndrome for signs of respiratory muscle weakness. Which one of the following variables would signal the earliest indication? A. PaO2 B. PaCO2 C. MIP D. VT

C, MIP, sometimes referred to as NIF, measures the patient's respiratory muscle strength. It is obtained when the patient inhales as deeply as possible through a mouthpiece or mask that is attached to a pressure manometer. The MIP is measured periodically in patients with neuromuscular disease to determine weakness in the ventilatory muscles. A normal MIP is -50 to -100 cm H2O.

An 8-day-old neonate is receiving pressure-controlled ventilation. Over the past 36 hours, the neonate's PaO2 has decreased from 58 torr to 47 torr. The physician wants to increase the mean airway pressure. Which of the following should the respiratory therapist recommend increasing? 1. Inspiratory pressure 2. Expiratory time 3. Inspiratory time A. 1 only B. 3 only C. 1 and 3 only D. 2 and 3 only

C, Mean airway pressure () is the average pressure applied to the airways over a specific period of time. () is affected by ventilator rate, PIP, and inspiratory time. will increase with increases in rate, PIP, or inspiratory time.

A patient is breathing 16 times per minute and has a VT of 450 mL. What is this patient's minute ventilation? A. 4.2 L B. 6.1 L C. 7.2 L D. 8.6 L

C, Minute ventilation is calculated as follows: VT×RR Convert VT from milliliters to liters by dividing by 1000. 0.45×16 = 7.2 L

The following data are collected from a patient receiving volume-controlled ventilation: PEEP level PaO2 PVO2 VT 6cmH2O 64 35 all 600 8cmH2O 70 38 10 cm H2O 75 43 12 cm H2O 80 34 Which of the following represents optimal PEEP? A. 6 cm H2O B. 8 cm H2O C. 10 cm H2O D. 12 cm H2O

C, Optimal PEEP is that level of PEEP that improves lung compliance without reducing cardiac output. In this question, compliance is not the issue. A decrease in cardiac output is observed when the mixed venous PO2(PvO2) starts decreasing. PvO2 is the partial pressure of O2in the pulmonary artery obtained via a Swan-Ganz catheter. It represents blood at the end of the venous circuit. Even though cardiac output is reduced, the tissues will extract O2 from the blood at the same rate. By the time the blood reaches the pulmonary artery, less O2will be present, as evidenced by a low PvO2. In this question, notice how, as the PEEP level is increased from 6 to 10 cm H2O, PvO2likewise increases. However, as PEEP is increased from 10 to 12 cm H2O, PvO2drops. This indicates that the cardiac output has decreased. Therefore, the optimal PEEP level is that level just before the PvO2 decreased, which is 10 cm H2O.

After PEEP is initiated for a patient, the respiratory therapist should expect which of the following to occur? A. Decreased FRC B. Increased plateau pressure C. Decreased P(A-a)O2 D. Decreased CL

C, PEEP increases FRC by recruiting collapsed alveoli. This results in a decrease in the plateau pressure (pressure needed to ventilate the lungs) and an increase in lung compliance. When more alveoli are opened, more oxygen will diffuse into the blood, which will increase the PaO2 and result in a decrease in the A-a gradient.

While making ventilator checks, the respiratory therapist measures the ET-tube cuff pressure to be 40 cm H2O. At PIP, air is passing around the cuff. Which of the following actions should the therapist take at this time? A. Decrease cuff pressure to 20 cm H2O B. Add more air to the cuff to stop the leak C. Recommend changing to a larger tube D. Maintain the cuff pressure at 40 cm H2O

C, Pressure in the cuff should be maintained at no more than 20-30 cm H2O. If there is an excessive amount of pressure and a leak is still present, the tube is too small and should be replaced with a larger one.

A patient has a VT of 450 mL and a respiratory rate that fluctuates between 15/min and 25/min. Which of the following is the best device for the administra- tion of a controlled O2 percentage? A. Partial rebreathing mask B. Simple O2 mask C. Air-entrainment mask D. Nasal cannula

C, Refer to the explanation for question 72

The respiratory therapist palpates no pulse on a patient, but the ECG monitor shows QRS complexes on the tracing. The therapist should A. Get a stat ABG B. Recommend defibrillation at 250 J C. Begin cardiac compressions D. Recommend cardioversion at 120 J

C, Regardless of what the ECG monitor is recording, if the patient has no pulse, compressions must be started immediately. An example of this rare situation is electromechanical dissociation (EMD), also referred to as pulseless electrical activity (PEA), in which the ECG monitor does not reflect the actual mechanical activity of the heart. (Analysis)

A patient has a pH of 7.18 and a PaCO2 of 24 torr. Which of the following can be concluded regarding this blood gas data? A. Respiratory acidosis is present B. The patient is hypoventilating C. Metabolic acidosis is present D. The base excess must be increased

C, Sometimes on the exams, all the blood gas data will not be provided. In this case, only the pH and PaCO2are given. There are two instances when the pH is acidotic: when the PaCO2is increased or when the HCO3−level is decreased. In this question, the PaCO2is low, which results in an alkalotic pH, so we know that the PaCO2is not responsible for the low pH. It has to be a decreased HCO3−causing the acidosis. Therefore, a metabolic acidosis is present.

Inspiratory stridor is the major clinical sign of A. Tracheal malacia B. Tracheal stenosis C. Glottic edema D. Laryngotracheal web

C, Stridor is a loud, high-pitched sound heard in the upper airway, generally in the glottic area where airflow is partially obstructed. Glottic edema is most commonly observed after extubation. An ET tube resting on the vocal cords may lead to inflammation and swelling of the glottic opening, resulting in stridor. (Application)

A patient in the cardiac ICU is intubated and is re- ceiving mechanical ventilation with 40% O2 and a PEEP of 5 cm H2O. The following data have been collected: pH 7.41 PaCO2 37 torr PaO2 81 torr HCO3 23 mEq/L BE 2 C(av)O2 8.1 vol% PCWP 2 mm Hg On the basis of these data, the respiratory therapist should recommend which of the following? A. Administer a diuretic B. Increase the PEEP to 10 cm H2O C. Administer fluids D. Increase the FiO2

C, The C(a-v)O2 is the difference between the O2 content in arterial and venous blood. The normal value is 4 to 6 vol%. An elevated C(a-v)O2level indicates a greater difference between the two, which suggests less O2 in the venous blood. This results from a decreased QT. Even though blood is flowing through the circulatory system at a slower rate (decreased QT), the tissues will extract the O2at the same rate. This causes less O2content in the venous blood, which results in an increased C(a-v)O2 level. Another value in this question that is not normal is the PCWP, sometimes referred to as PAWP. The normal value is 5 to 10 mm Hg. A decreased value, as in this problem, means a lower pressure in the left side of the heart as a result of the decreased venous return caused by the decreased QT or hypovolemia. This is best treated by increasing fluids.

After a patient has received bronchodilator therapy, the respiratory therapist attempts to perform nasotra- cheal suction on the patient. As the catheter enters the oropharynx, the following ECG waveform is observed on the ECG Monitor. bradycardia . This ECG pattern is most likely the result of which of the following? A. Excessive suction pressure B. Hypoxemia C. Vagal nerve stimulation D. Hypercapnia

C, The ECG strip indicates sinus bradycardia, which results from vagal stimulation from suctioning. The vagus nerve runs through the oropharynx. *When the vagus nerve is stimulated, bradycardia and hypotension result*. Thus, a catheter placed in the oropharynx during suctioning may elicit this response. Hypoxemia may also result in bradycardia, but with the catheter in the oropharynx, hypoxemia is unlikely. (Application)

A postoperative 46-year-old, 80-kg (176-lb) patient is breathing spontaneously at a rate of 30/min with an FiO2 of 0.50. The following ABG results are obtained: pH 7.29 PaCO2 62 torr PaO2 64 torr HCO3 29 mEq/L BE 4 Mechanical ventilation is instituted with a VT of 600 mL and an FiO2 of 0.5. The SIMV rate should be set on A. 4/min B. 8/min C. 15/min D. 20/min

C, The initial ventilator rate on the exam should be 10/min to 16/min. Generally, do not select a rate that is below 10 or above 16 for the initial rate setting. Higher rates may be indicated on ARDS patients. (Analysis)

The most appropriate ventilator settings would be which of the following? A. VT 600 mL, rate 18, SIMV mode B. VT 800 mL, rate 6, AC mode C. VT 550 mL, rate 12, AC mode D. VT 650 mL, rate 14, SIMV mode

C, The initial ventilator rate should be between 10 and 16 breaths/min, and the VT should be 6 to 8 mL/kg of ideal body weight. Although the VT of 550 mL slightly exceeds 8 mL/kg of ideal body weight, it still represents the best answer

A patient with COPD is in the emergency depart- ment and is complaining of shortness of breath. ABG results with the patient breathing room air are below: pH 7.31 PaCO2 62 torr PaO2 44 torr HCO334 mEq/L BE 10 The most appropriate recommendation for O2therapy is which of the following? A. Simple mask at 10 L/min B. Nasal cannula at 6 L/min C. Air-entrainment mask at 28% D. Aerosol mask at 40%

C, The patient with COPD in this problem has chronic retention of CO2, as evidenced by the elevated HCO3 level on admission. This indicates compensation has occurred and suggests this patient has chronic hypoxemia. The PaO2 should be maintained between 50 and 65 mm Hg to prevent suppressing the ventilator drive. The oxygen device of choice for these patients is an air entrainment mask at, initially, 24% to 35%.

A patient is receiving volume-controlled ventilation with a VT of 600 mL, but the exhaled volume display is reading 300 mL. The respiratory therapist wants to determine the volume that the ventilator is actually delivering. To most accurately measure this volume, the therapist should place a respirometer at the A. Exhalation valve B. Patient wye connector C. Ventilator outlet D. Humidifier outlet

C, The respirometer should be placed at the ventilator outlet because if it is placed anywhere else in the circuit and a leak is present, the reading will not be accurate.

A 6-day-old premature infant of 30 weeks' gestational age is experiencing frequent periods of apnea with desaturation. Which of the following medications should the respiratory therapist recommend? A. Surfactant (Survanta) B. Albuterol (Proventil) C. Theophylline D. Naloxone (Narcan)

C, Theophylline has respiratory stimulant properties that help prevent apneic spells in neonates. Albuterol is a bronchodilator. Naloxone is often administered to newborns to reverse the narcotic depressant effects sometimes passed from the mother to the infant through the placenta before birth. Surfactant is used to treat alveolar collapse in the newborn

the following data have been collected on 75-kg male pt receiving volume-controlled ventilation : TV 600 mL pH 7.29 SIMV PaCO 50 torr Vent rate 4 PaO2 72 spontaneous rate HCO 26 FIO2 0.35 On the basis of these data, which of the following should the respiratory therapist recommend? A. Increase the VT to 650 mL B. Increase the FiO2 to 0.40 C. Increase the ventilator rate to 8/min D. Change to assist-control mode at a rate of 15/min

C, This patient's increased PaCO2 level indicates hypoventilation, which can be reversed by increasing the minute ventilation. This can be accomplished by increasing the ventilator rate or VT, both of which are choices. We must assume the patient is being weaned from the ventilator based on the low ventilator rate (SIMV rate of 4). Weaning is accomplished as we reduce the ventilator rate and allow the patient to breathe more on his or her own. If the patient's PaCO2 begins to increase during weaning, we increase the rate, not the VT. The ventilator VT is at the maximum level of 8 mL/kg based on the patient's weight of 75 kg (8 x 75 = 600), therefore increasing the ventilator rate is the most acceptable choice.

A 48-year-old, 75-kg (165-lb) woman is in the ICU after coronary bypass surgery. The patient is to receive mechanical ventilation. As you connect the patient to the ventilator, you notice the PIP is registering only 10 cm H2O on the manom- eter and the exhaled volume display is showing 300 mL less than the ventilator volume setting. Which of the following could be causing this problem? A. Kink in the tubing B. Patient needs to be suctioned C. Leak around the HME D. Increased airway resistance

C, When less volume is being recorded on the exhaled volume display than the set machine volume, a leak is present. Leaks can occur at tubing connections, the humidifier or HME, the ET-tube cuff, or through chest tubes

The respiratory therapist is transporting a patient with a nasal cannula running at 6 L/min. For the E cylinder to last at least 1 hour, what is the minimum amount of pressure it must contain? A. 1000 psig B. 1200 psig C. 1400 psig D. 1600 psig

C, When working a problem like this, don't worry about arranging the equation to solve for pressure. Use the equation you are most familiar with. cylinder pressure * cylinder factor / liter flow 1400 * 0.28/ 6 = 65min

A patient is placed on a nonrebreathing mask at 15 L/min. An ABG analysis reveals a PaO2 of 580 torr. The respiratory therapist should recommend which of the following? A. Decrease the flow rate to 10 L/min B. Change to a partial rebreathing mask at 10 L/min C. Change to a simple O2 mask at 8 L/min D. Discontinue O2 therapy

D, A PaO2of 580 mm Hg with the use of 100% oxygen is normal; it indicates the patient is not in need of supplemental O2. A good rule of thumb to determine normal PaO2at various O2percentages is to multiply the percentage of O2the patient is using by 5. If the patient's PaO2is at least 5 times the delivered oxygen percent, then oxygen should be discontinued.

The polarographic O2 analyzer being used to analyze a patient's aerosol mask is reading inaccurately. This could be caused by all of the following EXCEPT A. No electrolyte gel B. Torn membrane C. Water on the membrane D. Dead fuel cell

D, A polarographic O2 analyzer uses a battery not a fuel cell

Which of the following processes or agents can sterilize equipment? A. Ethyl alcohol B. Pasteurization C. Acetic acid D. Ethylene oxide

D, Autoclave, ethylene oxide gas, and glutaraldehyde solution (Cidex) can all sterilize equipment.

The following data have been collected from a 70-kg (154-lb) patient receiving volume-controlled ventilation: Mode Assist/control ABGs: Ventilator rate 12 VT 550 FiO2 0.80 PEEP 10 pH 7.37 PaCO2 42 torr PaO2 161 torr HCO325 mEq/L BE 0 On the basis of these data, which of the following ventilator setting changes should the respiratory therapist recommend? A. Decrease VT to 500 mL B. Decrease PEEP to 8 cm H2O C. Increase the ventilator rate to 15/min D. Decrease FiO2 to 0.70

D, Because the patient is hyperoxygenating, the PaO2 may be decreased by reducing FiO2or PEEP. Because the FiO2is more than 0.60, it should be reduced first. Once the FiO2is 0.60, the PEEP should then be decreased. (Analysis)

While ventilating the lungs of an intubated apneic patient with a manual resuscitator, you notice very little resistance when the bag is compressed, and the patient's chest rises only minimally. Which of the following may be the cause of this problem? A)Excessive ET tube cuff pressure B)The exhalation valve is jammed in the closed position C)The patient's lung compliance is decreased D)Inadequate ET tube cuff pressure

D, If little resistance occurs when the bag is compressed and the chest rises minimally when you are manually resuscitating or "bagging" the patient, a leak is indicated. The leak may be around the ET-tube cuff, mask, exhalation valve, or bag inlet valve.

The physician wants to liberate a patient from a ventilator. Which of the following parameters obtained by the respiratory therapist indicate liberation will most likely be successful? A. MIP of 18cmHO B. VC 9 mL/kg C. PaO2/FiO2 ratio of 150 D. RSBI of 65

D, Only the RSBI of 65 meets the criteria for weaning. Below are the criteria for weaning: a. MIP of more than 20 cm H2O b. RSBI < 105 c. VC of more than 15 mL/kg of body weight d. PaO2/FiO2ratio >200

The respiratory therapist reviews a ventilator flow sheet and observes that the PIP has been gradually increasing over the past several hours with no change in the static pressure. Which of the following should the therapist conclude? A. The lungs are becoming harder to ventilate B. Lung compliance is decreasing C. Atelectasis is most likely developing D. Airway resistance is increasing

D, Peak inspiratory pressure increases as a result of increasing airway resistance, such as airway secretions, bronchospasm, or water in the ventilator tubing. PIP also increases when the lung compliance is decreasing, but lung compliance must be measured from the plateau (static) pressure during an inspiratory hold. This pressure closely resembles alveolar pressure. If static pressure remains unchanged by peak pressure increases, then lung compliance remains unchanged but airway resistance has increased. (Analysis) 120. D, A drop in mixed venous PO2is indicative of a decreased QT. This drop in PvO2occurs because the tissues extract O2from the blood at the same rate, even though the blood is flowing slower past the tissues (decreased QT). Therefore, more O2is extracted and by the time the blood reaches the pulmonary artery, which is where PvO2is measured, there is less O2is in the blood.

The following pulmonary function results are obtained on a patient: FEV1/FVC 90% of predicted FVC 55% of predicted These data indicate the patient could have which of the following? A. Emphysema B. Cystic fibrosis C. Chronic bronchitis D. Pulmonary fibrosis

D, Pulmonary fibrosis is an example of a restrictive lung disorder. Restrictive disorders are characterized by decreased volumes and capacities and normal flow studies on pulmonary function tests. Obstructive disorders are characterized by increased volumes and capacities due to air trapping and by decreased flow studies. When given a question on the exam where there are three obstructive disease selections and one restrictive disorder, you should select the one disorder not common to the other three. In other words, from these pulmonary function values you would not be able to determine emphysema from chronic bronchitis or cystic fibrosis (all obstructive disorders); therefore the answer must be the restrictive disorder.

Which of the following ABG results would be considered normal in a patient with severe COPD? A. pH 7.50, PCO2 40 torr, PO2 56 torr, HCO330 mEq/L, BE 4 B. pH 7.29, PCO2 54 torr, PO2 70 torr, HCO323 mEq/L, BE 0 C. pH 7.36, PCO2 40 torr, PO2 85 torr, HCO324 mEq/L, BE 1 D. pH 7.38, PCO2 60 torr, PO2 57 torr, HCO333 mEq/L, BE 10

D, Refer to the explanation for question 13

The development of ROP can be minimized if the PaO2 does not exceed what level? A. 50 torr B. 60 torr C. 70 torr D. 80 torr

D, Studies indicate that there is a reduced incidence of neonatal retinopathy in premature infants if the PaO2does not exceed 80 mm Hg. The normal PaO2range for neonates is 50 to 70 mm Hg. A PaO2of greater than 80 mm Hg can result in vasoconstriction of the retinal arteries, which can lead to detachment of the artery and blindness

If a small hole is present in the exhalation valve diaphragm of an IPPB circuit, the machine A. Automatically cycles into exhalation B. Cycles into exhalation prematurely on each breath C. Delivers an increased inspiratory pressure to the patient D. Does not cycle into exhalation

D, The exhalation diaphragm will not be able to close effectively if a hole is present. There will be a leak in the system, preventing it from pressurizing and cycling to the expiratory phase.

A patient is receiving volume-controlled ventilation, and the low-pressure alarm suddenly sounds. The corrective action is to? A)Suction the patient B)Begin manual ventilation C)Increase the flow D)Determine whether the patient is disconnected from the ventilator

D, The low-pressure alarm will sound if there is a leak in the ventilator tubing or around the ET-tube cuff, the patient is disconnected from the ventilator, or the low-pressure alarm is set too high.

After turning the O2 flowmeter completely off, you notice the water in the humidifier is still slightly bubbling. What is the most likely reason for this? A. The humidifier lid is not tight B. There is a crack in the humidifier jar C. The wall outlet is loose D. There is a faulty valve seat in the flowmeter

D, The needle valve, when completely closed, fits into a valve seat. If the valve seat is damaged and lets gas past it, the humidifier will bubble, but the flow is so low it will not show a reading on the flowmeter. The flowmeter should be replaced

The respiratory therapist is performing bag-valve- mask ventilation on a patient with severe COPD during CPR. Which of the following describes the best method for ventilating the lungs of this patient? A)The bag should be connected to an air flowmeter B)The flow to the bag should be 10 L/min with no reservoir attachment C)The bag should be connected to an O2 blender set at 30% D)The bag should have a reservoir attachment and a flow of 15 L/min

D, This is a tricky question because anytime we see "patient with severe COPD" we may think we have to alter oxygen levels because of the patient's chronic hypoxemia. This is often true but not during resuscitation. The patient's lungs must be ventilated with 100% oxygen so that the PaO2returns to the "normal" range

A 43-year-old patient in the ICU is receiving 40% O2 by air-entrainment mask. His PaO2 is 58 torr, and his shunt has been calculated to be 6%. Which of the following is most likely causing his hypoxemia? A. Pulmonary edema B. Lobar pneumonia C. Pneumothorax D. Hypoventilation

D, This patient has a slightly higher measured shunt than normal (2% to 5%). Pulmonary edema, lobar pneumonia, and pneumothorax would all cause shunts of more than 6%. Hypoventilation is an example of a V/Q mismatch, which will not result in increased shunt levels. (Analysis)

A 58-year-old patient with emphysema enters the emergency department on a 2-L/min nasal cannula. Blood for ABG analysis is drawn, and after the results are evaluated, the O2 flow is increased to 5 L/min. Below are ABG results for both flow rates: 2 L/min 5 L/min pH 7.34 7.28 PaCO2 62 torr 77 PaO2 44 torr 52 HCO3 35 mEq/L 35 BE 10 10 On the basis of these data, which of the following should the respiratory therapist recommend? A. Decrease the liter flow to 3 L/min B. Initiate CPAP at 4 cm H2O and 60% O2 C. Increase the liter flow to 6 L/min D. Institute NPPV

D, This patient with COPD clearly has chronic hypoxemia and hypercapnia, as evidenced by the initial ABG results with the use of 2 L/min. When the ABG results reveal elevated HCO3−levels on admission, compensation of the respiratory acidosis is occurring. This patient's primary problem is his PaO2, which should be maintained in the 50- to 65-mm Hg range. As the liter flow was increased, the patient's ABG results worsened, as reflected by an increasing PaCO2 and a decreasing pH. Automatically, the thought of suppressing the patient's ventilator drive comes to mind. However, for this to occur, the PaO2must be higher than 65 mm Hg. The PaO2is only 52 mm Hg, which is normal for this patient. The cause of the patient's deteriorating ventilatory status is not the result of the excessive oxygen but rather the result of a worsening pulmonary condition. The patient's lungs need to be ventilated more effectively, and this may be done initially with noninvasive positive pressure ventilation (NPPV), . The patient avoids being intubated yet still receives positive pressure ventilation. It buys some time for the patient so that the pulmonary problem may be treated and the patient can avoid intubation and mechanical ventilation. Because patients with COPD are typically difficult to wean from the ventilator, it is to their advantage to attempt NPPV first. (Analysis)

The respiratory therapist is called to the pediatric ICU to suction an 8-year-old ventilator patient with pneumonia who is intubated with a 6.0 ET tube. Which of the following represents the most appro- priate catheter size and suction pressure to use on this patient? A. 8-Fr catheter, 100 mm Hg B. 10-Fr catheter, 60 mm Hg C. 8-Fr catheter, 80 mm Hg D. 10-Fr catheter, 100 mm Hg

D, To determine proper suction catheter size, double the ET size and drop down to the next lowest number that represents a suction catheter size. The most common catheter are sizes are 6.5 Fr, 8 Fr, 10 Fr, 12 Fr, and 14 Fr. By doubling the ET size (6 × 2 = 12) and dropping down to the next lower number of catheter size, you will select 10 Fr as the proper size. This equation ensures that the catheter that is used occupies no more than half the diameter of the ET tube. This is what the NBRC exams prefer. The normal suction level for children is -80 to -100 mm Hg.

A V/Q scan is conducted on a patient in whom pulmonary embolism is suspected. The scan shows normal ventilation and the absence of perfusion in the left upper lobe. The respiratory therapist should estimate the V/Q ratio in this area to be which of the following? A. Less than 0.5 B. 0.8 C. 1.0 D. More than 2.0

D, To determine the V/Q ratio, divide ventilation (represented by the numerator) by perfusion (represented by the denominator). Normal alveolar ventilation is approximately 4 L/min, and an average pulmonary blood flow is about 5 L/min. Divide ventilation by perfusion (4/5); the result is a 0.8 V/Q ratio. In a healthy individual in the upright position, the upper portion of the lung receives greater ventilation than perfusion and therefore has an increased V/Q ratio (more than 0.8). Perfusion is greater than ventilation in the lower portions of the lung as a result of gravity; therefore the V/Q ratio is decreased (less than 0.8) in those areas. In this question, perfusion is decreased while ventilation remains normal; therefore the V/Q ratio is increased (more than 0.8). Since there is no perfusion to that lung, the ration would be very high, more than the 1.0. This is a classic example of a pulmonary embolism, in which pulmonary blood flow is obstructed while ventilation remains normal. (Application)

The high-pressure alarm on volume-controlled ventilation should be set approximately 10 cm H2O pressure above which of the following? A. PEEP level B. Plateau pressure C. Mean airway pressure D. Peak airway pressure

D, To prevent excessive pressure in the lungs, set the high pressure limit around 5 to 10 cm H2O above the average peak airway pressure because peak airway pressure is the highest pressure of the other choices.

A 5-ft 5-in., 120-kg (264-lb) woman is brought to the emergency department and is receiving ventila- tion with a manual resuscitator and mask at 100% O2. A drug overdose is suspected. After intubating the patient, the respiratory therapist is asked to rec-ommend initial ventilator settings. What are the most appropriate settings for this patient's ventilator? A)SIMV; rate, 10/min; VT, 700 mL; FiO2, 0.80 B)Assist-control; rate, 16/min; VT, 800 mL; FiO2, 0.60 C)Assist-control; rate, 12/min; VT, 600 mL; FiO2, 1.0 D)SIMV; rate, 12/min; VT, 450 mL; FiO2, 1.0

D,Remember on the initial ventilator setup to select a ventilator rate between 10/min and 16/min; the initial VT setting should be 6-8 mL/kg. (Analysis) 105 + 5 (height in inches - 60) 105 + 5 (65 - 60) 105 + 25 = 130 lb To convert 130 lb to kg

Normal PaO2for a neonate is 50 to 70 mm Hg. To increase the PaO2 in this question, increase either the FiO2or PEEP. Because the FiO2is above 0.60 and the infant still remains hypoxemic, the likelihood of atelectasis and right-to-left shunting is high.how would you treat ?

Increasing the PEEP to help open up atelectatic lung areas will increase the PaO2more than an increase in the FiO2would

the partial pressure of O2in the pulmonary artery obtained via a Swan-Ganz catheter.aka

PVO2

if the high-pressure alarm is triggered, what should you do ?

Suctioning the patient

if the PIP would have increased with no increase in the static pressure, what would be the cause ?

When airway resistance increases because of airway secretions, water in the ventilator tubing, or bronchospasm, PIP increases, but static pressure remains unchanged.

Surfactant is used to treat?

alveolar collapse in the newborn.

Refractory hypoxemia typically results from ?

atelectasis pneumonia pulmonary edema

High FIO2 levels, on the other hand, will lead to ?

atelectasis because of nitrogen washout of the lung and the suppression of surfactant production by the alveolar type 2 cells.

while ET suctioning , Failure to hyperoxygenate may cause hypoxemia, resulting in ?

cardiac arrhythmias

To best determine the severity of smoke inhalation, an HbCO level should be determined with ?

co-oximeter

Static pressure closely resembles alveolar pressure. An increasing static pressure is a sign that it is taking more pressure to ventilate the lung; therefore, lung ?

compliance is decreasing.

If the patient is able to perform simple tasks when asked, this best determines his or her ability to follow instructions. This is important before administering an?

incentive spirometry or IPPB treatment, which requires the patient to be able to follow instructions well or the treatment will not be effective. (Recall)

normal is the PCWP, sometimes referred to as PAWP. The normal value is 5 to 10 mm Hg. A decreased value, as in this problem, means a lower pressure in the left side of the heart as a result of the decreased venous return caused by the decreased QT or hypovolemia. This is best treated by ?

increasing fluids.

If the high O2 concentration results in high PaO2 levels (>80 mm Hg), retinal detachment may occur, leading to blindness in the premature neonate. Remember, what causes the damage the FIO2 or PaO2 ?

it is the high PaO2 that causes the damage, not the FIO2

what are the causes of low pressure alarm sounding in volume controlled ventilation ?

leak in the ventilator tubing or around the ET-tube cuff patient is disconnected from the ventilator low-pressure alarm is set too high.

when is Naloxone often administered to newborns?

reverse the narcotic depressant effects sometimes passed from the mother to the infant through the placenta before birth

If, after kinking the tubing, the pop-off valve fails to open, there is a leak somewhere in the setup. The most common leak occurs when

the humidifier bottle is not screwed on tight to the top. Other sources are small holes in the tubing or loose-fitting tubing on the humidifier outlet.

FENO levels begin to rise with airway inflammation. Levels of greater than 50 ppb may indicate?

the patient needs to increase their normal medication. The FENO level is commonly increased as a result of the patient's noncompliance with their corticosteroid use.

the tube is at the 29-cm mark and the patient has decreased breath sounds in the left lung, which indicates?

the tube is in the right mainstem bronchus and must be withdrawn.

true or false If hypoxemia is present, increase either the FIO2or PEEP level, depending on what FIO2the patient is receiving. Because the patient is on less than 50% oxygen, the board exams will want you to increase the oxygen level. Had the oxygen level been at 50% or higher, then the correct choice would be to increase the PEEP level, except for hypotensive patients or head trauma patients. In those cases, do not increase PEEP levels as this may worsen their situation

true

what is the formula for alveolar minute ventilation ?

(VT - VD) × respiratory rate

The following spontaneous ventilation parameters are collected from a 68-kg (150-lb) patient with a 2-L/min nasal cannula: VT 500 Respiratory rate 10/min This patient's alveolar minute ventilation is which of the following? A. 2.8 L B. 3.5 L C. 4.3 L D. 5.0 L

(vt - VD )* RR (500 - 150) *10=

The respiratory therapist is performing a leak test on a mechanical ventilator. Which adjustment should the therapist make to the ventilator? A. Set the high-pressure limit to its maximal level B. Set the rate control to its maximal level C. Set the flow control to its maximal level D. Remove the test lung from the circuit

*A, To make sure there are no leaks in the ventilator circuit, the ventilator flow rate should be set low with a moderate to high tidal volume. This results in a high peak pressure, so the high-pressure limit must be increased*

level of PEEP that improves lung compliance without reducing cardiac output. aka

Optimal PEEP

Pulmonary edema, lobar pneumonia, and pneumothorax would all cause shunts of? what is normal shunt ?

more than 6%. normal (2% to 5%)

how do you treat tension pneumothorax ?

needle decompression

Regardless of what the ECG monitor is recording, if the patient has no pulse, compressions must be started immediately. An example of this rare situation is electromechanical dissociation (EMD), also referred to as?

pulseless electrical activity (PEA)

Measuring fractional concentration of exhaled nitric oxide (FENO) can be helpful in determining airway inflammation. Normal FENO levels in adults is less than ________parts per billion (ppb) and less than _______ppb in children

25 <20

Normal PaO2for a neonate is?

is 50 to 70 mm Hg

while ET suctioning a pt, Bradycardia may occur as a result of ?

vagal stimulation

what causes an increase in mean airway pressure ?

ventilator rate PIP inspiratory time.