TMC Practice Questions

Which of the following is a complication of pulmonary artery catheter angiography?

D. cardiac arrhythmias

Activity of the accessory muscles of ventilation at rest suggests:

D. increased work of breathing

Which of the following factors can have a major impact on a patient's expired carbon monoxide (CO) levels?

D. inflammatory lung disease

A patient has a pH of 7.58 and a PaCO2 of 50 torr. Based on these data, what is the primary acid-base disturbance?

D. metabolic alkalosis

Which one of the following measures could be used to assess changes in exercise tolerance associated with participation in a pulmonary rehabilitation program?

D. pre- and post 6 minute walking distance

To measure the strength of a patient's respiratory muscle effort at the bedside, which of the following devices would you select?

D. pressure manometer

After you decide to conduct an interview, the next step should be to:

D. review the patient's medical record

As measured by the single breath DLco method, the diffusing capacity of the lungs would be increased in which of the following?

D. secondary polycythemia

During a patient-ventilator system check you notice the following airway pressures on an adult mechanically ventilated patient receiving 5 cm H2O of PEEP:

D. the patient is developing atelectasis

In observing the intracranial pressure (ICP) monitor of a patient receiving volume control A/C ventilation, you note that the ICP rises by about 3-5 mm Hg during each positive pressure breath. You can conclude that:

D. this is normal variation in ICP

Skin testing is used to help diagnose either chronic bronchitis or viral pneumonia.

False

Which of the following are potential complications of arterial puncture?

Arteriospasm, Embolization, Infection Hemorrhage

A patient's respirations are characterized by a gradual increase and then a gradual decrease in the depth of breathing, followed by a period of apnea. This pattern is known as which of the following?

B. Cheyne-Stokes breathing

You come upon a patient who is unresponsive and is not breathing. You had heard from her nurse that she had discussed a do not resuscitate (DNR) order with her physician. You should

B. Immediately call a code and begin resuscitation efforts

Which of the following would likely cause an incorrect or misleading pulse oximetry reading?

B. Incorrect probe size

A 20-year-old woman with diabetes who takes insulin has the following ABG results while breathing room air: Blood Gases pH 7.19 PaCO2 27 torr HCO3 10 mEq/L PaO2 107 torr

B. The patient has partially compensated metabolic acidosis

Which of the following would give the best indication of the adequacy of alveolar ventilation?

B. arterial blood gas analysis

Before connecting the sample syringe to an adult's arterial line stopcock, you would:

B. aspirate at least 5 mL fluid/blood using a waste syringe

A patient is admitted to the emergency room with chest trauma suffered in a motor vehicle accident. Inspection of the thorax reveals no major external abnormalities, just some cuts and large bruises. Which of the following would you recommend to determine the severity of the trauma?

B. chest x-ray

Which of the following is typically NOT part of a patient's social history?

B. childhood diseases

To help ensure that the SpO2 readings provided by a pulse oximeter are accurate, you should:

B. choose the correct sensor size

The second heart sound (S2) is created primarily by:

B. closure of the semilunar valves

Which of the following would tend to cause a patient to experience fluid overload (overhydration)?

B. congestive heart failure

Upon a return visit to a home care COPD patient on a inspiratory resistive breathing exercise program, you note no increase in MIP (maximum inspiratory pressure) since the last measure taken two weeks ago. No other changes are noted in the patient. What is the most likely cause of the observed lack of improvement in respiratory muscle strength?

B. noncompliance with the exercise regimen

Vesicular breath sounds indicate which of the following?

B. normal lungs

You are evaluating a patient in the recovery room following an exploratory laparotomy. The patient appears to be asleep. His respiratory rate is 14/min and heart rate is 84/min. To determine the patient's level of consciousness, you speak to the patient, who does not respond. Which of the following should you do FIRST?

B. shake the patient's arm gently

Which of the following respiratory signs noted on inspection of an adult patient would be considered ABNORMAL?

B. sternocleidomastoid muscles used at rest

A mixed venous sample obtained from a pulmonary artery catheter has a PO2 of 84 torr and an HbO2 saturation of 96%. Which of the following best explains these results?

B. the sample was withdrawn too quickly

Inspection of a trauma patient's chest wall and thorax reveals no obvious abnormalities. Which of the following should you INITIALLY recommend to determine the extent of the trauma?

B. thoracic ultrasound

At one minute after birth, a newborn infant's extremities appear cyanotic, her heart rate is 80/min, her respirations are gasping, she exhibits some flexion of the extremities and grimaces when stimulated. What is her Apgar score?

C. 5

You are providing BiPAP with 100% O2 to 55 year old female admitted to the ED with signs and symptoms of acute pulmonary edema. Which of the following laboratory tests would you recommend to help the doctor determine whether or not the patient is suffering from congestive heart failure?

C. B-type natriuretic peptide

After setting up a 12-lead ECG on a patient and verifying that the leads are connected properly, you note a "noisy" and unstable signal. To resolve this problem you would:

C. confirm that the patient is staying motionless

Which of the following tests would you recommend to assess an outpatient's compliance with a smoking cessation program?

C. exhaled carbon monoxide

Which of the following factors increase a patient's ventilatory demand?

C. increased physiologic deadspace

You would recommend apnea monitoring for an infant being discharged to home who:

C. is receiving methylxanthine treatment

Significant overinflation of an endotracheal tube cuff may cause which of the following?

C. mucosal ischemia

On review of an apnea monitor's event recording for a neonate with an estimated gestation age of 34 weeks you note a breathing pattern characterized by numerous respiratory pauses lasting 4-10 seconds with less than 20 seconds of respiration activity between pauses. During these events, there is no change in heart rate. The proper interpretation of this finding is:

C. periodic breathing

An echocardiogram on a one day-old infant with refractory hypoxemia finds no evidence of congenital heart disease but reveals right-to-left shunting through a patent ductus arteriosus, tricuspid valve regurgitation and an enlarged right ventricle. Which of the following is the most likely problem?

C. persistent pulmonary hypertension

Which of the following would most affect the accuracy a capnometer's end-tidal CO2 (PetCO2) measurements?

C. system leaks

Results of a sleep study on a 57 year old female reveal an average of 2 apneic periods/hr, each lasting about 6 seconds, and all associated with snoring. During apneic spells, the patient tries to breathe. Which of the following conclusions can you draw from this information?

C. the results of this sleep study are within normal limits

For which of the following would you recommend continuous waveform capnography?

C. to verify placement of artificial airways

A patient has a vital capacity of 3200 mL, a functional residual capacity of 4500 mL and expiratory reserve volume of 1200 mL. What is his total lung capacity (TLC)?

D. 6500 mL

Assuming ideal conditions (lighting, skin color, normal Hb), central cyanosis FIRST manifests itself in adults when the arterial hemoglobin saturation drops below:

D. 80%

You obtain the following pre- and post-bronchodilator measures on a 29 year old 6-foot 2 inch tall male patient with a chief complaint of exertional dyspnea who is undergoing disability evaluation:

D. The patient is not exerting sustained effort

For which of the following disorders would you recommend skin testing to aid in diagnosis?

D. allergic asthma

An adult patient is receiving 60% oxygen at 40 L/min via a high flow nasal cannula. Blood gas results are as follows: pH 7.52 PCO2 33 torr PaO2 48 torr SaO2 81% HCO3 26 mEq/L

A. 80

On entering a patient's room, you notice that his lips and nailbeds are blue-gray. This finding is a sign of:

A. Hypoxemia

You are called to the ER to perform an arterial puncture on a patient breathing room air complaining of shortness of breath. Blood gas results are as follows: pH 7.26 PCO2 60 torr PaO2 70 torr HCO3 26 mEq

A. alveolar hypoventilation

A premature infant receiving positive pressure ventilation exhibits acute respiratory distress, asymmetrical chest motion and hypotension. Which of the following procedures would you initially recommend?

A. chest transillumination

When assessing a patient, you observe inward motion of the abdomen as the rib cage uniformly expands during inspiration. Which of the following are potential causes of this problem?

A. diaphragm fatigue

The peak flow for an adult male patient is measured at 2 L/sec. Which of the following is a possible explanation?

A. expiratory air flow obstruction

A patient has an arterial pH of 7.58. What effect will this have on oxygen transport?

A. impaired blood oxygen unloading at the tissues

A doctor asks your advice on the best way for his home care asthma patient to assess changes in her airway tone over time. You would recommend:

A. peak expiratory flow rate monitoring

Which of the following abnormalities would appear as an area of increased radiodensity on a chest X-ray?

A. pulmonary edema

Which of the following formula is used to calculate cardiac output?

A. rate (f) x stroke volume (SV)

Which of the following is typically part of a patient's social history?

A. tobacco use C. marital status D. education

Alkalosis shifts the oxyhemoglobin curve to the left, which increases the affinity of hemoglobin for oxygen. Although this shift increases the arterial Hb saturation and CaO2 (and enhances blood O2 uptake at the lung), it impairs O2 unloading at the tissues.

True

Among the factors that can increase a patient's ventilatory demand are arterial hypoxemia, increased metabolic rate, fever, increased physiologic deadspace, metabolic acidosis, J-receptor stimulation (e.g., pulmonary edema), anxiety/confusion, and CNS stimulation

True

An abnormal decrease in density or (aka increased radiolucency) would be observed anywhere air replaces tissue, such as with hyperinflation, pneumothorax or pneumopericardium

True

An adult's breathing rate should be between 10-20/min; the ribs should be higher posteriorly than anteriorly at end-expiration; both side of thorax should expand equally, and the costal angle should be about 90° but increase with inspiration. The accessory muscles of respiration (scalenes, sternocleidomastoids, pectoralis major) should NOT be used during quiet breathing.

True

Any abnormality that increases the work of breathing may cause the accessory muscles of ventilation to become active, even at rest. This is common in acute and chronic airway obstruction, acute upper airway obstruction, and when lung compliance is reduced.

True

Apnea monitoring is indicated for preterm infants (< 34 weeks gestational age) at risk of recurrent apnea, bradycardia and hypoxemia. Apnea monitoring also is indicated for any infant receiving methylxanthine treatment for apnea or those with neurologic or metabolic disorders affecting respiratory control. Because standard home apnea monitors only measure chest wall movement and not air flow, they should not be used to detect obstructive sleep apnea.

True

Beside measurement of a patient's respiratory muscle strength is most often performed using a simple aneroid pressure manometer, usually in combination with a disposable valve system. Both inspiratory (MIP) and expiratory (MEP) muscle strength can be measured. MIP is often used to assess the need for mechanical ventilation, while MEP is helpful in assessing the ability to cough and clear secretions (for extubation).

True

Cheyne-Stokes breathing is characterized by a gradual increase and then a gradual decrease in tidal volume, followed by periods of apnea. This pattern is associated with brain injuries, especially to the respiratory centers in the brainstem (pons and medulla). It also is observed in some patients with chronic heart failure.

True

Common causes of fluid overload (overhydration) in patients include congestive heart failure, renal failure, high sodium intake, cirrhosis of the liver and overinfusion of fluids. On the other hand, diarrhea, vomiting, sweating/fever, hemorrhage, diuretics and excessive urination all can cause fluid depletion (dehydration).

True

Complications of arterial puncture include arteriospasm, air or clotted-blood emboli, anaphylactic reaction to local anesthetic (rare), patient or sampler contamination, hematoma. hemorrhage, trauma to the vessel, arterial occlusion, vasovagal response and pain.

True

First, RV = FRC - ERV. In this case, RV = 4500 - 1200 = 3300 mL. Second, TLC = VC + RV. In this case, TLC = 3200 mL + 3300 mL = 6500 mL

True

Hypothermia decreases metabolic rate and thus ventilatory demand and an overdose of barbiturates would cause CNS depression.

True

Immediate hazards or complications of PA catheter angiography include contrast media reaction (shared with CTPA), bleeding or hematoma formation at the puncture site, vessel dissection or occlusion, distal (pulmonary) embolization of catheter-associated clots, and potentially serious cardiac arrhythmias (as the catheter passes through the right ventricle

True

In general, central cyanosis does not appear until there is an average of at least 5 gm/dL de-oxygenated (aka reduced) Hb in the capillaries. Assuming a normal Hb content of 15 gm/dL, and a normal C(a-v)O2 of 5 ml/dL, a mean of 5 gm/dL de-oxygenated Hb in the capillaries will occur when the arterial O2 saturation (SaO2) drops below 80%. An SaO2 of 80% corresponds to a PaO2 of about 45-50 torr

True

In the absence of obvious deformities and abnormalities following a chest trauma, either a chest X-ray or thoracic ultrasound exam should be promptly performed. When used by a trained operator, thoracic ultrasound can readily detect bone fractures, hemithorax, pneumothorax and trauma to the diaphragm, heart, and large thoracic vessels.

True

Increases in DLco occur with increased Hb (as in secondary polycythemia), increased pulmonary blood flow, increased alveolar volume, and during exercise. The DLco is low in conditions that actually impair membrane diffusion (as in pulmonary fibrosis) or decrease surface area (as in emphysema). The DLco also can be less than normal with reduced Hb (as in anemia), decreased pulmonary capillary blood flow, or decreased alveolar volume.

True

Inward motion of the abdomen as the rib cage expands during inspiration is termed abdominal paradox

True

Measures useful in assessing changes in exercise tolerance due to participation in a pulmonary rehabilitation include: pre- and post 6 or 12 minute walking distance; pre- and post pulmonary exercise stress test; review of patient home exercise logs; strength measurements; and performance on specific exercises

True

Normal heart sounds are created by closure of the heart valves. The first heart sound (S1) is produced by the closure of the mitral and tricuspid valves (atrioventricular) during ventricular contraction. When systole ends, the semilunar valves (pulmonic and aortic) close, creating the second heart sound (S2).

True

Normal peak flow for adult males exceeds 8-10 L/sec. A peak flow of 2 L/sec indicates severe obstruction to expiratory air flow.

True

Normal variations in ICP occur with both the cardiac and respiratory cycles. Respiratory cycle variations are similar to those observed with CVP and PAWP measures, i.e., falling during spontaneous inspiration but rising with positive pressure breaths.

True

On average (except in patients with sepsis) ScvO2 values run about 5% higher than true mixed venous saturations. This is likely due to the contribution of deoxygenated blood from the heart (via the coronary sinus) in a true mixed venous sample.

True

Overinflating the cuff of an endotracheal tube (above 30 cm H2O) can decrease or occlude capillary blood flow, resulting in mucosal ischemia and tissue damage to the tracheal wall. Air leakage and 'silent' aspiration of pharyngeal secretions are complications of LOW cuff pressures, i.e., below 20 cm H2O.

True

Skin testing can support diagnosis of several common IgE-mediated allergic disorders, such as allergic asthma, rhinitis, and conjunctivitis; food allergies; drug allergies (primarily penicillin); venom allergies (e.g., bee/wasp venom); and latex allergy.

True

Sleep apnea refers to episodic cessation of breathing during sleep. Since brief apneic periods are normal during sleep, the sleep apnea syndrome is strictly defined as the occurrence of 5 or more apneic periods per hour, each lasting at least 10 seconds. Moreover, these episodes must manifest themselves in clinically signs or symptoms, such as polycythemia or day time hypersomnolence.

True

The Apgar score typically is performed at 1 and 5 minutes after birth and assesses the following 5 elements, each on a scale of 0 to 2: Appearance (color), Pulse/heart rate, Grimace (response to stimulation), Activity (muscle tone), and Respiratory effort (note the A-P-G-A-R mnemonic) . As described in this scenario, each of these 5 elements would be scored 1, for a total Apgar score of 5. At 1 minute an Apgar score of 7-10 is considered normal (10 being the maximum). Scores of 4-6 (as here) are intermediate and usually dictate the need for more intensive support. Infants with Apgar scores of 0-3 usually undergo aggressive resuscitation. Needed interventions should never be delayed in order to obtain the Apgar score, nor should these scores dictate resuscitation procedures.

True

The P/F ratio is used to judge the adequacy of oxygenation and is computed as the ratio of the PaO2 to the FIO2, i.e.,PaO2/FIO2

True

The blue-gray color of this patient's face and hands is called cyanosis, which is generally caused by low blood oxygen or hypoxemia.

True

The following conditions would appear as areas of increased radiodensity on a chest X-ray: atelectasis, consolidation, interstitial lung disease, pulmonary infiltrates/edema, pleural effusion, lung/mediastinal tumors, and calcification

True

The primary indications for capnography are (1) to assess the adequacy of ventilation (via PetCO2) in spontaneously breathing and mechanically ventilated patients, (2) to continuously evaluate the patient-ventilator interface, (3) to verify both endotracheal tube and supraglottic airway (e.g., LMA) placement, and (4) to evaluate circulatory status (via presence of expired CO2), especially during CPR

True

The total amount of blood pumped by the heart per minute, or cardiac output, is simply the product of the heart rate times the volume ejected by the left ventricle on each contraction, or stroke volume.

True

To determine the primary acid-base disturbance, first determine whether the pH is low (< 7.35 = academia) or high (> 7.45 = alkalemia). After judging the pH, you then assess the PaCO2. If the pH is low, the primary disturbance must be either respiratory acidosis (PaCO2 > 45 torr) or metabolic acidosis (PaCO2 £ 45 torr). With a high pH, the primary disturbance must be either respiratory alkalosis (PaCO2 < 35 torr) or metabolic alkalosis (PaCO2 ³ 35 torr).

True

Transillumination can quickly detect the presence of a pneumothorax in small infants. You should recommend transillumination for any high-risk infant (especially those receiving positive pressure ventilation) with clinical signs of unilateral pneumothorax, i.e., retractions, tachypnea, cyanosis, hypotension, and asymmetrical chest motion.

True

When obtaining a mixed venous sample from a pulmonary artery catheter, if the balloon is not deflated or the sample is withdrawn too quickly, you may contaminate the venous blood with blood from the pulmonary capillaries (oxygenated blood). The result is always a falsely high oxygen level

True

You encounter a patient who is sleepy but arouses easily and responds appropriately when stimulated. Which of the following terms best describes her level of consciousness?

lethargic

B-type natriuretic peptide (BNP) is a cardiac neurohormone secreted by cardiac muscle cells in response to ventricular volume expansion and pressure overload. BNP levels below 100 pg/mL can help rule out the presence of congestive heart failure (CHF), while levels above 500 pg/mL can help confirm this diagnosis

true

Blood urea nitrogen is a screening test used to assess renal function, total cholesterol is measured to assess risk for heart disease, and by themselves the serum electrolytes will not be diagnostic for CHF.

true

Capnography is NOT a replacement or substitute for assessing the PaCO2, nor useful for determining readiness to wean.

true

Exhaled carbon monoxide (eCO) measurements provide a quick, easy and noninvasive way for assessing a patient's smoking status. To make the measurement, the patient is instructed to take a deep breath and hold it for 15-20 seconds, after which they exhale into a portable monitor. The monitor samples the end-expired (alveolar) air and measures the eCO level in parts per million (ppm). In general, readings greater than 6 to 10 ppm strongly suggest that the patient has recently smoked.

true

Methacholine challenge testing is used mainly to assess the severity of airway hyperresponsiveness or evaluate occupational asthma

true

Peak expiratory flow rate monitoring is the primary means by which asthma patients can assess their airway tone over time, as well as changes in tone in response to bronchodilator therapy

true

Pre/post bronchodilator spirometry is used primarily to determine the effectiveness of bronchodilator therapy or the need for a change in the drug dose or frequency of administration

true

The quickest and best way to determine the extent of major trauma to the chest is to obtain a chest X-ray. A chest X-ray will reveal any fractured bones and also show the presence of lung contusions and any space-occupying lesions of the pleura or mediastimum (pneumothoraces, hemothoraces, etc).

true

When transillumination results are positive in infants with these signs (the affected side "lights up"), immediate chest tube insertion is indicated. On the other hand, if transillumination is negative but the infant still exhibits these signs, you should recommend an immediately chest X-ray

true