final rt 15

While percussing a patient's chest wall, you encounter an area that produces a decreased resonance to percussion. Which of the following are potential causes of this finding? 1. pneumothorax 2. pleural effusion 3. pneumonia 4. atelectasis a. 2 and 3 b. 2 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: C Any abnormality that increases lung tissue density, such as pneumonia, tumor, or atelectasis, results in a loss of resonance and decreased resonance to percussion over the affected area. Pleural spaces filled with fluid, such as blood or water, also produce decreased resonance to percussion.

Which medication is an anticholinergic bronchodilator? a. ipratropium bromide b. pirbuterol c. salmeterol d. terbutaline

ANS: A Inhaled anticholinergic agents, such as ipratropium bromide, are effective dilators of airway smooth muscles.

What should happen when the remote temperature sensor of a heated humidifier becomes disconnected or fails? 1. Power to the heater should be interrupted. 2. Auditory and visual alarms should trigger. 3. The unit's outlet valve should lock closed. a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: A

When stimulated, which of the following receptors cause bronchoconstriction? a. M3 b. M2 c. α1 d. β2

ANS: A

What is the normal range for P(A−a)O2 in a healthy 30-year-old person breathing room air? a. 0 to 10 mm Hg b. 5 to 15 mm Hg c. 10 to 20 mm Hg d. cannot predict

ANS: B For example, a healthy person has a P(A-a)O2 of 5 to 15 mm Hg while breathing room air.

When using a servo-controlled heated humidifier to deliver gas to an infant, the thermistor probe should be placed where? a. inside the circuit, outside the incubator, or away from the radiant warmer b. outside the circuit, inside the incubator, or away from the radiant warmer c. inside the circuit, inside the incubator, or away from the radiant warmer d. outside the circuit, outside the incubator, or away from the radiant warmer

ANS: A

Which of the following aerosol drug delivery devices would you recommend against using with a toddler or small child? 1. metered-dose inhaler (MDI) 2. small-volume jet nebulizer 3. dry powder inhaler 4. MDI, holding chamber, and mask a. 1 and 2 b. 1 and 3 c. 2 and 4 d. 3 and 4

ANS: A

Which of the following barrier precautions should be used when heated humidifier circuits are changed or removed? 1. wearing gloves 2. wearing goggles 3. 5-minute hand scrub a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: A

A physician orders bronchodilator drug therapy in combination with positive expiratory pressure (PEP). Which of the following methods could you use to provide this combined therapy? 1. Attach a dry powder inhaler in-line with the PEP apparatus. 2. Attach a metered-dose inhaler to the system's one-way valve inlet. 3. Place a small-volume nebulizer in-line with the PEP apparatus. a. 2 and 3 b. 1 and 2 c. 1, 2, and 3 d. 1 and 3

ANS: A

All of the following ventilator-related factors have a major effect on metered-dose inhaler delivery of aerosolized drugs during mechanical ventilation except: a. mode of support b. presence of positive end-expiratory pressure c. VT d. duty cycle

ANS: B

How often should heat-moisture exchangers be inspected and replaced? a. at least every shift b. when contaminated by secretions c. at least every day d. when condensate is visible

ANS: B

Which of the following are components of an ultrasonic nebulizer? 1. air-entrainment orifice 2. radiofrequency generator 3. nebulizer chamber 4. piezoelectric transducer 5. blower or fan a. 1, 3, and 4 b. 2, 3, 4, and 5 c. 1, 2, 3, 4, and 5 d. 3, 4, and 5

ANS: B

All of the following device-related factors have a major effect on pressurized metered-dose inhaler (MDI) delivery of aerosolized drugs during mechanical ventilation except: a. MDI propellant formula b. type of spacer or adapter used c. position of spacer in circuit d. timing of MDI actuation

ANS: A

An asthmatic patient in severe distress with wheezing and dyspnea is admitted to the emergency department. After a conducting a full assessment and obtaining a pretreatment baseline, you start the patient on albuterol with a small-volume jet nebulizer. You should continue assessing and documenting all appropriate variables before and after each treatment until what point? a. The patient's symptoms are relieved, or the peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEVl) exceeds 70% of "personal best." b. The patient's wheezing disappears, and the intensity of breath sounds decreases. c. The patient's symptoms are relieved, or the PEFR/FEVl returns to the predicted normal. d. The patient's SpO2 is above 90%, and the PEFR/FEVl returns to the predicted normal.

ANS: A

During routine use on an intubated patient, a heated humidifier should deliver inspired gas at which of the following? a. temperature of 33 ± 2° C, with a minimum of 30 mg/L of water vapor b. temperature of 37 ± 2° C, with a minimum of 44 mg/L of water vapor c. temperature of 20 ± 2° C, with a minimum of 10 mg/L of water vapor d. temperature of 30 ± 2° C, with a minimum of 24 mg/L of water vapor

ANS: A

For which of the following patients might you recommend bland aerosol therapy administration? 1. patient with upper airway edema 2. patient with a bypassed upper airway 3. patient who must provide a sputum specimen a. 1, 2, and 3 b. 2 and 3 c. 1 and 2 d. 1 and 3

ANS: A

In a dose-response assessment of a patient's response to a metered-dose inhaler bronchodilator, when would you stop increasing the dose? 1. when the peak expiratory flow rate improves <10% to 15% 2. when tachycardia occurs 3. when tremors are evident 4. when 6 to 8 puffs are delivered a. 1, 2, and 3 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: A

Proventil and Ventolin are brand names for which of the following β-adrenergic bronchodilators? a. albuterol b. isoetharine c. terbutaline d. metaproterenol

ANS: A

The temperature of gas delivered to a patient's airway by a servo-controlled heated humidifier should not vary by more than how much? a. 2° C b. 4° C c. 6° C d. 8° C

ANS: A

What is the dosage for ipratropium bromide (Atrovent)? a. 2 puffs four times daily b. 2 puffs three times daily c. 2 puffs twice daily d. 2 puffs every 12 hours

ANS: A

What is the duration of action for the formulation of ipratropium bromide plus albuterol sulfate (DuoNeb)? a. 4 to 6 hours b. 6 to 8 hours c. 8 to 10 hours d. 12 hours

ANS: A

Which of the following would you recommend to optimize drug delivery with a small-volume jet nebulizer (SVN) to an intubated, mechanically ventilated patient? 1. Increase dose to compensate for decreased delivery. 2. Place SVN in the inspiratory line 18 inches from the patient "wye." 3. Disconnect or bypass heated humidifier system. 4. Turn off flow-by or continuous flow while nebulizing. 5. Adjust ventilator volume or pressure limit for added flow. a. 1, 2, 3, and 5 b. 2, 3, and 4 c. 1, 2, and 3 d. 1, 2, 3, 4, and 5

ANS: A

While observing a patient's breathing, you note that the depth and rate first increase, then decrease, followed by a period of apnea. Which of the following are potential causes of this abnormality? 1. central nervous system disorder 2. congestive heart failure 3. metabolic acidosis a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: A

What term is used to describe the chest pain associated with blockage of the coronary arteries? a. angina b. myocarditis c. myalgia d. infarction

ANS: A A common cause of nonpleuritic chest pain is angina, which classically is a pressure sensation with exertion or stress and results from coronary artery occlusion.

A 23 year-old patient enters the emergency room complaining of dyspnea. The RT places the patient on oxygen as per hospital protocol and begins to interview the patient about her symptoms. She states that she's having difficulty taking a breath with chest tightness. Patient has a respiratory rate of 28 breaths/minute with a loose productive cough. During auscultation, the RT hears bilateral wheezing in the lungs. What is the most likely cause of the patient's symptoms? a. asthma b. bronchitis c. congestive heart failure d. emphysema

ANS: A A patient with asthma would suffer from dyspnea caused by the airway obstruction. Usually a patient with asthma will complain of chest tightness and difficulty to take a breath. Bilateral wheezing and a loose, productive cough are also signs of an asthma attack

Which of the following would you recommend as initial therapy for a patient admitted to the emergency department with acute airway obstruction (wheezing, cough, dyspnea, peak expiratory flow rate [PEFR] less than 60% predicted)? 1. Assess dose-response of metered-dose inhaler (MDI) albuterol (up to 12 puffs). 2. Provide up to three small-volume jet nebulizer (SVN) treatments with albuterol every 20 minutes. 3. Immediately begin continuous albuterol therapy at 15 mg/hr. a. 1 or 2 b. 1 or 3 c. 2 or 3 d. 1, 2, and 3

ANS: A According to the algorithm, a patient with acute airway obstruction (wheezing, cough, dyspnea, and PEFR less than 60% of predicted value) would receive up to three SVN treatments with a standard dose of albuterol, repeated at 20-minute intervals, or 4 puffs of pressurized MDI albuterol with a holding chamber (up to 12 puffs).

A physician orders bland water aerosol administration to a patient with an intact upper airway. Which of the following airway appliances could you use to meet this goal? 1. simple oxygen mask 2. face tent 3. T-tube 4. aerosol mask a. 2 and 4 b. 1, 2, and 3 c. 3 and 4 d. 2, 3, and 4

ANS: A Airway appliances used to deliver bland aerosol therapy include the aerosol mask, face tent, T-tube, and tracheostomy mask.

What is the most important factor contributing to the onset of pulmonary hypertension in the patient with COPD? a. alveolar hypoxia b. compression of pulmonary vasculature c. left ventricular failure d. loss of vascular surface

ANS: A Alveolar hypoxia, because of its potent pulmonary vasoconstrictive effect, is probably the most important factor contributing to pulmonary hypertension in patients with COPD. Sustained alveolar hypoxia causes pulmonary vasoconstriction and eventually medial hypertrophy, fibrosis of the intima, and narrowing of the lumen of the pulmonary blood vessels.

An increase in intensity and clarity of vocal resonance because of enhanced transmission of sound is referred to as which of the following? a. bronchophony b. vesicularity c. pectoriloquy d. egophony

ANS: A An increase in the intensity and clarity of vocal resonance produced by enhanced transmission of vocal vibrations is called bronchophony.

What term best describes a loud, high-pitched continuous sound heard (often with the unaided ear) primarily over the larynx or trachea during inhalation in patients with upper airway obstruction? a. stridor b. rhonchi c. crackles d. wheeze

ANS: A Another continuous type of adventitious lung sounds heard in certain situations, primarily over the larynx and trachea during inhalation, is stridor. Stridor is a loud, high-pitched sound, which sometimes can be heard without a stethoscope. Most common in infants and small children, stridor is a sign of obstruction in the trachea or larynx. Stridor is most often heard during inspiration.

Increasing the flow through an unheated bubble humidifier has which of the following effects? a. decreasing the water vapor content b. decreasing the relative humidity c. increasing the water vapor content d. increasing the relative humidity

ANS: A As gas flow increases, these devices become less efficient as the reservoir cools and contact time is reduced.

For which of the following patient groups is use of a dry power inhaler (DPI) for bronchodilator administration NOT recommended? 1. infants and children younger than 5 years 2. patients with an acute bronchospastic episode 3. patients requiring maintenance therapy a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A Because infants, small children (younger than 5 years) (Figure 36-17), and those not able to follow instructions cannot develop flow this high, these patient groups cannot use DPIs. Patients with severe airway obstruction also may not be able to achieve the required flow; therefore, DPIs should not be used in the management of acute bronchospasm.

Which of the following are TRUE regarding glucocorticoids? 1. They work through activation of intracellular receptors. 2. Relief is immediate. 3. Daily compliance is essential to controlling inflammation in asthma. 4. They work in a similar fashion to adrenergic bronchodilators. a. 1 and 3 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: A Because steroid action involves modification of cell transcription, full antiinflammatory effects require hours to days. It is important for patients to understand that inhalation of an aerosolized steroid will not provide immediate relief as with an adrenergic bronchodilator. However, daily compliance with the inhaled medication is essential to controlling the inflammation of asthma.

When using a chamber-style adapter with a metered-dose inhaler (MDI) to deliver a bronchodilator to a patient receiving mechanical ventilation, with what would you coordinate MDI firing? a. beginning of inspiration b. beginning of exhalation c. end of inspiration d. middle of inspiration

ANS: A Box 36-9 outlines the optimal technique for drug delivery by pressurized MDI to intubated patients undergoing mechanical ventilation.

The unit residence asked you to reduce the risk of contamination caused by condensation in the circuit of a mechanically ventilated patient. Which of the following would help to reduce or eliminate condensation in this patient's circuit? a. using a heat and moisture exchange (HME) b. by draining the circuit on a daily basis c. by not using any form of heater at all d. by lowering the temperature in the heater

ANS: A By replacing an active humidification system by a passive humidification one (HME), there will be less condensation in the circuit because no water is being used to heat and moisten the air, but instead the patient's own body heat is used. Draining the circuit daily, not using heat, or lowering the heater temperature are not acceptable and may place the patient at risk of infection caused by inspisated secretions among other consequences.

For which of the following patients would you recommend against using a flow-triggered metered-dose inhaler (MDI) as the sole bronchodilator delivery system? a. patient likely to develop acute severe bronchospasm b. stable elderly patient on maintenance bronchodilator therapy c. teenage asthmatic who refuses to use a holding chamber d. patient who cannot coordinate MDI firing with inhalation

ANS: A Caution may be appropriate in ordering breath-triggered pMDIs for small children and patients prone to severe levels of airway obstruction.

Which factor is associated with a decrease in the plasma levels of theophylline in an asthmatic patient? a. cigarette smoking b. heart failure c. hepatic disease d. viral infections

ANS: A Conditions that tend to decrease plasma levels of theophylline include cigarette smoking and the use of medications that increase hepatic clearance, such as phenobarbital.

Characteristics of a servo-controlled heated humidifier include all of the following except: a. monitors heater temperature b. adjusts heater power automatically c. provides automatic heater shutdown d. includes temperature safety alarms

ANS: A Conversely, a servo-controlled heating system monitors temperature at or near the patient's airway using a thermistor probe. The controller then adjusts heater power to achieve the desired airway temperature. Both types of controller units usually incorporate alarms and alarm-activated heater shutdown. Box 35-4 outlines key features of modern heated humidification systems.

What medication is currently the most effective for the treatment of asthma? a. corticosteroids b. fast-acting β2-agonists c. long-acting β2-agonists d. nonsteroidal antiinflammatory drugs

ANS: A Corticosteroids are the most effective medication currently available for the treatment of asthma.

Which of the following are indications for aerosolized administration of dornase alfa? 1. presence of nonpurulent mucoid secretions 2. management of cystic fibrosis 3. reduction of the frequency of exacerbations due to respiratory infection 4. management of bronchospasm a. 2 and 3 only b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: A Dornase alfa is indicated in the management of cystic fibrosis to reduce the frequency of respiratory infections requiring parenteral antibiotics and to improve pulmonary function of these patients.

For which of the following patients would you select a heated humidifier? 1. patient receiving oxygen through a bypassed upper airway 2. patient receiving long-term mechanical ventilation 3. patient receiving oxygen through an oronasal mask a. 1 and 2 b. 2 and 3 c. 2 d. 3

ANS: A Heated humidifiers are used mainly for patients with bypassed upper airways and/or for those receiving mechanical ventilatory support.

Why should you NOT heat the reservoirs of a bubble humidifier used with an oronasal oxygen delivery system? a. Condensate will obstruct the delivery tubing. b. Heating will melt the reservoir or cause a fire. c. Heating will absorb the extra water vapor. d. Heating will causes too much aerosol impaction.

ANS: A Heating the reservoirs of these units can increase humidity content but is not recommended because the resulting condensate tends to obstruct the small-bore delivery tubing to which they connect.

Which of the following is a TRUE statement about the cause of systemic hypertension in adult patients? a. The cause is often unknown. b. The cause is often related to poor diet. c. The cause is often related to a lack of exercise. d. The cause is often related to sleep apnea.

ANS: A Hypertension is a common medical problem in adults and the cause is often unknown.

When assessing a patient's response to bronchodilator therapy, you notice a decrease in wheezing accompanied by an overall decrease in the intensity of breath sounds. Which of the following is most likely? a. increasing airway obstruction b. improving ventilation/perfusion ratio () c. decreasing airway obstruction d. deteriorating oxygenation

ANS: A In terms of breath sounds, a decrease in wheezing accompanied by an overall decrease in the intensity of breath sounds indicates worsening airway obstruction or patient fatigue.

With which of the following devices are therapeutic aerosols generated? 1. atomizers 2. nebulizers 3. humidifiers a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A In the clinical setting, medical aerosols are generated with atomizers, nebulizers, or inhalers.

While percussing a patient's chest wall, you detect an abnormal increase in resonance. Which of the following are possible causes of this finding? 1. asthma 2. pneumothorax 3. emphysema 4. pneumonia a. 1, 2, and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

ANS: A Increased resonance can be detected in patients with hyperinflated lungs. Hyperinflation can result from acute or chronic bronchial obstruction, such as asthma or emphysema.

Proper use of a dry power inhaler (DPI) requires that the patient be able to do which of the following? a. generate inspiratory flows of 60 L/min or higher b. exhale forcibly through the device before drug delivery c. inhale slowly (less than 0.5 L/sec) and perform a breath-hold d. coordinate firing of the DPI with inspiration

ANS: A Individual doses are inhaled as soon as the seal is broken. The high peak inspiratory flow rates (greater than 60 L/min) required to dispense the drug powder from most current DPI designs result in a pharyngeal dose comparable with that received from a typical pressurized metered-dose inhaler without an add-on device.

Which of the following devices would you recommend to administer bland water aerosol to an infant or small child? a. face tent b. croup tents c. T-tube d. aerosol mask

ANS: A Infants and small children may not readily tolerate direct airway appliances such as masks, so enclosures such as mist tents and aerosol hoods are used to deliver bland aerosol therapy to these patients.

Which of the following changes in the characteristics of wheezing indicate improvement in airway obstruction following bronchodilator therapy? a. lower pitch, shorter duration b. higher pitch, shorter duration c. lower pitch, longer duration d. higher pitch, longer duration

ANS: A It is useful to monitor the pitch and duration of wheezing. Improved expiratory flow is associated with a decrease in the pitch and length of the wheezing. For example, if high-pitched wheezing is present during the entire expiratory time before treatment but becomes lower pitched and occurs only late in exhalation after therapy, the pitch and duration of the wheeze have diminished. This suggests that the degree of airway obstruction has decreased.

Which of the following is the most common source of patient infections? a. large-volume nebulizers b. small-volume nebulizers c. internal circuits of a ventilator d. oxygen therapy devices

ANS: A Large-volume nebulizers are the worst offenders.

In which of the following conditions would late inspiratory crackles be most likely to occur? 1. emphysema 2. pulmonary fibrosis 3. pneumonia 4. pulmonary edema 5. atelectasis a. 2, 3, 4, and 5 b. 1, 3, and 5 c. 3, 4, and 5 d. 1, 2, 4, and 5

ANS: A Late-inspiratory crackles are most common in patients with respiratory disorders that reduce lung volume. These disorders include atelectasis, pneumonia, pulmonary edema, and pulmonary fibrosis (Table 15-4).

What classification of drug would the leukotriene inhibitors fall under? a. antiinflammatory b. corticosteroid c. long-acting bronchodilator d. short-acting bronchodilator

ANS: A Leukotrienes are mediators of inflammation and bronchoconstriction and are thought to play a role in the pathogenesis of asthma. Three leukotriene antagonists are currently available for the treatment of asthma.

What is the primary fate of inhaled aerosol particles that are between 1 and 0.5 μm? a. Most are cleared during exhalation. b. Most deposit in the central airways. c. Most deposit in the upper airway. d. Most deposit in the alveoli.

ANS: A Particles between 1 and 0.5 μm are so stable that most remain in suspension and are cleared with the exhaled gas.

Which of the following equipment could be powered by a small diaphragm or turbine air compressor? 1. small-volume medication nebulizer 2. all-purpose large-volume jet nebulizer 3. intermittent positive-pressure breathing device a. 1 b. 1 and 2 c. 2 and 3 d. 1, 2, and 3

ANS: A Small diaphragm or turbine compressors are ideal for powering devices such as small-volume medication nebulizers.

Central mechanisms cause contraction and increased resistance to blood flow mainly through which of the following? a. adrenergic stimulation and the release of norepinephrine b. cholinergic stimulation and the release of acetylcholine c. cholinergic stimulation and the release of norepinephrine d. stimulation of specialized α-adrenergic receptors

ANS: A Smooth muscle contraction and increased flow resistance are mostly caused by adrenergic stimulation and the release of norepinephrine.

Which of the following are beneficial effects of using a holding chamber with a metered-dose inhaler (MDI)? 1. reduction in oropharyngeal aerosol deposition 2. decrease in need for hand-breath coordination 3. elimination of medication waste a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: A Spacers and valved holding chambers are pressurized MDI accessory devices designed to reduce both oropharyngeal deposition and/or the need for hand-breath coordination.

On palpating the neck region of a patient on a mechanical ventilator, you notice a crackling sound and sensation. What is the most likely cause of this observation? a. subcutaneous emphysema b. upper bronchial obstruction c. pneumonia of the upper lobes d. atelectasis of the upper lobes

ANS: A Subcutaneous emphysema is caused by air trapped in the subcutaneous tissues and is usually due to an air leak from the lung.

To minimize a patient's infection risk between drug treatments with a small-volume jet nebulizer (SVN), what would you do? a. Rinse the SVN with sterile water; air dry. b. Carefully repackage the SVN in its wet state. c. Rinse the SVN with tap water; run until dry. d. Throw out the SVN after every treatment.

ANS: A The Centers for Disease Control and Prevention recommends that nebulizers be cleaned and disinfected, or rinsed with sterile water, and air-dried between uses.

For which of the following purposes might a Venturi tube be used? 1. to restore fluid pressure distal to a restricted orifice 2. to help keep entrainment ratios constant with varying flows 3. to make possible entrainment of large volumes of gas a. 1, 2, and 3 b. 2 and 3 c. 1 and 2 d. 1 and 3

ANS: A The Venturi tube, as compared with a simple air injector, provides greater entrainment. Moreover, this design helps keep the percentage of entrained fluid constant, even when the total flow varies. A Venturi tube widens just after its jet or nozzle. As long as the angle of dilation is less than 15 degrees, this widening helps restore fluid pressure back toward prejet levels. However, the Venturi tube has one major drawback—any buildup of pressure downstream from the entrainment port decreases fluid entrainment.

A neonatologist is concerned about the possibility of hearing damage occurring to a premature infant receiving bland water aerosol delivered via air-entrainment nebulizers inside an incubator or isolette. Which of the following would you recommend as the best way to overcome this problem? a. Use a heated passover humidifier instead. b. Use an ultrasonic nebulizer system instead. c. Place sound baffles in the aerosol tubing. d. Place earplugs in the infant's outer ears.

ANS: A The best way to avoid this problem and further minimize infection risks is to use heated passover humidification instead of nebulization.

The greater the temperature of the gas, the: a. more water vapor it can hold b. less water vapor it can hold c. less efficient the humidifier is d. more water vapor is lost

ANS: A The greater the temperature of a gas, the more water vapor it can hold (increased capacity).

What is the most common cause of jugular venous distention (JVD)? a. right-sided heart failure b. arterial hypoxemia c. tension pneumothorax d. acute systemic hypertension

ANS: A The most common cause of JVD is the failure of the right side of the heart.

Indications of an adverse drug response during continuous bronchodilator therapy include all of the following except: a. decreased consciousness b. worsening tachycardia c. vomiting d. palpitations

ANS: A The patient must be observed for adverse drug responses, including worsening tachycardia, palpitations, and vomiting.

In which of the following clinical settings would hyperkalemia be a significant problem? a. during weaning from mechanical ventilation b. in a patient with pleural effusion c. in a patient with kyphoscoliosis d. during spirometry testing

ANS: A The potassium level is of particular interest in the patient being weaned from mechanical ventilation, because both hyperkalemia and hypokalemia may render the diaphragm weak and less effective.

The relief valve on a bubble humidifier serves which of the following functions? 1. It indicates when flow has been interrupted. 2. It protects the device from pressure damage. 3. It warns you when the water level is low. a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: A The relief valve on a bubble humidifier serves to warn of flow-path obstruction and to prevent bursting of the humidifier bottle.

Which of the following medications has NOT been delivered as an aerosol by a respiratory therapist? a. inotropics b. bronchodilators c. mucolytics d. antibiotics

ANS: A There has been a proliferation of medications designed for aerosol administration, including bronchodilators, mucolytics, antibiotics, and anti-inflammatory agents.

Which of the following is/are advantages of the digital blood pressure measurement devices? a. They reduce the risk of human error. b. They reduce the cost. c. They have an alarm. d. They measure blood pressure and stroke volume.

ANS: A These devices do not require the healthcare provider to listen for the Korotkoff sounds and eliminate variances in recorded blood pressures based on human perception. They are considered to be very accurate and simply require the clinician to apply the blood pressure cuff correctly and press the start button. Subsequently, the device takes over and inflates and deflates the cuff automatically. The blood pressure and pulse rate are then displayed on a digital screen.

What disease is associated with a barrel chest? a. emphysema b. heart failure c. pneumonia d. pleural effusions

ANS: A This abnormal increase in anteroposterior diameter is called barrel chest and is associated with emphysema.

In checking a servo-controlled heated-wire humidifier system, you notice that a few drops of condensate tend to form but only near the patient's airway. Based on this observation, what can you conclude? a. The gas at the airway is fully saturated. b. The temperature setting of the heater is too high. c. The airway temperature exceeds the dew point. d. The temperature setting of the heater is too low.

ANS: A To ensure that the inspired gas is being properly conditioned, clinicians should always adjust the temperature differential to the point that a few drops of condensation form near the patient wye. Lacking direct measurement of humidity, observation of this minimal condensate is the most reliable indicator that the gas is fully saturated at the specified temperature.

When using nebulizers, where should you place them to minimize risk of contamination? a. in the inspiratory limb only, at a high point in the circuit b. in both the expiratory and inspiratory limbs, at high points in the circuit c. in the expiratory limb only, at a low point in the circuit d. in both the expiratory and inspiratory limbs, at low points in the circuit

ANS: A To minimize this risk, place nebulizers in a superior position, so that any condensate travels downstream from the nebulizer.

All of the following oxygenation measures support a patient's readiness to wean except: a. PaO2/PAO2 (a/A) = 0.45 b. PaO2/FIO2 (P/F) = 110 c. PAO2 - PaO2 = 240 mm Hg d. physiologic shunt () = 12%

ANS: B

On the average, what is the range of the actual pulmonary deposition of small-volume jet nebulizer aerosolized drugs in intubated patients receiving mechanical ventilation? a. 1.5% to 3.0% b. 3.5% to 6.0% c. 6.5% to 9.0% d. 9.5% to 15.0%

ANS: A Under normal conditions with heated humidification and standard jet nebulizers, pulmonary deposition ranges between 1.5% and 3.0%.

What is the goal of using an unheated bubble humidifier with oronasal oxygen delivery systems? a. Raise the humidity of the gas to ambient levels. b. Fully saturate the inspired gas to body temperature, ambient pressure, saturated (BTPS) conditions. c. Cool the gas down to below room temperature. d. Fully saturate the inspired gas to ambient temperature, ambient pressure, saturated (ATPS) conditions.

ANS: A Unheated bubble humidifiers are commonly used with oronasal oxygen delivery systems (see Chapter 38) the goal is to raise the water vapor content of the gas to ambient levels.

Which of the following agents has been associated with increased intraocular pressure? a. anticholinergics b. epinephrine c. β2-agonists d. antibiotics

ANS: A Use of anticholinergic agents has been associated with increased ocular pressure, which could be dangerous for patients with glaucoma.

Soft, muffled sounds heard mainly during inspiration over the peripheral lung parenchyma best describe which of the following breath sounds? a. vesicular b. bronchovesicular c. bronchial d. tracheal

ANS: A When auscultating over the lung parenchyma of a healthy individual, soft, muffled sounds are heard. These normal breath sounds, referred to as vesicular breath sounds, are lower in pitch and intensity than bronchovesicular breath sounds. Vesicular sounds are heard primarily during inhalation, with only a minimal exhalation component

During examination of a patient's extremities, you press firmly for a brief period on a fingernail. You observe that it takes about 5 seconds for the color to return to the nail bed. This finding is most consistent with which of the following? a. reduction in cardiac output or poor peripheral perfusion b. presence of a disorder causing chronic hypoxemia c. reduction in venous return to the right side of the heart d. presence of a disorder causing systemic hypertension

ANS: A When cardiac output is reduced and digital perfusion is poor, capillary refill is slow, taking several seconds to complete. In healthy individuals with good cardiac output and digital perfusion, capillary refill time is less than 3 seconds.

All of the following are TRUE when heated wire circuits are used with heated humidifiers except: a. The humidifier operates at a higher temperature. b. There is less condensate and a reduced need for drainage. c. Cost savings (less water and staff time) are realized. d. There is less infection risk for both patient and caregivers.

ANS: A When heated-wire circuits are used, the humidifier heats gas to a lower temperature (32° to 40° C) than it does with conventional circuits (45° to 50° C). The reduction in condensate in the tubing results in less water use, reduced need for drainage, and less infection risk for both patient and healthcare workers.

An emergency room patient is lying on his bed with his head elevated at a 45-degree angle. An RT, who is coming to examine the patient, notices that the patient's jugular vein extends approximately 7 cm above his sternal angle. What can the RT assume about this patient's condition? a. Cor pulmonale b. pneumonia c. Kussmaul's sign d. pneumothorax

ANS: A When lying in a supine position, a healthy individual has neck veins that are full. When the head of the bed is elevated gradually to a 45-degree angle, the level of the blood column descends to a point no more than a few centimeters above the clavicle. With elevated venous pressure, the neck veins may be distended as high as the angle of the jaw, even when the patient is sitting upright. Jugular venous distention (JVD) is present when the jugular vein is enlarged and it can be seen more than 3 to 4 cm above the sternal angle. The most common cause of JVD is heart failure (cor pulmonale). Heart failure frequently occurs with advanced COPD because of hypoxemia. This causes chronic pulmonary vasoconstriction and hypertension which leads to right heart failure from the excessive workload. Other conditions associated with JVD include left heart failure, cardiac tamponade, tension pneumothoraces, and mediastinal tumors.

What is indicated by the presence of central cyanosis? a. respiratory failure b. circulatory failure c. anemia d. hypotension

ANS: A When respiratory disease reduces arterial oxygen content, cyanosis (a bluish discoloration of the tissues) may be detected, especially around the lips and in the oral mucosa of the mouth (central cyanosis).

A patient on mechanical ventilation was given 4 puffs of albuterol 5 minutes ago through a metered-dose inhaler (MDI) and holding chamber placed 18 inches from the circuit's airway connector. The patient continues to exhibit clinical signs of increased airway resistance but has demonstrated no apparent side effects from the drug. Which of the following would you recommend at this time? a. Discontinue the albuterol and switch to a systemic bronchodilator. b. Repeat administration until the desired response is achieved. c. Remove the circuit-holding chamber and repeat MDI actuation. d. Move the MDI closer to the patient's airway and repeat use.

ANS: B

A patient receiving ventilatory support is being provided with humidification using a heat-moisture exchanger (HME). A physician orders a bronchodilator drug administered through a metered-dose inhaler (MDI) via the ventilator circuit. Which of the following must be performed to ensure delivery of the drug to the patient? a. The inspiratory flow setting of the ventilator should be increased. b. The HME must be removed from the circuit during MDI use. c. The VT setting of the ventilator should be decreased. d. A heated humidifier should replace the HME when using the MDI.

ANS: B

After actuating a metered-dose inhaler with a holding chamber, what should the patient be instructed to do? a. Take a large breath and hold it for at least 5 seconds. b. Continue to breathe through the device for three breaths. c. Immediately exhale as fast and as much as possible. d. Take one quick breath and remove the holding chamber.

ANS: B

After initially conducting a pre- and post-bronchodilator assessment on a stable asthmatic patient admitted to the hospital, how often would you recommend reassessment of peak expiratory flow rate/forced expiratory volume in 1 second? a. with each treatment b. twice daily c. once per day d. every other day

ANS: B

All of the following indicate a potential need for administration of a water or isotonic saline aerosol except: a. stridor or brassy, croup-like cough b. evidence of increased volume of secretions c. hoarseness after extubation d. patient discomfort after bronchoscopy

ANS: B

Which of the following would indicate that administration of a bland water aerosol to a patient with post-extubation upper airway edema was having the desired effect? 1. decreased work of breathing 2. improved vital signs 3. decreased stridor or dyspnea 4. improved oxygen saturation a. 1, 2, and 3 b. 1, 2, 3, and 4 c. 3 and 4 d. 1, 2, and 4

ANS: B

What is the most reliable indicator of a change in airway resistance due to bronchodilator administration during mechanical ventilation? a. change in slope of the expiratory flow-volume curve b. difference between peak airway and plateau pressures c. change in peak expiratory flow during passive exhalation d. difference between plateau and baseline (PEEP) pressures

ANS: B A change in the differences between peak and plateau pressures (the most reliable indicator of a change in airway resistance during continuous mechanical ventilation) can be measured.

What device adds molecular water to gas? a. agitator b. humidifier c. nebulizer d. atomizer

ANS: B A humidifier is a device that adds molecular water to gas.

A creaking or grating sound that increases in intensity with deep breathing and is similar to coarse crackles, but is not affected by coughing, best describes which of the following? a. rhonchi b. friction rub c. rales d. wheezing

ANS: B A pleural friction rub is a creaking or grating sound that occurs when the pleural surfaces become inflamed and the roughened edges rub together during breathing, as in pleurisy. It may be heard only during inhalation but often is identified during both phases of breathing.

What is the major problem with using large-volume nebulizers for continuous aerosol drug therapy? a. decreased pulmonary deposition b. drug reconcentration and toxicity c. frequent interruption of therapy d. greater waste of drug

ANS: B A potential problem with continuous bronchodilator therapy is drug concentration increase.

What breathing pattern is associated with severe atelectasis? a. rapid and deep b. rapid and shallow c. slow and shallow d. slow and deep

ANS: B A significant reduction in lung volume, such as that which occurs with atelectasis, usually results in rapid, shallow breathing.

Which of the following best describes a proper a dose-response assessment of a metered-dose inhaler (MDI) bronchodilator? a. Give 4 puffs one after the other, wait 1 minute, repeat up to 16 puffs. The best dose is the highest dose given without side effects. b. Give 4 puffs spaced 1 to 2 minutes apart; repeat up to 12 puffs with continued improvement. The best dose provides maximum subjective relief and the highest peak expiratory flow rate (PEFR) without side effects. c. Give 12 puffs 1 minute apart; repeat every 20 minutes until maximum relief of symptoms is achieved without side effects. d. Give 2 puffs 1 to 2 minutes apart; repeat up to 6 puffs with continued improvement. The best dose provides maximum subjective relief and the highest PEFR without side effects.

ANS: B A simple albuterol dose-response titration involves giving an initial 4 puffs (90 μg/puff) at 1-minute intervals through an pressurized MDI with a holding chamber. If after 5 minutes, airway obstruction is not relieved, the respiratory therapist gives 1 puff per minute until symptoms are relieved, heart rate increases to more than 20 beats/min, tremors increase, or 12 puffs are delivered. The best dose is that which provides maximum relief of symptoms and the highest PEFR without side effects.

The key difference between a metered-dose inhaler (MDI) holding chamber and a spacer is that the holding chamber incorporates which of the following? a. larger enclosed space b. one-way inspiratory valve c. heated chamber d. series of baffles

ANS: B A spacer is a simple valveless extension device that adds distance between the pMDI outlet and the patient's mouth.

Which of the following medications is indicated for REGULAR use in patients with stable COPD? a. antibiotics b. β2-agonists c. corticosteroids d. methylxanthines

ANS: B Although the airflow obstruction from emphysema itself is irreversible, most (up to two thirds) patients with stable COPD will demonstrate a reversible component of airflow obstruction, defined as a 12% and 200-ml rise in the post-bronchodilator FEV1 and/or FVC. For this reason, as indicated in an algorithm developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), bronchodilator therapy is recommended for patients with COPD.

Which of the following nebulizers uses a piezoelectric transducer to generate liquid particle aerosols? a. hydrodynamic nebulizer b. ultrasonic nebulizer c. jet nebulizer d. centrifugal nebulizer

ANS: B An ultrasonic nebulizer is an electrically powered device that uses a piezoelectric crystal to generate aerosol.

All of the following are true regarding large-volume jet nebulizers except: a. A variable air-entrainment port allows air mixing and different FIO2 values. b. Liquid particles are generated by mechanical vibration energy. c. They are pneumatically powered and attach directly to a flowmeter. d. Baffling causes impaction or removal of large, unstable particles.

ANS: B As depicted in Figure 35-14, these devices are pneumatically powered, attaching directly to a flow meter and compressed gas source. Liquid particle aerosols are generated by passing gas at a high velocity through a small "jet" orifice. The resulting low pressure at the jet draws fluid from the reservoir up to the top of a siphon tube, where it is sheared off and shattered into liquid particles. The large, unstable particles fall out of suspension or impact on the internal surfaces of the device, including the fluid surface (baffling). The remaining small particles leave the nebulizer through the outlet port, carried in the gas stream. A variable air-entrainment port allows air mixing to increase flow rates and to alter FIO2 levels.

Which of the following would you recommend as the solution used to fill a bubble humidifier used for home O2 therapy? a. sterile water b. distilled water c. 0.9% saline d. tap water

ANS: B Because the mineral content of tap water may be high (hard water), water used in these humidifiers should be distilled.

What is the advantage of COPD patients breathing through pursed-lips during exhalation? a. helps the patient focus on breathing b. promotes more complete emptying of the lungs c. reduces the patient's anxiety level d. improves arterial pH levels

ANS: B Breathing through pursed lips during exhalation creates resistance to flow. The increased resistance causes development of a slight backpressure in the small airways during exhalation, which prevents their premature collapse and allows more complete emptying of the lung.

To protect against obstructed or kinked tubing, simple bubble humidifiers incorporate which of the following? a. HEPA outlet filter b. pressure relief valve c. automatic hygrometer d. electronic alarm system

ANS: B Bubble humidifiers incorporate a simple pressure-relief valve, or pop-off.

Advantages of passover humidifiers include all of the following except: a. They add minimal flow resistance to breathing circuits. b. They do not require heating to maintain body temperature, ambient pressure, saturated (BTPS) conditions. c. They do not generate any bacteria-spreading microaerosol. d. They can maintain water vapor saturation at high flows.

ANS: B Compared with bubble humidifiers, passover humidifiers offer several advantages. First, unlike bubble devices, they can maintain saturation at high flow rates. Second, they add little or no flow resistance to spontaneous breathing circuits. Third, they do not generate any aerosols, and thus pose a minimal risk for spreading infection.

Inspiratory crackles in patients without excess secretions are most commonly associated with which of the following? a. reduced chest-wall sound transmission b. airways popping open during inspiration c. complete obstruction of the upper airway d. mucosal edema or inflammation

ANS: B Crackles also may be heard in patients without excess secretions. These crackles occur when collapsed airways pop open during inspiration. Airway collapse or closure can occur in peripheral bronchioles or in larger, more proximal bronchi.

Which of the following should be assessed during the administration of mucolytic agents? 1. breathing pattern and rate 2. monitoring peak flow changes 3. patient's reaction to treatment 4. monitoring for presence of hydrogen sulfide (a rotten egg odor), which means that the acetylcysteine (Mucomyst) is no longer active a. 1 and 3 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: B During treatment and short term: • Instruct and then verify correct use of aerosol nebulization system, including cleaning. • Assess therapy based on indication for drug: mucolysis and improved clearance of secretions. • Monitor airflow changes or adverse effects such as a decrease in FEV1. • Assess breathing pattern and rate. • Assess patient's subjective reaction to treatment (changes in breathing effort or pattern). • Discontinue therapy if patient experiences adverse reactions.

To deal with incidents of hypoxemia, dyspnea, or airway hyperreactivity during physical reconditioning activities, which of the following should be available in the rehabilitation area? 1. intubation tray 2. bronchodilator agents 3. emergency oxygen a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: B Emergency oxygen and bronchodilator medications should also be maintained in the rehabilitation area.

Which of the following describes the mass of drug leaving the mouthpiece of a nebulizer as aerosol? a. single dose b. emitted dose c. multiple dose d. output dose

ANS: B For drug delivery systems, emitted dose describes the mass of drug leaving the mouthpiece of a nebulizer or inhaler as aerosol.

A patient receiving nasal oxygen at 3 L/min complains of nasal dryness and irritation. Which of the following actions would be appropriate? a. recommending that the flow be decreased to 2 L/min b. adding a humidifier to the delivery system c. recommending that the flow be increased to 4 L/min d. switching to a simple mask at 3 L/min

ANS: B For the occasional patient who complains of nasal dryness or irritation when receiving low-flow oxygen, a humidifier should be added to the delivery system.

Which of the following devices would you select to deliver an aerosolized bronchodilator to a young child? a. metered-dose inhaler (MDI) and spacer b. MDI, holding chamber, and mask c. MDI and holding chamber d. dry power inhaler

ANS: B Holding chambers with masks are available for use in the care of infants, children, and adults.

To minimize laryngeal swelling, a physician orders "continuous aerosol therapy" after the extubation of a patient. Which of the following specific approaches would you recommend? a. heated mist therapy through a jet nebulizer and aerosol mask b. cool mist therapy through a jet nebulizer and aerosol mask c. oxygen therapy through a "venti-mask" and bubble humidifier d. racemic epinephrine or saline through a small jet nebulizer

ANS: B If humidity/aerosol therapy is indicated, most clinicians suggest a cool mist immediately after extubation.

A patient with chronic obstructive pulmonary disease (COPD) is receiving heated water aerosol treatments through a jet nebulizer four times daily as a supplement to other bronchial hygiene measures designed to aid in mobilizing retained secretions. After each session, you notice the presence of moderate wheezing. Which of the following recommendations would you make to the physician? a. Discontinue the heated water aerosol treatments. b. Consider prior treatment with a bronchodilator. c. Switch to a higher-density aerosol (e.g., ultrasonic). d. Discontinue the other bronchial hygiene measures.

ANS: B If the physician still requests bland aerosol therapy for such a patient, pretreatment with a bronchodilator may be needed.

When checking an oxygen delivery system that incorporates a bubble humidifier running at 6 L/min, you occlude the delivery tubing, and the humidifier pressure relief immediately pops off. What does this indicate? a. malfunctioning humidifier b. normal, leak-free system c. malfunctioning flowmeter d. leak in the delivery tubing

ANS: B If the system is obstructed at or near the patient interface and the pop-off sounds, the system is leak free.

After administering a 30-minute bland water aerosol treatment to a dehydrated elderly patient with chronic bronchitis, you note increased wheezing and a general decrease in the intensity of breath sounds. Which of the following has probably occurred? a. Reactive bronchospasm has occurred and worsened airway obstruction. b. Inspissated secretions have swollen and worsened airway obstruction. c. Nothing; this is a normal response to bland aerosol therapy. d. The patient is developing atelectasis due to overhydration.

ANS: B In addition to overhydration of the patient, inspissated pulmonary secretions also can swell after high-density aerosol therapy, worsening airway obstruction.

What is indicated by retractions? a. an increase in PaCO2 b. an increase in the work of breathing c. a decrease in blood flow to the lungs d. reduce lung volumes

ANS: B Increased work of breathing also can result in retractions.

You increase the fill volume from 2 to 4 ml in a small-volume jet nebulizer being used to administer a bronchodilator agent with an aerosol. What effect will this have on the amount of drug delivered? a. no effect b. increase c. decrease d. more waste

ANS: B Increasing the fill volume allows a greater proportion of active medication to be nebulized.

What treatment usually causes improvement in the initial treatment of transient tachypnea of the newborn? a. mechanical ventilation with PEEP b. oxygen with low FIO2 c. bronchodilators d. mucolytics

ANS: B Infants with TTN usually respond readily to a low FIO2 by infant oxygen hood or nasal cannula

Which bronchodilator is commonly used in the hospital management of acute asthma exacerbation but is not the first-line bronchodilator? a. albuterol b. ipratropium bromide c. salmeterol d. terbutaline

ANS: B Ipratropium also can be used in treating acute asthma when first-line bronchodilators are ineffective.

What may be the drug of choice for managing atopic asthma in children? a. albuterol b. cromolyn c. salmeterol d. theophylline

ANS: B Many believe that cromolyn is the drug of choice for atopic children with asthma.

All of the following drugs or drug categories have been associated with increased airway resistance and bronchospasm during aerosol administration except: a. steroids b. albuterol c. acetylcysteine d. antibiotics

ANS: B Medications such as acetylcysteine, antibiotics, steroids, cromolyn sodium, ribavirin, and distilled water have been associated with increased airway resistance and wheezing during aerosol therapy.

Which of the following are first-line aerosol drug delivery systems for home care patients? 1. small-volume nebulizer 2. dry powder inhaler 3. metered-dose inhaler a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: B Most pulmonary drug agents are available in either metered-dose inhaler or dry powder inhaler form.

Your patient has a P(A-a)O2 of 200 mm Hg while breathing 100% oxygen. What is the estimated percentage shunt? a. 5% b. 10% c. 20% d. 30%

ANS: B P(A - a)O2 increases to 100 to 150 mm Hg when the person is breathing 100% oxygen.

What is the best way to confirm that an asthmatic outpatient can properly self-manage a newly prescribed aerosol drug therapy? a. Have the patient describe the proper procedural steps. b. Have the patient provide a repeat or return demonstration. c. Have the patient take a written or oral quiz on technique. d. Have the patient maintain detailed treatment logs.

ANS: B Patients should be able to demonstrate good technique regarding the use of each aerosol device that they are expected to use in self-care. Practitioner demonstration followed by repeated patient return demonstration is a must, and should be reviewed frequently, such as with each office/clinic visit.

All of the following are critical elements of a patient's social and environmental history except: a. occupation and employment history b. drugs and medications c. recent travel d. living arrangements

ANS: B Review the family and social/environmental history. This part of the medical history focuses on potential genetic or occupational links to disease and the patient's current life situation. Pulmonary disorders such as asthma, lung cancer, cystic fibrosis, and chronic obstructive pulmonary disease are believed to have a genetic link in many cases.

Long-acting adrenergic bronchodilators such as salmeterol (Serevent) are not well suited for relief of acute airflow obstruction because it takes about how long for their peak effect to occur? a. 1 to 3 hours b. 3 to 5 hours c. 5 to 7 hours d. longer than 12 hours

ANS: B Salmeterol is not well suited for relief of acute airflow obstruction or bronchospasm because its onset is longer than 20 minutes, with a peak effect occurring by 3 to 5 hours.

All of the following drug categories can impair mucociliary clearance in intubated patients except: a. general anesthetics b. bronchodilators c. opiates d. narcotics

ANS: B Several common drugs, including some general anesthetics and narcotic-analgesics, can depress mucociliary transport.

Short-acting adrenergic bronchodilators are considered what type of agent according to the National Asthma Education and Prevention Program? a. antiinflammatory b. rescue c. controller d. mucolytic

ANS: B Short-acting agents are termed "rescue" agents in the 1997 National Asthma Education and Prevention Program Expert Panel II (NAEPP EPR II) guidelines.

Smooth muscle relaxation and vessel dilation are caused mainly by which of the following? 1. action of local metabolites 2. cholinergic stimulation 3. stimulation of β-adrenergic receptors a. 1 and 3 b. 2 and 3 c. 1 and 2 d. 1, 2, and 3

ANS: B Smooth muscle relaxation and vessel dilation occur as a result of stimulation of cholinergic or specialized ß-adrenergic receptors.

What is the most important factor determining a humidifier's performance? a. surface area b. temperature c. time of contact d. gas flow

ANS: B Temperature is an important factor affecting humidifier performance.

According to the NAEP guidelines, what should be considered if the patient with asthma requires more than 3 or 4 puffs of β2-agonists per day? a. add or increase the dose of anticholinergic b. add or increase the dose of antiinflammatory c. add or increase the dose of magnesium sulfite d. increase dose of β2-agonists

ANS: B The NAEP guidelines recommend that inhaled β2-agonists be used as needed. If a patient needs more than 3 or 4 puffs a day of a β2-agonist, additional antiinflammatory therapy should be considered.

What is the normal P(A−a)O2 range while breathing room air? a. 25 mm Hg to 50 mm Hg b. 10 mm Hg to 25 mm Hg c. greater than 25 mm Hg d. less than 10 mm Hg

ANS: B The P(A-a)O2 ranges from 10 mm Hg in young patients to approximately 25 mm Hg in the elderly while breathing room air.

A physician has ordered the antiviral agent ribavirin (Virazole) to be administered by aerosol to an infant with bronchiolitis. Which of the following devices would you recommend in this situation? a. hydrodynamic (Babbington) nebulizer b. small-particle aerosol generator (SPAG) c. ultrasonic (piezoelectric) nebulizer d. large-volume heated jet nebulizer

ANS: B The SPAG was manufactured by ICN Pharmaceuticals specifically for the administration of ribavirin (Virazole) to infants with respiratory syncytial virus infection.

Which of the following comprises the largest single group of drugs among aerosolized agents used for inhalation? a. inhaled corticosteroids b. adrenergic bronchodilators c. mucus-controlling agents d. anticholinergic bronchodilators

ANS: B The adrenergic bronchodilators represent the largest single group of drugs among the aerosolized agents used for oral inhalation.

Why should the respiratory therapist perform a blood pressure assessment fairly quickly? a. The procedure is expensive. b. The procedure cuts off blood flow to the forearm temporarily. c. The respiratory therapist has other procedures to do. d. The procedure is billed by the time involved.

ANS: B The clinician must perform the procedure rapidly, because the pressurized cuff impairs circulation to the forearm and hand.

What is the average mean mass aerodynamic diameter (MMAD) generated by the vibrating mesh nebulizers? a. 1 to 2 μm b. 2 to 3 μm c. 3 to 4 μm d. 5 to 6 μm

ANS: B The exit velocity of the aerosol is low, less than 4 m/sec, and the particle size can range between 2 to 3 μm MMAD, varying with the exit diameter of the apertures (Figure 36-27).

Which of the following alternatives may increase the FIO2 capabilities of air-entrainment nebulizers? 1. Add open reservoir to expiratory side of T-tube. 2. Connect together two or more nebulizers. 3. Use a commercial dual-flow system. 4. Add open reservoir to inspiratory side of T-tube. a. 1 and 2 b. 1, 2, and 3 c. 1 and 4 d. 1, 2, 3, and 4

ANS: B The five alternatives for boosting the FIO2 capabilities in these situations are presented in Box 38-2.

Which of the following drugs present the greatest exposure risks for health care workers? 1. albuterol (Proventil) 2. pentamidine (Pentam 300) 3. ribavirin (Virazole) 4. acetylcysteine (Mucomyst) a. 1 and 4 b. 2 and 3 c. 1, 2, and 3 d. 2, 3, and 4

ANS: B The greatest occupational risk for respiratory therapists has been associated with administration of ribavirin and pentamidine.

What change in the patient's respiratory breathing pattern is commonly seen with significant fever? a. slower rate b. more rapid rate c. more prolonged expiratory time d. more prolonged inspiratory time

ANS: B The increased need for oxygen intake and carbon dioxide removal may cause tachypnea.

What is the average amount of dead volume in a small-volume jet nebulizer after the device runs dry? a. 0.1 ml b. 0.5 to 2.2 ml c. 2.0 to 4.0 ml d. less than 0.1 ml

ANS: B The residual volume of a 3-ml dose varies from as little as 0.5 ml to more than 2.2 ml, which can be more than two thirds of the total dose.

What is the area of the anterior chest wall overlying the heart called? a. epigastrium b. precordium c. pericardium d. axill

ANS: B The techniques for physical examination of the chest wall overlying the heart (precordium) include inspection, palpation, and auscultation.

An RT is examining a patient suspected to have a left-sided tension pneumothorax. During, inspection and palpation, the RT notices the patient's trachea has shifted to the left. Is the patient's diagnosis correct? a. Yes, the patient may have left-sided tension pneumothorax. b. No, the patient may have left upper lobe atelectasis. c. No, the patient may have right lower lobe pneumonia. d. No, patient may have left-sided large pleural effusion.

ANS: B The trachea shifts away from areas with increased air, fluid, or tissue (e.g., in tension pneumothorax or large pleural effusion) and towards atelectasis. In general, abnormalities in the lung bases do not shift the trachea.

You must connect a large-volume nebulizer to a bedside compressed-air outlet through a flowmeter. You have only standard O2 flowmeters available. Which of the following actions is appropriate? a. Connect the O2 flowmeter to the air outlet with piping tape. b. Use an O2-to-air DISS adapter to join the flowmeter and outlet. c. Connect the O2 flowmeter to the air outlet with a petroleum jelly seal. d. Try to cross-thread an O2 flowmeter directly on the air outlet.

ANS: B To avoid stocking a large variety of pressure regulators, flowmeters, and connectors for special gas use, adapters can be used to convert various DISS connections so that they can be used for a different purpose.

A design that increases surface area and enhances evaporation by incorporating an absorbent material partially submerged in a water reservoir that is surrounded by a heating element best describes what type of humidifier? a. bubble b. wick c. cascade d. hygroscopic

ANS: B Typically a wick is placed upright with the gravity-dependent end in a heated water reservoir.

Simple unheated bubble humidifiers are commonly used to humidify gases with what type of systems? a. mechanical ventilation b. oronasal oxygen delivery c. tracheal oxygen airway d. aerosol drug delivery

ANS: B Unheated bubble humidifiers are commonly used with oronasal oxygen delivery systems (see Chapter 38) to raise the water vapor content of the gas to ambient levels.

A dehydrated, feverish patient suffering from acute bacterial pneumonia is being intubated in order to provide mechanical ventilatory support. Which of the following devices would you select to control humidification and airway temperature for this patient? a. unheated large-volume wick humidifier b. heated wick humidifier with servo-control c. large-reservoir, high-output heated jet nebulizer d. heat-moisture exchanger

ANS: B We prefer an optimal humidity approach and use of a heated humidifier to deliver gas in the range of 35° to 37° C at the airway.

A patient suffering from postoperative complications has been receiving mechanical ventilation for 6 days with a volume ventilator. A heat-moisture exchanger (HME) is providing control over humidification and airway temperature. Over the past 24 hours, the patient's secretions have decreased in quantity but are thicker and more purulent. Which of the following actions would you suggest at this time? a. Replace the HME. b. Switch over to a heated wick humidifier. c. Administer acetylcysteine every 2 hours via the nebulizer. d. Increase the frequency of suctioning.

ANS: B We prefer an optimal humidity approach and use of a heated humidifier to deliver gas in the range of 35° to 37° C at the airway.

Loud, tubular breath sounds with an expiratory component equal to the inspiratory component best describes which of the following breath sounds? a. adventitious b. bronchial c. vesicular d. bronchovesicular

ANS: B When the expiratory component of harsh breath sounds equals the inspiratory component, they are described as bronchial breath sounds.

A physician orders continuous bronchodilator therapy with 1:200 albuterol for an asthmatic patient at the dosage of 20 mg/hr. How much 1:200 albuterol will be needed for the first hour of treatment? a. 2 ml b. 3 ml c. 4 ml d. 5 ml

ANS: C

A semiconscious patient with inadequate spontaneous ventilation requires aerosol drug administration. Which of the following approaches would you recommend? a. large-volume continuous nebulizer b. small-volume jet nebulizer (SVN) c. SVN with delivery by intermittent positive-pressure breathing d. metered-dose inhaler and holding chamber

ANS: C

All of the following are contraindications for heat-moisture exchangers except: a. presence of thick, copious, or bloody secretions b. presence of a large leak around artificial airway c. when a patient is suffering from hyperpyrexia d. when a patient's minute ventilation exceeds 10 L/min

ANS: C

All of the following are potential hazards of using a heated humidifier during mechanical ventilation except: a. aerosolization of condensate during disconnection b. underhydration or impaction of secretions c. hypoventilation due to increased dead space d. unintended tracheal lavage from condensate

ANS: C

During auscultation of a patient's chest, you hear abnormal discontinuous "bubbling" sounds at the lung bases. Which of the following chart entries best describes this finding? a. "Bronchial sounds heard at lung bases." b. "Wheezes heard at lung bases." c. "Crackles heard at lung bases." d. "Rhonchi heard at lung bases."

ANS: C

Normally, when using a 50-psi flowmeter to drive a small-volume jet nebulizer, to what should you set the flow? a. 2 to 4 L/min b. 4 to 6 L/min c. 6 to 10 L/min d. 8 to 10 L/min

ANS: C

To decrease the VDS of a small-volume jet nebulizer during drug administration, what should you do? a. Decrease the nebulizer flow. b. Turn the nebulizer upside-down. c. continue treatment until nebulizer begins to sputter d. Increase the nebulizer flow.

ANS: C

What amount of ipratropium bromide (Atrovent) is delivered by metered-dose inhaler? a. 10 μg/puff b. 15 μg/puff c. 17 μg/puff d. 90 μg/puff

ANS: C

What are some common side effects seen with ipratropium bromide (Atrovent)? a. tachycardia b. blood pressure increase c. cough and dry mouth d. tolerance

ANS: C

What schedule of peak expiratory flow rate assessment would you recommend for a home care asthmatic patient? a. 1 to 2 times daily (on rising and at bedtime) b. once per day (on rising or at bedtime) c. 3 to 4 times daily (on rising, noon, 4 to 7 PM, bedtime) d. 1 to 2 times daily (at noon and around bedtime)

ANS: C

What happens to the P(A−a)O2 with V/Q mismatch and shunt? a. It increases with V/Q mismatch and decreases with shunt. b. It decreases with both V/Q mismatch and shunt. c. It increases with both V/Q mismatch and shunt. d. It does not change.

ANS: C A V/Q mismatch and shunt both result in elevated P(A−a)O2 levels.

What is the recommended dosage for continuous bronchodilator therapy (CBT)? a. 0.5 mg/hr b. 5.0 mg/hr c. 15.0 mg/hr d. 50.0 mg/hr

ANS: C According to this protocol, children older than 6 years with tachypnea and those with hypoxemia, increased work of breathing, and restlessness who do not respond to standard therapy are given CBT with a large-volume nebulizer or small-volume jet nebulizer at a dosage of 15 mg/hr.

Which of the following is TRUE about the use of ribavirin? 1. It is used as an antiviral agent against respiratory syncytial virus. 2. It is delivered via a Respirgard unit. 3. Adverse effects include skin rash, conjunctivitis, and eyelid erythema. 4. It can occlude endotracheal tube and ventilator exhalation valves. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

ANS: C Administration of the aerosol requires use of a special large-reservoir nebulizer called the small particle aerosol generator (SPAG).

The mass of aerosol particles produced by a nebulizer in a given unit time best describes which quality of the aerosol? a. stability b. density c. output d. deposition

ANS: C Aerosol output is defined as the mass of fluid or drug contained in aerosol produced by a nebulizer generated per unit of time.

Which of the following causes decreased breath sounds? 1. air or fluid in the pleural space 2. hyperinflation of lung tissue 3. mucus plugging of the airways 4. shallow or slow breathing a. 2 and 4 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 2, 3, and 4

ANS: C Airways plugged with mucus and hyperinflated lung tissue attenuate sounds through the lungs. Air or fluid in the pleural space and obesity also reduce sound transmission through the chest wall.

A patient with an acute exacerbation of asthma is not responding to the standard dose and frequency of an aerosolized bronchodilator and is now receiving small-volume jet nebulizer (SVN) therapy every 30 minutes. Which of the following would you recommend to the patient's physician at this time? a. Discontinue the aerosolized bronchodilator. b. Increase the frequency of SVN therapy to every 10 minutes. c. Consider continuous nebulization of the drug. d. Add more diluent to the SVN to extend treatment time.

ANS: C An alternative approach is to provide continuous nebulization with a specialized large-volume nebulizer

Which of the following pulmonary disorders is most likely to result in hepatomegaly? a. pulmonary atelectasis b. acute viral infections c. cor pulmonale d. acute asthma

ANS: C An enlarged liver is called hepatomegaly and may be caused by right-sided heart failure from chronic hypoxemia (cor pulmonale), although many other causes exist.

What does the presence of stridor indicate? a. lower airway obstruction b. increased secretions in the large airways c. upper airway obstruction d. bronchial spasm

ANS: C Another continuous type of adventitious lung sounds heard in certain situations, primarily over the larynx and trachea during inhalation, is stridor. Stridor is a loud, high-pitched sound, which sometimes can be heard without a stethoscope. Most common in infants and small children, stridor is a sign of obstruction in the trachea or larynx. Stridor is most often heard during inspiration.

What is the brand name of the (R)-isomer of formoterol? a. Foradil b. Survanta c. Brovana d. Tornalate

ANS: C Arformoterol (Brovana), the single (R)-isomer of formoterol, is the newest long-acting β-agonist on the market.

What is the typical water vapor output of an unheated bubble humidifier? a. 5 to 10 mg/L b. 10 to 15 mg/L c. 15 to 20 mg/L d. 20 to 25 mg/L

ANS: C As indicated in Table 35-2, unheated bubble humidifiers can provide absolute humidity levels between approximately 15 and 20 mg/L.

What is a potential limitation of flow-triggered metered-dose inhaler devices? a. increased pharyngeal impaction b. less effective lung deposition c. high flows necessary for actuation d. requires accessory equipment

ANS: C Patients experiencing an acute exacerbation of bronchospasm may not be able to generate sufficient flows to trigger the Autohaler.

Even in healthy young subjects, regional differences in pulmonary ventilation and blood flow result in the PaO2 being lower than the PAO2. Why is this so? a. Most blood flows through the apexes of the lung. b. Most blood flows through areas with high /. c. Most blood flows through the bases of the lung. d. Most ventilation goes to the apexes of the lung.

ANS: C As shown in Table 11-1, because of gravity most blood flows to the lung bases, where the PO2 is lower and the PCO2 is higher than normal. After leaving the lung, this relatively large volume of blood combines with the smaller volume coming from the middle and apical regions. The result is a mixture of blood with less oxygen and more carbon dioxide than would come from an ideal gas exchange unit.

All of the following are true of heat-moisture exchangers (HMEs) except: a. Moisture output falls at high volumes and rates of breathing. b. High inspiratory flows and high FIO2 values can decrease HME efficiency. c. In-use HMEs have little effect on flow resistance to breathing. d. HMEs reduce bacterial colonization of ventilator circuits.

ANS: C As shown in Table 35-3, the moisture output of HMEs tends to fall at high volumes and rates of breathing. In addition, high inspiratory flows and high FIO2 levels can decrease HME efficiency. Flow resistance through the HME also is important. When an HME is dry, resistance across most devices is minimal. However, because of water absorption, HME flow resistance increases after several hours' use. For some patients, the increased resistance imposed by the HME may not be well tolerated, particularly if the underlying lung disease already causes increased work of breathing. Because HMEs eliminate the problem of breathing-circuit condensation, many consider these devices (especially hydrophobic filter HMEs) to be helpful in preventing nosocomial infections.

To minimize bony interference with percussion on the posterior chest wall, the practitioner should have the patient do which of the following? a. Lean forward at a 45-degree angle. b. Keep his or her arms at the sides of the body. c. Raise his or her arms above the shoulders. d. Place his or her hands on the hips.

ANS: C Asking patients to raise their arms above their shoulders will help move the scapulae laterally and minimize their interference with percussion on the posterior chest wall.

Which of the following therapies is considered controversial in the management of the infant with severe bronchiolitis? a. hydration b. oxygen c. bronchodilator therapy d. CPAP

ANS: C Because bronchiolitis and childhood asthma have similar symptoms, a trial course of bronchodilator therapy with a β-agonist may be useful if airway obstruction is relieved after administration. This practice is controversial, and practitioners should assess the efficacy of all bronchodilator therapy before continuing.

What is the average duration of action of the short-acting noncatecholamine agents? a. 1 to 2 hours b. 2 to 4 hours c. 4 to 6 hours d. 6 to 8 hours

ANS: C Because their duration of action is approximately 4 to 6 hours, these drugs were more suited to maintenance therapy than catecholamines and could be taken on a four-times-daily schedule.

Bland aerosols are better classified as: a. mucolytics b. secretagogues c. expectorants d. mucoactive therapy

ANS: C Bland aerosols are therefore more properly considered expectorants rather than mucolytic agents.

What is the total water output of unheated large-volume jet nebulizers? a. 10 to 16 mg H2O/L b. 16 to 25 mg H2O/L c. 26 to 35 mg H2O/L d. 33 to 55 mg H2O/L

ANS: C Depending on the design, input flow, and air-entrainment setting, the total water output of unheated large-volume jet nebulizers varies between 26 and 35 mg H2O/L.

Exhalation into which device can result in loss of drug delivery? a. small-volume jet nebulizers b. metered-dose inhaler c. dry power inhaler d. ultrasonic nebulizer

ANS: C Exhalation into the dry powder inhaler before inspiration can result in loss of drug delivery to the lung.

What type of medications may lead to first-degree heart block? a. bronchodilators b. corticosteroids c. β-blockers d. xanthines

ANS: C First-degree heart block is common following a myocardial infarction that damages the atrioventricular node, or it may be a complication of certain medications such as digoxin or β-blockers.

Which of the following conditions is most likely to cause a dry, nonproductive cough? a. chronic bronchitis b. cystic fibrosis c. pulmonary fibrosis d. chronic obstructive pulmonary disease

ANS: C For example, a dry, nonproductive cough is typical for restrictive lung diseases such as congestive heart failure or pulmonary fibrosis.

A patient with chronic bronchitis is receiving heated water aerosol treatments through a jet nebulizer four times daily to aid in mobilizing retained secretions. After each treatment, you note a dramatic increase in the magnitude of coarse crackles heard on auscultation. Which of the following recommendations would you make to the physician? a. Discontinue the heated water aerosol treatments. b. Switch to a higher-density aerosol (e.g., ultrasonic). c. Add coughing and postural drainage to the therapy. d. Consider prior treatment with a bronchodilator.

ANS: C For patients unable to clear their own secretions, suctioning or other airway clearance techniques may be indicated as an adjunct to aerosol therapy.

For a hospitalized patient who will require ongoing maintenance bronchodilator therapy after discharge, what should your end goal be? a. complete relief of all patient symptoms b. normal airflow and cessation of therapy c. effective self-administration of the drug d. peak expiratory flow rate that exceeds 70% of "personal best"

ANS: C For patients who need ongoing maintenance therapy after the acute phase of illness, the goal should be effective self-administration.

What medication would likely be the least often ordered during the emergency department management of an acute asthma attack? a. β2-agonists b. corticosteroids c. methylxanthines d. oxygen

ANS: C Hospital and ICU care for patients with asthma should be aggressive. The goals are to decrease mortality and morbidity and to return the patient to preadmission stability and function as quickly as possible. Management includes oxygen supplementation, frequent administration of high doses of aerosolized β2-agonists (limited only by tachycardia or tremor), high-dose parenteral corticosteroids (more than 0.5 to 1.0 mg/kg/day), and antibiotics if there is evidence of infection.

Foradil is a brand name for which of the following β-adrenergic bronchodilators? a. albuterol b. isoetharine c. terbutaline d. formoterol ANS: DForadil is a brand name for which of the following β-adrenergic bronchodilators? a. albuterol b. isoetharine c. terbutaline d. formoterol

ANS: D

After administering 12 puffs of metered-dose inhaler (MDI) albuterol to an acutely ill asthmatic patient in the emergency department, assessment indicates no significant improvement in symptoms. Which of the following would you now recommend? a. Switch over to high-dose MDI steroids. b. Discontinue the bronchodilator therapy. c. Use continuous bronchodilator therapy. d. Switch over to an anticholinergic agent.

ANS: C If these strategies fail to provide relief, continuous bronchodilator therapy (CBT) with nebulized albuterol doses ranging from 5-20 mg/hour have proved safe and effective for both adult and pediatric patients.

When assessing a patient's response to bronchodilator therapy, you notice a decrease in wheezing accompanied by an overall increase in the intensity of breath sounds. Which of the following is most likely? a. increasing airway obstruction b. improving c. decreasing airway obstruction d. deteriorating oxygenation

ANS: C Improvement is indicated when wheezing decreases and the overall intensity of breath sounds increases.

A home care patient will be receiving nasal O2 at 0.5 L/min using a large compressed gas cylinder. Which of the following additional equipment would you specify for this patient? 1. bubble humidifier 2. pressure-reducing valve 3. calibrated low-flow flowmeter a. 1 and 2 b. 1, 2, and 3 c. 2 and 3 d. 1 and 3

ANS: C In addition to the cylinder gas, a pressure-reducing valve with flowmeter is needed to deliver O2 at the prescribed flow. Standard clinical flowmeters deliver flows up to 15 L/min; flows used in alternative settings are typically in the 0.25 to 5.0 L/min range. For this reason, the respiratory therapist should select a calibrated low-flow flowmeter whenever possible. Alternatively, a preset flow restrictor can be used.

All of the following are TRUE about humidification and contact time except: a. The longer a gas is exposed to water, the greater is the amount of evaporation. b. The rate of gas flow through a humidifier determines contact time. c. Low flows decrease and high flows increase relative humidity output. d. Bubble humidifier contact time depends on the water column depth.

ANS: C In passover and wick-type humidifiers, the flow rate of gas through the humidifier is inversely related to contact time, with high flow rates reducing the time available for evaporation to occur.

How often would you recommend that a home care patient disinfect a home ultrasonic room humidifier? a. per manufacturer's specifications, or at least every day b. per manufacturer's specifications, or at least every 3 days c. per manufacturer's specifications, or at least every 6 days d. per manufacturer's specifications, or at least every 2 weeks

ANS: C In the absence of a manufacturer's recommendation, these units should undergo appropriate disinfection at least every 6 days.

Which of the following statements are TRUE about the use of bronchodilators in the treatment of asthma? 1. β2-Agonists are the drug of choice in exercise-induced asthma. 2. β2-Agonists do not prevent the late-onset asthma response. a. 1 b. 2 c. 1 and 2

ANS: C Inhaled β2-agents are the most rapid and effective bronchodilators for the treatment of asthma. They are the drugs of choice for all types of acute bronchospasm, and, when given prophylactically, they provide protection from all bronchoconstrictor challenges. However, they do not prevent the late-onset asthma response.

Ipratropium bromide (Atrovent) is indicated for maintenance treatment of the following diseases, except: a. chronic bronchitis b. emphysema c. asthma d. chronic obstructive pulmonary disease (COPD)

ANS: C Ipratropium and tiotropium are indicated as bronchodilators for maintenance treatment in COPD, including chronic bronchitis and emphysema.

What term is used to describe an abnormal anteroposterior curvature of the spine? a. scoliosis b. pectus excavatum c. kyphosis d. pectus carinatum

ANS: C Kyphosis is a spinal deformity in which the spine has an abnormal anteroposterior curvature.

Which type of humidifier "traps" the patient's body heat and expired water vapor to raise the humidity of inspired gas? a. membrane b. bubble c. heat-moisture exchanger d. passover

ANS: C Like the nose, a heat-moisture exchanger captures exhaled heat and moisture and uses it to heat and humidify the next inspiration.

Which of the following is the least likely cause of lymphadenopathy in the neck? a. lymphoma b. pulmonary infection c. congestive heart failure d. lung cancer

ANS: C Lymphadenopathy occurs with a variety of medical disorders including infection, malignancy, and sarcoidosis. Tender lymph nodes in the neck are suggestive of a nearby infection. The lymph nodes are not tender when malignancy is the cause.

Most nebulizers used in respiratory care produce which type of aerosol suspension? a. monodisperse b. microaerosol c. heterodisperse d. macroaerosol

ANS: C Most aerosols found in nature and used in respiratory care are composed of particles of different sizes, described as heterodisperse.

What β2-agonist is associated with 12 to 24 hours of bronchodilation? a. albuterol b. metaproterenol c. salmeterol d. terbutaline

ANS: C Newer, longer-acting (12 to 24 hours) β2-agonists, such as salmeterol and formoterol, are now available in the United States.

A patient with asthma would tend to exhibit which of the following? a. prolonged inhalation b. slow and shallow breathing c. prolonged exhalation d. deep and fast breathing

ANS: C Obstruction of the intrathoracic airways (as occurs with asthma) results in a prolonged exhalation time because airways within the chest tend to narrow more on exhalation.

Which of the following are acceptable means to help minimize the problems caused by condensation in heated humidifier circuits? 1. installing water traps in the circuit 2. using a heated wire circuit 3. setting heater temperature to 25° to 28° C a. 1, 2, and 3 b. 2 and 3 c. 1 and 2 d. 1 and 3

ANS: C One common method is to place water traps at low points in the circuit (both the inspiratory and expiratory limbs of ventilator circuits). The most common approach uses wire heating elements inserted into the ventilator circuit.

Which of the following devices depends on the patient's inspiratory effort to dispense the dose? a. small-volume jet nebulizers b. metered-dose inhaler c. dry power inhaler d. ultrasonic nebulizer

ANS: C Passive or patient-driven, dry power inhalers rely on the patient's inspiratory effort to dispense the dose.

Hazards and complications of bland aerosol therapy include all of the following except: a. bronchospasm b. overhydration c. infection d. hemoconcentration

ANS: D

A patient exhibits persistent stridor after a fiberoptic bronchoscopy procedure. Which of the following would you recommend? a. aerosol therapy with albuterol (Proventil) b. administration of a benzodiazepine (e.g., Valium) c. aerosol therapy with racemic epinephrine d. administration a narcotic antagonist (e.g., Narcan)

ANS: C Patients should also be assessed for the development of stridor or wheezes. The physician should be notified and appropriate aerosol therapy with nebulized racemic epinephrine or bronchodilators should be instituted.

What abnormality in the complete blood count is often seen in a patient with significant hypoxemia caused by chronic lung disease? a. leukocytosis b. anemia c. polycythemia d. leukopenia

ANS: C Polycythemia helps prevent the negative side effects of reduced PO2 in the blood by increasing the oxygen-carrying capacity of the blood.

What are some potential adverse effects with use of adrenergic bronchodilators? 1. hypokalemia 2. dizziness 3. worsening ventilation/perfusion ratio () 4. bradycardia a. 1 and 4 b. 2 and 3 c. 1, 2, and 3 d. 1, 2, 3, and 4

ANS: C Potential adverse effects with use of adrenergic bronchodilators include the following: • clorofluorocarbon (CFC) propellant-induced bronchospasm • dizziness • hypokalemia • loss of bronchoprotection • nausea • tolerance (tachyphylaxis) • worsening ventilation/perfusion ratio (decrease in PaO2)

What is the preferred method for delivering bronchodilators to spontaneously breathing and intubated, ventilated patients? a. dry powder inhaler b. small-volume jet nebulizer c. metered-dose inhaler d. hand-bulb atomizer

ANS: C Pressurized metered-dose inhalers often are the preferred method for delivering bronchodilators to spontaneously breathing patients as well as those who are intubated and undergoing mechanical ventilation.

In which of the following conditions might the intensity of the heart sounds be reduced? 1. heart failure 2. severe obesity 3. pneumothorax 4. pleural effusion 5. pulmonary hyperinflation a. 1, 3, and 4 b. 2, 3, 4, and 5 c. 1, 2, 3, 4, and 5 d. 3, 4, and 5

ANS: C Pulmonary hyperinflation, pleural effusion, pneumothorax, and obesity make identification of both S1 and S2 difficult. The intensity of S1 and S2 also decreases when the force of ventricular contraction is poor, as in heart failure, or when valvular abnormalities exist.

Which of the following is NOT a common cause of tachypnea? a. hypoxemia b. exercise c. narcotic overdose d. metabolic acidosis

ANS: C Rapid respiratory rates are associated with exertion, fever, arterial hypoxemia, metabolic acidosis, anxiety, atelectasis, and pain.

During aerosol drug delivery using a small-volume jet nebulizer (SVN) set at 8 L/min input flow, a patient asks that the head of the bed be lowered to a semi-Fowler's position. Immediately after doing so, you observe a significant drop in SVN aerosol output, despite there being at least 3 ml of solution left in the reservoir. What would you do to correct this problem? a. Add 1 to 2 ml more diluent to the nebulizer reservoir. b. Increase the nebulizer input flow to 10 to 12 L/min. c. Reposition the patient so that the SVN is more upright. d. Decrease the nebulizer input flow to 3 to 4 L/min.

ANS: C Some SVNs stop producing aerosol when tilted as little as 30 degrees from vertical.

What is the most common cause of pedal edema? a. liver failure b. kidney failure c. heart failure d. electrolyte imbalances

ANS: C Swelling of the lower extremities is known as pedal edema. It most often occurs with heart failure, which causes an increase in the hydrostatic pressure of the blood vessels in the lower extremities.

You enter the room of a patient who is receiving nasal O2 through a bubble humidifier at 5 L/min. You immediately notice that the humidifier pressure relief is popping off. Which of the following actions would be most appropriate in this situation? a. Check and tighten all connections. b. Replace the humidifier with a new one. c. Look for crimped or twisted delivery tubing. d. Decrease the flow rate to 2 L/min.

ANS: C Table 38-5 provides guidance on troubleshooting the most common clinical problems with nasal cannulas. In this instance, the problem is probably with the tubing which is twisted or crimped down-stream from the humidifier.

A physician orders bland water aerosol administration to a patient with a tracheostomy. Which of the following airway devices could you use to meet this goal? 1. tracheostomy mask 2. face tent 3. T-tube 4. aerosol mask a. 2 and 4 b. 1, 2, and 3 c. 1 and 3 d. 2, 3, and 4

ANS: C The T-tube is used for patients who are orally or nasally intubated or who have a tracheostomy. The tracheostomy mask is used solely for patients who have a tracheostomy.

Identify the drug whose regular use in the treatment of asthma may worsen control or even increase the risk of death by asthma. a. anticholinergic b. antiinflammatory c. β2-agonists d. corticosteroid

ANS: C The effectiveness of β2-agonists as bronchodilators is not disputed, and they remain the drug of choice for acute emergency management of asthma. However, there is concern that they may worsen asthma control if used regularly and that excessive use may increase the risk of death from asthma, which makes their role in long-term maintenance therapy questionable

The particle size produced by an ultrasonic nebulizer depends mainly on which of the following? a. blower (fan) speed b. signal amplitude c. signal frequency d. chamber baffling

ANS: C The frequency at which the crystal vibrates, preset by the manufacturer, determines aerosol particle size.

Which of the following is an indication for use of an adrenergic bronchodilator? a. treatment of excessive, viscous mucus secretions b. antiinflammatory treatment of mild to moderate persistent asthma c. treatment of reversible airflow obstruction d. prophylactic management of asthma

ANS: C The general indication for use of an adrenergic bronchodilator is the presence of reversible airflow obstruction.

What is the most common device used to generate bland aerosols? a. small-volume jet nebulizer b. ultrasonic nebulizer c. large-volume jet nebulizer d. spinning disk nebulizer

ANS: C The large-volume jet nebulizer is the most common device used to generate bland aerosols.

A heat-moisture exchanger (HME) should be avoided in which of the following circumstances? 1. patients with excessive secretions 2. patients with a high FIO2 3. patients with low body temperature a. 1 only b. 1 and 2 only c. 1 and 3 only d. 1, 2, and 3

ANS: C Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (less than 32° C), high spontaneous minute ventilation (greater than 10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

A patient is brought into the ER with chest pain. The physician is having difficulty confirming the patient's diagnosis through an ECG. Blood results show an elevated level of CPK-2. What can the physician suspect after reviewing the blood work? a. pulmonary embolism b. gastroesophageal reflux c. myocardial infarction d. valvular stenosis

ANS: C The most common CPK enzyme test is CPK-2 (CPK-MB) which is released from the heart following myocardial infarction. Peak levels occur sometime between 12 to 24 hours following injury. Serial CPK-2 measurements are monitored in patients with suspected myocardial infarction, as well as patients with cardiac contusion from chest trauma, open-heart surgery, or myocarditis.

Which of the following devices are most commonly used to deliver aerosols by the inhalation route? 1. dry powder inhaler 2. metered dose inhaler 3. small-volume nebulizer 4. slip-stream nebulizer a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

ANS: C The most commonly used devices to administer orally or nasally inhaled aerosols are the metered-dose inhaler, the small-volume nebulizer, and the dry-powder inhaler.

All of the following are critical elements of a patient's past medical history except: a. childhood diseases b. prior major illnesses or surgery c. marital status d. drugs and immunizations

ANS: C The next step is to review the patient's past medical history, which describes all past major illnesses, injuries, surgeries, hospitalizations, allergies, and health-related habits.

In mouth-breathing adult patients, which of the following factors is crucial in determining whether to use a mask or mouthpiece for aerosol drug delivery with a small-volume jet nebulizer? a. clinician experience b. drug concentration c. patient preference and comfort d. brand of small-volume jet nebulizer

ANS: C The selection of delivery method (mask or mouthpiece) should be based on patient ability, preference, and comfort.

Which of the following automatic feed systems are used to regulate water levels when using a humidifier with a continuous feed system? 1. leveling reservoirs 2. flotation controls 3. optical sensors a. 2 and 3 b. 1 and 2 c. 1, 2, and 3 d. 1 and 3

ANS: C The simplest type of automatic feed system is the level-compensated reservoir (Figure 35-8). In these systems, an external reservoir is aligned horizontally with the humidifier, maintaining relatively consistent water levels between the reservoir and the humidifier chamber. In flotation-type systems, a float rises and falls with the water level. As the water level falls below a preset value, the float opens the feed valve; as the water rises back to the set fill level, the float closes the feed valve. An optical sensor can also be used to sense water level, driving a solenoid valve to allow refilling of the humidifier reservoir.

A physician specifies an incorrect dose in a prescription for a powerful bronchodilator drug to be given to an asthmatic patient. When the respiratory therapist gives the prescribed dose, the patient suffers a fatal response and dies. Based on the principle of duty, against whom could a suit of negligence be brought? 1. respiratory therapist 2. attending physician 3. dispensing pharmacist a. 1 and 2 b. 2 and 3 c. 1, 2, and 3 d. 1 and 3

ANS: C The suit could be brought against the physician for negligence for ordering the overdose, against the nurses and the respiratory therapist for failing to recognize that the dose was incorrect for the child, and, possibly, against the pharmacist for failing to gain adequate information as to the nature of the patient so that an appropriate dosage could be calculated.

Which of the following may cause the trachea to shift to the right? a. right-sided tension pneumothorax b. right-sided large pleural effusion c. right upper lobe atelectasis d. left lower lobe pneumonia

ANS: C The trachea shifts away from areas with increased air, fluid, or tissue (e.g., in tension pneumothorax or large pleural effusion) and toward atelectasis. In general, abnormalities in the lung bases do not shift the trachea.

Which of the following is NOT a cause of hypotension? a. heart failure b. hypovolemia c. mild tachycardia d. peripheral vasoconstriction

ANS: C The usual causes are left ventricular failure, low blood volume, and peripheral vasodilation

The vibration created by percussion penetrates the lung to about what depth? a. 1 to 2 cm b. 3 to 5 cm c. 5 to 7 cm d. 8 to 10 cm

ANS: C The vibration created by percussion penetrates the lung to a depth of 5 to 7 cm below the chest wall.

Which of the following asthma medications is not usually administered during pregnancy? a. albuterol b. cromalyn c. ipratropium bromide d. theophylline

ANS: C Theophyllines, β2-agonists, inhaled or oral corticosteroids, or cromolyn can be used during pregnancy without significant risk of fetal abnormalities.

Which of the following are types of heat-moisture exchangers (HMEs)? 1. simple condenser 2. hygroscopic condenser 3. hydrophobic condenser a. 1 and 2 b. 2 and 3 c. 1, 2, and 3 d. 3

ANS: C There are three basic types of HMEs: (1) simple condenser humidifiers, (2) hygroscopic condenser humidifiers, and (3) hydrophobic condenser humidifiers.

Which of the following measures can help to ensure a good sputum sample? a. using an ultrasonic nebulizer instead of a jet nebulizer b. using a 5% saline solution instead of a 3% concentration c. having the patient rinse the mouth or blow the nose before induction d. using the lowest possible aerosol density (high flow and low output)

ANS: C To ensure a good sputum sample, every effort must be made to separate saliva from true respiratory tract secretions. In some cases, protocols include having patients brush their teeth and tongue surface thoroughly and rinse their mouths before sputum induction.

What is the most reliable indicator that the gas delivered by a servo-controlled heated-wire humidifier system is fully saturated at the airway? a. observing no visible condensate anywhere in the delivery tubing b. confirming an airway temperature between 32° and 35° C c. observing a few drops of condensate at or near the patient's airway d. observing condensate over the full length of the delivery tubing

ANS: C To ensure that the inspired gas is being properly conditioned, clinicians should always adjust the temperature differential to the point that a few drops of condensation form near the patient wye. Lacking direct measurement of humidity, observation of this minimal condensate is the most reliable indicator that the gas is fully saturated at the specified temperature.

For which of the following patients would you NOT recommend bland aerosol therapy administration? 1. patient with a history of airway hyperresponsiveness 2. patient with a bypassed upper airway 3. patient with active bronchoconstriction a. 1, 2, and 3 b. 2 and 3 c. 1 and 2 d. 1 and 3

ANS: D

Which of the following criteria should be met before considering use of a heat-moisture exchanger (HME) for a patient being placed on ventilatory support? 1. There should be no problem with retained secretions. 2. The patient should not have a fever (normothermic). 3. The patient should be adequately hydrated. 4. The support should be short term (24 to 48 hours). a. 1, 2, and 3 b. 2 and 4 c. 1, 2, 3, and 4 d. 3 and 4

ANS: C Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (less than 32° C), high spontaneous minute ventilation (greater than 10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

Which of the following is false about the optimal technique for using a small-volume jet nebulizer (SVN) for aerosol drug delivery? a. SVNs are less technique- and device-dependent. b. Slow inspiration improves SVN aerosol deposition. c. Deep breathing or breath-holding improves SVN deposition. d. Use of a mouthpiece or mask provides similar results.

ANS: C Use of an SVN is less technique and device dependent than use of a pressurized metered-dose inhaler or dry powder inhaler delivery system. Slow inspiratory flow does optimize SVN aerosol deposition. However, deep breathing and breath-holding during SVN therapy do little to enhance deposition over normal tidal breathing. Because the nose is an efficient filter of particles larger than 5 mm, many clinicians prefer not to use a mask for SVN therapy. As long as the patient is mouth-breathing, there is little difference in clinical response between therapy given by mouthpiece and that given by mask.

When administering aerosolized pentamidine, what should the respiratory care practitioner do? 1. Use a nebulizer that produces particles in the 1- to 2-μm mean mass aerodynamic diameter (MMAD) range. 2. Use a nebulizer system with one-way valves and scavenging expiratory filters. 3. Provide isolation and an environmental containment system. 4. Screen patients for human immunodeficiency virus (HIV). a. 1 and 2 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

ANS: C When administering aerosolized pentamidine, isolation, an environmental containment system (e.g., a booth or negative pressure room), and personnel barrier protection should be provided. Subjects should be screened for tuberculosis. The drug is given using a nebulizer system with one-way valves and scavenging expiratory filters (e.g., the Respirgard). This reduces environmental contamination. Nebulizer systems capable of producing an MMAD of 1 to 2 μm for peripheral lung deposition may reduce coughing.

What is the total water output of heated large-volume jet nebulizers? a. 16 to 25 mg H2O/L b. 26 to 35 mg H2O/L c. 33 to 55 mg H2O/L d. 56 to 75 mg H2O/L

ANS: C When heated, output increases to between 33 and 55 mg H2O/L, mainly because of increased vapor capacity.

In palpating a patient's feet and hands, you note extreme coolness to the touch. This finding is most consistent with which of the following? a. presence of a disorder causing chronic hypoxemia b. reduction in venous return to the right side of the heart c. peripheral vasoconstriction due to inadequate perfusion d. presence of a disorder causing systemic hypertension

ANS: C When perfusion is poor (as in heart failure or shock), the compensatory vasoconstriction in the extremities helps shunt blood to the vital organs. This reduction in peripheral perfusion causes the extremities to become cool to the touch. The extent to which the coolness to touch extends toward the body is an indication of the degree of circulatory failure.

A heated humidifier should trigger both auditory and visual alarms and interrupt power to the heater when the delivered temperature exceeds which of the following? a. 25° C b. 30° C c. 35° C d. 40° C

ANS: D

A patient has been supported by a mechanical ventilator using a heat-moisture exchanger for the last 3 days. Suctioning reveals an increase in the amount and tenacity of secretions. Which of the following actions is indicated? a. Increase the hygroscopic condenser humidifier temperature. b. Reassess the patient's secretions over the next 24 to 48 hours. c. Replace the hygroscopic condenser humidifier with a new one. d. Switch the patient to a large-volume heated humidifier.

ANS: D

All of the following are potential hazards of using heat-moisture exchangers except: a. failure of low-pressure alarms to detect disconnection b. underhydration or impaction of secretions c. hypoventilation due to increased dead space d. unintended tracheal lavage from condensate

ANS: D

All of the following circuit-related factors have a major effect on metered-dose inhaler delivery of aerosolized drugs during mechanical ventilation except: a. endotracheal tube size b. type of humidifier c. relative humidity d. temperature

ANS: D

All of the following source gas characteristics affect the performance of small-volume jet nebulizers except: a. humidity b. flow c. pressure d. viscosity

ANS: D

An asthmatic patient in severe distress with wheezing and dyspnea is admitted to the emergency department and started on albuterol via small-volume jet nebulizer. Which of the following approaches would you recommend to assess this therapy for this patient? 1. Perform arterial blood gas analysis. 2. Continuously monitor the SpO2. 3. Assess breath sounds and vital signs before and after each treatment. 4. Measure peak expiratory flow rate or forced expiratory volume in 1 second before and after each treatment. a. 1 and 2 b. 1, 3, and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D

Appropriate documentation when conducting point-of-care assessment of a patient's response to bronchodilator therapy includes all of the following except: a. medication type, dose, and time received b. vital signs, breath sounds, and pulmonary function test measures c. patient's progress and ability to self-assess symptoms d. blood levels of the bronchodilator agent

ANS: D

Conditions that can cause temperature "overshoot" with servo-controlled heated humidifiers include all of the following except: a. The unit is allowed to warm up without flow. b. Flow is decreased during normal operation. c. The airway temperature probe becomes dislodged. d. The unit reservoir is refilled with sterile water.

ANS: D

Factors associated with reduced pulmonary deposition of aerosolized drugs include all of the following except: a. mechanical ventilation b. artificial airways c. poor patient technique d. mouth breathing

ANS: D

For which of the following patients might you recommend administration of a hypertonic saline aerosol? 1. acquired immune deficiency syndrome (AIDS) patient with severe pneumonia symptoms 2. patient with a bypassed upper airway 3. patient suspected of having tuberculosis a. 1, 2, and 3 b. 2 and 3 c. 1 and 2 d. 1 and 3

ANS: D

Indications for assessment of patient's response to bronchodilator therapy include all of the following except to: a. confirm whether the therapy works as intended b. individualize the dose, frequency, or type of medication c. help follow the patient's status during long-term therapy d. quantify the degree of bronchial hyperresponsiveness

ANS: D

To minimize the risk of infection associated with aerosol drug therapy, what should you do? 1. Sterilize nebulizers between patients. 2. Frequently replace in-use units. 3. Rinse nebulizers with sterile water. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D

What is the dosage for salmeterol MDI? a. 2 puffs every 4 to 6 hours b. 1 to 2 puffs four times daily c. 2 puffs three times daily d. 2 puffs every 12 hours

ANS: D

Where should you place the thermistor probe for a servo-controlled heated humidifier being used on a patient receiving mechanical ventilation? a. in the expiratory limb of the circuit, near but not at the "wye" b. in the inspiratory limb of the circuit, as close to the "wye" as possible c. in the expiratory limb of the circuit, as close to the "wye" as possible d. in the inspiratory limb of the circuit, near but not at the "wye"

ANS: D

Which of the following are considered to be "quick relief" agents in treating asthma? 1. methylxanthines 2. ipratropium 3. systemic corticosteroids (oral or intravenous) 4. short-acting inhaled β2-agonists 5. long-acting inhaled β2-agonists 6. leukotriene antagonists a. 2, 3, and 4 b. 2, 5 and 6 c. 1, 3, 5, and 6 d. 1, 2, 3, and 4

ANS: D

Which of the following are necessary features to look for in selecting a heated humidifier? 1. water level readily visible 2. over-temperature protection 3. auditory and visual alarms 4. minimal temperature overshoot a. 2 and 4 b. 1, 2, and 3 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D

Which of the following are potential indications for positive airway pressure therapies? 1. reduce air-trapping in asthma or chronic obstructive pulmonary disease 2. help mobilize retained secretions 3. prevent or reverse atelectasis 4. optimize bronchodilator delivery a. 2 and 4 b. 1, 2, and 3 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D

Which of the following small-volume jet nebulizer design features affect its performance? 1. position 2. residual volume 3. baffles 4. reservoirs a. 1, 2, and 3 b. 2 and 4 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D

You observe a patient's breathing pattern as very irregular and interspersed with long periods of apnea. Which of the following is the most likely cause of this problem? a. central nervous system disorder b. congestive heart failure c. metabolic acidosis d. increased intracranial pressure

ANS: D

All of the following are TRUE regarding a membrane-type humidifier except: a. Water and gas are separated by a hydrophobic membrane. b. The membrane is permeable to water vapor but not to liquid water. c. As with other passover humidifiers, there is no bubbling action. d. A small layer of liquid water remains on both sides of the membrane.

ANS: D A membrane-type humidifier separates the water from the gas stream by means of a hydrophobic membrane (Figure 35-4). Water vapor molecules can easily pass through this membrane, but liquid water (and pathogens) cannot. As with the wick-type humidifier, bubbling does not occur. Moreover, if a membrane-type humidifier were to be inspected while it was in use, no liquid water would be seen in the humidifier chamber.

Which of the following types of humidifiers are used in clinical practice? 1. heat-moisture exchanger 2. passover humidifier 3. bubble humidifier a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: D Active humidifiers typically include: (1) bubble humidifiers, (2) passover humidifiers, (3) nebulizers of bland aerosols and (4) vaporizers. Passive humidifiers refer to typical heat and moisture exchangers (HMEs).

Drug aerosol delivery systems include all of the following except: a. dry powder inhalers (DPIs) b. small-volume jet nebulizers c. metered-dose inhalers (MDIs) d. spinning disk nebulizers

ANS: D Aerosol generators in use include pressurized metered-dose inhalers (pMDIs) with or without spacers/holding chambers, dry powder inhalers (DPIs), small and large volume (jet) nebulizers, ultrasonic nebulizers (USNs), hand-bulb atomizers (including nasal spray pumps), vibrating mesh nebulizers, and a number of emerging technologies.

Gas leaving an unheated humidifier at 10° C and 100% relative humidity (absolute humidity = 9.4 mg/L) would provide what relative humidity at body temperature? a. about 100% b. about 60% c. about 40% d. about 20%

ANS: D Although the humidifier fully saturates the gas, the low operating temperature limits total water vapor capacity to approximately 9.4 mg/L water vapor, equivalent to approximately 21% of body humidity.

What treatment for patients with COPD has been shown to improve long-term survival? a. bronchodilators b. corticosteroids c. mechanical ventilation d. oxygen

ANS: D Among the available treatments for COPD, supplemental oxygen is important because, like smoking cessation and lung volume reduction surgery in selected individuals (see below), it can prolong survival. Box 23-2 reviews the indications for supplemental oxygen, and Figure 23-6 shows the results of the American Nocturnal Oxygen Therapy Trial and the British Medical Research Council Trial of Domiciliary Oxygen, 1980-1981. Survival was improved when eligible patients used supplemental oxygen for as close to 24 hours as possible and that survival improved less for those using oxygen only 15 hours per day.

Which of the following factors is most crucial in developing an effective program of aerosol drug self-administration in an adult patient requiring maintenance bronchodilator therapy? a. proper device selection b. well-written brochures c. reliable peak expiratory flow rate meter d. good patient education

ANS: D An effective program of aerosol drug self-administration depends on thorough patient education.

Which of the following is NOT considered part of the assessment of severity of symptoms recommended by the NAEPP and GOLD guidelines to modify level or dosage of corticosteroids? a. number of exacerbations b. missed work or school days c. pulmonary function d. use of anticholinergics

ANS: D Assess severity of symptoms (coughing, wheezing, nocturnal awakenings, symptoms during exertion; use of rescue bronchodilator; number of exacerbations, missed work/school days; and pulmonary function), and modify level or dosage as recommended by NAEPP and GOLD guidelines.

Which of the following are assessment features for evaluating patient response to bronchodilator therapy? 1. reversibility of airflow obstruction 2. changes in flow rates using a peak flowmeter or portable spirometry 3. changes in vital signs 4. changes in ventilation and oxygenation 5. the patient's subjective reaction to treatment a. 2, 3, and 4 b. 2, 3, and 5 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5

ANS: D Assessment of therapy with adrenergic bronchodilators should be based on the indication(s) for the aerosol agent (presence of reversible airflow due to primary bronchospasm or other obstruction secondary to an inflammatory response and/or secretions, either acute or chronic). With all aerosol drug therapy, basic vital signs (respiratory rate and pattern, pulse, breath sounds) should be assessed before and after treatment, especially for initial drug use, as well as the patient's subjective reaction (complaints of breathing difficulty).

At high flow rates, what do some bubble humidifiers produce? a. additional heat b. microorganisms c. low pressures d. aerosol particles

ANS: D At high flow rates, bubble humidifiers can produce aerosols.

Which of the following short-acting catecholamines are used for their strong α1-vasoconstricting effects to reduce swelling in the nose and larynx and to control bleeding during bronchoscopic biopsy? a. isoproterenol b. isoetharine c. dobutamine d. racemic epinephrine

ANS: D Because of their strong α1 activity and vasoconstricting effect, epinephrine and the synthetic racemic epinephrine are used to reduce swelling in the nose (nasal decongestant) and larynx (croup, epiglottitis) and to control bleeding during bronchoscopic biopsy.

Which of the following is FALSE about heated humidifier condensate? a. It can block or obstruct the delivery circuit. b. It must be treated as contaminated waste. c. It requires that circuits be drained frequently. d. It poses minimal infection risk.

ANS: D Condensation can disrupt or occlude gas flow through the circuit, potentially altering FIO2 and/or ventilator function. Moreover, condensate can work its way toward the patient and be aspirated. For these reasons, circuits must be positioned to drain condensate away from the patient and must be checked often, and excess condensate must be drained from heated humidifier breathing circuits on a regular basis. Typically, patients contaminate ventilator circuits within hours, and condensate is colonized with bacteria and thus poses an infection risk. To avoid problems in this area, health care personnel should treat all breathing-circuit condensate as infectious waste.

Which of the following is TRUE of peripheral cyanosis? a. reliable indicator of tissue hypoxia b. develops early in patients with anemia c. develops late in patients with polycythemia d. sign of inadequate tissue perfusion

ANS: D Cyanosis of the digits is referred to as peripheral cyanosis and is mainly the result of poor blood flow, especially in the extremities.

Advantages of the dry power inhaler (DPI) drug delivery systems include all of the following except: a. low relative cost b. no propellants required c. no hand-breath coordination necessary d. unaffected by humidity

ANS: D DPIs are relatively inexpensive, do not need propellants, and do not require the hand−breath coordination needed for pressurized metered-dose inhalers.

Acetylcysteine (Mucomyst) is indicated in all of the following diseases except: a. acute tracheobronchitis b. bronchiectasis c. chronic obstructive pulmonary disease (COPD) d. asthma

ANS: D Diseases of excessive viscous mucus secretions and poor airway clearance include COPD, acute tracheobronchitis, and bronchiectasis.

Which of the following are true of early inspiratory crackles? 1. They most often occur in COPD patients. 2. They generally indicate severe airway obstruction. 3. They are not affected by coughing or positional change. 4. They are usually scant (few in number). a. 2 and 4 b. 1, 2, and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4

ANS: D Early inspiratory crackles are usually scanty but may be loud or faint. They often are transmitted to the mouth and are not silenced by a cough or a change in position. They most often occur in patients with COPD, such as chronic bronchitis, emphysema, or asthma, and usually indicate a severe airway obstruction.

For which of the following patients might you recommend bland aerosol therapy via an ultrasonic nebulizer (USN)? 1. patient with upper airway edema 2. patient with a bypassed upper airway 3. patient who must provide a sputum specimen a. 1, 2, and 3 b. 2 and 3 c. 2 d. 3

ANS: D Exceptions include the use of the USN for sputum induction where the high output (1 to 5 ml/min) and aerosol density seems to yield higher quantity and quality of sputum specimens for analysis, but at some cost increased airway reactivity.

During auscultation of a patient's chest, you hear coarse crackles throughout both inspiration and expiration. These sound clear when the patient coughs. Which of the following is the most likely cause of these adventitious sounds? a. opening of closed smaller airways or alveoli b. opening of collapsed large, proximal airways c. variable obstruction to flow in the upper airway d. movement of excessive secretions in the airways

ANS: D Excessive mucus in the airways causes crackles that are usually coarse (low pitched) and heard during inspiration and expiration. These crackles often clear when the patient coughs or when the upper airway is suctioned.

The amount of condensation occurring in a heated, humidified gas delivery system depends on which of the following? 1. length, diameter, and mass of the circuit 2. temperature differential along the circuit 3. ambient temperature 4. rate of gas flow through the circuit a. 2 and 4 b. 1, 2, and 3 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D Factors influencing the amount of condensation include (1) the temperature difference across the system (humidifier to airway), (2) the ambient temperature, (3) the gas flow, (4) the set airway temperature, and (5) the length, diameter, and thermal mass of the breathing circuit.

For maintenance administration of bronchodilators to an adult patient with adequate inspiratory flow, which of the following aerosol drug delivery devices would you recommend? 1. pressurized metered-dose inhaler (pMDI) 2. small-volume jet nebulizer 3. dry powder inhaler 4. pMDI and holding chamber a. 1 or 2 b. 2 or 3 c. 2 or 4 d. 3 or 4

ANS: D For administration of maintenance therapy bronchodilators and antiinflammatory agents to adults, a pMDI with a valved holding chamber is the most convenient, versatile, and cost-effective approach. Dry powder inhalers are gaining popularity as an equivalent to pMDIs for maintenance therapy with available drugs for patients capable of generating adequate inspiratory flow.

In the face of hyperoxia, what is the response of the peripheral chemoreceptors to hypercapnia? a. There is a decreased drive to breathe. b. There is an increased drive to breathe. c. There is insufficient information. d. There is virtually no response.

ANS: D High arterial PO2 (hyperoxia) decreases the peripheral chemoreceptors' PCO2 sensitivity to almost zero.

Which of the following is false about a simple heated humidifier (one that does not incorporate a servo-control mechanism)? a. The controller regulates the heating element's electric power. b. The controller monitors the temperature of the heating element. c. The controller varies current to achieve a set airway temperature. d. The patient's airway does affect the controller.

ANS: D Humidifier heating systems also have a controller that regulates the element's electric power. In the simplest systems, the controller monitors the heating element, varying the delivered current to match either a preset or an adjustable temperature. In these systems, the patient's airway temperature has no effect on the controller.

When checking a patient attached to a servo-controlled heated-wire humidifier breathing circuit, you notice no visible condensate anywhere in the tubing. Based on this observation, you can conclude that the relative humidity of the delivered gas is which of the following? a. less than 25% b. 25% to 90% c. 90% to 100% d. less than 100%

ANS: D If condensate cannot be seen, there is no way of knowing the level of relative humidity without direct measurement—it could be anywhere between 99% and 0%!

Which of the following is NOT a common cause of an increase in the drive to breathe which would increase the sensation of dyspnea? a. hypoxemia b. acidosis c. high fever d. hypocarbia

ANS: D Increases in the drive to breathe occur with hypoxemia, acidosis, fever, exercise, or anxiety.

All of the following reduce the risk of nosocomial infection when using heated humidification systems except: a. use of wick or membrane humidifiers b. use of heated-wire delivery circuits c. high humidifier reservoir temperatures d. frequent changing of delivery circuits

ANS: D It is now known that frequent ventilator-circuit changes actually increase the risk of nosocomial pneumonia.

Key considerations in selecting or recommending humidity or bland aerosol therapy for a patient include which of the following? 1. required gas flow 2. presence of an artificial tracheal airway 3. character of pulmonary secretions 4. need for or duration of mechanical ventilation 5. presence of heat-moisture exchanger (HME) contraindications a. 2, 3, and 4 b. 1, 2, and 3 c. 3, 4, and 5 d. 1, 2, 3, 4, and 5

ANS: D Key considerations include (1) gas flow, (2) presence or absence of an artificial tracheal airway, (3) character of the pulmonary secretions, (4) need for and expected duration of mechanical ventilation, and (5) contraindications to using an HME.

Which of the following would you consider recommending for a home care patient receiving nasal CPAP who complains of severe nasal dryness? 1. room vaporizer 2. heat-moisture exchanger (HME) 3. in-line humidifier 4. saline nasal spray a. 2 and 4 b. 1, 3, and 4 c. 1, 2 and 3 d. 1, 2, 3, and 4

ANS: D Methods used to overcome excessive drying include in-line humidifiers, room vaporizers, HMEs, chin straps (to decrease loss of upper airway moisture), and saline nasal sprays.

Which of the following is a common way to increase the surface area ratio of humidifiers? 1. Generate a water droplet aerosol. 2. Expose the gas to a saturated wick. 3. Use a bubble or diffusion head. a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: D More space-efficient ways to increase the water/gas surface-area ratio include bubble diffusion, aerosol, and "wick" technologies.

When using water traps to help minimize the problems caused by condensation in a heated humidifier ventilator circuit, where would you place the traps? a. in the expiratory limb only, at a high point in the circuit b. in both the expiratory and inspiratory limbs, at high points in the circuit c. in the expiratory limb only, at a low point in the circuit d. in both the expiratory and inspiratory limbs, at low points in the circuit

ANS: D One common method is to place water traps at low points in the circuit (both the inspiratory and expiratory limbs of ventilator circuits).

In addition to bedside pulmonary function test measures, what other components of patient assessment are useful in evaluating bronchodilator therapy? 1. patient interview and observation 2. measurement of vital signs 3. chest auscultation 4. arterial blood gas analysis and oximetry a. 1, 3, and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D Other components of patient assessment useful in evaluating bronchodilator therapy include patient interviewing and observation, measurement of vital signs, auscultation, blood gas analysis, and oximetry.

When administering acetylcysteine (Mucomyst), the respiratory therapist should be particularly focused on which of the following potential adverse effects? 1. incompatibility with certain antibiotics when administered together 2. nausea 3. bronchospasm 4. airway obstruction due to rapid liquefaction of mucus a. 2 and 3 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

ANS: D Other side effects that can occur include the following: • airway obstruction due to rapid liquefaction of secretions • disagreeable odor due to hydrogen sulfide • incompatibility with certain antibiotics (sodium ampicillin, amphotericin B, erythromycin, tetracyclines, and aminoglycosides) if mixed in solution • increased concentration and toxicity of nebulizer solution toward end of treatment • nausea and rhinorrhea • stomatitis • reactivity of acetylcysteine with rubber, copper, iron, and cork

Which of the following medications should be used in the hospital for prophylactic deep venous thrombosis therapy? a. acetylcholine esterase b. albuterol c. aspirin d. heparin

ANS: D Pharmacologic choices for prophylaxis include low-dose subcutaneous heparin, low-molecular-weight heparin, and fondaparinux.

Which of the following characteristics is least typical for pleuritic chest pain? a. located laterally b. sharp and stabbing in nature c. increases with breathing d. radiates to the arm

ANS: D Pleuritic chest pain usually is located laterally or posteriorly. It worsens when the patient takes a deep breath and is described as a sharp, stabbing type of pain.

Which of the following prophylactic therapies is recommended to reduce the irritant effect of acetylcysteine? a. administration of anticholinergics b. administration of dornase alfa c. administration of corticosteroids d. administration of adrenergic bronchodilator

ANS: D Pretreatment with an adrenergic bronchodilator, allowing adequate time for a bronchodilatory effect to be produced, can prevent or reduce airway resistance with acetylcysteine.

In auscultating the heart sounds of a patient with chronic hypoxemia, you notice a marked increase in the intensity of the second heart sound (S2) and no splitting during inhalation. This finding is most consistent with which of the following? a. mitral insufficiency b. left ventricular hypertrophy c. tricuspid valve stenosis d. pulmonary hypertension

ANS: D Pulmonary hypertension produces an increased intensity of S2. This sound is referred to as a loud P2 and is a result of more forceful closure of the pulmonic valve.

In general, to deliver oxygen to the upper airway, a bubble humidifier is required only when the gas flow exceeds which of the following? a. 1 L/min b. 2 L/min c. 3 L/min d. 4 L/min

ANS: D Regarding delivery of oxygen to the upper airway, the American College of Chest Physicians advises against using a bubble humidifier at flow rates of 4 L/min or less.

What is the simplest way to increase the humidity output of a humidifier? a. Increase the time that the gas and the water are in contact. b. Increase the surface area between the water and the gas. c. Decrease the water vapor pressure of the gas. d. Increase the temperature of either the water or the gas.

ANS: D Simply heating the humidifier to 40° C (Figure 35-3, right) increases its output to 51 mg/L, which is more than adequate to meet BTPS conditions.

Which of the following methods are used to heat the gas delivered by a heated humidifier system? 1. using a wraparound heater (yoke or collar) 2. placing a heating element in-line with gas flow 3. using a reservoir immersion heater 4. placing a "hot plate" at humidifier base a. 2 and 4 b. 1, 2, and 3 c. 3 and 4 d. 1, 2, 3, and 4

ANS: D Six types of heating elements are common: (1) a "hot plate" element at the base of the humidifier; (2) a "wraparound" type that surrounds the humidifier chamber; (3) a yolk, or collar, element that sits between the water reservoir and the gas outlet; (4) an immersion-type heater, with the element actually placed in the water reservoir; (5) a heated wire in the inspiratory limb warming a saturated wick or hollow fiber, and (6) a thin film, high surface area broiler.

Small volume nebulizers produce bacterial aerosols that have been commonly associated with which of the following diseases? a. Pseudomonas aeruginosa b. measles c. small pox d. nosocomial pneumonia

ANS: D Small volume nebulizers produce bacterial aerosols that have been associated with nosocomial pneumonia.

While palpating the chest of a patient who repeats the words "ninety-nine," you note an area of increased tactile fremitus over the left lower lobe. Which of the following could explain this finding? 1. pneumothorax 2. emphysema 3. pneumonia a. 2 and 3 b. 1 and 2 c. 1, 2, and 3 d. 3

ANS: D Tactile fremitus is increased when the lung becomes consolidated as with pneumonia because sound vibrations travel better through a more solid medium.

Factors affecting a humidifier's performance include all of the following except: a. surface area b. temperature c. time of contact d. outlet size

ANS: D The following four variables affect the quality of a humidifier's performance: (1) temperature, (2) surface area, (3) time of contact, and (4) thermal mass.

Adrenergic bronchodilators improve flow rates for all the following diseases except: a. asthma b. acute bronchitis c. chronic bronchitis d. pulmonary fibrosis

ANS: D The most common use of these agents clinically is to improve flow rates in asthma (including exercise-induced asthma), acute and chronic bronchitis, emphysema, bronchiectasis, cystic fibrosis, and other obstructive airway states.

Which of the following is NOT a side effect of newer, more β2-selective bronchodilators? a. tremor b. insomnia c. nervousness d. bradycardia

ANS: D The newer, more β2-selective agents are safe and typically cause tremor as the main side effect. Other common side effects with the inhaled agents include headache, insomnia, and nervousness.

While a patient is receiving an albuterol treatment, the nurse performs an ECG. The ECG shows the patient's heart rate had increased from 98 to 120 beats/minute with narrow QRS complexes proceeded by a P wave. What is the appropriate course of treatment for this patient? a. atropine b. activate the rapid response team c. lidocaine d. discontinue the treatment

ANS: D The patient is experiencing sinus tachycardia. Most often, sinus tachycardia is caused by anxiety, pain, fever, hypovolemia, or hypoxemia. It may also be a side effect of certain medications such as beta agonist bronchodilators. Treatment for sinus tachycardia typically involves eliminating the underlying cause.

What is the major potential problem in the application of bland aerosol therapy in the home care setting? a. overhydration b. electrical shock c. mechanical failure d. Infection

ANS: D The potential problem is infection from contaminated equipment.

Which of the following is NOT a short-acting noncatecholamine bronchodilator? a. pirbuterol b. terbutaline c. albuterol d. salmeterol

ANS: D The release of salmeterol offered the first long-acting adrenergic bronchodilator in the United States.

The risk of overhydration with continuous delivery of bland water aerosols is greatest among which patient group? 1. patients with fluid or electrolyte imbalances 2. patients with fever and infection 3. infants and small children a. 1, 2, and 3 b. 1 and 2 c. 2 and 3 d. 1 and 3

ANS: D The risk of overhydration is highest for infants, small children, and those with preexisting fluid or electrolyte imbalances.

What are some types of passover humidifiers? 1. simple reservoir 2. membrane 3. wick a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: D There are three common types of passover humidifiers: (1) the simple reservoir type, (2) the wick type, and (3) the membrane type.

Which of the following principles is used by the ultrasonic nebulizer to produce aerosol droplets? a. evaporative cooling b. mechanical baffling c. fractional distillation d. high-frequency vibrations

ANS: D This crystal transducer converts radio waves into high-frequency mechanical vibrations (sound).

Which of the following medications is generally only used if the patient still has debilitating symptoms from stable COPD, despite inhaled bronchodilator therapy? a. antibiotics b. β2-agonists c. corticosteroids d. methylxanthines

ANS: D Treatment with methylxanthines offers little additional bronchodilation in patients on inhaled bronchodilators, and generally it is reserved for patients with debilitating symptoms from stable COPD, despite optimal inhaled bronchodilator therapy.

The typical pressure pop-off incorporated into most simple bubble humidifiers releases pressure above which of the following? a. 760 mm Hg b. 10 cm H2O c. 250 kPa d. 2 psig

ANS: D Typically, the pop-off is either a gravity or spring-loaded valve that releases pressures above 2 psi.

What are some potential problems with manually refilled heated humidifier reservoirs? 1. cross-contamination and infection 2. variable compliance or delivered volume 3. delivery of dry and/or hot gases a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3

ANS: D Unfortunately, the use of manually refilled reservoirs requires a momentary interruption of humidifier operation and mechanical ventilation. Moreover, because the system must be "opened" for refilling, cross contamination can occur. Water levels in manually filled systems are constantly changing, so that changes in the humidifier fill volume alter the gas compression factor and thus the delivered volume during mechanical ventilation.

Unheated bubble humidifiers are of limited effectiveness at flows above which of the following? a. 4 L/min b. 6 L/min c. 8 L/min d. 10 L/min

ANS: D Unheated bubble humidifiers are of limited effectiveness at flow rates higher than 10 L/min.

For which of the following patients requiring ventilatory support would you recommend against using a heat-moisture exchanger (HME) for airway humidification? 1. patient whose expired VT is less than 70% of the delivered VT 2. patient with a spontaneous minute ventilation of 14 L/min 3. patient with body temperature less than 32° C a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (less than 32° C), high spontaneous minute ventilation (greater than 10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

Which of the following represent proper chest auscultation technique? 1. The practitioner should begin auscultation at the lung bases. 2. The bell or diaphragm should be placed directly on the chest wall. 3. The patient should be instructed to breathe through an open mouth. 4. The patient should be placed in a comfortable upright position. 5. The patient should be told to breathe more deeply than normal. a. 2, 3, 4, and 5 b. 1, 2, 3, and 5 c. 3, 4, and 5 d. 1, 2, 3, 4, and 5

ANS: D When possible, the patient should be sitting upright in a relaxed position. Instruct the patient to breathe a little more deeply than normal through an open mouth. Inhalation should be active, with exhalation passive. Place the bell or diaphragm directly against the chest wall when possible, because clothing may produce distortion. The tubing must not be allowed to rub against any objects, because this may produce extraneous sounds, which could be mistaken for adventitious lung sounds.

What artery is most often used to assess arterial blood pressure? a. femoral b. radial c. ulnar d. brachial

ANS: D When the cuff is applied to the upper arm and pressurized to exceed systolic blood pressure, the brachial artery blood flow stops.

Which of the following patient skills are necessary to ensure effectiveness of drug administration via the aerosol route? 1. ability to keep track of dosing requirements 2. understanding of the methods and goals of therapy 3. ability to recognize undesirable side effects a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Whenever possible, patients should be taught to understand the basic administration techniques, to keep track of dosing requirements, to recognize undesirable side effects, and to understand the options and actions required to reduce or eliminate these effects.

Which of the following factors affect pulmonary deposition of an aerosol? 1. size of the particles 2. shape and motion of the particles 3. physical characteristics of the airways a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Whether aerosol particles that are inhaled into the lung are deposited in the respiratory tract depends on the size, shape, and motion of the particles and on the physical characteristics of the airways and breathing pattern.

Causes of inadequate mist production with pneumatically powered jet nebulizers include all of the following except: a. inadequate input flow b. siphon tube obstruction c. jet orifice misalignment d. tripped circuit breaker

ANS: D With pneumatically powered jet nebulizers, poor mist production can be caused by inadequate input flow of driving gas, siphon tube obstruction, or jet orifice misalignment.

What happens as the pressure or flow delivered through a small-volume jet nebulizer gets higher? 1. Treatment time becomes shorter. 2. Particle size becomes smaller. 3. Aerosol output becomes greater. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

ANS: D Within operating limits, the higher the pressure or flow, the smaller is the particle size, the greater is the output, and the shorter is the treatment time.