tmc practice test

After setting up a 12-lead ECG on a patient and verifying that the leads are connected properly, you note a "noisy" and unstable signal. To resolve this problem, you would: Select one: A.deactivate/turn off the electronic noise filter B.change the paper/scan speed to 50 mm/second C.confirm that the patient is staying motionless D.change the calibration to 5 mm/millivolt

A "noisy" ECG signal is usually due to either patient motion or bad electrical connections. If due to movement, make sure the patient remains motionless during the recording. If the patient is still, check and confirm that: (1) the ECG lead snaps are clean and corrosion-free; (2) the lead electrodes are connected properly to the patient; (3); the electrode gel is not dry (replace suspect electrodes); and (4) the main lead cable is undamaged. If the connections are working properly, make sure that the device's electronic noise filter is ON. The correct answer is: confirm that the patient is staying motionless

Which of the following specialized imaging tests would be most useful in confirming a diagnosis of pulmonary emboli? Select one: A.standard AP chest X-ray B.ventilation-perfusion scan C.CT pulmonary angiography D.arterial blood gas (ABG)

A chest X-ray and an ABG might be useful in detecting an abnormality, but not specifically pulmonary embolization. Both CT angiography and ventilation-perfusion (V/Q) scans can help in diagnosis of this problem. Of the two, CT pulmonary angiography (CTPA) is the most accurate modality for confirming ('ruling in') a diagnosis of pulmonary embolism. However, either imaging modality can be used to exclude ('ruling out') the diagnosis. The correct answer is: CT pulmonary angiography

You and a nurse are performing a procedure on a 2-year-old child. To assess the level of pain that the child is experiencing you would: Select one: A.use a visual analog pain scale B.ask the nurse's for her judgment C.observe for crying or facial grimacing D.confirm when last pain medication was give

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

In examining the neck of a patient, you note that the trachea is not positioned in the midline. Which of the following conditions would be the mostly likely cause of this observation? Select one: A.pulmonary fibrosis B.chronic bronchitis C.pleural effusion D.pulmonary edema

Any voumetric change to either side of the movable mediastinum will cause a shift in the position of the trachea. In general, the mediastinum and trachea are pulled toward areas of decreased lung volume (e.g., lobar collapse, atelectasis, surgical resection) and pushed away from space occupying lesions (e.g., tension pneumothorax, large pleural effusions or mass lesions). Diseases or disorders that affect the lungs as a whole, such as chronic bronchitis or pulmonary fibrosis do not normally cause a shift in the mediastinum and trachea. The correct answer is: pleural effusion

Transcutaneous gas monitoring would be most accurate for a patient with which of the following conditions? Select one: A.peripheral vasoconstriction B.sleep apnea syndrome C.induced hypothermia D.severe hypovolemic shock

Accurate measurement of transcutaneous blood gas parameters (PtcO2/PtcCO2) depends on good perfusion to the skin in the area of electrode placement. Any condition causing poor cutaneous perfusion or peripheral vasoconstriction (shock, hypothermia) causes large discrepancies between arterial and transcutaneous partial pressures. Sleep apnea causes neither poor perfusion nor peripheral vasoconstriction. The correct answer is: sleep apnea syndrome

You are having difficulty passing a suction catheter through a patient's orotracheal tube. Which of the following could be causing this problem? Select one: A.too large an ET tube B.too small a catheter C.patient biting on ET tube D.ET tube in right bronchus

Assuming the catheter is properly lubricated and not too large for the airway, the most common causes of difficulty in passing a suction catheter through an ET include would be either a mucus plug or a tubing kink;(more common with nasal intubation due to the sharper angle needed to pass the tube into the pharynx). Kinking also can occur when a patient flexes the neck. With oral intubation, a patient biting down on the tube can obstruct catheter passage (prevented with a 'bite block'). Also, difficulty in passing a catheter can occur if it is too LARGE for the ET tube. Endobronchial intubation (most commonly in the right mainstem bronchus) would not hinder catheter passage. The correct answer is: patient biting on ET tube

At its point of generation, solid infectious waste should be: Select one: A.placed in standard garbage bags and sent out for incineration B.broken into small pieces and flush into the sanitary sewer C.placed in the unit's utility sink and soaked in disinfectant D.placed in a color-coded, puncture-resistant bag or container

At the point of generation, solid infectious waste should be separated from noninfectious waste and immediately contained/packaged in clearly identifiable containers or bags that are leakproof and puncture-resistant. Containers or bags should be color-coded (red or orange) and marked with the universal symbol for biological hazards. The correct answer is: placed in a color-coded, puncture-resistant bag or container

A nondisposable tracheal airway cannot under go steam autoclaving but needs to be processed for re-use on other patients. Which of the following is an acceptable alternative for processing this device? Select one: A.pasteurization at 63 °C for 30 minutes B.exposure to micowave radiation for 20-30 min C.surface disinfection with 70% ethyl alcohol D.placement in a hot air (375 °F) chamber for 15 min

Because a tracheal airway directly contact mucous membranes, it is classified as semicritical medical equipment. If sterilization of semicritical items is not feasible, they should undergo high-level disinfection or pasteurization (immersion in water at 63 °C for 30 minutes). The correct answer is: pasteurization at 63 °C for 30 minutes

In a dual-limb or 'Y' ventilatory breathing circuit with a heated humidifier, you should place the inspiratory HEPA filter between: Select one: A.the heated humidifier and the 'Y' connector B.the 'Y' connector and the expiratory valve C.the ventilator outlet and heated humidifier D.the 'Y' connector and the patient's airway

Because its performance can be affected by condensation, the HEPA filter must be positioned proximal to any active humidification system, i.e., between the ventilator outlet and heated humidifier. To prevent airborne cross-contamination; some ventilators also place a HEPA filter at or near the expiratory valve, which must be heated to avoid condensation. The correct answer is: the ventilator outlet and heated humidifier

In reviewing the chart of a patient with a suspected pulmonary embolus, you would expect to find an order for which of the following diagnostic procedures? Select one: A.chest radiography B.CT angiography C.pulmonary function test D.bronchoscopy

CT pulmonary angiography (CTPA) has become the gold standard for the diagnosis of pulmonary embolism, replacing both traditional X-ray angiography and V/Q scanning. During CTPA the patient receives an intravenous injection of an iodine-containing contrast agent. A normal CTPA scan will show the contrast filling all the pulmonary vessels, appearing as bright white. Any area of the pulmonary circulation where a blockage is present will appear dark instead of white. The correct answer is: CT angiography

Which of the following is a contraindication against performing CT pulmonary angiography (CTPA)? Select one: A.right bundle branch block B.allergy to contrast media C.bleeding abnormalities D.pulmonary embolism

CT pulmonary angiography (CTPA) is the preferred imaging test for diagnosing pulmonary embolism. The primary contraindications against CTPA are 1) known or suspected allergy to the contrast media and 2) renal insufficiency (where contrast media could further impair renal function). Bleeding disorders, right bundle branch block, phlebitis and thrombosis represent contraindications against the older more invasive angiography procedure, which required insertion of a pulmonary artery catheter. CTPA simply requires regular peripheral venous access to inject the contrast media. The correct answer is: allergy to contrast media

How often should you conduct blood gas or hemoximetry calibration verification using control media? Select one: A.at least one control should be analyzed every 8 hours B.at least one control should be analyzed every hour C.at least three control should be analyzed every 8 hours D.at least one control should be analyzed every 24 hours

Calibration verification establishes and periodically confirms the validity of blood gas analyzer results. As a general recommendation, at least one control should be analyzed every 8-hour shift. A rotation system should assure that all three levels of the control media are analyzed at least once each 24 hours. The correct answer is: at least one control should be analyzed every 8 hours

Factors that affect the concentration of oxygen delivered by an air-entrainment (Venturi) mask include Size ofgas jetSize ofentrainment portDownstreamresistanceA.YesYesNoB.YesNoYesC.NoYesYesD.YesYesYes Select one: A.A B.B C.C D.D

Design factors that determine the concentration of oxygen delivered by an air-entrainment mask include: 1) the size of the jet (and the resultant velocity of gas through it), and 2) the size of the air-entrainment port(s). In general, the smaller the jet and the larger the air-entrainment ports, the more air dilution occurs and the lower the delivered FIO2. The key operational factor affecting these relationships is downstream resistance. An increase in downstream resistance always decreases air-entrainment, increases the delivered O2 concentration, and lowers total output flow. The correct answer is: D

In assessing a patient in the acute phase of ARDS, you would expect to find: Select one: A.increased lung volumes B.refractory hypoxemia C.increased compliance D.metabolic alkalosis

In ARDS, pulmonary edema, atelectasis, and surfactant loss combine to reduce lung volumes and compliance. The decrease in lung volumes and compliance increases the patient's spontaneous work of breathing, typically resulting in dyspnea and tachypnea, In addition, physiologic shunting causes severe hypoxemia that does not respond well to increases in FIO2 (refractory hypoxemia). If the hypoxemia is severe enough to compromise O2 delivery to the tissues, anerobic metabolism and a metabolic acidosis (lactic acidosis) can develop. The correct answer is: refractory hypoxemia

Under which of the following conditions would you recommend ending a cardiopulmonary exercise evaluation? Select one: A.10 mm Hg rise in systolic blood pressure B.heart rate increase from 88/min to 165/min C.10% decrease in SpO2 from baseline value D.increase in patient's level of dyspnea

Indications for ending a cardiopulmonary exercise evaluation include: (1) significant ECG abnormalities (e.g., dangerous dysrhythmias, ventricular tachycardia, ST-T wave changes); (2) severe O2 desaturation (SaO2 < 80% or SpO2 < 83% and/or a 10% fall from baseline values; (3) a hypotensive response (e.g., a fall of > 20 mm Hg in systolic BP); (4) development of angina; (5) lightheadedness; or 6) a request from the patient to stop the test. The correct answer is: 10% decrease in SpO2 from baseline value

When monitoring a patient during a spontaneous breathing trial (SBT), which of the following observations would cause you to stop the trial and return the patient to ventilatory support? Select one: A.decrease in O2 saturation from 93% to 88% B.increase in respiratory rate from 15 to 25/min C.increase in end-tidal PCO2 from 45 to 53 torr D.development of thoracoabdominal paradox

Measures indicating failure of a SBT include inadequate gas exchange (SpO2 ≤ 85-90% or PaO2 ≤ 50-60 torr; pH ≤ 7.30; increase in PaCO2 ≥ 10 torr); unstable hemodynamics (heart rate > 120-140/min; %change > 20%; systolic BP > 180-200 mm Hg or < 90 mm Hg or %change > 20%); and an unstable ventilatory pattern (respiratory rate ≥ 30-35/min or %change > 50%; presence of accessory muscle use or thoracoabdominal paradox). The correct answer is: development of thoracoabdominal paradox

For which of the following conditions would postural drainage be ineffective? Select one: A.cystic fibrosis B.bronchiectasis C.bronchitis D.pleural effusion

Postural drainage can be effective in aiding airway clearance in patients with symptomatic secretion retention associated with conditions such as cystic fibrosis, bronchiectasis or chronic bronchitis. Postural drainage (with or without percussion and vibration) is not indicated for patients who can effectively clear secretions via other means (such as coughing) nor for routine or prophylactic postoperative care. Airway clearance therapies such as postural drainage also serve no purpose in managing patients with pleural effusions. A pleural effusion is OUTSIDE the lung and cannot be drained via the airways; pleural effusions are removed via thoracentesis. The correct answer is: pleural effusion

You would generally avoid inserting an oropharyngeal airway in a patient who: Select one: A.requires manual ventilation B.is less than 12 years old C.is unconscious/unresponsive D.has an active gag reflex

Because oropharyngeal airways can cause gagging, vomiting or laryngospasm, these devices normally are contraindicated in patients with an active gag reflex (mainly those who are conscious). These airways also are contraindicated in cases of oromaxillary or mandibular trauma. Oropharyngeal airways should never be placed when a foreign body is already obstructing the oropharynx. Oropharyngeal airways are a common adjunct to help maintain the airway during manual (bag-valve-mask) ventilation and--properly sized--can be used on children and infants. However, because incorrect sizing or placement can worsen obstruction, these airways must be placed with care, and only by trained personnel. The correct answer is: has an active gag reflex

Which of the following procedures can help decrease the infection risk of in-use ventilator equipment and circuitry? Changing thecircuit every24 hoursSterilizingreusablecomponentsProperlydraining tubingcondensateChanging HMEstwice per8-hour shiftA.NoYesYesNoB.YesYesNoYesC.YesYesYesYesD.YesNoYesYes Select one: A.A B.B C.C D.D

To help decrease the infection risk of in-use ventilator equipment and circuitry, one should: sterilize or high-level disinfect reusable breathing circuits components; use sterile water to fill humidifiers; periodically drain tubing condensate away from the patient; implement hand hygiene after draining or handling tubing condensate; and change heat-moisture exchangers (HMEs) only according to the manufacturer's recommendation or when there is evidence of obstruction or gross contamination. One should change ventilator circuits only when they become visibly soiled or malfunction. The correct answer is: A

To manually test a ventilator's high pressure alarm, you would: Select one: A.adjust the peak flow B.occlude the circuit C.disconnect the circuit D.change the alarm setting

To test a ventilator's high pressure alarm, you would occlude the circuit during a mandatory breath. The correct answer is: occlude the circuit

A patient with viral pneumonia and bilateral infiltrates on X-ray is intubated and placed on pressure control ventilation with 40% O2 and 10 cm H2O PEEP. After 30 minutes of ventilatory support you obtain the following blood gas:pH = 7.49PCO2 = 34 torrPaO2 = 60 torrSaO2 = 91%HCO3 = 25 mEq/LBE = +2 MEq/LWhen asked by the patient's doctor, you would describe her condition as being consistent with: Select one: A.hemic hypoxia B.mild ARDS C.moderate ARDS D.severe ARDS

Your answer is correct. The patient's P/F ratio is 150 (P/F = PaO2/FIO2 = 60/0.4 = 150. For patients on PEEP/CPAP with bilateral infiltrates, a P/F ratio between 200 to 300 indicate mild ARDS, 100-200 moderately severe ARDS and < 100 severe ARDS. Based on the clinical presentation and X-ray findings, this patient has moderately severe ARDS and should be started on the ARDSNet or equivalent protocol. The correct answers are: moderate ARDS, severe ARDS

A 35 lb (16 kg) toddler requires intubation with a laryngeal mask airway (LMA). What size LMA would you select for this patient? Select one: A.1 B.1-1/2 C.2 D.2-1/2

Proper size selection is critical to effective use of the LMA, as well as maximum cuff inflation volumes. The recommended size LMA for a 10-20 kg infant/children is a #2, with a maximum cuff inflation volume of 10 mL. Often lesser volumes are sufficient to obtain a seal and/or achieve 60 cm H2O cuff pressure. The correct answer is: 2

A large adult (110 kg) requires intubation with a laryngeal mask airway (LMA). What size LMA would you select for this patient? Select one: A.3 B.4 C.5 D.6

Proper size selection is critical to effective use of the LMA, as well as maximum cuff inflation volumes. The recommended size LMA for a large adult (> 100 kg) is a #6, with a maximum cuff inflation volume of 50 mL. Often lesser volumes are sufficient to obtain a seal and/or achieve 60 cm H2O cuff pressure. The correct answer is: 6

Based on the following blood-gas report, what is the most likely acid-base diagnosis? pH = 7.52 pCO2 = 44 torr HCO3 = 35.1 mEq/L Select one: A.acute (uncompensated) metabolic alkalosis B.combined respiratory & metabolic alkalosis C.acute (uncompensated) respiratory alkalosis D.fully compensated respiratory alkalosis

The pH is above normal (alkaline). The PCO2 is in the normal range and thus not a factor in the alkalosis. The HCO3 is high, which indicates a primary metabolic alkalosis. Since the PCO2 is normal, no compensation is occurring, and the problem is an acute or uncompensated metabolic alkalosis. The correct answer is: acute (uncompensated) metabolic alkalosis

To continuously monitor the adequacy of ventilation of a patient in ICU being supported by mask BiPAP, you would recommend which of the following? Select one: A.capnography B.pulse oximetry C.ABG analysis D.vital capacity

To assess the adequacy of ventilation, we need to measure either the arterial blood or alveolar PCO2. Continuous PCO2 measurement requires either a transcutaneous PCO2 monitor (PtcO2, a blood estimate) or capnograph (PetCO2, an alveolar estimate). In most patients, the transcutaneous PCO2 accurately reflects the PaCO2, making it a good choice for continuously monitoring of ventilation. Due to the continuous flow and leakage that occurs during NPPV ventilation, getting good PetCO2 data can be challenging. However, using a sidestream capnograph with a nasal sampling catheter placed under the NPPV mask has proved to be an effective monitoring strategy. The correct answer is: capnography

In order to assure maximum stimulation when using the airway occlusion method to measure maximum inspiratory pressure (MIP; NIF; PImax), you should occlude the airway for: Select one: A.5 seconds B.10 seconds C.20 seconds D.30 seconds

To assure maximum stimulation when using the airway occlusion method to measure maximum inspiratory pressure (MIP; NIF; PImax), the airway should be occluded for a full 20 secs. The therapist then observes and records the maximum deflection of the manometer. The correct answer is: 20 seconds

To change the level of negative pressure delivered by a pleural drainage system, you would: Select one: A.adjust the vacuum level on the suction regulator B.adjust the water level in the suction control chamber C.adjust the water level in the water seal chamber D.adjust the size of the atmospheric vent

To change the level of negative pressure delivered by a pleural drainage system, you adjust the water level in the suction control chamber. The correct answer is: adjust the water level in the suction control chamber

When testing a ventilator's operation, the actual oxygen concentrations delivered by the device should be within what percentage of that set on its FIO2 control? Select one: A.±1% B.±2% C.±5% D.±20%

To confirm accurate O2 delivery during ventilator testing, set the oxygen concentration on the ventilator and verify this concentration using a calibrated oxygen analyzer. The difference between the set and measured FIO2 should be within ± 2%. The correct answer is: ±2%

Which of the following must be documented after obtaining an arterial blood gas sample via the brachial artery? Select one: A.pain tolerance of procedure B.number of puncture attempts C.results of the modified Allen test D.the FIO2 and key ventilator settings

To document a patient's status after obtaining an ABG sample, you must properly record (1) the date, time and site of sampling; (2) the patient's body temperature; and (3) the FIO2/O2 flow and all applicable ventilator settings. Only if the sample was obtained via the radial artery do you need to document the results of the Allen test. Specific reference to the patient's pain tolerance and the number of attempts are not required chart entries. The correct answer is: the FIO2 and key ventilator settings

Lab tests on a patient with COPD reveal a hematocrit of 61% and a markedly increased red call mass. Which of the following clinical findings is most likely in this patient? Select one: A.cool, clammy skin B.central cyanosis C.dependent edema D.skin pallor/paleness

A hematocrit of 61% with a markedly increased red call mass indicates secondary polycythemia. In patients with COPD, secondary polycythemia is most often due to chronic hypoxemia, which stimulates RBC production. When hypoxemia is combined with an increased red call mass, the likelihood of central cyanosis increases. Central cyanosis generally appears when the amount of unoxygenated hemoglobin in the capillaries exceeds 5 g/dL. The more hemoglobin in the blood, the more likely this threshold will be reached. The correct answer is: central cyanosis

Bases on evaluation of the chest X-ray, a doctor want to increase the CPAP level on a infant receiving O2 via a high flow nasal cannula set to 8 L/min. To do so, you would: Select one: A.increase the system flow B.switch to larger nasal prongs C.decrease the system flow D.switch to smaller nasal prongs

A high flow nasal cannula can provide CPAP for infants. CPAP levels depend on 1) the size of the prongs relative to the size of the nares (the larger the prongs, the greater the pharyngeal pressure created), and 2) the system flow (higher flows yield higher CPAP pressures). Given that the system flow is already at the maximum range recommended for infants (1-8 L/min), the best option would be to switch to larger prongs. In general, CPAP is created only when the outside diameter of the nasal prongs is more than 50% of the inside diameter of the patient's nares. The correct answer is: switch to larger nasal prongs

During a successful CPR attempt, a patient's airway is intubated, and the patient is placed on a mechanical ventilator. During each inspiration you can feel air escaping from the patient's mouth. What should be done? Select one: A.recommend placement of an NG tube B.put more air into the cuff C.recommend a chest x-ray film D.replace the endotracheal tube

A leak from the mouth of an intubated patient receiving mechanical ventilation generally indicates a leak around the tube cuff. More air should be added to the cuff to eliminate the leak, ideally at a pressure between 20 to 30 cm H2O. Lower pressures might allow aspiration of supraglottic secretions and higher pressures can cause mucosal ischemia. The correct answer is: put more air into the cuff

On physical examination of a patient with pulmonary emphysema, you would expect to find which of the following? Course bilateralrhonchiWeight loss/cachexiaSigns of corpulmonaleIncreased APchest diameterA.YesYesYesYesB.NoYesYesNoC.YesNoNoYesD.NoYesNoYes Select one: A.A B.B C.C D.D

A patient with COPD due primarily to emphysema typically will exhibit a "quiet chest" with marked overdistention of the thorax (increased AP diameter). Sputum is usually scanty and mucoid, while weight loss may be severe and the patient appear malnourished (cachexia). Signs of cor pulmonale, so common in chronic bronchitis, are usually absent. The correct answer is: D

You note on the arterial pressure monitor of a conscious patient in no apparent distress that the pressure waveform is absent (pressure reading = 0 mm Hg), and the alarm is sounding. Your first action should be to: Select one: A.check the A-line stopcock position B.call for the Rapid Response Team C.get a new or replacement monitor D.confirm that the monitor is set to zero/cal

An absent pressure waveform with low pressure could indicate cardiac arrest, but not in a conscious patient in no apparent distress. Instead, you need to troubleshoot this apparent equipment problem. An absent pressure waveform may indicate an occluded catheter (aspirate the line and flush with heparin); catheter positioned out of the vessel (notify doctor and prepare to replace line); stopcock off to patient (position stopcock correctly); loose vascular line or electrical connections (tighten loose connections); monitor set to zero, cal, or off (make sure monitor set to proper function/display); or incorrect scale selection (select appropriate scale, e.g., arterial = high/venous = low). The correct answer is: check the A-line stopcock position

An electronic bedside spirometer should provide which of the following automated validity checks on the forced expiratory maneuver? Time topeak flowBack extrapolatedvolumeEnd-of-testvolumeA.YesYesNoB.NoYesYesC.YesNoYesD.YesYesYes Select one: A.A B.B C.C D.D

An electronic bedside spirometer should provide automated validity checks on the (1) back extrapolated volume (should be < 5% of FVC or < 150 mL), (2) time to peak expiratory flow (should be < 120 msec), and (3) end-of-test volume (should.be < 100 mL during the last 0.5 sec of the maneuver). If the spirometer you use at the bedside does not provide these automated validity checks, you will need to manually inspect the FVC tracing(s) for the errors that these measures reveal. The correct answer is: D

A patient has the following clinical signs and symptoms: confusion; a rapid pulse; low blood pressure; tachycardia; distended neck veins; and a low urine output. What is the most likely diagnosis? Select one: A.anaphylactic shock B.neurogenic shock C.cardiogenic shock D.hypovolemic shock

Clinical signs and symptoms of cardiogenic shock are similar to acute left ventricular failure. As in hypovolemic shock, the patient may be anxious, agitated, confused, or obtunded. Clinical signs of poor tissue perfusion (ie, oliguria, cyanosis, cool extremities) are usually present along with systemic hypotension. Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present. Jugular venous distention and crackles in the lungs are usually (but not always) present; peripheral edema also may be observed. Heart sounds are usually distant, and third and fourth heart sounds may be present. The pulse pressure may be low, and patients usually exhibit tachycardia and tachypnea. The correct answer is: cardiogenic shock

You are assisting a physician in exchanging the ET tube of a patient using a fiberoptic bronchoscope (FOB) as the re-intubation guide. You would remove the old tube Select one: A.immediately upon insertion of the FOB into the pharynx B.only after confirming the FOB tip is just above the carina C.prior to insertion of the FOB into the pharynx D.only after the new tube is positioned in the trachea

During fiberoptic assisted ET tube exchange, a small (pediatric size) bronchoscope is "pre-loaded" or ensleeved with a new ET tube. Using the scope for visual guidance, the tip of the new tube is positioned in the laryngopharynx. Then the tip of the scope is passed through the glottis and into trachea alongside the existing tube (requires deflation of the old tube cuff). Only after the scope tip is confirmed to be in proper position (just above the carina), should the old tube be removed. Once the old tube is removed, the physician threads the new tube over the bronchoscope into the trachea The correct answer is: only after confirming the FOB tip is just above the carina

While assessing a patient receiving volume controlled A/C ventilation, you notice that the peak pressure has increased 10 cm H2O over the last hour. The plateau pressure has not changed. You also notice that the patient has significant wheezing in both lungs that was not present earlier. You would recommend: Select one: A.nebulizing a bronchodilator B.nebulizing a corticosteroid C.suctioning the patient D.increasing the VT by 100 mL

During volume controlled ventilation the difference between peak and plateau pressure is the pressure due to airway resistance. Therefore, when peak pressure increases without an increase in plateau pressure, airway resistance has increased. The patient's wheezing suggests bronchospasm, which would cause airway resistance to rise. Based on these observations, this patient should be administered a quick acting, sympathomimetic bronchodilator such as albuterol. The correct answer is: nebulizing a bronchodilator

Which of the following would be the airway of choice for a semi-conscious patient to prevent upper airway obstruction? Select one: A.oropharyngeal airway B.tracheostomy tube C.nasopharyngeal airway D.esophageal obturator

Either an oropharyngeal or nasopharyngeal airway can be used to prevent upper airway obstruction in obtunded patients. However, oropharyngeal airways are contraindicated in conscious or semi-conscious patients, due to provocation of the gag reflex. Thus the airway of choice to prevent upper airway obstruction in a semi-conscious patient is the nasopharyngeal airway. The correct answer is: nasopharyngeal airway

The purpose of the pilot balloon on an endotracheal or tracheostomy tube is to: Select one: A.help ascertain proper tube position B.minimize mucosal trauma during insertion C.protect the airway against aspiration D.monitor cuff integrity and pressure

Endotracheal and tracheostomy tube cuffs are permanently bonded to the tube body, providing the capability to seal the airway for protection or to provide positive pressure ventilation. From the cuff, a small filling tube leads to a pilot balloon, which is used to monitor cuff integrity and pressure once the tube is in place. Finally, most tubes incorporate a valve with syringe attachment, which allows inflation and deflation of the cuff. The correct answer is: monitor cuff integrity and pressure

A patient has had a cuffed tracheostomy tube in place for 7 days. After changing the tube and twice inserting 10 mL of air, cuff pressure measures zero. The most appropriate action would be to Select one: A.insert an additional 10 mL of air B.insert a new tracheostomy tube C.insert an uncuffed tracheostomy tube D.orally intubate the patient

If the cuff pressure is 0 cm H2O after inserting 10 mL of air, it is likely that the cuff was torn on insertion. A torn or blown cuff usually means that the tube has to be replaced. The correct answer is: insert a new tracheostomy tube

To spot check a patient's oxygen saturation at the bedside you would select which of the following? Select one: A.oxygen analyzer B.hemoximeter C.transcutaneous monitor D.pulse oximeter

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

For which of the following patients would you recommend extra precautions if undergoing a cardiopulmonary exercise test? Select one: A.a patient being evaluated for coronary artery disease B.a patient with a resting systolic BP > 200 mm Hg C.a patient recommended for cardiac rehabilitation D.a patient being assessed for cardiopulmonary disability

Extra precautions should be considered for any patient undergoing a cardiopulmonary exercise evaluation whose condition represent a relative contraindications to testing. Relative contraindications to cardiopulmonary exercise testing include (1) severe pulmonary hypertension/cor pulmonale; (2) known electrolyte disturbances (e.g., hypokalemia); (3) resting diastolic blood pressure > 110 mm Hg or resting systolic blood pressure > 200 mm Hg; (4) neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise; (5) uncontrolled metabolic disease (e.g., diabetes); (6) SaO2 or SpO2 < 85% breathing room air; and (7) untreated or unstable asthma. Evaluating patients for coronary artery disease, cardiac rehabilitation or cardiopulmonary disability are all indications for the procedure. The correct answer is: a patient with a resting systolic BP > 200 mm Hg

A nondisposable humidifier will not bubble if: Select one: A.the reservoir jar is loose B.the pop-off valve is open C.a diffuser plate is missing D.the down tube is plugged

Failure of a humidifier to bubble indicates a problem at or before the diffusing head. This eliminates a loose reservoir jar and open pop-off as possible problems. A missing diffuser plate/head would simple cause large (as opposed to small) bubbles. The most likely problem is a clogged or plugged downtube. The correct answer is: the down tube is plugged

Upon a return visit to a home care COPD patient on a inspiratory resistive breathing exercise program, you note no increase in MIP (maximum inspiratory pressure) since the last measure taken two weeks ago. No other changes are noted in the patient. What is the most likely cause of the observed lack of improvement in respiratory muscle strength? Select one: A.rapid progression of the disease process B.noncompliance with the exercise regimen C.a faulty inspiratory resistive device D.development of an upper airway infection

If a patient's PImax does not increase after a program of inspiratory resistive exercises, the therapist should attempt to determine the cause by questioning the patient and inspecting the exercise log. In most cases, a lack of improvement in PImax can be attributed to simple noncompliance with the exercise regimen. The correct answer is: noncompliance with the exercise regimen

Following successful endotracheal intubation of a patient, you should recommend: Select one: A.performing inline stabilization B.taking a 12-lead ECG C.securing a sputum sample D.obtaining a chest x-ray

Following successful orotracheal intubation of a patient, the proper tube position needs to be confirmed. Although auscultation and expired CO2 analysis can suggest proper placement, only a chest x-ray can confirm it. In adults, the ET tube tip should be positioned 4-6 cm above the carina or between T2 and T4. This position minimizes the chances for tube movement down into the bronchi (endobronchial intubation) or up into the larynx (extubation). The correct answer is: obtaining a chest x-ray

At a normal arterial blood PaO2 of 100 torr, what is the approximate percent saturation of hemoglobin with oxygen? Select one: A.82% B.87% C.94% D.97%

Hb saturation with O2 is determined by its affinity for this gas at various PO2s, as described by the S-shaped oxyhemoglobin dissociation curve. The flat upper part of the curve represents the normal range for arterial blood. With a normal PaO2 of 100 torr, Hb is about 97% saturated with O2. Because the slope in this area is minimal, minor changes in arterial PO2s have little impact on Hb saturation, indicating a strong affinity of Hb for oxygen. The correct answer is: 97%

Which of the following occurs when the water reservoir of a large volume jet nebulizer is heated above ambient temperatures? Select one: A.decreased aerosol particle size (MMD) B.increased aerosol output (mL/min) C.decreased condensation in the circuit D.increased aerosol particle stability

Heating a large volume jet nebulizer increases its total aerosol output (in mL/min). However, these warm aerosols cool as they travel toward the patient, resulting in condensation of water vapor both on the walls of the tubing and on the aerosol particles themselves (a process called coalescence). Coalescence increases particle size (MMD) and decreases the stability of the aerosol. The correct answer is: increased aerosol output (mL/min)

A patient has an FRC of 2900 mL measured by helium dilution but a thorax gas volume of 4100 mL as measured by body plethysmography. Which of the following is the most likely diagnosis? Select one: A.bullous emphysema B.pulmonary atelectasis C.interstitial lung disease D.kyphoscoliosis

Helium dilution and nitrogen washout methods both measure the actual FRC (lung volume communicating with the airways). Body plethysmography measures the total thorax gas volume (TGV). Normally FRC = TGV. When TGV > FRC (as in this case), "trapped' gas (air not in communication with the airways) is present. This is a common finding in bullous emphysema. The correct answer is: bullous emphysema

Physical examination and X-rays suggests that a patient has a right-sided pleural effusion. Which of the following additional tests would you recommend to determine the cause of the effusion? Select one: A.thoracic ultrasound B.bronchoscopy C.thoracentesis D.CT scan

In general, thoracentesis should be performed on all patients with pleural effusions of unknown origin. In most instances, analysis of the pleural fluid yields valuable diagnostic information or definitively establishes the cause of the pleural effusion. This is the case when malignant cells, microorganisms, or chyle are found, or when a transudative effusion is present in patients with heart failure or cirrhosis. Thoracentesis is urgent when hemothorax or empyema is suspected (requiring chest tube insertion). Additional imaging (CT or ultrasound) would only further demonstrate the presence of the effusion, not its cause. And because an effusion exists outside the lung, bronchoscopy is of no diagnostic value. The correct answer is: thoracentesis

Which of the following indicates adequate humidification of a patient receiving ventilatory support with a heated wire humidification system? Select one: A.the presence of condensate throughout the entire patient circuit B.the absence of any condensate in the inspiratory limb of the circuit C.the presence of condensate only in the expiratory limb of the circuit D.the presence of a little condensate at or near the patient connection

In heated wire humidification systems, the presence of a few drops of condensation at or near the patient connection is the best indicator of adequate humidification. The correct answer is: the presence of a little condensate at or near the patient connection

A patient with a large tension pneumothorax will usually exhibit: Decreasedbreathsounds*Dullnesstopercussion*Mediastinalshift towardpneumothoraxHypotensionandshockA.YesYesYesYesB.YesNoNoYesC.NoNoYesYesD.YesYesNoNo*affected side Select one: A.A B.B C.C D.D

In patients with a large pneumothorax, dyspnea, decreased chest expansion, a resonant percussion note, and decreased breath sounds are apparent over the affected area. In a tension pneumothorax, the build-up of pressure causes the mediastinum to shift AWAY from the affected side, compressing the mediastinal structures and the contralateral lung. Mediastinal compression also can disrupt cardiac filling, resulting in a rapid fall in blood pressure and shock. The correct answer is: B

The following figure represents the PO2 calibration curves (initial vs. desired) for a manually calibrated blood gas analyzer. To eliminate the difference labeled 'A' between the pre-calibration and desired response, you would: Select one: A.change the calibration controls to match the actual (desired) input B.adjust the offset (balance) so that the low output equals the low input C.check and replace the PO2 electrode's membrane D.adjust the gain (slope) so that the high output equal the high input

In this figure, the instrument's initial precalibration response indicates that the output readings are consistently higher than the actual (desired) input, with this positive bias worsening at the higher levels. Calibration is performed first by adjusting the offset (or balance) of the instrument (labeled here as A), so that the low output equals the low input (in this case zero). Next, the gain (or slope) of the device is adjusted to ensure that the high output equal the high input. Once both offset and gain are adjusted against known inputs, the instrument is properly calibrated. The correct answer is: adjust the offset (balance) so that the low output equals the low input

During manual bag-valve ventilation of an adult patient via endotracheal tube, you note poor chest expansion. Which of the following is the most likely cause of this problem? Select one: A.bag refill too slow B.O2 reservoir leaking C.oxygen flow excessive D.ET tube improperly placed

Inadequate ventilation during manual bag-valve ventilation via ET tube would be due to either 1) airway problems (e.g., deflated or blown tube cuff, improper tube placement) or 2) failure of the bag-valve system (misassembly, missing or torn valves, etc). To quickly differentiate between these two categories of problems, secure a new bag and continue manual ventilation. If the problem persists after applying a new bag, the problem is likely the airway. Bag refill time, O2 flow rates and O2 reservoir issues would affect the FIO2, but not the adequacy of lung inflation. The correct answer is: ET tube improperly placed

Which of the following are appropriate instructions for a patient about to receive incentive spirometry? Select one: A.exhale maximally after a normal inspiration B.inhale maximally after a normal exhalation C.exhale maximally after a maximal inspiration D.inhale maximally after a maximal exhalation

Incentive spirometry is based on a breathing maneuver called the sustained maximal inspiration, or SMI. The SMI mimics a normal sigh by having the patient inhale from the resting expiratory level up to his or her inspiratory capacity (inhaling maximally after a normal exhalation). This increases the transpulmonary pressure gradient and thus alveolar expansion. Moreover, the sustained effort at end-inspiration improves gas distribution to areas of the lung with abnormal time constants. The correct answer is: inhale maximally after a normal exhalation

A resident having difficulty intubation the trachea of a 6 foot 4 inch 90 kg male patient request a laryngeal mask airway (LMA). What size LMA would you recommend? Select one: A.size 3 B.size 4 C.size 5 D.size 6

Laryngeal mask airways come in six sizes and are selected based on patient weight. Size 5 is appropriate for large adults (70-100 kg). The size 5 LMA requires 40 mL air to inflate its mask cuff. The correct answer is: size 5

You are measuring the expired minute volume of a spontaneously breathing intubated patient in ICU using a mechanical volumeter (Wright respirometer) with a disposable one-way breathing valve and bacterial filter. After connecting this setup to the patient, you note that no volume whatsoever is recorded. Which of the following is the most likely cause of this problem? Select one: A.the respirometer's outlet is attached to the inspiratory side of the valve B.the respirometer's inlet is attached to the expiratory side of the valve C.the respirometer's outlet is attached tothe expiratory side of the valve D. the bacterial filter is placed between the valve and respirometer

Mechanical volumeters like the Wright measure flow only in one direction, from device inlet to outlet. To properly record a patient's expired volumes with a volumeter, you need to connect its inlet to the expiratory side of the valve assembly. There are three common causes for failing to record volumes with a mechanical volumeter. First, you may have left the ON/OFF switch set to OFF. Second, you may have incorrectly attached the respirometer's outlet connector to the expiratory side of the one-way valve. Third, by mistake you may have attached the respirometer's inlet to the inspiratory side of the valve. On the other hand, if you attach the respirometer's outlet to the inspiratory side of the valve, inspired--not expired--volume will be recorded. The bacterial filter should is placed between the expiratory side of the valve and respirometer. The correct answer is: the respirometer's outlet is attached tothe expiratory side of the valve

The major goal of medication reconciliation is to: Select one: A.educate the patient B.prevent medication errors C.increase patient compliance D.reduce prescription costs

Medication reconciliation is a process ideally implemented across the continuum of care that compares what drugs the physician orders to those that the patient is taking. The major goals of medication reconciliation are to: (1) avoid/correct discrepancies between physician prescriptions and drugs the patient is actually taking; and (2) prevent medication errors, adverse drug reactions and potential patient harm. The correct answer is: prevent medication errors

For which of the following situations would you recommend transcutaneous monitoring of PO2 or PCO2? Select one: A.assessing oxygenation status in suspected CO poisoning B.titrating FIO2 levels in patients receiving oxygen therapy C.spot checking blood oxygen levels in postoperative patients D.monitoring ventilation during noninvasive support (NPPV)

Monitoring the adequacy of ventilation during noninvasive support (NPPV) is one of the good indications for transcutaneous (TC) PCO2 monitoring. This is because obtaining accurate PCO2 data by capnography during NPPV is technically difficult. TC blood gas monitoring also is indicated when the need exists to continuously monitor oxygenation and/or ventilation in patients who either lack arterial access or for whom frequent blood draws are to be avoided. Likewise, TC monitoring can be used to quantify in real-time a patient's response to diagnostic or therapeutic interventions. Because pulse oximetry (SpO2) is not particularly sensitive in detecting hyperoxia (higher than normal PO2s), TC PO2 monitoring is the best way to continuously monitor for this problem in neonates (a potential cause of retinopathy). Last, TC PO2 monitoring is used in wound care to assess tissue perfusion status (a TC PO2 of 30-40 torr over the affected area indicates adequate perfusion). Because it measures PO2 and not HbO2, TC monitoring is not useful for assessing oxygenation in suspected CO poisoning. And due to its technical complexity and requisite warm-up time, using TC blood gas monitoring (vs. pulse oximetry) to titrate patients' FIO2s or spot check their O2 levels make no sense. The correct answer is: monitoring ventilation during noninvasive support (NPPV)

A patient is considered as having sufficient respiratory muscle strength to maintain adequate ventilation and prevent secretion retention when the maximum inspiratory pressure (MIP; NIF) is more negative than: Select one: A.-5 cm H2O B.-10 cm H2O C.-15 cm H2O D.-20 cm H2O

Most clinicians cite -20 to -25 cm H2O as the threshold level for the MIP/NIF, meaning that only patients who can generate values more negative than this (e.g., - 40 cm H2O) are likely able to maintain adequate ventilation and take breaths deep enough to facilitate coughing and secretion clearance. In the past, values more negative than -20 to -25 cm H2O (along with other bedside measures like the VC) also were used to indicate that a patient was ready for weaning. The correct answer is: -20 cm H2O

Which of the following are power sources can be used with most portable O2 concentrators? HouseholdAC current12 volt DCcar outletPortablebattery packA.YesYesNoB.NoYesYesC.YesNoYesD.YesYesYes Select one: A.A B.B C.C D.D

Most portable O2 concentrators employ the same method to separate O2 from room air as used by home concentrators, i.e., passing it through a regenerative, N2-adsorbent material or "molecular sieve." To do so requires electrical power, supplied by either household AC, 12 volt DC (available in cars, RVs, and motorhomes), or portable battery packs. The correct answer is: D

An ambulatory home oxygen therapy patient complains that her portable liquid system (at 2 L/min) doesn't last long enough for her to visit with her grandchildren. What might you recommend to overcome this limitation? Select one: A.decrease the flow to 1 L/min B.use an oxygen-conserving device C.put a couple E cylinders in her car D.put the large liquid unit in her car

Most portable liquid oxygen units provide 5-8 hours of O2 at flow of 2 L/min. This in-use time can be extended (doubled or even tripled) when the patient uses an oxygen-conserving device. The correct answer is: use an oxygen-conserving device

During postural drainage therapy, a patient's heart rate remains stable at 92/min and the SpO2 is 97%. However, after you pre-oxygenate the patient and begin nasotracheal suctioning, the patient's heart rate suddenly drops to 40/min. The most likely reason for this is: Select one: A.severe mucus plugging B.hypoxemia during suctioning C.a vago-vagal reflex D.postural hypotension

Sudden and severe bradycardia during suctioning is most often associated with strong vagal stimulation due to mechanical manipulation of the airway (a vago-vagal reflex). Hypoxemia (which would tend to cause tachycardia) is unlikely here due to pre-oxygenation. The correct answer is: a vago-vagal reflex

Upon entering a room to provide therapy, you determine that the patient is somnolent and breathing at a rate of 10/minute. The pulse oximeter shows an SpO2 of 86% and a heart rate of 39/minute. Which of actions should you initially take? Select one: A.call for help and a defibrillator B.prepare for emergency intubation C.initiate cardiac compressions D.palpate and assess the pulse rate

No emergency or advanced life support options should be taken until you quickly complete your basic assessment of the patient (treat the patient, not the monitor!). Given the presence of respirations, you should first quickly assess the patient's heart rate. Because this parameter (and the SpO2) is being provided by the oximeter and can be affected by probe position, you should first determine the true pulse rate by palpation. If the actual pulse is normal, the likely problem is probe position, which should be corrected. Only if the pulse oximetry data is confirmed as accurate should any emergency action be taken, in this case calling for the hospital's rapid response team. The correct answer is: palpate and assess the pulse rate

Arterial hemoglobin saturation (SaO2) should be kept above what level in order to guarantee adequate oxygen delivery to the tissues? Select one: A.65% B.70% C.75% D.90%

Normal SaO2 should be more than 95% breathing room air. Levels below 90% indicate the need for supplemental O2 therapy. Drops in oxyhemoglobin content are usually the result of cardiac, pulmonary, or combined cardiopulmonary disease. Hb saturation data must always be interpreted with knowledge of Hb/Hct levels. For example, a patient with an SpO2 of 97% and severe anemia (Hb < 7 g/dL) is still suffering from hypoxemia, due to reduced blood O2 content. The correct answer is: 90%

The normal range of adult blood pressure (systolic/diastolic) is about: Select one: A.80-100/40-70 mm Hg B.100-140/60-90 mm Hg C.120-140/90-100 mm Hg D.130-150/100-110 mm Hg

Normal systolic pressure range from 100 to 140 mm Hg, with an average of 120 mm Hg. Normal diastolic pressures range from 60 to 90 mm Hg, with an average of 80 mm Hg. The blood pressure is recorded with systolic listed over diastolic; i.e., 120/80 mm Hg. The correct answer is: 100-140/60-90 mm Hg

To assess for normal diaphragm activity, you should look for which of the following during inspiration? Select one: A.outward motion of the abdomen B.supraclavicular retractions C.intercostal retractions D.inward motion of the abdomen

Normally as the diaphragm contract during inspiration, it drops and displaces the abdominal contents, forcing the abdominal wall to move outward (in men more than women). If this does not occur, or if it occurs out-of-phase with inspiration, an abnormality exists. Failure of the diaphragm to descend normally indicates either a neuromuscular disorder or advanced emphysema, (in which 'flattening' of this muscle impairs its function). Out-of-phase motion (aka thoracoabdominal asynchrony or paradox) indicates increased work of breathing and/or muscle fatigue. The correct answer is: outward motion of the abdomen

On examination of a normal patient's neck, the midline of the trachea should be directly below the center of the: Select one: A.suprasternal notch B.midclavicular line C.midaxillary line D.anterior axillary line

Normally, the trachea is located centrally in the neck of a forward facing patient. The midline of the neck can be located by palpation of the suprasternal notch at the base of the anterior neck. The midline of the trachea should be directly below the center of the suprasternal notch. The correct answer is: suprasternal notch

Obstructive apnea is defined as: Select one: A.a decrease in breathing greater than 30% that causes desaturation B.a period ≥ 10 seconds of no airflow with increasing respiratory effort C.increasing respiratory effort that leads to an arousal from sleep D.a period ≥ 10 seconds of no airflow without respiratory effort

Obstructive apnea is defined as a period of no airflow lasting at least 10 sec, accompanied by increasing respiratory effort. Central apnea also is characterized by a lack of airflow ≥ 10 sec, but occurs without respiratory effort. Hypopnea is a reduction in air flow of at least 30% lasting at least 10 sec and associated with O2 desaturation > 3-4%. A respiratory effort-related arousal (RERA) is a sequence of breaths lasting at least 10 sec characterized by increasing respiratory effort leading to arousal from sleep. The correct answer is: a period ≥ 10 seconds of no airflow with increasing respiratory effort

Which of the following aspects of a patient's social history is most important in the diagnosis of lung disease? Select one: A.marital status B.cultural background C.education D.occupational history

Of the items list, occupational history is most important in the diagnosis of lung disease. Many lung diseases are associated with inhalation of dusts or toxic chemicals in the work setting. The correct answer is: occupational history

For which of the following infants would you recommend prophylactic administration of surfactant at or soon after birth? Select one: A.born to diabetic mother at 40 weeks gestation and requiring neonatal resuscitation B.born at 32 weeks gestation with amniotic fluid positive for phosphatidylglycerol C.born at 34 weeks, weighing 2000 g with diagnosis of congenital diaphragmatic hernia D.born at 28 weeks gestation with amniotic lecithin/sphingomyelin ratio = 1:1

Prophylactic administration is indicated for premature infants at high risk of developing RDS secondary to surfactant deficiency (e.g. < 32 weeks or low birth weight < 1,300 g) and for infants in whom there is laboratory evidence of surfactant deficiency, e.g., lecithin/sphingomyelin ratio < 2:1 or the absence of phosphatidylglycerol (PG). Congenital diaphragmatic hernia is not an indication for surfactant therapy. The recommended method for prophylactic administration is the INSURE (Intubation, Surfactant, Extubation) procedure, i.e. early intubation and surfactant instillation, followed by prompt extubation to nasal CPAP. The correct answer is: born at 28 weeks gestation with amniotic lecithin/sphingomyelin ratio = 1:1

A patient coughs productively after receiving airway clearance therapy. You note that the sputum sample is foul smelling and green. You would suspect that the patient has: Select one: A.Pulmonary edema B.Chronic bronchitis C.Pneumococcal pneumonia D.Lung abscess

Purulent sputum (yellow, green) usually indicates a pulmonary infection. Foul-smelling or fetid purulent sputum is characteristic of lung abscess or bronchiectasis. The correct answer is: Lung abscess

A patient with an acute upper airway obstruction would have which of the following physical signs? Select one: A.inspiratory crackles B.unilateral lung expansion C.dullness to percussion D.inspiratory stridor

Signs of acute upper airway obstruction include marked respiratory distress, altered voice, dysphagia, stridor, decreased breath sounds, and tachycardia. Conscious patients also may exhibit the 'hand-to-the-throat' choking sign. If the obstruction is complete and not resolved by treatment, asphyxiation will progress to cyanosis, bradycardia, hypotension, and cardiovascular collapse. The correct answer is: inspiratory stridor

Which of the following would probably characterize the emotional state of a patient with a tension pneumothorax? Select one: A.panic B.anger C.euphoria D.depression

Since a tension pneumothorax is a life-threatening event, the most common emotional response would be agitation and panic. The correct answer is: panic

A two year-old child is admitted to the Emergency Department with stridor, nasal flaring, tachypnea and inspiratory retractions. Which of the following procedures would you recommend to help diagnose this patient's problem? Select one: A.ventilation-perfusion scan B.AP and lateral neck X-rays C.arterial blood gas analysis D.bedside spirometry

Stridor and respiratory distress in children indicates upper airway obstruction, usually due to either infection (croup or epiglottitis) or aspirated foreign bodies. In combination, AP and lateral neck X-rays can help differentiate among these problems. The correct answer is: AP and lateral neck X-rays

Which of the following is needed in order for a patient to generate an effective cough? Select one: A.open glottis B.vagal stimulation C.low alveolar pressure D.deep inspiration

Strong abdominal muscles, the ability to close the glottis, a deep inspiration and high intraalveolar pressures are needed to generate an effective cough. The correct answer is: deep inspiration

What approximate volume should be used to inflate the larger #1 cuff of an esophageal-tracheal Combitube® (ETC)? Select one: A.12 - 15 mL B.20 - 30 mL C.40 - 60 mL D.80 - 100 mL

The ETC comes in two sizes: 37 and 41 French. Cuff inflation volumes for the 41 Fr: ETC are: large cuff (#1) - 100 mL; small cuff (#2) - 15 mL. For the 37 Fr ETC, you fill the large cuff with 85 mL and the small one with 12 mL. The correct answer is: 80 - 100 mL

A portable spirometer requires that you enter the patient's height in cm in order to derive normal values. The patient tells you that she is 5 feet 6 inches tall. What value would you enter into the device? Select one: A.26 cm B.66 cm C.168 cm D.186 cm

The conversion factor for inches to cm is 2.54 cm = 1 inch. The patient is 66 inches tall [(5 x 12) + 6]. 66 x 2.54 = 167.6 in. The correct answer is: 168 cm

The normal C(a-v)O2 in a healthy adult at rest is about: Select one: A.5 ml/dL B.15 ml/dL C.20 ml/dL D.250 ml/dL

The difference between the arterial and venous oxygen contents is normally about 5 ml/dL. This arterial-venous oxygen contents difference, or C(a-v)O2, represents the amount of oxygen given up to the tissues by every 100 ml of blood on each pass through the systemic capillaries. Obviously, this value reflects the mean of the body as a whole, with different organ systems extracting more or less oxygen according to need. The correct answer is: 5 ml/dL

The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the: Select one: A.cerebral perfusion pressure B.cerebral vascular resistance C.blood-brain barrier pressure D.jugular venous pressure

The difference between the mean arterial pressure (MAP) and intracranial pressure (ICP) is the cerebral perfusion pressure (CPP); CPP = MAP - ICP. As this equation makes clear, any factor that increases ICP and/or lowers MAP will decrease CPP and thus potentially cause brain damage or death. In general perfusion is adequate if the CPP can be maintained between 60 to 100 mm Hg. The correct answer is: cerebral perfusion pressure

When inspecting a chest radiograph, you note that the heart is shifted to the patient's left. Which of the following is the most likely cause of this finding? Select one: A.left sided atelectasis/lung collapse B.left sided pleural effusion C.left sided tension pneumothorax D.right sided pneumonectomy

The heart and mediastinum are pulled toward areas of decreased lung volume (e.g., atelectasis, fibrosis, surgical resection) and pushed away from space occupying lesions (e.g., pneumothorax, pleural effusion, large mass lesions). A shift of the heart position to the right would therefore be caused either decreased right-sided lung volume or a space occupying lesion on the left. Of the options listed, only left sided atelectasis/lung collapse would shift the heart's position to the left. The correct answer is: left sided atelectasis/lung collapse

Analysis of exhaled nitric oxide (FeNO) would be most helpful for: Select one: A.treating pulmonary hypertension B.assessing presence of air trapping C.titrating asthma drugs and dosages D.treating refractory hypoxemia

The measurement of exhaled nitric oxide (FeNO) has been found useful in establishing the correct diagnosis of asthma; predicting the response to corticosteroids in patients with asthma; titrating anti-inflammatory medication in patients with asthma; attaining and maintaining asthma control; predicting impending asthma exacerbation; and monitoring asthma medication adherence. The correct answer is: titrating asthma drugs and dosages

A 42-year-old (50 kg) patient is admitted to the emergency department after overdosing on heroin. The patient is unconscious and is making minimal respiratory efforts. Blood gases on a nonrebreathing mask @ 12 L/min are as follows:pH =7.19PCO2 =70 torrHCO3 =26 mEq/LPaO2 =320 torrWhat should you recommend? Select one: A.intubate/apply SIMV, VT 400 mL, rate 6/min, FIO2 0.40 B.apply mask BiPAP, IPAP 20 cm H2O, EPAP 5 cm H2O, FIO2 0.30 C.intubate/apply A/C ventilation, VT 400 mL, rate 12/min, FIO2 0.50 D.apply 10 cm H2O mask continuous positive airway pressure, FIO2 1.00

The patient is in acute respiratory acidosis and needs airway protection plus full ventilatory support. First the patient needs to be intubated (noninvasive ventilation and mask CPAP do not provide adequate airway protection). Second the mode chosen should provide full support. CPAP provides no ventilatory support (only oxygenation). SIMV at a rate of 6/min is partial ventilatory support. The best option for this patient is thus assist/control ventilation at a normal rate, with an initial tidal volume of 8 mL/kg. The correct answer is: intubate/apply A/C ventilation, VT 400 mL, rate 12/min, FIO2 0.50

The primary cause of bronchospasm, mucosal edema, and retained secretions is: Select one: A.inflammation B.CNS stimulation C.arterial hypoxemia D.neoplasia

The primary cause in the development of bronchospasm, mucosal edema, and retained secretions is the inflammatory response due to immune reactions or infection. The correct answer is: inflammation

To evaluate and follow the course of a patient with interstitial lung disease, which of the following pulmonary function testing procedures would you recommend? Select one: A.diffusing capacity (DLco) B.He dilution FRC and TLC C.forced expiratory volumes/flows D.methacholine challenge test

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

Home apnea monitoring of infants is medically indicated for which one of the following groups? Select one: A.infants discharged prior to 40 weeks postconceptual age B.infants diagnosed with cyanotic congenital heart disease C.infants who required surfactant therapy during hospitalization D.infants with BPD requiring supplemental oxygen and CPAP

The primary indication for using an apnea monitor is to identify and warn of life-threatening events in neonates at risk of recurrent apnea, bradycardia and hypoxemia after hospital discharge. Other conditions that may require home apnea monitoring include: 1) infants receiving aminophylline or caffeine therapy for a history of apnea and bradycardia; 2) infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation; 3) infants with gastroesophageal reflux (GER) if symptomatic with color and tone change; 4) infants of substance abusing mother if clinically symptomatic; 5) infants with a tracheostomy or anatomic abnormalities that make them vulnerable to airway compromise; and 6) infants with neurologic or metabolic disorders affecting respiratory control. The correct answer is: infants with BPD requiring supplemental oxygen and CPAP

The primary reason for selecting a high flow nasal cannula system for a patient would be to Select one: A.provide CPAP therapy B.increase inspired humidity C.washout anatomic deadspace D.assure a stable/fixed FIO2

The primary reason for selecting a high flow nasal cannula system is to assure delivery of a stable/fixed FIO2 or medical gas mixture to the patient. These systems overcome the discomfort associates with high flows through standard cannulas by humidifying the gas to BTPS conditions (37º C and 100% RH). As an added benefit, high flow nasal cannulas washout CO2 from the anatomic deadspace of the nose and pharynx, thus increasing the efficiency of ventilation. Depending on the flow and size of the nasal prongs, high flow nasal cannulas also can provide CPAP to infants. However, the extra humidity, deadspace washout and CPAP effect are 'side benefits' of high flow nasal cannulas, not the primary reason for their use. The correct answer is: assure a stable/fixed FIO2

Which of the following would require that a bedside measure of a patient's forced vital capacity, be 'rejected' or deemed invalid? Select one: A.obtained value < 50% of predicted B.peak flow occurs early in exhalation C.repeated measures differ greatly D.expiratory time is > 3 seconds

The primary reasons for rejecting a bedside measure of forced vital capacity include validity issues such as poor patient effort and lack of repeatable results ('nonreproducibility' of the measurement). To assure reproducibility of FVC measurement you must confirm that the two largest values are within 150 mL of each other. Peak flow should occur early in exhalation and a valid FVC requires collection over more than 3 seconds (6 seconds is recommended) The correct answer is: repeated measures differ greatly

Which of the following would be the best method for assessing a patient's learning needs for self-administration of an MDI formulated aerosolized drug? Select one: A.patient interview B.patient observation C.family interview D.chart review

To assess learning needs you need to determine the gap between what the patient already knows/can do and what he or she needs to know/do. Methods include patient interview, patient observation, and questioning of the patient's family. To assess learning needs related to a patient-initiated procedure, observing the patient would be the best approach. In general, the patient's chart cannot provide the information required to determine learning needs. The correct answer is: patient observation

To provide CPR to an unresponsive 10 month old infant before help and equipment arrives you would: Select one: A.initiate CPR at a ratio of 15:2, with breaths provided via mouth to mouth and nose ventilation B.initiate compression-only CPR at a rate of at least 100/min C.initiate CPR at a ratio of 30:2, with breaths provided via mouth to mouth and nose ventilation D.initiate CPR at a ratio of 3:1, with breaths provided via mouth to mouth ventilation

To ventilate a 10 month old infant without support equipment, use a mouth-to-mouth-and-nose technique. If you have difficulty making an effective seal over the mouth and nose, try either mouth-to-mouth or mouth-to-nose ventilation. If you use the mouth-to-mouth technique, pinch the nose closed. If you use the mouth-to-nose technique, close the mouth. In either case make sure the chest rises when you give a breath, with each lasting about 1 second. If the chest does not rise, reposition the head, make a better seal, and try again. If you are alone, provide 2 breaths (using as short a pause as possible) after each set of 30 compressions. If two rescuers are present use a ratio of 15 compressions for every 2 breaths. The correct answer is: initiate CPR at a ratio of 30:2, with breaths provided via mouth to mouth and nose ventilation

How often should a transcutaneous blood gas sensor probe be relocated on a neonate? Select one: A.every 2 to 6 hours B.every 8 to12 hours (each shift) C.once daily (every 24 hours) D.whenever the FIO2 changes

Transcutaneous sensor probes are heated to 42-44 °C to "arterialize" the capillary blood. To avoid thermal injury, the probe must be moved frequently. Depending on patient age, sensor temperature and manufacturer's recommendation, the sensor site should be changed every 2-6 hours. The 'smaller' the patient and the higher the sensor temperature, the more frequent the need to change sensor location. The correct answer is: every 2 to 6 hours

A nutritionist arrives at the bedside of an ICU patient receiving pressure triggered volume control A/C ventilation with an order to measure the patient's energy expenditure. Just prior to her arrival you lowered the set tidal volume from 600 mL to 450 mL. Which of the following would you recommend? Select one: A.postponing metabolic measurements for at least 30 minutes B.switching the ventilator trigger from pressure to flow C.paralyzing the patient with cisatracurium (Nimbex) D.suctioning the patient just prior to connecting the analyzer

Valid metabolic measures require that the patient be in a steady state, i.e., have a stable minute ventilation and cardiac output. Typically this requires waiting at least 30 minutes after any procedure that can alter metabolism/gas exchange, e.g., CPT, suctioning, ventilator changes, etc. Paralysis is not needed for metabolic measurements, and in fact would cause falsely low VO2 and VCO2 readings. And switching from pressure to flow-triggering will cause measurement errors due to the continuous bias flow through the circuit. The correct answer is: postponing metabolic measurements for at least 30 minutes

A patient is asked to inhale as deeply as possible and blow out all his air as hard as they can until empty. What test is being performed? Select one: A.FVC B.IC C.TLC D.MVV

When a patient performs a maximal exhalation after a maximal inhalation, he is performing the forced vital capacity (FVC) maneuver. The correct answer is: FVC

A physician is having difficulty establishing an intravenous route for drug administration to a 3 year old child during resuscitation. You would recommend: Select one: A.central venous cannulation B.peritoneal administration C.intraosseous cannulation D.arterial cannulation

When fluid and drugs need to be administered to children under 6 years old and the intravenous route cannot be established, intraosseous cannulation is recommended. The correct answer is: intraosseous cannulation

A mechanically ventilated patient is being transported to X-ray. You notice that the patient's heat and moisture exchanger (HME) has become clogged with secretions. Which of the following should you do to correct the problem? Select one: A.increase the flow through the heat moisture exchanger B.rinse the heat moisture exchanger with sterile water C.replace the heat moisture exchanger D.increase the relative humidity being delivered

Whenever a heat and moisture exchanger (HME) becomes clogged with secretions, it should be changed. Clogged HMEs increase flow resistance in the breathing circuit and are less effective in adding water vapor to the inspired air. The correct answer is: replace the heat moisture exchanger

A patient has a systolic arterial pressure of 180 mm Hg and a diastolic value of 90 mm Hg. What is his approximate mean arterial pressure? Select one: A.100 mm Hg B.110 mm Hg C.120 mm Hg D.130 mm Hg

You estimate mean vascular pressures using the following formula: mean pressure = diastolic + 1/3 x (systolic - diastolic). In this case, the estimated mean arterial pressure = 90 + 1/3 x (180 - 90) = 90 + 30 = 120 mm Hg. The correct answer is: 120 mm Hg

You normally should recommend AGAINST performing a diagnostic bronchoscopy procedure on a patient with Select one: A.suspicious sputum cytology results B.an X-ray indicating a pulmonary mass C.an uncorrected bleeding disorder D.unexplained dyspnea, wheezing and stridor

You should recommend against performing diagnostic bronchoscopy in patients who (1) cannot be adequately oxygenated during the procedure (severe refractory hypoxemia); (2) have a bleeding disorder that cannot be corrected; or 3) are hemodynamically unstable (including those with pre-existing major arrhythmias). Abnormal X-ray findings of unknown etiology (e.g., suspected atelectasis, infiltrates, presence of mass or nodules); unexplained cough, dyspnea, wheezing or stridor; hemoptysis; suspected inhalation injuries (e.g., burns, toxic gases, etc.); and suspicious or positive sputum cytology results are all potential indications for diagnostic bronchoscopy. The correct answer is: an uncorrected bleeding disorder

The wife of a patient receiving post-operative incentive spirometry asks if this therapy will help get rid of his snoring, daytime sleepiness, and morning headaches. In communicating this information to the patient's surgeon, you would recommend which of the following diagnostic procedures? Select one: A.lateral neck X-ray B.arterial blood gas C.polysomnography D.diffusing capacity

You should recommend polysomnography for patients who complain of or exhibit signs or symptoms associated with sleep-disordered breathing, e.g., daytime sleepiness and fatigue; morning headaches; pulmonary hypertension, and polycythemia. The correct answer is: polysomnography

An adult patient with bilateral infiltrates on X-ray is receiving volume control (A/C) ventilation with 60% O2. He has a mean airway pressure (MAP) of 12 cm H2O and a PaO2 of 60 torr. What action would you recommend? Select one: A.implementing the ARDSNet protocol B.switching to high frequency oscillation C.switching to pressure control SIMV D.initiating a spontaneous breathing trial

Your answer is correct. The patient has a P/F ratio of 100 and an oxygenation index (OI) is 12 ([FIO2 x mean airway pressure x 100]/PaO2. In general, an OI > 8 (≈ P/F < 200) indicates moderate to severe ARDS which should be managed via the ARDSNet protocol. An OI > 20 justifies nonconventional ventilation, e.g. HFOV, and an OI > 40 (in infants) justifies extracorporeal membrane oxygenation (ECMO). The correct answer is: implementing the ARDSNet protocol