RRT-ACCS EXAM PREPARATION PRACTICE QUESTIONS COMPLETE WITH VERIFIED ANSWERS AND DETAILED RATIONALES

RRT-ACCS EXAM PREPARATION PRACTICE QUESTIONS COMPLETE WITH VERIFIED ANSWERS AND DETAILED RATIONALES 1. A 58-year-old male with COPD exacerbation is on a 40% Venturi mask. ABG: pH 7.31, PaCO2 68, PaO2 62, HCO3- 32. What is the most appropriate next step? A. Increase FiO2 to 60% B. Initiate noninvasive ventilation (NIV) C. Intubate and mechanically ventilate D. Administer sodium bicarbonate Correct Answer: B Rationale: The patient has acute-on-chronic respiratory acidosis (pH 7.35, PaCO2 elevated with elevated HCO3- indicating chronic compensation). NIV is first-line for acute exacerbation of COPD if not in extremis. No immediate need for intubation (no hemodynamic instability, severe hypoxemia, or inability to protect airway). Sodium bicarbonate not indicated. Increasing FiO2 alone does not address hypoventilation. ________________________________________ 2. A patient with severe asthma is intubated. Ventilator settings: PRVC, rate 14, Vt 450 mL, PEEP 5, FiO2 0.8. Plateau pressure = 38 cmH2O. What is the priority? A. Increase Vt to 500 mL B. Decrease Vt to 350 mL C. Increase PEEP to 10 D. Switch to pressure control Correct Answer: B Rationale: Plateau pressure 30 cmH2O increases risk of barotrauma and ventilator-induced lung injury. In asthma, high plateau pressures are usually due to dynamic hyperinflation or auto-PEEP. Lowering tidal volume (Vt) reduces plateau pressure. Increasing PEEP could worsen hyperinflation. Pressure control may not lower plateau pressure without lowering Vt. ________________________________________ 3. A 72-year-old post-op day 2 from CABG develops acute hypoxemic respiratory failure. CXR: bilateral opacities, no cardiomegaly. PAOP is 12 mmHg. What is the best initial ventilatory strategy? A. Low tidal volume (6 mL/kg IBW) with PEEP 5 B. High tidal volume (10 mL/kg) with low PEEP C. Spontaneous breathing trial D. Inverse ratio ventilation Correct Answer: A Rationale: Likely ARDS (bilateral opacities, PAOP ≤18, acute onset). ARDSnet low tidal volume ventilation (6 mL/kg ideal body weight) with moderate to high PEEP reduces mortality. High tidal volume worsens lung injury. Spontaneous breathing trial inappropriate for acute hypoxemia. Inverse ratio not first-line. ________________________________________ 4. A patient on pressure support (PS) 10, PEEP 5, FiO2 0.4 triggers every breath but has a rapid shallow breathing index (RSBI) of 105. What should the RT recommend? A. Extubate immediately B. Continue weaning with lower PS C. Return to full ventilator support D. Perform a cuff leak test Correct Answer: C Rationale: RSBI 105 suggests high likelihood of weaning failure. Continuing weaning increases risk of respiratory muscle fatigue and reintubation. Return to full support and address cause (e.g., secretions, heart failure, weakness). Cuff leak test assesses upper airway edema, not weaning readiness. ________________________________________ 5. Which ABG finding is most consistent with compensated metabolic alkalosis? A. pH 7.48, PaCO2 50, HCO3- 34 B. pH 7.36, PaCO2 60, HCO3- 36 C. pH 7.40, PaCO2 40, HCO3- 24 D. pH 7.31, PaCO2 30, HCO3- 18 Correct Answer: A Rationale: Metabolic alkalosis (high HCO3-) with respiratory compensation (PaCO2 increases) to normalize pH. Expected compensation: PaCO2 = 0.7 × HCO3- + 20 ± 5. Here 0.7×34+20=43.8, actual 50 is close. pH slightly alkalemic but near normal. ________________________________________ 6. A 45-year-old with pneumonia on volume-controlled ventilation (Vt 450, rate 16, PEEP 8, FiO2 0.6) has SpO2 88%. ABG: PaO2 55. What change is most effective? A. Increase rate to 20 B. Increase PEEP to 14 C. Increase Vt to 600 D. Change to pressure control Correct Answer: B Rationale: Hypoxemia on FiO2 0.6 indicates need for increased mean airway pressure. Increasing PEEP recruits alveoli and improves oxygenation. Increasing rate may worsen auto-PEEP. Increasing Vt raises plateau pressure and risk of VILI. Changing mode alone does not address oxygenation. ________________________________________ 7. A patient with Guillain-Barré syndrome has decreasing vital capacity (from 18 to 10 mL/kg) and maximal inspiratory pressure (MIP) -20 cmH2O. What is indicated? A. Noninvasive ventilation B. Immediate intubation C. Chest physiotherapy D. High-flow nasal cannula Correct Answer: B Rationale: Guillain-Barré with rapidly declining vital capacity (15 mL/kg) and MIP less negative than -30 cmH2O indicates risk of acute respiratory failure. Immediate intubation is needed because neuromuscular weakness can progress quickly to apnea. NIV not safe due to bulbar weakness and aspiration risk. ________________________________________ 8. Which of the following is a contraindication to noninvasive ventilation (NIV)? A. COPD exacerbation with pH 7.32 B. Cardiogenic pulmonary edema C. Facial burns with copious secretions D. Obesity hypoventilation syndrome Correct Answer: C Rationale: Absolute contraindications to NIV include facial burns/trauma, copious thick secretions, inability to protect airway, hemodynamic instability, and decreased mental status. COPD exacerbation (pH 7.25-7.30) often benefits from NIV. Cardiogenic pulmonary edema and obesity hypoventilation are indications. ________________________________________ 9. A patient on APRV with P high 30, P low 0, T high 4.0 sec, T low 0.6 sec has spontaneous breaths but end-expiratory flow does not return to zero. What should be adjusted? A. Increase T low B. Decrease P high C. Decrease T high D. Increase P low Correct Answer: A Rationale: In APRV, if end-expiratory flow does not reach zero before next P high, there is incomplete exhalation (auto-PEEP). Increase T low to allow more exhalation time. Decreasing P high reduces mean airway pressure but does not address incomplete exhalation. ________________________________________ 10. A 60-year-old with CHF on BiPAP (IPAP 14, EPAP 8, backup rate 12) has SpO2 92% on FiO2 0.5. After 30 minutes, he is dyspneic and tachypneic (RR 32). What is the next step? A. Increase IPAP to 20 B. Switch to high-flow nasal cannula C. Intubate and mechanically ventilate D. Decrease EPAP to 6 Correct Answer: C Rationale: Failure of NIV despite adequate settings (worsening tachypnea, dyspnea) suggests need for intubation. Increasing IPAP may not help if patient is fatiguing. High-flow nasal cannula not appropriate for ventilatory failure. Decreasing EPAP worsens oxygenation and may increase work of breathing. ________________________________________ 11. A trauma patient with a flail chest has paradoxical chest wall motion. Ventilator settings: Vt 6 mL/kg, rate 18, PEEP 5, FiO2 0.4. ABG: pH 7.38, PaCO2 41, PaO2 88. The patient is breathing over the ventilator frequently. What is the best adjustment? A. Increase sedation B. Switch to pressure support C. Increase Vt to 8 mL/kg D. Decrease rate to 14 Correct Answer: A Rationale: Patient-ventilator asynchrony due to pain or anxiety in flail chest. Increased sedation improves synchrony and reduces oxygen demand. Increasing Vt risks lung injury. Pressure support may worsen tachypnea. Decreasing rate may cause hypoventilation.