Lindsey Jones Final TMC Exam Questions With Correct Answers

Condensation has developed on the fuel cell of a galvanic oxygenation analyzer. Which of the following is true? A. The fuel cell should be replaced B. The analyzer will still function properly C. The gold grid in the analyzer should be replaced D. The reading will be erroneous - Answer D. The reading will be erroneous Condensation on the fuel cell of a galvanic-type oxygen analyzer may result in an erroneous reading of oxygen percentage. A sputum gram stain report indicates the presence of a gram-positive organism (diplococcus) in the sputum. The following data is available: WBC 28,000 cu mm Hb 14.5 g/dL RBC 4.6 g/dL HCT 42% Which of the following medication would be most appropriate? A. vancomycin B. gentamycin C. budesonide D. amoxicillin - Answer D. amoxicillin Gram positive organisms, such as diplococcus, staphylococcus, etc) are treated using penicillin class antimicrobials. These include penicillin, amoxicillin, carbenicillin, and others. Which of the following data should be recorded in the patient's medical record after the therapist coaches a post-op patient through sustained maximal inhalation therapy with a volume-oriented incentive spirometer? A. expiratory reserve volume B. inspiratory reserve volume C. inspiratory capacity D. vital capacity - Answer C. inspiratory capacity If the patient is using a volume oriented incentive spirometer, inspiratory capacity must be included in the documentation in the medical record. A 39-week gestational age neonate delivered 1 hour prior requires oxygen by hood. Which of the following devices should be assembled? 1. aerosol heater 2. O2/air blender 3. large-bore tubing 4. oxygen analyzer A. 2, 3, and 4 B. 1, 2, 3, and 4 C. 1, 3, and 4 D. 1, 2, and 3 - Answer B. 1, 2, 3, and 4 Because maintaining constant body temperature is paramount for an infant, use of an aerosol heater is important. An oxygen-air blender, along with large-bore corrugated tubing will also be needed to deliver supplemental oxygen. Additionally, an oxygen analyzer will be needed to determine, maintain, and adjust FIO2 as needed. The respiratory therapist notices a disparity in the heart rate as reported by an SpO2 monitor and a finger probe compared to a palpated heart rate. Which can best explain this? 1. poor peripheral perfusion 2. excessive ambient light 3. presence of finger-nail polish 4. low hemoglobin A. 1, 2, and 3 only B. 1 and 4 only C. 2 and 3 only D. 2, 3, and 4 only - Answer A. 1, 2, and 3 only A 150-lb (68-kg) male is receiving volume-cycled mechanical ventilation on the following settings: Mode SIMV Rate 16 VT 450 mL FIO2 0.45 PEEP 12 cm H2O Peak Pressure 32 cm H2O Which of the following alarm settings is most appropriate? A. Low VT 350 mL, low pressure 22 cmH2O, high pressure 45 cmH2O B. Low VT 350 mL, low pressure 30 cmH2O, high pressure 35 cmH2O C. Low VT 400 mL, low pressure 20 cmH2O, high pressure 50 cmH2O D. Low VT 300 mL, low pressure 30 cmH2O, high pressure 48 cmH2O - Answer A. Low VT 350 mL, low pressure 22 cmH2O, high pressure 45 cmH2O The low VT alarm should be set at 100 mL below VT, low-pressure should be set at 10 cm H2O below baseline peak pressures, and the high-pressure limit alarms should be set 10-15 cm H2O above the baseline peak pressure. A patient is orally intubated and receiving mechanical ventilation. The respiratory therapist notes the PetCO2 monitor is persistently reading 60 mmHg. Which of the following can the therapist conclude? A. the patient is being hyperventilated B. the CO2 detector is covered with condensate C. minute ventilation should be increased D. the infrared device is not working properly - Answer C. minute ventilation should be increased End-tidal CO2 is correlated to arterial CO2. An end-tidal CO2 reading of 60 mmHg correlates with an arterial CO2 of 70 mmHg. This is clearly hypoventilation and should be addressed by increasing minute ventilation. Local FEMA representatives have asked a hospital to prepare for intermittent, sweeping power outages in the area due to a nearby passing F4 hurricane. Which of the following would be the most important preparation that a respiratory care supervisor should consider? A. Call for extra staff to report the hospital. B. Instruct nurses on proper techniques for providing manual resuscitation. C. Contract an equipment rental company for extra ventilators. D. Check the function of back-up power outlets (red plugs) in critical areas. - Answer D. Check the function of back-up power outlets (red plugs) in critical areas. Of the options listed, checking for the proper operation of red plugs during a power outage is most helpful. It would also be appropriate to ensure vital equipment (life support machines) are plugged into those red outlets. Which is the preferred order to manipulate a mechanical ventilator in order to gradually increase alveolar minute ventilation while limiting MAP? A. increase VT, increase RR, decrease mechanical deadspace B. increase RR, decrease mechanical deadspace, increase VT C. increase VT, decrease mechanical deadspace, increase RR D. decrease mechanical deadspace, increase VT, increase RR - Answer D. decrease mechanical deadspace, increase VT, increase RR MAP, or mean airway pressure, does not increase as mechanical deadspace is decreased. Increasing the tidal volume will increase the mean airway pressure, but not as much as increasing the respiratory rate will. Which of the following cannot be measured or evaluated in a comatose patient? A. tidal volume B. pupillary response C. objective information D. symptoms - Answer D. symptoms If the patient is comatose, they cannot cooperate with procedures or follow commands. To answer this question one must pick the option that does not require compliance with verbal commands. Symptoms, coming from the root word sympathy, require the patient to tell you something. From the list only a tidal volume can be measured without help from the patient. But, the question is asking which of the following CANNOT be measured in a comatose patient. Therefore symptoms, vital capacity, maximum inspiratory pressure are all appropriate answers. Prior to intubation, a physician has ordered succinylcholine chloride (Anectine) for a male patient to facilitate the procedure. Which of the following is true regarding this medication? A. can be reversed with Atropine B. also known as Pavulon C. response time is 30 minutes D. intubation should begin once muscle twitching is observed about the face and neck - Answer D. intubation should begin once muscle twitching is observed about the face and neck Succinylcholine chloride is a fast-acting paralytic. Paralysis is indicated when twitching is seen about the face and neck. It is also known as Anectine, not Pavulon. Atropine will not reverse its effects. What pulmonary function maneuver will reveal information required to diagnose COPD? A. SBN2 B. FVC C. DLCO D. SVC - Answer B. FVC Although FVC is a volume, which is not directly helpful in diagnosing COPD, the actual name of the maneuver that is used to establish flow rates such as FEV1, is forced vital capacity (FVC). This can be confusing because the FVC is an actual volume, but when compared to time it also produces flow data, which is used to diagnose obstructive lung disease. A patient who is being intubated prior to being placed on mechanical ventilation receives vecuronium (Norcuron). Which of the following ventilator alarms will be the most important when the patient is placed on the ventilator? A. low pressure B. I:E ratio C. high inspiratory pressure D. low PEEP - Answer A. low pressure A patient who is under the influence of paralytic medication, for the purpose of intubation, should be monitored closely for accidental disconnection of the ventilator. Normally, a patient who is not paralyzed may show physical signs of respiratory difficulty if they inadvertently become disconnected. However, a patient who is paralyzed is unable to show such signs. The low-pressure alarm setting is a useful alarm that will show any inadvertent disconnection from the ventilator. Although not listed here, a better, more sensitive alarm would the the "low-PEEP" alarm, sometimes called a "disconnect alarm" A 68-year-old, male patient with COPD is participating in a pulmonary rehabilitation program. During a walking activity, the patient's SpO2 falls to 88% while receiving 1 L/min by nasal cannula. Which of the following would be an appropriate reaction to the decline in oxygenation during exercise? A. Avoid the walking activity for one month then reassess. B. Ask the patient how he feels. C. Increase oxygen to 3 L/min during the activity. D. Continue the activity, monitor the patient's subjective condition. - Answer C. Increase oxygen to 3 L/min during the activity. Which of the following PaO2 ranges is acceptable for a patient with ARDS according to the ARDSnet protocol? A. 60 to 100 mm Hg B. 70 to 85 mm Hg C. 50 to 65 mm Hg D. 55 to 80 mm Hg - Answer D. 55 to 80 mm Hg According to the ARDSnet protocol, PaO2 should be kept between 55 and 80 mm Hg during ventilatory support. This is known as permissive hypoxemia. After instructing a patient and demonstrating the proper use of a metered dose inhaler with a valved holding chamber, the patient performs the maneuver by placing the chamber in his mouth, actuating the cannister, and then exhaling prior to performing inhalation. The respiratory therapist should A. remove the cannister and have the patient reattempt the dose delivery. B. instruct the patient to inhale while depressing the cannister. C. document that the education was effective. D. re-instruct the patient to inhale immediately after actuation of the cannister. - Answer D. re-instruct the patient to inhale immediately after actuation of the cannister. If the patient exhales through the chamber immediately after actuating the inhaler, the medication may be ejected through the valve and out of the chamber. This would discard the medication. After depressing the cannister, the first action should be to inhale through the chamber. A patient receiving PSV with pressure of 12 cm H2O is demonstrating signs of increased work of breathing. RR 24/min. VT(spont) 180 mL. SpO2 88%. The physician orders an increase in the PS pressure. This will result in an increase in which of the following? A. PAO2 B. cardiac index C. functional hemoglobin D. alveolar ventilation - Answer D. alveolar ventilation Decreasing the duration of applied suction pressure is most appropriate when the patient is experiencing A. a strong cough with suction attempts. B. effective secretion clearance. C. bradycardia with suction attempts. D. retained secretions. - Answer C. bradycardia with suction attempts. The respiratory therapist should decrease suction pressure if mucosal trauma or cardiac distresss is noted during the suction procedure. A 57-year-old cachectic male patient with known COPD is receiving oxygen by nasal cannula at 5 L/min. The patient is very drowsy with a respiratory rate of 8/min. Oxygen saturation is 100%. The therapist should A. draw an arterial blood gas. B. reduce supplemental oxygen delivery. C. place on a NRB mask. D. obtain a CT scan. - Answer B. reduce supplemental oxygen delivery. A patient with COPD should not receive more than 1 to 2 L/min by nasal cannula or more than 28% oxygen. If excessive oxygen is administered the patient may experience a reduced ventilatory drive. Optimal oxygen saturation for a patient with COPD is between 92 and 94%. A patient is receiving noninvasive ventilation with no back-up rate. RR is 34/min. Accessory muscle use is noted. SpO2 is 94%. The therapist should A. increase IPAP. B. increase EPAP. C. decrease EPAP. D. introduce a ramp time. - Answer A. increase IPAP. Because spontaneous respiratory rate is elevated, an increase in ventilation is warranted. Additionally, SpO2 appears adequate. Thus, an increase in IPAP is the best option. This will increase the distance between IPAP and EPAP pressures, which will result in an increase in ventilation. What would occur on a time-cycled ventilator with a fixed rate if the inspiratory flow rate were reduced? A. increase in inspiratory time B. increase in tidal volume C. decrease in inspiratory time D. decrease in tidal volume - Answer D. decrease in tidal volume On a time cycle ventilator, with a fixed rate and a fixed inspiratory time, if inspiratory flow rate is decreased, the result would be a decrease in tidal volume. Which of the following precautions should be taken when performing nasal tracheal suctioning on a patient who has a tendency for mucosal bleeding? A. Stop all blood-thinning medication prior to suctioning B. Apply intermittent suctioning during withdraw of the catheter C. Be gentle D. Keep suctioning to no longer than 30 second - Answer C. Be gentle The most common hazard of suctioning is mucosal bleeding. The best way to prevent mucosal damage and injury is to use water-soluble lubricant and a gentle technique when suctioning. A patient who has a tracheostomy is complaining of dried secretions and difficulty expectorating sputum from the tracheostomy tube. Which of the following will be most helpful to the patient? A. Ensure inspired gas temperature is 35 deg C and humidified B. Chest physiotherapy C. PEP therapy D. Administer Acetylcysteine (Mucomyst) - Answer A. Ensure inspired gas temperature is 35 deg C and humidified Secretions are best hydrated with heated humidity. This is especially true for patients who are orally or nasally intubated. In order to deliver proper humidification, inspired gases must be at temperatures that are close to normal body temperature (37 deg C). A 40-year-old female is brought to the emergency department (ED) after being found down in a burning building. A quick assessment reveals singed nasal hairs and cherry-red arytenoids. She is on a non-rebreathing mask and oxygen SAT is 97%. Which of the following interventions should be given priority? A. COHb determination from arterial blood B. multiple wave-length spectrophotometry C. blind oral intubation D. intubation with a bronchoscope - Answer Patients who have had exposure to extremely heated air masses, such as seen with firefighters, are at risk for swelling of the tissues in the upper airways and ultimate loss of that airway. Priority, therefore, is to ensure an airway through intubation. However, blind intubation is extremely dangerous because probing those tissues with an endotracheal tube may incite additional inflammation and cause complete closure of the airway. Intubating with direct visualization is most appropriate. Usually, this means the use of a bronchoscope. To calculate alveolar minute ventilation, the respiratory therapist should A. measure while the patient is receiving mechanical ventilation. B. multiply the RR by the VT. C. measure with a metabolic cart study. D. subtract anatomical deadspace from the VT, then multiply by the RR. - Answer D. subtract anatomical deadspace from the VT, then multiply by the RR. Alveolar ventilation is calculated by subtracting the anatomical dead space from the tidal volume then multiplying by the respiratory rate. If the weight is known, the absolute value in pounds can be used to estimate anatomical deadspace. For example a patient weighing 130 pounds would have 130 mL of anatomical dead space. If weight is unknown, anatomical dead space should be estimated at 150 mL. An 8-year-old pediatric patient with a 6.0 mm endotracheal tube requiring endotracheal suctioning is experiencing bradycardia during the procedure. Suction pressure is set to -100 mm Hg. A respiratory therapist is suctioning for approximately 15 seconds using a 9 Fr catheter and is able to clear the airway effectively. To remedy the problem, the therapist should A. decrease suction duration time. B. decrease catheter size. C. increase the pressure to -110 mm Hg and decrease duration to 5 seconds. D. decrease the suction pressure. - Answer A. decrease suction duration time. If suctioning is not adequate, correct the problem in this order:_x000D_ 1. check connections, change collection bottle if full 2. ensure suction pressure is in the right range 3. increase to the maximum size catheter within range 4. increase pressure within range 5. increase suction time A patient with myasthenia gravis presents to the clinic with a fever, suspected pneumonia secondary to an infiltrate seen on a chest radiograph, and the following ABG results: pH 7.33 P aCO2 47 torr PaO2 85 torr HCO3- 26 mEq/L FIO2 0.21 Based upon this information, the patient needs A. oxygen at 2 L/min nasal cannula. B. pulmonary function testing. C. intubation. D. antibiotic therapy. - Answer D. antibiotic therapy. In this example, we see a problem with ventilation as the PaCO2 is 47 torr. However, there is no option that will resolve ventilation, therefore we must look to the scenario for other problems. There is an underlying problem of infection for which antibiotic therapy is indicated. A 50-year-old male presents in the emergency department (ED) complaining of frequent vomiting. Arterial blood gas results on room air show: pH 7.54 PaCO2 41 torr PaO2 96 torr HCO3- 30 mEq/L BE +6 mEq/L Which of the following would account for this blood gas anomaly? A. K+ 3.4 mEq/L B. Cl- 110 mEq/L C. K+ 4.9 mEq/L D. Hyperventilation - Answer A. K+ 3.4 mEq/L Carbon dioxide in this blood gas shows adequate ventilation. However, a pH of 7.54 is an indication of alkalosis. Because the alkalosis cannot be attributed to an elevated CO2, it must be caused metabolically. Observation of the bicarb shows an elevation. Of the options offered the most likely cause of this elevation is the potassium of 3.4 mEq/L. Which of the following could be associated with asymmetrical chest rise? A. COPD B. cystic fibrosis C. significant atelectasis D. pleural effusion - Answer C. significant atelectasis Of the options given, only atelectasis is associated with asymmetrical chest rise. A physician asks the respiratory therapist to evaluate the effectiveness of PEP therapy on a patient with cystic fibrosis. The therapist can conclude the therapy is effective if A. increased inspiratory capacity is observed B. improved arterial blood gas values are observed C. increased oxygen saturation during treatment is noted D. the patient develops rhonchi that clears with coughing - Answer D. the patient develops rhonchi that clears with coughing Of the options listed the development of rhonchi, which means secretions in the large upper airways, is the best evidence that secretions are being mobilized by the PEP therapy. The other options offered are either too indirect or are not related. The respiratory therapist is paged to the intensive care unit (ICU) to assess a patient who has just self-extubated. Currently, the patient is resting comfortably with an SpO2 of 98% on FIO2 0.40 by air-entrainment mask. Respiratory rate is 14/min and breath sounds are normal, for a mild inspiratory stridor which is audible without the stethoscope. The therapist will recommend: A. Switch to cool aerosol at FIO2 0.40 B. Send the patient to surgery for a tracheostomy C. Re-intubate the patient D. Administer racemic epinephrine - 3 doses 20 minutes apart - Answer A. Switch to cool aerosol at FIO2 0.40 Mild inspiratory stridor may be treated with racemic epinephrine and/or cool aerosol. In this case, since the patient is already receiving 40% by air-entrainment device, switching to a cool aerosol is the best option. Multiple doses of racemic epinephrine are not indicated. A patient's chest radiograph shows consolidation in the right middle and lower lobes. What additional finding is likely? A. increased FRC and air-trapping B. dull to percussion over the affected areas C. radiologic evidence of a pulmonary embolism D. significant tracheal deviation to the left - Answer B. dull to percussion over the affected areas Consolidation indicates pneumonia. With diagnostic chest percussion, a dull sound would be emitted over areas of consolidation. Tracheal deviation could occur, but it would most likely be toward the affected side (the right). Neither an increase in FRC nor a pulmonary embolism is related, given the current data. A respiratory therapist notes a newborn has an order for daily administration of caffeine citrate at home when discharged. What home monitoring would be appropriate? A. continuous SpO2 B. Holter C. APGAR determination daily D. apnea monitoring - Answer D. apnea monitoring Caffeine citrate is a medication used to stimulate a patient's respiratory drive. If a newborn is ordered this medication, it is likely that the physician has concerns regarding the patient's natural respiratory drive and therefore, of the options given, apnea monitoring would be a consistent care technique. The on-coming respiratory therapist reads the documentation on a patient receiving non-invasive positive pressure ventilation. The record indicates an increase in static compliance over the last eight hours. What adjustment should the therapist make to maintain the ordered tidal volume? A. decrease IPAP B. reestablish baseline flows C. increase the pressure limit D. decrease EPAP - Answer A. decrease IPAP An increase in static compliance indicates the lungs are more pliable. To maintain a constant tidal volume, inspiratory pressure should be decreased. A patient with increased airway resistance from a fixed upper airway obstruction would benefit most from which of the following? A. aerosolized atropine B. bronchodilator therapy C. epinephrine D. heliox therapy - Answer D. heliox therapy A fixed upper airway obstruction means air is having difficulty moving both in and out. It is usually caused by cancer or other non-changeable conditions. In this case the best thing we can do is decrease airway resistance by using helium or Heliox therapy. Which of the following is the most significant complication of bronchoscopy? A. vagal nerve stimulation B. coughing C. laryngospasms D. hypotension - Answer C. laryngospasms The most significant complication of a bronchoscopy is laryngospasm. This tendency may be reduced by administering aerosolized Lidocaine or any other tissue numbing agent prior to the procedure. A patient begins to gag significantly immediately after the placement of an oral pharyngeal airway. The respiratory therapist should A. remove the airway and try something smaller. B. switch to a nasal pharyngeal airway. C. provide sedation for the patient. D. replace it with an oral endotracheal tube. - Answer A. remove the airway and try something smaller. Gagging after the placement of an oropharyngeal airway (an OPA) is likely due to an excessively long OPA. A smaller airway may be more appropriate. Multiple wavelength spectrophotometry oxygen saturation is 97% on a patient with a respiratory rate of 14/min, heart rate 80/min, and clear breath sounds. Arterial blood gas results are as follows: pH 7.42 PaCO2 37 torr PaO2 125 torr HCO3- 25 mEq/L FIO2 0.21 What should the respiratory therapist recommend? A. Conduct proficiency testing on the Clark electrode. B. Discontinue supplemental oxygen. C. Check the most recent quality control values. D. Run a two-point calibration on the ABG analyzer, then repeat the sample. - Answer D. Run a two-point calibration on the ABG analyzer, then repeat the sample. In this example, the PaO2 is not possible while breathing on room air, which can be seen more easily after calculating the alveolar air equation. A multiple wavelength spectophotometer (oximeter) is a non-invasive way to measure oxygen saturation, metHb, COHb, etc. The ABG analyzer should be recalibrated and the sample repeated. A routine screening blood gas performed on an asymptomatic patient prior to surgery shows the following: pH 7.38 PaCO2 42 mm Hg PaO2 80 mm Hg HCO3- 26 mEq/L SaO2 96% COHb 24% What should the respiratory therapist do? A. Place the patient on a NRB mask B. Evaluate saturation using a single wave-length spectrophotometer C. Report the findings and emphasize that the patient is likely a smoker D. Run quality control material and evaluate the accuracy of the Co-oximeter - Answer D. Run quality control material and evaluate the accuracy of the Co-oximeter In this case the patient is presented as asymptomatic. A patient with a carboxyhemoglobin level of 24% would feel dyspnea and present with tachypnea. Therefore, the respiratory therapist should evaluate the accuracy of the laboratory results, specifically the carboxyhemoglobin (COHb). When checking accuracy of lab results, one would use quality control measures. Due to an air leak, a respiratory therapist adds air to the cuff of an endotracheal tube inserted five hours prior in the emergency room. Cuff pressure following a minimal-seal technique is 32 mm Hg. The therapist should recommend A. advancing the tube 2 cm B. minimal-leak cuff management C. a larger tube D. a radiologic view of the tube - Answer C. a larger tube Because cuff pressure is higher than the limit after minimum-seal technique is used, the endotracheal tube is likely too small. The emergency response team is monitoring a patient when the rhythm on the monitor transitions to ventricular tachycardia. The patient has a pulse. Prior to cardioversion, the respiratory therapist should do which of the following before handing the physician the paddles? A. set defibrillation to 360 joules B. administer sodium bicarbonate C. ensure synchronization is active D. call "Clear" - Answer C. ensure synchronization is active Ventricular tachycardia with a pulse must be treated by cardioversion. Cardioversion differs from defibrillation by the number of watts or Jules administered and by how it synchronizes with the heart. Pure defibrillation requires no synchronization with a heart. However, cardioversion requires that the synchronization be set to active prior to delivery of the electrical shock. Which of the following is the correct postural position for drainage of the anterior upper segment of the lungs? A. trendelenburg B. supine C. upright leaning slightly forward D. semi-Fowlers - Answer D. semi-Fowlers A 75-kg (165-lb) male is receiving mechanical ventilation by a volume-controlled ventilator in the assist/control mode on the following settings: Mandatory rate 14/min VT 800 mL FIO2 0.6 PEEP 5 cmH2O ABGs: pH 7.31 PaCO2 49 mmHg PO2 88 mmHg HCO3- 23 mEq/L BE -1 mEq/L Which of the following represents the most appropriate action? A. remove 200 mL deadspace B. increase VT to 950 mL C. decrease rate D. decrease FIO2 to 0.5 - Answer A. remove 200 mL deadspace In the arterial blood gas results, the CO2 is high indicating the patient is not ventilating well. To correct this CO2 you can either increase rate, increased tidal volume, or remove deadspace. Of those options removing deadspace is most appealing because it causes the least amount of change in mean airway pressure. A patient admitted to the hospital for pneumonia is receiving oxygen therapy by transtracheal catheter. Twenty minutes after the completion of a meal, the patient complains of shortness of breath and expresses the device is not working properly. The respiratory therapist should first A. increase the oxygen flow rate to the catheter B. initiate oxygen by air-entrainment mask C. remove the catheter D. apply suction to the catheter - Answer B. initiate oxygen by air-entrainment mask When a problem is encountered with one oxygen delivery modality, the first best response is to initiate oxygen therapy with a different modality and then troubleshoot the problem. A COPD patient is receiving oxygen at 1 L/min when he was admitted to the hospital for suspected pneumonia. The physician orders a target SpO2 of 90%. The following clinical and laboratory data is obtained: RR 17 HR 101BP 142/88 mm Hg SpO2 86% pH 7.35 PaCO2 68 torr PaO2 51 torr HCO3- 34 mEq/L BE +7 mEq/L The respiratory therapist should recommend which of the following FIRST? A. switch to an air-entrainment mask at 0.55 B. titrate the oxygen flow rate C. place a heated aerosol mask at FIO2 1.0 D. implement NIPPV - Answer B. titrate the oxygen flow rate An SpO2 of 86% does not meet the physician's requirement to maintain oxygen saturation at 90%. Therefore, the titration of oxygen is required. Titration refers to a process of increasing or decreasing FIO2 in response to data to achieve a desired SpO2 or PaO2 value. While performing a biopsy of a tissue extracted from a patient's right mainstem bronchus with a bronchoscope, the physician reports sudden bleeding from the site. Which of the following should the respiratory therapist have ready to instill? A. epinephrine B. racemic epinephrine C. normal saline D. atropine sulfate - Answer A. epinephrine When encountering a bleed in the bronchial tree during a bronchoscopy, the first step to stop the bleed is to instill epinephrine on the site through the bronchoscope. After doing so, the site should be compressed with the bronchoscope. Ultimately, a Fogarty catheter may be inserted to tamponade any remaining bleeding. After attempting to pass a catheter down an oral ET tube, the respiratory therapist feels strongly that the endotracheal tube cuff is herniated over the end of the ET tube. The bag-valve remains difficult to squeeze and oxygen saturation is 86% and falling. The therapist should do which of the following? A. switch to a high pressure demand valve B. remove the ET tube and insert a new one C. call the physician and report the finding D. perform nasal intubation with the oral tube left in place - Answer B. remove the ET tube and insert a new one A herniated endotracheal tube cuff indicates th ET tube is defective and therefore should be replaced. A 70-year-old female with chronic lung disease is admitted to the emergency department with a weak cough and fever. She demonstrates difficulty remaining awake and does not follow directions accurately. The following data is available: HR 101/min BP 119/85 mm Hg Temp 38.3 deg C (101 deg F) FIO2 0.24 by 1 L/min NC pH 7.31 PaCO2 66 torr PaO2 54 torr HCO3- 32 mEq/L BE -2 mEq/L The respiratory therapist should recommend A. intubation and mechanical ventilation B. non-invasive ventilation C. intravenous antibiotic therapy D. oxygen at 2 L/min - Answer A. intubation and mechanical ventilation Ostensibly, this patient is demonstrating very slight respiratory deficiency which is manifested by an elevated CO2 and a pH that is slightly acidotic. With this clinical data it is evident that the patient would benefit from some amount of ventilatory support, which could be best accomplished through noninvasive ventilation. However, because the patient is DEMONSTRATING INABILITY TO FOLLOW COMMANDS OR STAY AWAKE, the practitioner must have concern about the patient's ability to protect their own airway. When protection of the airway is a central concern, intubation and the use of mechanical ventilatory support is more appropriate. A fire fighter is brought to the emergency department after being found down in a room of a burning building. He was found with his protective mask off. Which of the following already documented findings would be helpful to rapidly evaluate the patient? 1. visual examination of the oral and nasal pharynx 2. nature of breath sounds 3. co-oximetery values 4. capnographic data A. 2 , 3 and 4 B. visual examination of the oral and nasal pharynx C. capnographic data D. 2 and 4 only - Answer B. visual examination of the oral and nasal pharynx For a firefighter found down in a burning building, visually examining the oral and nasal pharynx for redness and inflammation will help in assessing the degree at which the firefighter was exposed to hot gases. Listening to breath sounds will assess general airway movement and co-oximetry results will help determine if smoke inhalation and CO poisoning is a factor. Determining end-tidal CO2 is not significantly helpful. A patient on the general floor becomes a primary mouth-breather while asleep, resulting in a drop in SpO2 from 95% to 87% while on 3 L/min nasal cannula. The best remedy while asleep is to A. change to a 30% air-entrainment mask. B. place the cannula in the patient's mouth. C. apply CPAP with oxygen bleed-in. D. apply a chin strap. - Answer A. change to a 30% air-entrainment mask. The FIO2 of a nasal cannula is approximated to be 3 to 4% per liter. Therefore, a 30% Venturi mask most closely approximates the FIO2 of a nasal cannula running at 3 L/min. Which of the following modalities is appropriate for a patient with chronic obstructive pulmonary disease (COPD) who has hypoxemia at rest? A. nonrebreathing mask B. partial rebreathing mask C. air-entrainment mask D. aerosol mask - Answer C. air-entrainment mask Of the options listed, an air-entrainment mask delivering no more than 28% oxygen is most appropriate for a patient with COPD. More commonly used is a nasal cannula running a flow of 1 to 2 L/min. However, that option is not offered here. An orally intubated COPD patient has been on mechanical ventilation for 2 weeks. Repeated spontaneous breathing trails have been unprogressive. The following data is obtained: VT 320 mL VC 0.8 L MIP -20 cm H2O Which of the following approaches would be most helpful in progressing the patient? A. daily monitoring of RSBI B. extubation to non-invasive ventilation C. IV corticosteroid therapy D. alveolar recruitment maneuvers - Answer B. extubation to non-invasive ventilation A patient underdoing a cardiopulmonary stress test has the following data: Baseline: Hr 98 BP 124 mmHg spo2 98% Increased work HR 122 BP 122/85 mmHg spo2 95% Which interpretation is most accurate? A. appropriate cardiac and blood responses B. inappropriate cardiac response, appropriate blood pressure response C. appropriate cardiac response, inappropriate blood pressure response D. inappropriate cardiac and blood pressure responses - Answer C. appropriate cardiac response, inappropriate blood pressure response During a cardiopulmonary stress test, when workload is increased, both heart rate and blood pressure should also naturally increase. This is known as normal cardiac and blood pressure responses, respectively. In this case, data shows that only the HR increased (normal cardiac response). The blood pressure, however, failed to increase and is therefore considered to be an abnormal (inappropriate) blood pressure response. C(a-v)O2 values have been increasing over the last eight hours on a patient who is post-operative for coronary artery bypass. Which of the following is most likely increasing? A. cardiac output B. SpO2 C. oxygen consumption D. cardiac index - Answer C. oxygen consumption As the gap between CaO2 and CvO2 increase, oxygen consumption by the tissues increases. A 42-year-old, male patient is brought to the emergency room (ER) unconscious and obtunded. Spontaneous tidal volume is 5.3 mL/kg and RR is 12/min. Arterial blood gas analysis reveals: FIO2 0.40 pH 7.35 PaCO2 45 torr PaO2 80 torr HCO3- 24 mEq/L BE -1 mEq/L Which of the following should be recommended? A. placement of an oral pharyngeal airway B. non-invasive ventilation C. increase FIO2 to 0.50 D. oral intubation - Answer D. oral intubation Explanation : ABG data shows that ventilation is adequate. However, the UNCONSCIOUS and obtunded status of the patient suggests that the patient may not be able to protect his airway. Intubation is appropriate. A 75-kg (165-lb) male is receiving mechanical ventilation by a volume-controlled ventilator in the assist/control mode on the following settings: Mandatory rate 14/min VT 450 mL FIO2 0.5 PEEP 5 cmH2O ABG results: pH 7.32Pa CO2 48 mmHg PO2 76 mmHg HCO3- 23 mEq/L BE -1 mEq/L Which of the following represents the most appropriate action? A. increase VT to 550 mL B. increase rate to 18 C. increase PEEP to 8 cm H2O D. increase FIO2 0.6 - Answer A. increase VT to 550 mL The CO2 is slightly high. There are three ways that we can lower CO2 - increase rate, increased tidal volume, or remove dead space. In this problem increasing tidal volume by 100 mL is the best option because it will reduce CO2 by smaller increments than would an increase in rate. Increasing the rate from 12 to 16 or even from 12 to 14 would cause a significant change in CO2 which is not what we want. The other two options relate to oxygenation, which is indeed a problem, but we should be addressing ventilation first. The respiratory therapist responds to an adult patient on a ventilator whose low pressure alarm is sounding. The therapist determines the 6.0 mm ET tube is in proper position according to the markings. Gas escaping around the ET tube is audible. The therapist should A. add air to the cuff B. switch to a cuffless ET tube C. switch to a larger ET tube D. schedule the patient for a tracheotomy - Answer C. switch to a larger ET tube The first, most obvious problem in this question is that an adult patient has a 6.0 mm ET tube. For a normal sized adult, this endotracheal tube size is likely too small. Further evidence indicates gas escaping around ET tube. This is also likely due to a small endotracheal tube. A 35-year old that is receiving VC, SIMV ventilation has the following parameters: f 6/min Total rate 28/min VT (set) 450 mL VT (spont) 160 mL FIO2 0.45 PS 5 cm H2O Which of the following would be an appropriate change? A. increase PS to 10 cm H2O B. increase rate to 10/min C. decrease set VT to 400 mL D. increase set VT to 500 mL - Answer A. increase PS to 10 cm H2O The presence of a low spontaneous VT (likely well below 5 mL/kg) suggests that the patient requires additional pressure support. This will help to lower total rate and generally decrease the work of breathing. A 55-year old male is receiving VC, SIMV ventilation. The following parameters are observed: f 4/min Total rate 32/min VT (set) 500 mL VT (spont) 180 mL FIO2 0.45 Which of the following would be an appropriate change? A. administer Narcan (naloxone) B. increase rate to 12/min C. add pressure support D. begin a spontaneous breathing trial (SBT) - Answer C. add pressure support A patient complains of recent flu-like symptoms and an ensuing paralysis developing from the lower extremities upward. Which of the following monitoring techniques would be most helpful in diagnosing the patient? A. edrophonium (Tensilon test) B. myelogram C. monitoring MIP and VC D. spinal fluid analysis - Answer D. spinal fluid analysis A therapist is making several changes to the mechanical ventilator on a patient receiving volume-controlled ventilation in the SIMV mode. If the therapist decreases peak inspiratory flow but makes no changes in tidal volume or rate, which of the following could the therapist expect to occur? A. Increased peak inspiratory pressures B. Decreased inspiratory time C. Increased I:E ratio D. Increased expiratory time - Answer C. Increased I:E ratio A decrease in inspiratory flow rates low will cause an increase in inspiratory time. This changes the I:E ratio. A patient receiving 1 L/min oxygen by TTO complains of air hunger. The therapist should FIRST A. place the patient on an air-entrainment mask at 28% B. place the patient on 1 L/min nasal cannula C. flush the trans-tracheal catheter D. connect suction pressure directly to the catheter - Answer A. place the patient on an air-entrainment mask at 28% When the patient is receiving oxygen by trans-tracheal oxygen catheter and a chang in modality is required, the flow rate and oxygen percentage required is double that which was administered by the transtracheal device. For instance, in this case the patient was receiving 1 L per minute by transtracheal catheter. This means that by nasal cannula the patient should receive 2 L a minute, twice that which was delivered by the transtracheal oxygen catheter. However, 2 L/min is not offered in these options. The most appropriate oxygen percentageoffered would be 28%, which is equivalent to 2 L/min nasal cannula. The patient has a PetCO2 that has been decreasing over the last several hours while PaCO2 roughly remains unchanged. Vd/Vt has been climbing and is currently at 38%. Which of the following can be concluded? A. Physiological dead space is increasing. B. Anatomical dead space is increasing. C. Anatomical dead space is decreasing. D. A pleural effusion is likely present. - Answer A. Physiological dead space is increasing. Dead space is increasing as shown by an increasing Vd/Vt ratio. Normal Vd/Vt is less than 10-15 percent and most of that is anatomical. When dead space increases, the most likely cause is physiological. Anatomical dead space refers to the non-gas exchanging areas of the pulmonary tree (such as the trachea) and cannot be altered significantly. Thus, increases in dead space is most often due to malfunctioning alveoli. A therapist has just decreased the peak flow on a patient receiving volume-controlled ventilation in the assist/control mode. Assuming no changes in controls that would affect minute ventilation, which of the following should the therapist also expect to occur? A. Increased I:E ratio B. Improved gas distribution C. Decreased peak inspiratory pressures D. Increase in expiratory time - Answer B. Improved gas distribution A decrease in peak flow will cause inspiratory time to increase. When gases enter the lung over a slower, longer period of time, gases penetrate the extremities of the lung space better. Therefore, better gas exchange is noted. A patient receiving mechanical ventilation is experiencing an increase in autoPEEP. Which of the following should the respiratory therapist increase to lower autoPEEP? A. flow rate B. mandatory rate C. pressure support D. PEEP - Answer A. flow rate AutoPEEP is caused when a mechanical ventilator delivers the next breath before the patient has exhaled completely. This air-trapping causes over distention of the alveoli and results in intrinsic PEEP. To minimize this, greater time for expiration must be allowed. This can be done by increasing flow rate, which will decrease inspiratory time and prolonged expiratory time. A 183-cm (6-ft), 87-kg (192-lb) male with ketoacidosis is receiving 60% oxygen by air-entrainment mask with the flow meter set at 15. SpO2 is fluctuating widely from minute to minute in spite of a good waveform and heart rate correlation. The most likely cause of this is