The National Board for Respiratory Care, Inc. Therapist Multiple-Choice SAE (Form 2020 B) INDIVIDUAL FEEDBACK REPORT

A patient with a PBW of 55 kg (121 lb) is receiving VC, A/C ventilation. Ventilator settings and blood gas analysis results are: FIO2 0.70 Mandatory rate 14 VT 350 mL PEEP 5 cm H2O pH 7.35 PaCO2 35 mm Hg PaO2 40 mm Hg HCO3 - 19 mEq/L BE -6 mEq/L SO2 (calc) 74% A respiratory therapist should recommend A. changing to SIMV mode. B.√ increasing to 10 cm H2O PEEP. C. changing to 5 cm H2O CPAP. D. increasing to 400 mL VT . EXPLANATIONS (h) A. Changing to SIMV will not treat the hypoxemia. It may also cause a decrease in minute ventilation and adverse changes in the acid-base status. (c) B. The increase in PEEP will increase FRC, decrease the intrapulmonary shunt, and address the hypoxemia. (h) C. Changing to CPAP may decrease minute ventilation causing adverse changes in the acid-base status. The National Board for Respiratory Care, Inc. Therapist Multiple-Choice SAE (Form 2020 B) INDIVIDUAL FEEDBACK REPORT (u) D. Increasing the tidal volume will further decrease the PaCO 2 . It will not significantly improve oxygenation. √ 2. When instructing a patient on the administration of umeclidinium/vilanterol (Anoro Ellipta), which of the following is most important to emphasize? A. Gargle immediately after use. B. Inhale slowly with a breath hold. C.√ Breathe in fast and deep. D. Shake medication vigorously before use. EXPLANATIONS: (u) A. Umeclidinium/vilanterol (Anoro Ellipta) is not an inhaled steroid and, thus, does not require gargling after use. (u) B. Umeclidinium/vilanterol (Anoro Ellipta) is a DPI that requires rapid inhalation. (c) C. Breathing in fast and deep is the proper method of administration for umeclidinium/vilanterol (Anoro Ellipta). (u) D. Umeclidinium/vilanterol (Anoro Ellipta) is a DPI and does not require shaking before use. √ 3. Following placement of a tracheostomy tube for long-term mechanical ventilation, which of the following patient positions best prevents ventilator-associated pneumonia? A. prone B. Trendelenburg C. supine D.√ semi-Fowler EXPLANATIONS: (h) A. Prone positioning is contraindicated following tracheostomy placement. (h) B. Use of Trendelenburg positioning may increase the risk of aspiration. (u) C. A decreased incidence of ventilator-associated pneumonia has been observed with an elevated head of bed as compared to supine. (c) D. Routine use of semi-Fowler positioning with the head of the bed elevated at an angle of 30-45 degrees has been shown to decrease rates of ventilator-associated pneumonia. √ 4. Which of the following is used to monitor the partial pressure of transcutaneous carbon dioxide? A. red-light absorption sensor B. electromechanical transducer C. infrared analyzer D.√ Stow-Severinghaus electrode EXPLANATIONS: (u) A. A red-light absorption sensor is used in a pulse oximeter. (u) B. An electromechanical transducer measures airway pressure. (u) C. An infrared analyzer is used in a capnometer. (c) D. A Stow-Severinghaus blood gas electrode is used in transcutaneous monitors. √ 5. An adult patient requires frequent blood sampling and medication administrations through an IV for 1 month. The preferred vascular access is a A.√ peripherally inserted central catheter. B. subclavian central vascular line. C. standard peripheral IV line. D. internal jugular catheter. EXPLANATIONS: (c) A. A PICC is the best choice for long-term IV access and allows for blood sampling. (u) B. A subclavian central vascular line is recommended for short-term use and should be removed as soon as feasible to avoid infection. (u) C. A standard peripheral IV line is not meant for long-term use. (u) D. An internal jugular catheter is recommended for short-term use and should be removed as soon as feasible to avoid infection. √ 6. A 170-cm (5-ft 7-in), 69-kg (152-lb) male with ARDS has the following ABG analysis results: pH 7.37 PCO2 43 mm Hg PO2 95 mm Hg HCO3 - 25 mEq/L BE -1 mEq/L SO2 (calc) 97% The patient is receiving VC, A/C ventilation with the following settings: FIO2 0.70 Mandatory rate 12 VT 450 mL PEEP 8 cm H2O Which of the following is most appropriate? A.√ Decrease the FIO2 to 0.60. B. Change the PEEP to 5 cm H2O. C. Increase the minute ventilation. D. Maintain the current settings. EXPLANATIONS: (c) A. Since the PaO2 is adequate, it is now appropriate to decrease the F IO2 . (u) B. The PEEP needs to be maintained to prevent derecruitment of alveoli. (u) C. There is no indication for changing the minute ventilation. The patient's ventilation is appropriate. (u) D. The FIO2 needs to be decreased to minimize oxygen-induced lung injury. √ 7. Following an emergent C-section, a 35 year old is receiving VC, A/C ventilation. The following pressure-volume loop is observed: Which of the following ventilator settings should be adjusted? A. PEEP B. flow rate C. tidal volume D.√ trigger sensitivity EXPLANATIONS: (u) A. Adjusting the PEEP is not indicated and does not address the dyssynchrony. (u) B. A flow rate that is too low is represented by a scooped inspiratory flow curve. There are no indications to adjust the flow rate. (u) C. There are no indications that the tidal volume is inadequate. The patient's trigger sensitivity should be adjusted so less negative force is needed to trigger a breath. (c) D. The patient is having difficultly triggering the breath, which is shown by the significant negative force created before the breath is delivered. The trigger should be adjusted to be more sensitive to improve the patient's ability to trigger a breath. √ 8. Which of the following techniques is preferred for a quadriplegic patient having difficulty expectorating secretions? A. pursed lip breathing B.√ abdominal thrust C. PEP therapy D. inspiratory muscle training EXPLANATIONS: (u) A. Pursed lip breathing is used as an expiratory maneuver to stabilize airways typically with COPD patients and not as a cough assist. (c) B. An abdominal thrust is used to assist patients with decreased respiratory muscle function, such as quadriplegics, to more forcefully cough out secretions. (u) C. PEP therapy is used by patients who can spontaneously take a deep breath and follow-up with a forced cough effort. (u) D. Inspiratory muscle training is used to enhance inspiratory muscle strength typically with COPD patients and not for quadriplegic patients. √ 9. A patient with a history of hypertension was awakened by cough and shortness of breath. He has fine inspiratory crackles bilaterally. Which of the following should a respiratory therapist recommend? A. prednisone B. albuterol C.√ furosemide (Lasix) D. guaifenesin (Mucinex) EXPLANATIONS: (u) A. The history, signs, and symptoms point to CHF. Prednisone will not address the cause of the patient's symptoms. (u) B. The history, signs, and symptoms point to CHF. Albuterol will not address the cause of the patient's symptoms. (c) C. Nocturnal dyspnea and coarse crackles are indications of CHF. Hypertension can be an etiologic factor for heart failure. A diuretic, such as furosemide (Lasix), is useful in controlling water retention that can lead to fluid accumulation and narrowing in airways. (u) D. The history, signs, and symptoms point to CHF. Guaifenesin (Mucinex) will not address the cause of the patient's symptoms. √ 10. The preferred suction device to remove large amounts of secretions from the oral cavity of an adult patient is a A.√ Yankauer device. B. DeLee suction trap. C. whistle-tip catheter. D. Coudé catheter. EXPLANATIONS: (c) A. Yankauer suction devices are designed specifically to suction secretions from the mouth in an efficient way. (u) B. A DeLee suction trap is common in neonatal care, but would likely be unable to adequately remove large amounts of secretions from an adult. (a) C. While it is possible to use a 14 Fr catheter for adult suctioning of the oral cavity, the Yankauer is designed for it. A 14 Fr catheter would possibly get easily occluded by large secretions and be ineffective. (u) D. There is no reason to use a catheter designed to enter the left mainstem bronchus selectively on an oral suction procedure. It would be costly, and just like the 14 Fr whistle-tip, not as effective as the Yankauer. √ 11. A respiratory therapist examines a patient and notes coarse crackles over both lung fields. Which of the following does this most likely indicate? A. subcutaneous emphysema B. pleurisy C. bronchospasm D.√ secretions EXPLANATIONS: (u) A. Subcutaneous emphysema is demonstrated by the presence of crepitus during chest wall palpation. (u) B. Pleurisy is a symptom of pain while breathing, typically associated with inspiration. There are often no physical findings for pleurisy. (u) C. Bronchospasm is noted as a wheezing sound from narrowed airways. (c) D. Secretions in the airway produce low-pitched, discontinuous lung sounds described as coarse crackles upon auscultation. √ 12. A 28-year-old patient is being evaluated by a respiratory therapist after a trauma. The patient is receiving VC ventilation with the following settings: FIO2 0.65 Mandatory rate 14 VT 450 mL PEEP 8 cm H2O The therapist notes the following pressure-volume tracing: The therapist should recommend decreasing the A. mandatory rate. B. PEEP. C.√ VT . D. expiratory time. EXPLANATIONS: (h) A. Decreasing the mandatory rate will not resolve the "bird-beak" pattern caused by excessive tidal volume. (h) B. The lungs are already being hyperinflated with each breath. Decreasing PEEP will potentially exacerbate the hyperinflation. (c) C. "Bird-beak" patterns are a result of hyperinflation. Decreasing the tidal volume will correct the hyperinflation. (h) D. Decreasing the expiratory time will cause an increase in tidal volume and exacerbate the hyperinflation (autoPEEP). √ 13. A 74-year-old female patient is admitted for management of community-acquired pneumonia. The patient's chest radiograph and CT scan show an RLL infiltrate with a nonloculated, significant pleural effusion on the right side. Which of the following should the therapist anticipate? A. echocardiogram B.√ thoracentesis C. V̇/Q̇scan D. bronchoscopy EXPLANATIONS: (u) A. A diagnostic tool, such as an echocardiogram, will not treat the patient's pleural effusion. (c) B. Thoracentesis is indicated based on the patient's chest radiograph and clinical findings. (u) C. A diagnostic tool, such as a V̇/Q̇scan, will not treat the patient's pleural effusion. (u) D. The patient's pleural effusion requires treatment, which cannot be addressed through a bronchoscope in the patient's airways. A thoracentesis is required to access the patient's pleural space and drain the effusion. √ 14. Which of the following is typically associated with bilateral, fluffy infiltrates on a chest radiograph? A.√ pulmonary edema B. neoplasm C. pleural effusion D. hemothorax EXPLANATIONS: (c) A. Fluffy-appearing infiltrates in both lungs are consistent with the increased interstitial and alveolar fluid in pulmonary edema. (u) B. Neoplasm would appear more localized and mass-like. (u) C. The increased opacification of a pleural effusion is localized to the dependent areas of the chest and generally is not described as fluffy in appearance. (u) D. An area of hemothorax will appear as an increased opacification in the dependent regions of the chest and generally is not described as fluffy in appearance. √ 15. Which of the following should a respiratory therapist use to confirm the presence of auto-PEEP during VC ventilation? A. square-wave inspiratory flow B.√ end-expiratory hold C. plateau pressure D. PSV mode EXPLANATIONS: (u) A. Auto-PEEP is not detected during the inspiratory phase. (c) B. Auto-PEEP is detected at the end of the expiratory phase. Expiratory hold permits pressure to be equilibrated throughout the ventilator circuit and the patient's airway, allowing estimation of alveolar pressure. (u) C. Plateau pressure is an end-inspiratory measurement. (u) D. Changing to PSV mode should not be done to determine the presence of auto-PEEP while in the VC mode. √ 16. Which of the following best maintains airway patency during bag-mask ventilation in an unconscious patient? A. cricoid pressure B.√ oropharyngeal airway C. Trendelenburg position D. neck hyperflexion EXPLANATIONS: (h) A. Cricoid pressure is used during a rapid-sequence induction where bag-mask ventilation is avoided. If attempted, cricoid pressure may impair ventilation by altering the geometry of the trachea. (c) B. The oropharyngeal airway can help restore airway patency and maintain adequate ventilation by pulling the tongue forward in an unconscious patient, where the tongue would otherwise obstruct the oropharynx. (h) C. Trendelenburg position will cause the tongue to move cranially, further obstructing the oropharynx. (u) D. Neck extension, rather than flexion, is recommended to open the airway and optimize positioning for bag-mask ventilation. √ 17. Which of the following can result in an increase in PVR? A. hyperoxia B. hypovolemia C.√ excessive PEEP D. decreased cardiac output EXPLANATIONS: (u) A. Hypoxemia, not hyperoxia, will result in an increase in PVR. (u) B. Hypovolemia will most likely result in a decrease in PVR. (c) C. Excessive PEEP can compress the pulmonary vessels and obstruct blood flow, resulting in an increase in PVR. (u) D. Decreased cardiac output results in decreased circulating volume and decreased PVR. X 18. Which of the following is a characteristic of pulse-dose oxygen-conserving devices? A. Flow is constant regardless of tubing length. B.X Gas delivery is synchronized with the beginning of exhalation. C. It is preferred for patients who need more than 2 L/min of oxygen. D.√ Most of the oxygen delivery occurs during the first quarter of inhalation. EXPLANATIONS: (u) A. The oxygen concentration delivered by a pulse-dose oxygen-conserving device may be reduced when longer tubing is used. (u) B. Pulse-dose oxygen systems synchronize gas delivery with the beginning of inspiration. (u) C. Pulse-dose oxygen systems are effective for those patients with low F IO2 needs. (c) D. With continuous oxygen delivery, most oxygen is delivered during the first half of inspiration with the remainder being wasted. With pulse-delivered oxygen, most of the oxygen is delivered during the first quarter of the inspiration and no waste occurs. √ 19. Which of the following best describes VC ventilation?