ACCS NBRC PRACTICE EXAM QUESTIONS COMPLETE WITH 100% CORRECT ANSWERS AND DETAILED RATIONALES

ACCS NBRC PRACTICE EXAM QUESTIONS COMPLETE WITH 100% CORRECT ANSWERS AND DETAILED RATIONALES 1. A 58-year-old with COPD exacerbation is on BiPAP (IPAP 14, EPAP 6, FIO2 0.4). ABG: pH 7.31, PaCO2 68, PaO2 68, HCO3 28. Next step? A. Increase IPAP to 18 B. Intubate and ventilate C. Decrease EPAP to 4 D. Change to CPAP at 10 Correct: A – Increasing IPAP improves alveolar ventilation, lowering PaCO2. EPAP 6 is adequate for oxygenation. Intubation not needed if noninvasive ventilation can be optimized. CPAP won’t help hypercapnia. ________________________________________ 2. Which ventilator mode is best for a patient with severe ARDS and plateau pressure 32 cm H2O on VCV? A. Pressure control with inverse ratio (PC-IRV) B. High-frequency oscillatory ventilation (HFOV) C. Airway pressure release ventilation (APRV) D. Pressure support ventilation (PSV) Correct: C – APRV allows spontaneous breathing while maintaining high mean airway pressure, potentially reducing barotrauma. PC-IRV may increase mean pressure but sedation needs are high. HFOV is second-line. PSV inadequate in severe ARDS. ________________________________________ 3. A 45-year-old with traumatic brain injury has ICP 22 mm Hg, CPP 58 mm Hg. PaCO2 is 45 mm Hg. Best intervention? A. Hyperventilate to PaCO2 30 mm Hg B. Mannitol 1 g/kg IV C. Increase PEEP to 15 cm H2O D. Elevate HOB to 90 degrees Correct: B – Mannitol reduces ICP rapidly. Hyperventilation is only for herniation, not routine. High PEEP may reduce venous return and ICP if autoregulation impaired. HOB 30° is standard; 90° risks hypotension. ________________________________________ 4. Which finding indicates weaning failure in a patient on pressure support of 8 cm H2O? A. RSBI = 55 breaths/min/L B. P0.1 = 6 cm H2O C. MIP = −30 cm H2O D. VT = 6 mL/kg Correct: B – P0.1 (airway occlusion pressure at 100 ms) 4–6 cm H2O suggests high respiratory drive and impending failure. RSBI 105 suggests success. MIP −30 adequate. VT 6 mL/kg is acceptable. ________________________________________ 5. A patient with pulmonary embolism develops hypotension. TTE shows right ventricular dilation. What is the best initial therapy? A. Alteplase 100 mg IV B. Unfractionated heparin bolus C. Norepinephrine infusion D. Dobutamine infusion Correct: C – Norepinephrine restores perfusion to RV and systemic circulation. Thrombolytics indicated if hemodynamic collapse, but not first line before stabilization. Heparin alone won’t reverse shock. Dobutamine can worsen hypotension if RV ischemia. ________________________________________ 6. While suctioning an intubated patient, heart rate drops from 110 to 48 bpm. Action? A. Continue suctioning to clear secretions B. Administer atropine 0.5 mg IV C. Stop suctioning and give 100% O2 D. Increase PEEP to recruit atelectasis Correct: C – Bradycardia from vagal stimulation requires immediate cessation of suction and hyperoxygenation. Atropine is second step if persists. Continuing worsens hypoxia/bradycardia. PEEP not relevant. ________________________________________ 7. Which ABG indicates optimal ventilation for a status asthmaticus patient on mechanical ventilation? A. pH 7.28, PaCO2 55, PaO2 90 B. pH 7.38, PaCO2 40, PaO2 80 C. pH 7.30, PaCO2 65, PaO2 70 D. pH 7.48, PaCO2 32, PaO2 95 Correct: A – Permissive hypercapnia (pH 7.25, PaCO2 up to 60-70) is target to avoid dynamic hyperinflation. Normal PaCO2 may require high rate/volume, risking barotrauma. Respiratory acidosis well tolerated. ________________________________________ 8. A 70-kg patient with ARDS: VCV, VT 420 mL, Pplat 30, PEEP 14, FIO2 0.8. PaO2 65 mm Hg. Next? A. Increase VT to 500 mL B. Increase PEEP to 18 C. Increase FIO2 to 1.0 D. Prone positioning Correct: D – Prone positioning improves oxygenation in severe ARDS (PaO2/FIO2 150). PEEP 14 already high; increasing may not help and can drop BP. Increasing VT worsens lung injury. FIO2 1.0 toxicity. ________________________________________ 9. A patient with septic shock on norepinephrine 0.3 mcg/kg/min has MAP 62, CVP 18, ScvO2 65%. Next? A. Increase norepinephrine B. Give 500 mL crystalloid C. Start dobutamine D. Transfuse PRBCs Correct: C – ScvO2 70% despite adequate MAP and CVP (fluid replete) indicates need for inotropy (dobutamine) to increase O2 delivery. More fluids with CVP 18 risks edema. Transfusion if Hb 7. ________________________________________ 10. Which statement about APRV is true? A. Spontaneous breaths are not allowed in APRV B. T-high is set longer than T-low C. APRV requires patient paralysis D. Release volume equals set tidal volume Correct: B – APRV uses long T-high (4-6 sec) and short T-low (0.5-0.8 sec) to maintain mean airway pressure. Spontaneous breaths encouraged. Paralysis not required. Release volume varies with compliance. ________________________________________ 11. A 62-year-old post-op day 2 develops sudden dyspnea, hypotension, and JVD. What is the priority? A. STAT chest X-ray B. ECG for S1Q3T3 C. Bedside echocardiogram D. Immediate heparin bolus Correct: C – Suspected massive PE causing obstructive shock; bedside echo (or TEE) quickly confirms RV strain/dilation faster than CXR or ECG. Heparin before diagnosis if high suspicion, but echo is diagnostic. S1Q3T3 is late. ________________________________________ 12. In a patient with pneumonia and sepsis, lactate is 4.2 mmol/L. Initial fluid resuscitation of 30 mL/kg given. Repeat lactate 4.0. Next? A. Start norepinephrine B. Give another 2 L crystalloid C. Measure ScvO2 D. Start hydrocortisone Correct: C – Persistent hyperlactatemia after initial fluids suggests need for ScvO2-guided therapy (goal 70%). Vasopressors if MAP 65 despite fluids. More fluids without assessing response risks edema. ________________________________________ 13. Which setting minimizes auto-PEEP in an obstructive patient on VCV? A. Short I:E ratio (1:3) B. Long inspiratory time (1:1) C. Low inspiratory flow rate (30 L/min) D. High respiratory rate (25/min) Correct: A – Short I:E ratio (long expiratory time) allows full exhalation, reducing air trapping. Long inspiration/ low flow increases auto-PEEP. High rate shortens expiratory time, worsening auto-PEEP. ________________________________________ 14. When titrating PEEP for ARDS using PEEP/FIO2 table, PaO2 70 on FIO2 0.5, PEEP 10. Next PEEP? A. 14 B. 8 C. 12 D. 16 Correct: A – ARDSnet low-PEEP table: FIO2 0.5 with PaO2 70 → need higher PEEP (14) if target 55-80. Table ranges: FIO2 0.5 → PEEP 10 or 14 depending on O2 response. 14 is next step.