TMC 9th Edition Bank NBRC 460 Q&A 2023 update

TMC 9th Edition Bank NBRC 460 Q&A 2023 update TMC 9th Edition Bank NBRC 460 Q&A 2023 update 1. Disadvantages of noninvasive ventilation include which one of the follow- ing? A. costs more than invasive ventilation B. requires heavy patient sedation C. limits direct access to lower airway D. increases the likelihood of VAP: Disadvantages of noninvasive ventilation (NPPV) include the following: it can only be used in cooperative patients; it does not provide direct airway access (thus increas- ing the risk of secretion retention), and more therapist time is needed during the initial period of use. On the other hand NPPV may help decrease the incidence of VAP and typically costs less than invasive ventilation. The correct answer is: limits direct access to lower airway 2. On a patient receiving volume control AC ventilation, you observe a flow-volume with a sawtooth pattern on exhalation. Which of the following actions would 1 / 222 you consider most appropriate? A. recommend administering a bronchodilator B. assess the patient's need for suctioning C. measure the endotracheal tube cuff pressure D. switch to pressure control ventilation: The flow-volume loop reveals irregular sawtooth- like oscillations, primarily in the expiratory portion of the loop. This indicates either 1) accumulation of airway secretions in the trachea/large airways (requiring suctioning), or 2) condensate partially blocking the expiratory limb of the ventilator circuit proximal to the expiratory flow sensor. Auscultation of rhonchi or tactile fremitus over the trachea would confirm excess secretions as the problem. The correct answer is: assess the patient's need for suctioning 3. A 30 year-old male was found supine and unresponsive. In the ER it was confirmed he had aspirated while on his back. After the patient is transferred to ICU his physician orders postural drainage and percussion every 4 hours. What is the best position to place him in to drain the affected area? A. prone with a pillow under his hips 2 / 222 B. prone with feet elevated 30 degrees C. supine with a pillow under his hips D. supine with feet elevated 30 degrees: This patient aspirated while lying flat on his back. Most commonly, this affects the superior segments of both lower lobes. The position which facilitates drainage from this lung region is a prone position with a pillow under the patient's hips. The correct answer is: prone with a pillow under his hips 4. You need to perform nasotracheal suctioning on a patient with retained secretions. As compared to suctioning via a tracheal airway, which of the following complications are unique to this procedure? A. hypotension B. gagging/aspiration C. hypoxemia D. increased ICP: Complication/hazards common to both tracheobronchial and nasotracheal suctioning include hypoxemia, cardiac dysrhythmias, bradycardia, hyper-/hypotension, bronchospasm, atelectasis, increased intracranial pressure and the potential for contamination/infection. Unique complications of nasotracheal suctioning include nasal trauma/epistaxis, pharyngeal trauma, gagging (with potential 241 vomiting/aspiration), and laryngospasm. Also misdirection of the catheter is more common with nasotracheal suctioning. 5. Which of the following indicates a deficit in fluid balance A. Pedal edema B. Poor skin turgor 3 / 222 C. cap refill D. JVD: Poor skin turgor 6. ARDS patient, what should RT use to evaluate oxygen delivery for optimal PEEP A. ABG B. mixed venous C. serum lactate D. CO: mixed venous 7. RT performing a high calibration on a nitric oxide, expected value is A. 45 B. 10 C. 25 D. 80: 45 4 / 222 8. To help prevent infection after an aerosol drug treatment provided via small volume nebulizer (SVN) you would: A. shake out any residual solution then bag the SVN B. rinse the SVN with tap water then dry and bag it C. run the SVN at high flows until completely dry D. rinse the SVN with sterile water then dry and bag it: To minimize the likelihood of infection in patients receiving aerosol drug therapy via a small volume nebulizer (SVN), you should 1) use a different SVN for each patient, 2) change the SVN and tubing every 24 hours, and 3) perform thorough hand hygiene prior to each therapy session. It is also recommended that the nebulizer NOT be rinsed with tap water, but rather rinsed with sterile water and blown dry between uses. If rinsing with sterile water not feasible, rinse the device with filtered or tap water, then rinse with isopropyl alcohol and dry. The correct answer is: rinse the SVN with sterile water then dry and bag it 9. A doctor orders aerosol drug therapy via small volume nebulizer for a patient receiving mechanical ventilation via a dual-limb breathing circuit. To prevent drug residue from affecting ventilator performance you must make sure that: A. both inspiratory and expiratory HEPA filters are in place B. a HEPA filter is in place on the inspiratory limb of the circuit 5 / 222 C. a heat and moisture exchanger is in place at the patient connector D. a HEPA filter is in place on the expiratory limb of the circuit: HEPA filters are needed to prevent drug residue from entering the ventilator and affecting its performance. For dual-limb circuits, be sure that inspiratory and expi- ratory HEPA filters are in place. For single-limb circuits, you normally only need an inspiratory HEPA filter; expiratory filtration may be required on patients with disorders requiring droplet or respiratory precautions. The correct answer is: both inspiratory and expiratory HEPA filters are in place 10. Your patient is receiving aerosolized bronchodilators to treat her asthma. What is the best way to determine whether this treatment is achieving the desired goal? 6 / 222 A. measure the patient's MIP before-and-after treatment 279 B. measure the patient's inspiratory capacity before-and-after treatment C. measure the patient's FEV1% before-and-after treatment D. calculate the patient's alveolar minute volume: The best way to determine the effectiveness of bronchodilator therapy at the bedside is to measure the patient's forced expiratory flows before and after treatment. Either the FEV1% or the peak expiratory flow rate (PEFR) can be used, although the FEV1% is a more reliable and valid measure. In general, an improvement of at least 12-15% between the pre- and post-test values is needed to indicate reversibility of the obstruction with the bronchodilator. The correct answer is: measure the patient's FEV1% before-and-after treatment 11. A cooperative patient receiving aerosol therapy with 0.9% NaCl is unable to produce an acceptable volume of sputum for laboratory studies. The most appropriate action would be to A. administer the aerosol continuously B. change to hypertonic saline C. initiate chest physiotherapy D. perform nasotracheal suctioning: Hypertonic saline solution can help draw fluid out of the airway mucosa. For this reason, the aerosolization of hypertonic saline solution can help mobilize secre- tions and can be effective with sputum induction. 7 / 222 The correct answer is: change to hypertonic saline 12. A patient with asthma is given an adrenergic bronchodilator agent to combat an acute airway obstruction. Instead of demonstrating improvement in airflow, the patient's symptoms worsen (e.g., increased wheezing, etc.). A possible explanation for this observation is: A. tachyphylaxis or tolerance to the agent B. alterations in the V/Q ratio (a beta-2 effect) C. the additive effect of other drug agents D. a paradoxical response to the agent: Although rare, some patients exhibit a paradoxical response to adrenergic bronchodilators in which the symptoms of acute airway obstruction actually are made 8 / 222 worse by drug agent. It is believed that this adverse effect is a result of an allergy to some of the metabolic products of the adrenergic drugs. The correct answer is: a paradoxical response to the agent 13. Which of the following patient instructions for using a dry powder inhaler (DPI) is correct? A. hold the device vertically after loading B. inhale rapidly for 1-2 seconds C. blow slowly into the device D. breath normally in/out of the device: The following general guidelines apply to effective use of a DPI: (1) never use a spacer or VHC with a DPI; (2) lips must be tightly sealed around the mouthpiece; (3) after loading, most DPIs must be held horizontally (to avoid loss of drug); (4) patient should inhale rapidly ( 60 L/min for 1-2 sec) and deeply; and (5) patient must exhale to room (not back into the device). The correct answer is: inhale rapidly for 1-2 seconds 14. Which of the following is the preferred delivery method for cromolyn sodium to young children? A. MDI with mask B. small volume nebulizer C. MDI with holding chamber 9 / 222 D. dry powder inhaler: A small volume nebulizer (SVN) is the method of choice for administering cromolyn sodium to young children. You should use a tightly fitting face mask for any child unable to a mouthpiece. The correct answer is: small volume nebulizer 15. You are called to the ED to provide a bronchodilator treatment for a patient having a severe asthma attack. When quickly confirming the written order you find it contains some prohibited notations and thus could be read as either '.5 U albuterol by SVN' or 5 c.c albuterol by SVN" The prescribing physician is busy overseeing a code. You should: 272 10 / 222 A. wait until the physician is done with the code so you can clarify the improper notation and the correct order B. administer the treatment using the standard dosage (0.5 mL) and clarify the order as soon as possible thereafter C. cross out the prohibited notations, provide the correct abbreviations and initial and date the changes D. have the nurse review the order and correct the improper notation: This order contains at least two improper notations, i.e., c.c. (use mL), and lack of leading zeros before a decimal point (that may be 'lost' on the order line). Normally, if an order contains a prohibited notation, the respiratory therapist must confirm the intent of the order before proceeding. The exception is when order confirmation might delay essential or emergency patient treatment (as here). In these cases, if, in the judgment of the caregiver the order is clear and complete and the delay to obtain confirmation from the prescriber would place the patient at greater risk, then the order should be carried out and the confirmation obtained as soon as possible thereafter. The correct answer is: administer the treatment using the standard dosage (0.5 mL) and clarify the order as soon as possible thereafter 16. A doctor orders 10 mg of 0.5% albuterol (Proventil) in 50 mL normal saline via 11 / 222 continuous nebulization for a patient with asthma. How many mL of albuterol would you place in the nebulizer? A. 0.5 B. 2 C. 5 D. 20: mL = dosage (mg) ¸ concentration (mg/mL) = 10/5 = 2 mL. Note that a 0.5% solution has a concentration of 5 mg/mL. The correct answer is: 2 17. Venous return is LEAST impaired by which of the following modes of mechanical ventilation? A. A/C with a mandatory rate of 10/min, 5 cm H2O PEEP B. SIMV with a mandatory rate of 6/min, no PEEP 12 / 222 C. SIMV with a mandatory rate of 12/min, 5 cm H2O PEEP D. A/C with a mandatory rate of 15/min, no PEEP: In this instance, the absence of PEEP and the lowest number of "machine" breaths would result in the lowest mean airway pressure, thus resulting in the least impairment to venous return. The correct answer is: SIMV with a mandatory rate of 6/min, no PEEP 18. Which of the following parameters would you set to establish the minute volume for a patient being ventilated in the volume control assist/control mode (VC, A/C)? exp. time,rate,vt,insp. flow: The minute volume (VE) during VC, A/C ventilation is determined by the respiratory rate or frequency (f) and tidal volume setting (VT), that is VE = f x VT The correct answer is: A 19. A 65-year-old female patient has distended external jugular veins even though her head and body are raised 45 degrees above her legs. This would indicate that she likely is: A. hypertensive B. fluid-overloaded 268 C. an emphysema patient D. dehydrated: Fluid overload cause the jugular veins to be distended. Dehydra- 13 / 222 tion may result in the jugular veins being flat. Emphysema and hypertension should not have any effect on the jugular veins. The correct answer is: fluid-overloaded 20. At the bedside of a patient receiving volume control ventilation, you suddenly observe the simultaneous sounding of the high pressure and low volume alarms. Which of following is the most likely cause of this problem? A. a leak in the ET tube cuff B. a mucous plug in the ET tube C. ventilator circuit disconnection 14 / 222 D. development of pulmonary edema: During volume-control ventilation, a high pressure/low volume condition signals an obstruction (increased impedance). Although either the mucous plug or the development of pulmonary edema increases impedance, only a plugged ET tube would cause a sudden rise in airway pressure. The correct answer is: a mucous plug in the ET tube 21. Which of the following is true regarding synchronous intermittent manda- tory ventilation (SIMV)? A. machine breaths cannot be pressure controlled B. asynchrony is prevented during machine breaths C. only partial ventilatory support can be provided D. patient normally contributes to minute ventilation: SIMV allows sponta- neous breathing between machine breaths, so that the patient can control both the overall rate and pattern and contribute to the total minute ventila- tion. SIMV provides full ventilatory support at normal rates and partial support at lower rates. Machine breaths may target either volume (VC, SIMV) or pressure (PC, SIMV) and spontaneous breaths may be pressure supported. Asynchronous breathing still can occur during machine breaths, usually due to improper machine sensitivity or flow settings. The correct answer is: patient normally contributes to minute ventilation 15 / 222 22. To initiate weaning, a patient was changed from volume control A/C ventilation to pressure support. After 30 minutes on pressure support, the high respi- ratory rate alarm sounds, with the patient breathing at a rate of 25 to 30 per minute. What change should you make to the ventilator settings? A. increase the pressure support level B. increase the high pressure alarm to 50 cm H2O C. increase the high rate alarm to 30-35 D. switch the patient back to volume control A/C: During weaning procedures, a modest increase in respiratory rate is common and generally should be tolerated up to a maximum of 30-35 breaths per minute. In this instance, the high respiratory rate alarm should be increased to 30-35 breaths per 16 / 222 minute. The correct answer is: increase the high rate alarm to 30-35 23. Which of the following ventilator graphics displays would be the best choice to assess the work of breathing associated with patient triggering? A. volume vs. time display B. flow vs. volume display C. flow vs. time display D. pressure vs. volume display: The best choice to assess the work of breathing associated with patient triggering using ventilator graphics would be a pressure vs. volume loop. The correct answer is: pressure vs. volume display 24. 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? A. decrease in O2 saturation from 91% to 82% B. increase in respiratory rate from 18 to 28/min C. increase in arterial PCO2 from 45 to 53 torr D. increase in heart rate from 98/min to 115/min: Measures indicating failure of a SBT include inadequate gas exchange (SpO2 d 85-90% or PaO2 d 50-60 torr; pH d 7.30; increase in PaCO2 e 10 torr); unstable hemodynamic (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 e 30- 17 / 222 35/min or %change 50%; presence of accessory muscle use or thoracoabdom- inal paradox). The correct answer is: decrease in O2 saturation from 91% to 82% 25. Which of the following categories of patients are good candidates for negative pressure ventilation? A. patients with acute obstructive disorders of the upper airway B. patients suffering acute exacerbations of chronic lung disease C. patients with end-stage chronic obstructive pulmonary disease D. patients with chronic neuromuscular disorders and normal airways: Al- though its use has declined in recent years, negative pressure ventilation remains a 18 / 222 viable alternative to the positive pressure approach with certain patient categories. Specifically, patients with permanent neuromuscular impairments who retain ade- quate upper airway protective and clearance reflexes (thereby not needing an artificial airway) but cannot tolerate masks/mouthpieces are ideally suited to ventilatory support via negative pressure ventilation, especially for use in the home. The correct answer is: patients with chronic neuromuscular disorders and normal airways 26. Which of the following is the appropriate load to establish for patients receiving inspiratory muscle training? A. at least 33% of the predicted inspiratory capacity (IC) B. at least 10-15 ml/kg of predicted body weight (PBW) C. at least 30% of the maximum inspiratory pressure (MIP/NIF) D. at least -25 cm H2O, as measured by a calibrated manometer: For inspira- tory training to be effective, the load against which the patient breathes must be sufficient to increase muscle strength. The minimal resistance load to achieve this end is an inspiratory pressure that is at least 30% of the MIP/NIF. The correct answer is: at least 30% of the maximum inspiratory pressure (MIP/NIF) 27. Which of the following is an indication for positive-end expiratory pres- sure? A. to provide graded levels of ventilatory support B. to decrease physiologic deadspace C. to decrease hypoxemia due to shunting 19 / 222 D. to increase the efficiency of ventilation: The primary indication for PEEP is to decrease hypoxemia due to shunting in conditions like ARDS and IRDS. PEEP can also lower FIO2 needs in patients with refractory hypoxemia and help maintain or increase the FRC (e.g., in thoracic surgery). Last, extrinsic PEEP can be applied to decrease auto-PEEP in patients with airway obstruction receiving ventilatory support. The correct answer is: to decrease hypoxemia due to shunting 28. Which of the following are acceptable changes in patient status during a spontaneous breathing trial for weaning from mechanical ventilation? A. heart rate rises from 103 to 118/min B. SpO2 falls from 90% to 80% C. scalene muscle activity increases 20 / 222 D. systolic BP falls from 110 to 75 mm Hg: Measures indicating a successful SBT include acceptable gas exchange (SpO2 e 85-90% or PaO2 e 50-60 torr; pH e 7.30; increase in PaCO2 d 10 torr); stable hemodynamic (heart rate 120-140/min; %change 20%; systolic BP 180-200 mm Hg and 90 mm Hg with %change 20%); and a stable ventilatory pattern (respiratory rate d 30- 35/min, %change 50%; no accessory muscle use or thoracoabdominal paradox). The correct answer is: heart rate rises from 103 to 118/min 29. In the management of a patient with brain trauma, therapeutic hyperven- tilation should be used: A. only during the initial 24 hours of management B. prophylactically to prevent an increase in ICP C. in urgent situations such as brain herniation D. to help wean the patient off ventilatory support: For patients with traumatic brain injury, therapeutic hyperventilation should be avoided during the first 24 hours after injury (typically the period with the lowest cerebral blood flow). Hyperventilation should be considered only in emergent situations in which there are signs of brain herniation and/or when other treatment strategies have failed to lower ICP. Hyperventilation should not be used prophylactically. The correct answer is: in urgent situations such as brain herniation 30. The most common problem encountered in applying assist-control mode ventilation is: A. hypoventilation/hypercapnia 21 / 222 B. need for neuromuscular paralysis C. hyperventilation/hypocapnia D. increased work of breathing: In the assist-control (A/C) mode patients can trigger machine breaths at a higher rate than the ventilator rate setting. Although this generally increases tolerance and 252 comfort, some patients will develop tachypnea and thus be prone to hyperventilation/hypocapnia due to an excessive minute ventilation. This problem is most common in patients suffering from pain, anxiety and other causes of acute distress. Tachypnea in the A/C mode also can cause air-trapping and auto-PEEP, especially in those with obstructive disorders. The correct answer is: hyperventilation/hypocapnia 22 / 222 31. A patient who is receiving mechanical ventilation requires an FIO2 of 0.70 and a PEEP of 10 cm H2O to maintain an acceptable PaO2.The patient is rest- less and has become disconnected from the ventilator circuit several times, during which she experiences cardiac rhythm disturbances. A respiratory therapist should conclude that the patient will benefit from a: sedative. mucolytic. neuromuscular blocker. pulmonary vasodilator.: (c) A. Sedation is required to eliminate excessive activity so the patient's cardiopulmonary status can be properly evaluated and treated. (h) B. A mucolytic will thin secretions, which will not correct this patient's problem. (h) C. A neuromuscular blocker will paralyze the patient, but is not recommended without a sedative. (h) D. Decreasing pulmonary vascular resistance will not ease the patient's rest- lessness. 32. A male patient who is 180 cm (5 ft 11 in) tall and weighs 75 kg (165 lb) is intubated and receiving mechanical ventilation. The endotracheal tube is secured at the 23-cm mark at his incisor. The cuff pressure is 30 mm Hg. Which of the following should a respiratory therapist do? Deflate the cuff until a slight leak is heard at peak inspiration. 23 / 222 Reintubate the patient with a larger endotracheal tube. Maintain a cuff pressure of 25 mm Hg. Advance the endotracheal tube to the 25-cm mark.: (c) A. Establishing the minimal leak technique will determine the pressure needed to maintain the tidal volume. (h) B. There is no indication that the tube is too small or that it has been improperly placed. Therefore, reintubation should not be performed. (h) C. Cuff inflation is based on proper protection of the airway, not specific pressure. 24 / 222 (h) D. Depth of insertion should be determined by clinical assessment and chest radiograph, not predefined goals. 33. In the last 6 months, a patient with bronchiectasis who uses postural drainage at home has had three exacerbations requiring hospitalization. Which of the following should a respiratory therapist recommend? insufflation/exsufflation device nebulized ipratropium bromide (Atrovent) inhaled corticosteroid HFCWO: u) A. Secretion clearance will not directly improve with an insufflation/ex- sufflation device. The device acts as a cough in clearing secretions, but it does not loosen the secretions. (u) B. Nebulized ipratropium bromide is indicated for reversible airways bron- choconstriction. It is not helpful in secretion clearance. (u) C. Inhaled corticosteroids are useful for reducing airways inflammation. This therapy will provide little benefit for clearing airways secretions. (c) D. HFCWO provides an effective method to loosen and mobilize airways secretions. 34. A respiratory therapist is assisting a physician with a tracheostomy for a patient who is receiving PC ventilation. Following percutaneous placement of a tracheostomy tube, the therapist observes increasing heart rate, de- creasing exhaled tidal volume, and increasingly distant breath sounds over 25 / 222 the right chest. The therapist should anticipate treatment for: cardiac tamponade. a pneumothorax. a lacerated blood vessel. an anteriorly displaced tub: A. Cardiac tamponade will present with tachycardia and tachypnea, but should not cause a change in the exhaled volume or ventilation to the right lung. (c) B. A pneumothorax will result in tachycardia, decreased ventilation, and de- creased breath sounds on the affected side. 26 / 222 (u) C. Lacerating a blood vessel may result in hemorrhage; however, it should have no immediate effect on the exhaled volume or diminish breath sounds. (u) D. Anterior displacement of the tube may result in subcutaneous emphysema or airway obstruction. 35. A patient with neuromuscular disease has been receiving ventilatory support for 4 months through a tracheostomy. The patient uses a speaking valve during the day, but receives VC, A/C ventilation at night. Which of the following should be used? tracheostomy button foam cuff tracheostomy tube cuffed tracheostomy tube cuffless tracheostomy tube: u) A. A tracheostomy button will not provide a patent airway for ventilatory support. (u) B. A foam cuff tracheostomy tube is not designed to have the cuff collapsed for prolonged periods of time. A leak in the system may cause a foam cuff to reinflate, blocking the patient's ability to exhale. (c) C. When using a speaking valve, the cuff can be deflated and then reinflated for mechanical ventilation. (h) D. A cuffless tracheostomy tube will not provide a closed system for periods of 27 / 222 volume ventilation between ventilatory support. 36. Which of the following may be caused by the administration of aerosolized pentamidine isethionate (NebuPent)? tachycardia bradycardia bronchospasm hypotension: (u) A. No causal relationship between the use of NebuPent and tachycardia has been established. (u) B. No causal relationship between the use of NebuPent and bradycardia has been established. 28 / 222 (c) C. Bronchospasm is the most frequently reported adverse effect associated with the use of NebuPent. (u) D. Hypotension is associated with the use of IV or IM pentamidine isethionate (Pentam). It has not been shown to be a problem when the drug is aerosolized. 37. A fixed-wing medical transport with an unpressurized cabin has as- cended to 10,000 ft while transporting a patient with COPD. The patient is receiving nasal oxygen at 2 L/min and becomes agitated and confused. A respiratory therapist should: increase oxygen flow. initiate mask CPAP. recommend a diuretic. recommend a sedative.: (c) A. The patient is experiencing hypoxemia associated with altitude and a lower inspired alveolar PO2. Increasing the oxygen flow will increase the inspired FIO2. (u) B. The patient does not need CPAP. An increase in the FIO2 will help alleviate the hypoxemia associated with the high altitude. (u) C. Administration of a diuretic will delay providing appropriate care. (h) D. A sedative may cause hypoventilation and exacerbate the hypoxemia. 38. A patient with COPD is receiving PC ventilation with flow triggering and has significant air trapping displayed on ventilator graphics. The patient's 29 / 222 spontaneous breathing efforts are not always detected by the ventilator. Which of the following changes should a respiratory therapist recommend to improve patient-ventilator synchrony? Switch to pressure triggering. Switch to a square-wave flow pattern. Increase peak inspiratory flow. Increase the set PEEP.: u) A. Research has shown flow triggering to be more sensitive than pressure triggering in most cases. (u) B. A square-wave flow pattern cannot be used in the PC mode. The decelerating flow pattern generated during the PC mode has been found to improve synchrony when compared with a square-wave pattern. 30 / 222 (u) C. The peak inspiratory flow cannot be independently adjusted in the PC mode. The flow is variable in this mode. (c) D. A patient who demonstrates patient-ventilator dyssynchrony associated with air trapping will often benefit from an increase in the set (extrinsic) PEEP level. The increase in applied PEEP can help reduce the difference between end alveolar pressure and end-inspiratory pressure. 39. A 4-year-old child is seen by a respiratory therapist for a follow-up asthma evaluation. The child denies any dyspnea. The parents report giving the child albuterol by inhaler twice daily. The therapist should: r explain the purpose of the quick-relief medication. demonstrate peak flow monitoring. recommend changing to a small-volume nebulizer. develop an exercise regimen for the child.: (c) A. Albuterol is a quick-relief medication. It should be used as needed, not at a scheduled frequency. (u) B. Peak flow monitoring will not address the need to reeducate the parents on the indications and use of a quick-relief inhaler. (u) C. The route of administration does not need to be addressed. Rather, education on the indications and use of a quick-relief inhaler is warranted. (u) D. An exercise regimen will not address the family's educational needs. 31 / 222 40. A patient receiving mechanical ventilation had a total fluid intake of 4200 mL and a total fluid output of 1200 mL over a 24-hour period. Which of the following might increase in this situation? lung compliance serum HCO3- P(A-a)O2 hematocrit: (u) A. Fluid output indicates an excess in interstitial fluid which can potentially decrease lung compliance. (u) B. An excess in interstitial fluid will not increase the serum HCO3-. (c) C. An excess in interstitial fluid can impair oxygen diffusion into the capillaries and increase the P(A-a)O2. 32 / 222 (u) D. Excessive fluid administration can result in a reduction of hematocrit. 41. A patient lost an unknown quantity of blood as a result of a motor vehicle crash. To fully assess oxygen delivery, a respiratory therapist should recommend: a complete blood count. exhaled nitric oxide. crossmatch of the patient's blood type. serial blood pressure assessment: (c) A. A complete blood count will provide a hemoglobin value that is used to calculate oxygen delivery. (u) B. Exhaled nitric oxide can detect an inflammatory process, but it does not measure oxygen delivery. (u) C. A crossmatch of the patient's blood type should be completed in the event of blood loss; however, it does not provide information about oxygen delivery. (u) D. Serial blood pressure assessment should be completed due to volume loss; however, it does not provide information about oxygen delivery. 42. An adult patient in the ICU is receiving beta-blocker medication and requires bronchodilator therapy. Which of the following should a respiratory therapist recommend? levalbuterol sulfate (Xopenex) 33 / 222 albuterol sulfate (Proventil) triamcinolone acetonide (Azmacort) ipratropium bromide (Atrovent): (u) A. Levalbuterol is a beta-receptor stimulator and may show reduced efficacy in the presence of beta-blocking agents. (u) B. Albuterol is a beta-receptor stimulator and may show reduced efficacy in the presence of beta-blocking agents. (u) C. Triamcinolone acetonide is an anti-inflammatory drug that does not directly achieve bronchodilation. (c) D. Ipratropium bromide is an anticholinergic. Beta blockers do not affect its ability to achieve bronchodilation. 34 / 222 43. Which of the following best reflects the adequacy of ventilation? PaO2 r PaCO2 vital capacity FEF25-75%: (u) A. PaO2 is influenced by several factors other than ventilation. (c) B. The arterial level of CO2 reflects the alveolar CO2 and is the best indication of the adequacy of ventilation. (u) C. Vital capacity is a volume measurement of the air within the lung. It is a static volume and cannot reflect the status of ventilation. (u) D. FEF25-75% is a measure of the flow during the midportion of a forced exhalation. It is measured during a single breath; therefore, it cannot reflect the adequacy of ventilation. 44. During mechanical ventilation, mean airway pressure will always change with a change in: dead space. patient's body position. 35 / 222 inspiratory time. FIO2.: (u) A. The addition of dead space to a circuit will increase the degree of CO2 rebreathing, causing the PaCO2 to increase. Mean airway pressure is unaffected. (u) B. Patient body position may or may not alter the mean airway pressure. (c) C. Lengthening the inspiratory time allows the ventilator to increase the tidal volume and the mean airway pressure. (u) D. Mean airway pressure and FIO2 are unrelated. 45. Which of the following values are needed to determine a patient's physi- ologic dead space? 36 / 222 mixed expired PCO2 and Pv CO2 arterial PCO2 and mixed expired PCO2 Pv CO2 and arterial PO2 arterial PO2 and PCO2: B. Physiological dead space is calculated from the Bohr equation [(VD/VT = (PaCO2 - PeCO2)/PaCO2]. Thus, it is necessary to know the values for the arterial and mixed expired values for carbon dioxide. 46. A 27-year-old male patient has mild asthma. The patient's pulse is 80 before administration of an aerosolized bronchodilator. The patient's pulse rises and stabilizes at 92 during the treatment. Which of the following should a respiratory therapist do? Terminate the treatment and document in the progress notes. Terminate the treatment and notify the head nurse. Continue the treatment as ordered. Continue the treatment with normal saline.: (u) A. There is no indication that the treatment needs to be terminated. (u) B. See explanation A. (c) C. The heart rate response is within normal limits, so continuing the treatment as ordered is appropriate. (u) D. Normal saline has no pharmacological value in this situation. 37 / 222 47. Which of the following factors will influence the oxygen concentration delivered by a self-inflating manual resuscitator? oxygen flow and reservoir size PEEP setting and oxygen flow bag size and PEEP setting reservoir size and bag size: (c) A. FIO2 is impacted by both the flow into the bag and the presence of a reservoir. With oxygen flow set at 15 LPM and a reservoir attached, the concentration approaches 100%. When a reservoir is not attached, the concentration is approximately 40% less. (u) B. A PEEP valve is a threshold resistor and has no effect on oxygen concen- tration. 38 / 222 (u) C. Bag size has no effect on oxygen concentration. A PEEP valve is a threshold resistor and has no effect on oxygen concentration. (u) D. Bag size has no effect on oxygen concentration. 48. Common complications associated with arterial punctures include: fistula formation and hematoma formation. pulmonary embolism and fistula formation. hematoma formation and spasm of the vessel. spasm of the vessel and pulmonary embolism.: (u) A. Fistulas are abnormal connections between tissues or organs and are rarely caused by arterial punc- tures. (u) B. Fistulas are abnormal connections between tissues or organs and are rarely caused by arterial punctures. A pulmonary embolism is not associated with an arterial puncture. (c) C. Hematomas, or large extravascular blood accumulations, will result when post-puncture pressure has not been applied adequately. Vessel spasm is a common complication associated with needle trauma. (u) D. A pulmonary embolism is not associated with an arterial puncture. 49. A 56-year-old man requires continuous mechanical ventilation following cardiac arrest. His heart rate is 110 and blood pressure is 96/50 mm Hg. A 39 / 222 pulmonary artery catheter has been inserted. Patient data are below: Body surface area 2 m2 Cardiac output 3.6 L/min Mean PAP 30 mm Hg PCWP 12 mm Hg 40 / 222 A respiratory therapist should recommend administering: a beta blocker. a pulmonary vasodilator. a diuretic. an inotropic agent.: (u) A. A beta blocker is used to treat abnormal heart rhythm, hypertension glaucoma, and other conditions. It is not indicated for this patient who is hypotensive. (u) B. A pulmonary vasodilator is not indicated for this patient. (u) C. A diuretic will assist in the formation of urine in the kidneys. This will result in the elimination of salts and water from the body which are used to control hypertension and decrease afterload. (c) D. An inotropic agent will control fluid overload and decrease preload. It should be used to increase the contractility of the myocardium in this patient to increase the BP. 50. A 188-cm (6-ft, 2-in), 80-kg (176-lb) male patient who has undergone a right lower lobectomy is receiving VC, A/C ventilation with the following settings: FIO2 0.50 41 / 222 Mandatory rate 12 Total rate 14 VT 400 mL The following blood gas results are available: pH 7.32 42 / 222 PaCO2 48 torr PaO2 75 torr HCO3- 25 mEq/L BE -2 mEq/L A respiratory therapist should recommend: changing to SIMV. initiating PEEP of 10 cm H2O. maintaining current therapy. increasing the tidal volume.: u) A. Changing to SIMV and retaining the same settings will likely result in a reduction in ventilation. (h) B. PEEP of 10 cm H2O is not indicated because of the presence of a bronchial stump. (c) C. Although the patient has a mild respiratory acidosis, the values are accept- 43 / 222 able for this patient. (h) D. Increasing the tidal volume is not indicated due to the presence of a bronchial stump. 51. A 25-year-old patient with apnea is receiving PC ventilation. Arterial blood gas results are as follows: pH 7.20 PCO2 65 torr 44 / 222 PO2 70 torr HCO3- 25 mEq/L BE -4 mEq/L A respiratory therapist should recommend increasing the: set inspiratory pressure. expiratory time. sensitivity. peak flow.: (c) A. In PC ventilation, increasing the inspiratory pressure will result in an increased tidal volume and minute ventilation, potentially causing a decrease in the PCO2. (u) B. Increasing expiratory time will decrease tidal volume and minute ventilation, potentially causing an increase in PCO2 and a further decrease in pH. (u) C. Increasing sensitivity will not increase ventilation in this patient. 45 / 222 (u) D. Increasing the peak flow in PC ventilation may decrease the tidal volume and minute ventilation, potentially causing an increase in the PCO2. 52. While reviewing a medical record, a respiratory therapist notes a pa- tient has shortness of breath, pleuritic chest pain, low-grade fever, tachyp- nea, tachycardia, and a swollen and tender right leg. The patient has a 50 pack-year history of smoking and known coronary artery disease. These findings are MOST consistent with: pneumonia. pulmonary embolism. 46 / 222 myocardial infarction. acute exacerbation of COPD.: u) A. Temperature irregularities such as fever or a lower than normal body temperature, productive cough, chest pain on inspiration, shortness of breath and diaphoresis are symptoms associated with pneumonia. (c) B. The signs and symptoms are consistent with pulmonary embolism. (u) C. A patient experiencing a myocardial infarction will have nausea and/or vomiting, diaphoresis as well as pain radiating to the arms and/or shoulders, neck and back and/or epigastric, but not chest wall tenderness. (u) D. Pleuritic chest pain and swelling and tenderness in one or both legs are not associated with an exacerbation of COPD. 53. A patient receiving VC, SIMV has the following ventilator settings and blood gas results: FIO2 0.55 Mandatory rate 12 Total rate 12 VT 750 mL 47 / 222 pH 7.56 PaCO2 26 torr PaO2 92 torr HCO3- 22 mEq/L SaO2 96% 48 / 222 Which of the following should a respiratory therapist recommend? Increase the inspiratory time. Increase the tidal volume to 800 mL. Decrease the FIO2 to 0.50. Decrease the mandatory rate.: (u) A. Increasing the inspiratory time will not affect alveolar ventilation or the respiratory alkalosis. (h) B. Increasing the tidal volume will increase the minute volume and further worsen the respiratory alkalosis. (u) C. The PaO2 is within normal limits. There is no indication to decrease the FIO2. (c) D. Decreasing the mandatory rate will decrease the minute volume and reduce the respiratory alkalosis. 54. A patient is intubated after a motor vehicle crash. A respiratory therapist palpates asymmetrical chest movement during inspiration, but no crepitus. Breath sounds are diminished on the left. Which of the following should the therapist do FIRST? Perform colorimetric capnometry. Administer a bronchodilator. Obtain an arterial blood gas sample. Assess depth of endotracheal tube insertion.: (u) A. Colorimetric capnometry 49 / 222 will not address the described problem of asymmetrical chest expansion. (u) B. Relieving bronchoconstriction will not address the described problem of asymmetrical chest expansion. (u) C. Arterial blood gas analysis does not address the described problem of asymmetrical chest expansion. (c) D. Intubation of the right mainstem bronchus most likely explains the asymmet- rical chest movement and decreased breath sounds. The best corrective action is to assess the depth of the endotracheal tube insertion. 55. An adult patient is intubated after being pulseless for several minutes. An exhaled CO2 detection device fails to change color despite confirmation 50 / 222 of tracheal placement by auscultation and chest rise. A respiratory therapist should recommend: performing a direct laryngoscopy. replacing the CO2 detection device. obtaining a stat chest radiograph. performing pulse oximetry.: c) A. Direct visualization of the larynx with a laryn- goscope will confirm the tube has passed through the cords. (h) B. It is unlikely that the CO2 detector is not functioning correctly. Since the patient has been pulseless for several minutes, the amount of CO2 exhaled will be significantly reduced as the pulmonary blood flow is minimal. (h) C. A chest radiograph will confirm placement of the endotracheal tube; however, an unacceptable amount of time would be required to complete this procedure in a pulseless patient. (h) D. Pulse oximetry will offer no guidance with this pulseless patient. 56. A 55-year-old male presents with GI bleeding. Arterial blood gas results reveal an arterial oxygen tension of 45 torr. Pulse oximetry readings are unreliable. The patient is in mild respiratory distress, but is not cyanotic. To evaluate the patient's oxygenation status further, it is most important to review the patient's: COHb. 51 / 222 Hb. Pv O2. P(A-a)O2.: (u) A. There is no indication that this patient was exposed to carbon monoxide. (c) B. Hemoglobin is needed to determine the oxygen-carrying capacity. (a) C. Pv O2 may provide additional information regarding oxygenation status, but does not explain the lack of cyanosis. (a) D. P(A-a)O2 may provide additional information regarding oxygenation status, but does not explain the lack of cyanosis. 57. A physician orders smoking cessation counseling for a 60-year-old male newly diagnosed with COPD. At the 1-month follow-up visit, the following 52 / 222 ABG results are obtained: pH 7.38 PCO2 45 torr PO2 56 torr HCO3- 26 mEq/L Hb 16 g/dL O2Hb 82.1% COHb 5.5% MetHb 1.0% Regarding the success of the smoking cessation counseling, a respiratory therapist should conclude the results: 53 / 222 reflect no smoking or environmental exposure. reflect smoking or environmental exposure. are inconclusive. reflect inaccurate data.: B. A COHb of 3% is indicative of continued smoking or environmental exposure. 58. A 34-week gestational age infant has been stable while receiving mechan- ical ventilation. Oxygen saturation decreases to 85% and does not respond to an increased FIO2. Transillumination of the chest produces a 1-cm halo that extends around the point of contact with the skin. Which of the following should a respiratory therapist recommend? insertion of a chest tube 54 / 222 turning the infant to the prone position increased fluid administration additional diagnostic assessments: (h) A. A small halo measuring only 1 cm is normal and does not indicate a pneumothorax. Insertion of a chest tube would be harmful. (u) B. Because increasing the FIO2 had no effect on oxygenation, it is unlikely that changing the infant's position will result in improvement. (h) C. Increased fluid administration will not improve oxygenation and may result in fluid overload which could impair gas exchange. (c) D. Because transillumination findings are normal and increasing the FIO2 fails to improve oxygenation, it is necessary to evaluate other causes that can be contributing to hypoxia. 59. Which of the following could result in an increase in pulmonary vascular resistance (PVR)? hyperoxia hypovolemia Correct Answer decreased cardiac output: EXPLANATIONS: (u) A. Hypoxemia, not hyperoxia, will result in an increase in PVR. 55 / 222 (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. 60. In which of the following circumstances will tracheal secretions tend to dry in an intubated patient? a water vapor pressure of 47 torr a relative humidity of 100% at 22° C (71.6° F) a dew point of 37° C (98.6° F) 56 / 222 an absolute humidity of 44 mg/L: u) A. A water vapor pressure of 47 torr provides 100% humidity at body temperature. (c) B. The absolute humidity at this temperature is inadequate. (u) C. A dew point of 37° C (98.6° F) indicates the gas is completely saturated at that temperature. (u) D. The absolute tracheal humidity must be greater than or equal to 30 mg/L. 61. Which of the following indicates a physical conditioning program has been effective for a patient with COPD after 2 months of therapy? Resting pulse rate is unchanged. The 6-minute walk distance is increased by 60 meters. Vital capacity has increased by 5%. FEV1 has improved by 10%.: (u) A. Increased conditioning usually results in a lower resting pulse rate. (c) B. An important part of physical conditioning is an increase in exercise toler- ance, easily measured by increased walking distance. (u) C. Pulmonary function results do not normally improve with pulmonary rehabil- itation. 57 / 222 (a) D. See explanation C. 62. A 50-year-old patient with a tracheostomy is receiving VC ventilation. The high pressure alarm is sounding intermittently and the exhaled tidal volume is reduced. Which of the following should a respiratory therapist do? Change the mode of ventilation. Increase the high pressure alarm setting. Suction the airway. Administer a beta agonist.: (u) A. Changing the mode of ventilation will not resolve the high pressure alarm. (u) B. A high pressure alarm sounds and inspiration ends when a preset pressure 58 / 222 is reached. This occurs with increased airway resistance and is most often due to accumulated secretions, which is an indication for suctioning. (c) C. Suctioning the patient will allow delivery of the set tidal volume by decreasing airway resistance. (u) D. There is no indication for administering a beta agonist for a patient who is not experiencing bronchospasm. 63. Which of the following values is used to evaluate an individual's response to inhaled bronchodilators? FVC FEV1 FEF200-1200 diffusing capacity: (u) A. FVC is used to assess the patient's ability to cough and deep breathe. (c) B. FEV1 is the best indicator of reversible airway obstruction in response to inhaled bronchodilators. (u) C. FEF200-1200 is a good indicator of large airway function, but is not useful in evaluating small airway response to bronchodilators. 59 / 222 (u) D. Diffusing capacity measures the ability of gases to diffuse across the alveolar-capillary membrane. 64. An air-entrainment mask will deliver an FIO2 higher than intended if: the flow is set too high. nebulized water is being added through the air-entrainment ports. corrugated tubing was added between the air-entrainment adapter and mask.r the air-entrainment ports have been blocked.: u) A. Increasing the flow will entrain more room air while maintaining the same FIO2. (u) B. Adding nebulized water will have no effect on the FIO2. 60 / 222 (u) C. Additinal tubing placed between the mask and air entrainment adapter will have no effect on the FIO2. (c) D. Blocked air entrainment ports prevents air from being added to the inspired gas flow and results in a higher FIO2. 65. A respiratory therapist is reviewing a chest radiograph of a patient with a hemothorax and notes the presence of the end of a chest tube. Where should the therapist expect to find the tube as it enters the chest wall? intercostal space line A. second mid-clavicular B. third mid-clavicular C. fourth mid-axillary D. fifth mid-axillary: (u) A. The second intercostal space in the mid-clavicular line is more appropriate for a pneumothorax. (u) B. The third intercostal space in the mid-clavicular is more appropriate for a pneumothorax. 61 / 222 (u) C. The fourth intercostal space in the mid-axillary line is too high to drain a hemothorax. (c) D. The fifth intercostal space in the mid-axillary line is appropriate for draining fluid from the chest. A tube placed any higher than the thorax may not adequately drain the fluid. 66. An alert adult patient is receiving CPAP with PS of 5 cm H2O and an FIO2 of 0.28. The patient has a respiratory rate of 25 and a heart rate of 88. Blood gas results are as follows: 62 / 222 pH 7.43 PaCO2 35 torr PaO2 95 torr HCO3- 23 mEq/L BE -1 mEq/L Which of the following is a respiratory therapist's most appropriate action? Recommend extubation of the patient. Assess pulmonary mechanics. Wean if the shunt is less than 5%. Maintain current ventilator settings.: (c) A. This patient is alert and ready for extubation. (a) B. Assessing pulmonary mechanics will provide additional clinical information; however, it is unnecessary in this patient. (u) C. The P(A-a)O2 is normal. There are no indications for a shunt study. (u) D. The patient is alert and ready for extubation. Maintaining mechanical venti- lation exposes the patient to nosocomial infections and delays discharge. 67. An adult patient is receiving PC, SIMV with the following settings: 63 / 222 FIO2 0.80 Mandatory rate 15 Spontaneous rate 32 Set inspiratory pressure 20 cm H2O 64 / 222 PEEP 10 cm H2O SpO2 92% On inspection, the patient demonstrates suprasternal retractions during spontaneous breaths. Which of the following should a respiratory therapist do NEXT? Decrease rise time setting. Switch to A/C mode. Increase the FIO2 to 0.90. Change inspiratory pressure setting to 25 cm H2O.: (u) A. Rise time is not an active setting. (c) B. The suprasternal retractions are indicative of increased work of breathing and should be resolved by changing the mode to A/C. The respiratory rate may also come down. (h) C. The patient is adequately oxygenated with the current FIO2. 65 / 222 (u) D. Increasing inspiratory pressure will not affect the tidal volume of the sponta- neous breaths or breathing effort. 68. A male patient who is experiencing an acute myocardial infarction will most likely have which of the following clinical findings? jaw pain pedal edema nausea and vomiting fever: c) A. Jaw pain with nausea and vomiting are classic signs that a male patient is experiencing an acute myocardial infarction. 66 / 222 (u) B. Pedal edema and fever are not indicators of an acute myocardial infarction. (u) C. Fever is not an indicator of an acute myocardial infarction. (u) D. Pedal edema is not an indicator of an acute myocardial infarction. 69. During a ventilator pre-use check to evaluate the integrity of the circuit, a respiratory therapist should assess: pressure during tidal volume delivery. compressible volume of the circuit. peak pressure change when the circuit is capped. volume delivery distal to the exhalation valve.: (u) A. Measurement of pressure will not evaluate the volume delivered or any volume lost due to a leak in the tubing circuit. (u) B. Determining the compressible volume of the circuit does not assess the 67 / 222 integrity of the circuit. (c) C. Maintaining peak pressure when the circuit is capped indicates a tight circuit without leaks. (u) D. Although this measures the volume leaving the humidifier, it does not include volume through the circuit and could potentially miss volume lost through any leak distal to the humidifier. 68 / 222 70. Which of the following is suggestive of a malfunctioning arterial catheter? patient complaints of pain at the site an increase in the systolic pressure reading the presence of a hematoma difficulty aspirating blood: (u) A. The throbbing sensation may be due to nerve irritation and not related to catheter function. (u) B. The systolic pressure reading would not increase; rather, the pressure tracing would be damped. (u) C. A hematoma is a possible complication of arterial cannulation, but not a sign of catheter malfunction. (c) D. Difficulty withdrawing blood through an arterial catheter is a sign of malfunc- tion. 71. Which of the following should a respiratory therapist instruct a patient to 69 / 222 use when cleaning the home CPAP mask and connecting tubing? acetic acid hydrogen peroxide dishwashing soap isopropyl alcohol: (c) C. Dishwashing soap is recommended for cleaning home CPAP masks and tubing. 72. While performing a patient-ventilator check, a respiratory therapist ob- serves very little condensation in the heated wire circuit. The heated wick humidifier contains an appropriate amount of water. The most likely expla- 70 / 222 nation is that the: minute ventilation is greater than 15 L/min. patient circuit is operating normally. flow is set at too low of a value. room temperature is lower than normal.: (u) A. The minute ventilation will not impact condensation in the circuit. (c) B. The heated wire circuit is designed to maintain gas temperature to prevent condensation. (u) C. Condensation is not significantly affected by low flow. (u) D. A lower than normal room temperature may result in an increase in tubing condensation. 73. During manual bag-valve ventilation through an endotracheal tube, inad- equate ventilation may be caused by: 71 / 222 lack of an oxygen reservoir. a deflated endotracheal tube cuff. high pulmonary compliance. disconnection of medical gas.: (u) A. Lack of an oxygen reservoir may affect FIO2, but not delivered volume. (c) B. During manual ventilation, gas will flow past the deflated cuff and result in less volume to the lungs. 72 / 222 (u) C. High pulmonary compliance may result in hyperventilation, not inadequate ventilation. (u) D. Manual bag-valve ventilation does not require supplemental medical gas for adequate ventilation. 74. he most common rhythm in a witnessed sudden cardiac arrest is: ventricular tachycardia. ventricular fibrillation. pulseless electrical activity. asystole.: (c) B. Ventricular fibrillation is the most common cardiac arrhythmia in a witnessed sudden cardiac arrest. 75. Following placement of a subclavian venous catheter, the high pres- sure alarm on a patient's ventilator begins sounding. After 10 minutes, the patient's peak inspiratory pressure has increased from 40 to 60 cm H2O and mean arterial pressure decreased from 80 to 40 mm Hg. After ordering a chest radiograph, which of the following should a respiratory therapist recommend FIRST? 73 / 222 Increase the peak flow. Administer vasopressors. Perform endotracheal suction. Insert a chest tube.: (u) A. Increasing the peak flow is not indicated when peak pressures are increasing. (u) B. Administering vasopressors will not correct increased airway pressures. 74 / 222 (u) C. Accumulated airway secretions can increase inspiratory pressures, but should not cause a decrease in mean arterial pressure. Therefore, suctioning is not indicated. (c) D. Pneumothorax is a possible complication of venous catheter insertion and can result in increased airway pressure. This would sound the high pressure alarm and decrease arterial pressure. Inserting a chest tube is indicated in treating a pneumothorax. 76. A doctor orders aerosol therapy for a patient receiving mechanical ven- tilation who is being provided humidification with a heat and moisture exchanger (HME). To assure effective therapy you must: A. place the aerosol device proximal to the HME in the stream of flow B. remove the HME before aerosol therapy and replace it afterward C. place the aerosol device distal to the HME in the stream of flow D. switch from an HME to an active heated the humidification system: Be- cause an HME traps aerosol, you must you must remove it before aerosol therapy and replace it afterward The correct answer is: remove the HME before aerosol therapy and replace it afterward 77. A physician orders 2.5 mL ipratropium bromide (Atrovent) 0.2% TID for a COPD 75 / 222 patient with recurrent bronchospasm.Which of the following methods would you use to deliver this drug? A. small volume nebulizer with mask B. ultrasonic nebulizer with mask C. small volume nebulizer with mouthpiece D. MDI: Ipratropium bromide aerosol can cause temporary blurring of vision as well as narrow angle glaucoma or eye pain if the solution comes into direct contact with the eyes. Use of a nebulizer with a mouthpiece (rather than face mask) reduces the likelihood of the nebulizer solution reaching the eyes. The correct answer is: small volume nebulizer with mouthpiece 76 / 222 78. Tactile fremitus would be reduced in all of the following conditions ex- cept: A. COPD B. pneumothorax C. pleural effusion D. pulmonary edema: Tactile fremitus would be reduces in COPD and a pneu- mothorax because the lung is overinflated. A pleural effusion would block and decrease the sounds coming from the lungs. The correct answer is: pulmonary edema 79. Which of the following drug would you recommend for a patient with acute bronchospasm? A. racemic epinephrine B. acetylcysteine (Mucomyst) C. albuterol (Proventil) D. cromolyn sodium (lntal): For patients with acute bronchospasm, you normally select an aerosolized bronchodilator (a beta-adrenergic like albuterol and/or a cholinergic blocker like ipratropium). Acetylcysteine is a mucolytic that would only worsen bronchospasm in sensitive patients. Cromolyn is a prophylactic anti-inflammatory useful in prevent- ing bronchospasm in asthmatics. Racemic epinephrine (strong alpha-adrenergic) is 77 / 222 selected to reverse the vasodilation and mucosal edema that can cause upper airway obstruction episodes such as croup. The correct answer is: albuterol (Proventil) 80. An 80 kg (176 lb) patient is receiving volume control A/C ventilation with 35% oxygen at a rate of 12/min and a VT of 600 mL. The following information is available (blood gases obtained while on ventilator): pH 7.38 Spon VT 175 mL PaCO2 35 mmHg Spon VE 7.0 L/min HCO3 21 mEq/L VC 600 mL PaO2 110 mm Hg MIP/NIF -10 cmH2O Which of the following actions would be appropriate at this time? 78 / 222 A. place the patient on a 40% T-tube and monitor closely B. maintain current ventilator settings and re-evaluate later C. switch the patient to SIMV at a rate of 4/minute D. place the patient on 5 cm H2O CPAP and monitor closely: Although the patient's on-ventilator blood gases are acceptable, the bedside measurements indicate that the patient is not yet ready for a spontaneous breath- ing trial. With a spontaneous VE of 7.0 L/min and VT of 175 mL, the patient's sponta- neous rate is 40/min, with the rapid shallow breathing index (RSBI) over 200 (40/.175 = 228). In general, a RSBI over 100-105 predicts weaning failure, so in this case it would be best to maintain the current ventilator settings and re-evaluate the patient later. The correct answer is: maintain current ventilator settings and re-evaluate later 81. COPD patient has the following arterial blood gas results in room air: pH 7.33 PaCO2 65 torr PaO2 49 torr HCO3 33 mEq/L BE +7 The patient complains of shortness of breath and lightheadedness, has bilateral bronchial breath sounds with inspiratory crackles and exhibits cyanosis around 79 / 222 his lips. Which of the following would you recommend for this patient? A. 10 L/min nonrebreathing mask B. 28% air-entrainment mask C. albuterol (Proventil) by SVN D. 4 L/min nasal cannula: The ABG indicates partially compensated respiratory acidosis with severe hypoxemia, likely due to an acute exacerbation of the condition, possibly caused by pneumonia. Given the severity of the hypoxemia, immediate O2 therapy is indicated. However especially during acute exacerbations of COPD, it is recommended that blood oxygen levels be carefully titrated in order to avoid oxygen-induced hypercapnia. Common- ly cited target levels are PaO2s in the 55-70 torr range or SpO2s in the 88 to 93% range. 80 / 222 Given the added issue of dyspnea, this patient should be placed on a high flow device capable of giving a precise low FIO2, i.e. a 28% air-entrainment device. The correct answer is: 28% air-entrainment mask 82. A 58-year-old patient in the open heart unit had cardiopulmonary bypass surgery with significant blood loss. On physical exam the patient presents with tachypnea and tachycardia and the SpO2 is 85% on 4 L/min nasal cannula. You should now recommend: A. non-rebreathing mask at 12 L/mi