Chapter 16 - Assist a Provider in Performing Procedures Flashcards Preview

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Flashcards in Chapter 16 - Assist a Provider in Performing Procedures Deck (18)
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1

An intubated patient in ICU needs to undergo bedside bronchoscopy and is in need of short-term sedation. Which of the following agents would you recommend for this procedure?

  1. haloperidol (Haldol)
  2. propofol (Diprivan)
  3. lorazepam (Ativan)
  4. cisatracurium (Nimbex)

2

Propofol is the agent of choice for rapid sedation of patients undergoing minor invasive procedures. It has a quick and short half-life (<30 minutes). Haloperidol (Haldol) is a neuroleptic/antipsychotic, not a sedative. Lorazepam (Ativan) is a sedative, but used for long-term sedation. Cisatracurium (Nimbex) is a neuromuscular blocking agent, not a sedative.

2

At the end of each graded step of a cardiopulmonary exercise test, you normally would measure which of the following?

  1. physiologic deadspace
  2. intrapulmonary shunt
  3. Borg exertion rating
  4. pulmonary diffusing capacity

3

Toward the end of each graded interval of an exercise test, you typically measure the patient's blood pressure, heart rate, SpO2, Borg exertion rating, and symptoms (if any). You sometimes may need to draw an ABG specimen (for blood gas values and lactate levels) at each step in the protocol.

3

To help minimize family distress, a doctor wants to avoid gurgling, sonorous breathing or stridor in a terminally ill patient who is scheduled for withdrawal of ventilatory support. Which of the following procedures would you recommend to help achieve the doctor’s goal?

  1. immediate extubation to nasal cannula
  2. withdrawal to T-tube with humidified O2
  3. IMV weaning followed by rapid extubation
  4. exchange the endotracheal tube for an LMA

2

Rapid withdrawal of the patient from the ventilator and placement on a T-tube (with ET tube remaining in place) ensures that the airway remains patent and protected through the procedure, avoiding occurrences that may be distressful to the family, such as gurgling or post-extubation stridor. On the other hand, some family members may want their loved one to be free of tubes before dying. It is for these reasons that the differences between immediate extubation and withdrawal to T-tube must be well explained to the family so that they can make the final decision as to what is best for them.

4

When assisting a physician with needle thoracostomy for a patient with a confirmed pneumothorax, you should advise the physician that the needle should be inserted in what anatomic location?

  1. over the fourth rib, mid-sternal line
  2. over the fourth rib, mid-clavicular line
  3. over the second rib, mid-clavicular line
  4. under the fourth rib, laterally

3

When assisting a physician with an emergency needle decompression of a tension pneumothorax, you should recommend that it be inserted over the second rib, in the mid-clavicular line.

5

An intubated patient in ICU needs to undergo bedside bronchoscopy and is in need of short-term sedation. Which of the following agents would you recommend for this procedure?

  1. Haloperidol (Haldol)
  2. Propofol (Diprivan)
  3. Lorazepam (Ativan)
  4. Cisatracurium (Nimbex)

2

Propofol is the agent of choice for rapid sedation of patients undergoing minor invasive procedures. It has a quick and short half-life (<30 minutes). Haloperidol (Haldol) is a neuroleptic/antipsychotic, not a sedative. Lorazepam (Ativan) is a sedative, but used for long-term sedation. Cisatracurium (Nimbex) is a neuromuscular blocking agent, not a sedative.

6

You are using an SIMV protocol to terminally wean a cancer patient from ventilatory support. When you decrease the rate from 6 to 3 breaths/min, you observe some agitation and labored breathing. Which of the following should you recommend?

  1. Restore full ventilatory support
  2. Remove the ventilator and extubate
  3. Provide an IV push of sedating agents
  4. Immediately decrease the rate to 0

3

Common signs of distress during ventilator withdrawal include labored breathing, tachypnea, grimacing and/or agitation. If any of these signs of distress occur, you should recommend pushing the prescribed sedating agents by IV until the distress is relieved. Then the infusion rate should be readjusted to maintain relief from distress. Restoring full ventilatory support will only delay the desired outcome, while immediate withdrawal of support (rate of 0 or extubation) without additional sedation will likely only increase the intensity of the distress.

7

A first-year resident has just inserted an indwelling arterial catheter in an ICU patient. A good indication that the catheter has been successfully inserted in an artery is:

  1. a positive Allen test
  2. a good blood return
  3. ability to flush the line
  4. proper blood pressure and waveform

4

The Allen test is indicated only to assess for collateral circulation on the radial artery site before performing the procedure. Blood return and ability to flush the line can also occur if the catheter has been inserted on a venous vessel. The best indication that the line has been properly inserted on an artery is the return of arterial blood pressure values accompanied by a good arterial waveform once the line is connected to the transducer and the monitor.

8

The doctor of a patient diagnosed with severe obstructive sleep apnea contacts you because after a week of treatment her patient is refusing to continue CPAP therapy. What actions would be appropriate?

  1. Accept the patient's decision and recommend switching to an oral appliance
  2. Recommend the patient undergo reconstructive surgery (uvulopalatopharyngoplasty)
  3. Assess causes of poor compliance and evaluate equipment/interface alternatives
  4. Accept the patient's decision and recommend initiation of modafinil (Provigil) therapy

3

If a patient refuses or rejects CPAP, the RT should evaluate common causes of poor compliance (e.g., bad sleep habits, mask discomfort/leaks, conjunctivitis, skin breakdown, mouth breathing, nasal problems, etc.) and assess equipment/interface alternatives to improve tolerance, e.g., various mask options, added humidification, ramp feature, auto titration, pressure relief (aka C-flex, EPR), BiPAP or ASV. Modafinil (Provigil) is not a primary therapy for sleep apnea and recommended only for OSA patients who have residual daytime sleepiness despite effective C PAP treatment. Oral appliances would be considered only if the CPAP alternatives fail. And only if noninvasive therapies (CPAP, behavioral strategies, positional therapy, oral appliances) fail should surgery be considered.

9

While assisting a physician who is inserting a pulmonary artery (PA) catheter, you note a changeover on the monitor from pulsatile pressures of about 32/18 mm Hg to a nonpulsatile pressures of 15 mm Hg. Which of the following has occurred?

  1. the catheter has slipped back into the right atrium and needs to be and re-inserted
  2. the catheter has moved from right ventricle into the pulmonary artery
  3. the catheter has advanced into the pulmonary wedge or occluded position
  4. the catheter is in lung Zone I and needs to be withdrawn and re-inserted

3

During insertion of a PA catheter, pressure waveforms indicate its position. In the vena cava/right atrium, pressures normally are < 10 mm Hg and barely pulsatile. As the catheter moves into the right ventricle, a changeover to pulsatile pressures occurs, normally about 25/5 mm Hg. As the catheter passes into the pulmonary artery, pulsatile pressures continue, but with a raised diastolic baseline (normally about 25/15 mm Hg). In the "wedge" position (PAWP or PCWP), strong pulsations are lost, and pressures normally drop to 6-12 mm Hg.

10

An anesthesiologist is planning a rapid sequence induction to intubate an adult patient in the surgical ICU. In preparation for intubation, you are pre-oxygenating the patient with a bag-valve-mask system. The anesthesiologist is concerned about the potential for gastric distention and aspiration before the tube is placed. To help avoid this problem, you would:

  1. place the patient in the lateral decubitus position
  2. apply downward pressure on the cricoid cartilage
  3. place gentle pressure on the upper epigastrium
  4. rotate the patient's head 45 degrees to the right

2

Applying downward pressure on the cricoid cartilage during intubation (the Selleck maneuver) can help prevent gastric distention during bag-valve-mask ventilation and also help avoid aspiration of gastric contents during rapid sequence induction prior to intubation. As an added benefit, this maneuver may provide better visualization of vocal cords during laryngoscopy.

11

If the first attempt at cardioversion is unsuccessful, what action should take place to avoid the delivery of an unsynchronized shock during subsequent attempts?

  1. immediately increase the energy level to maximum
  2. ensure that the "unsynchronized" mode is activated
  3. ensure that the "synchronized" mode is activated
  4. immediately begin CPR

3

Most defibrillators default back to unsynchronized mode after delivery of a synchronized shock. In order to avoid the delivery of an unsynchronized shock on subsequent cardioversion attempts, ensure the "synch" mode is activated.

12

A patient requiring mechanical ventilatory support has just undergone tracheotomy in the ICU. The attending physician asks you to secure the equipment needed to deal with accidental extubation of this patient, should it occur. Which of the following would you place at the bedside?
 

                                            A           B           C            D
Manual resuscitator/mask           Yes             Yes          Yes              Yes

Replacement trach tube              No              Yes           Yes             Yes

Vaseline gauze pads                   Yes              No            Yes             No

 

  1. A
  2. B
  3. C
  4. D

3

Due to the ever-present hazard of accidental extubation, a replacement airway and manual resuscitator/mask should be kept at the bedside of any intubated patient. For tracheostomized patients, Vaseline gauze pads (needed to seal the tracheal stoma) are also needed.

13

You are assisting a physician performing a bronchoscopy for a spontaneously breathing patient. The patient is alert, awake and anxious. Which of the following medications should you recommend prior to the procedure?

  1. lidocaine (Xylocaine)
  2. vecuronium bromide (Norcuron)
  3. epinephrine 1:10,000 solution
  4. midazolam (Versed)

4

Benzodiazepines like Midazolam (Versed) are usually recommended for the treatment of anxiety prior and during conscious (moderate) sedation procedures. The effects of medication such as Versed are also reversible, if the need arises.

14

A physician has attempted on several occasions to insert a central venous catheter into the right subclavian vein of a patient receiving mechanical ventilation. Suddenly the ventilator's high-pressure alarm sounds, the patient's blood pressure drops, and the SpO
2
value drops from 96% to 84%. Breath sounds are greatly diminished over the right-lung field. What action should you recommend?

  1. Pull the ET back 2-3 cm into the trachea
  2. Insert a chest tube into the left pleural space
  3. Insert a pulmonary artery catheter
  4. Insert a chest tube into the right pleural space

4

Pneumothorax is a recognized complication of central venous catheter placement via the subclavian vein. The high pressure vent alarm, the patient's sudden drop in blood pressure and SpO2, and the diminished breath sounds over the right-side all suggest a pneumothorax. In this case, the best course of action would be to recommend placement of a chest tube on the affected side (right), followed by a STAT chest X-ray.

15

You are asked by a physician to assist him in monitoring a patient during a fiberoptic bronchoscopy procedure. Which of the following would you recommend?
 

                                                         A         B        C          D
vital signs                                                        YES        YES      YES       YES

heart rhythm via electrocardiogram (ECG)    NO         YES      YES        NO

forced expiratory flow rates (e.g., FEV1)        YES         NO       YES       NO

arterial oxygen saturations via oximetry        YES        YES       NO      YES

 

  1. A
  2. B
  3. C
  4. D

2

Patient monitoring during a fiberoptic bronchoscopy procedure is often done by the therapist and should include ongoing assessment of the pulse, respiratory rate, and ECG. In addition, pulse oximetry can be used to monitor changes in arterial oxygen saturations.

16

After assisting with a tube thoracostomy at the bedside of a patient receiving mechanical ventilation, you connect the chest tube to a pleural drainage system and apply -15 cm H2O suction. Five minute later you note crepitus occurring around the insertion site. This indicates:

  1. application of excessive suction
  2. proper re-expansion of the lung
  3. air leakage into the pleural space
  4. loss of the suction system water seal

3

Crepitus at the site of chest tube insertion always suggests recurrence of air leakage into the pleural space. You should immediately notify the physician who inserted the chest tube regarding this problem.

17

In what position should you place an unconscious patient in order to facilitate a thoracentesis procedure?

  1. slighted rotated from supine with the affected side up near the edge of the bed
  2. prone position with foot of bed raised 12-18 inches
  3. slighted rotated from supine with the affected side down on edge of the bed
  4. sitting at the edge of the bed leaning forward at a 45 degree angle

3

For thoracentesis, immobile or unconscious patients should be placed with the affected side down on the very edge of the bed, slighted rotated from supine (toward the bed edge), with the ipsilateral arm behind the head and the mid-/posterior axillary line accessible for needle insertion (elevating the head of the bed to 30° may help).

18

You are assisting a physician performing orotracheal intubation of a 100 kg 6-foot 4-inch male patient. Which of the following endotracheal tube sizes would you select for this patient?

  1. 6.0 mm
  2. 7.0 mm
  3. 8.0 mm
  4. 9.0 mm

4

For a large adult male patient requiring endotracheal intubation, you should select a tube at least 8.5 mm in internal diameter.