Practice Questions Flashcards

Question

Following placement of a subclavian venous catheter, the high pressure 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. A respiratory therapist should FIRST A. increase the peak flow. B. suggest administering a vasopressor. C. suction the endotracheal tube. D. recommend needle decompression.

Answer 1

D. Tension 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. Needle decompression is indicated.

Answer 2

(c) A. Metabolism decreases when nicotine is withdrawn. If dietary intake remains unaltered and exercise is not included, there may be a resulting weight gain.

Answer 3

C. The sudden loss of cuff pressure and air noted coming from the mouth indicates a ruptured cuff and must be addressed immediately. An endotracheal tube exchanger is a safe means to reintubate successfully.

Answer 4

(c) A. Fluticasone/salmeterol (Advair) is a long-acting bronchodilator and inhaled steroid that is the generally accepted care for COPD. (u) B. Montelukast (Singulair) is a leukotriene-modifying agent. There is no documented clinical basis for its use in the management of severe COPD. (h) C. N-acetylcysteine is a mucolytic agent and may promote additional bronchospasm in the patient. (u) D. Guaifenesin (Robitussin) is an over-the-counter expectorant. Its use will not decrease symptoms of dyspnea.

Answer 5

D. PEF measurements are routinely used to monitor airways obstruction in patients with asthma.

Answer 6

B. Caffeine citrate is used to treat apneic conditions and indicates the need for home apnea monitoring.

Answer 7

D. The integrity of the gas analysis system and its ability to return expected results are critical elements in DLCO measurement.

Answer 8

B. The suprasternal retractions are indicative of increased work of breathing and may be resolved by changing the mode to A/C. The respiratory rate may also come down.

Answer 9

A. Excessive cuff pressure will obstruct mucosal blood flow to the tracheal wall. The resulting ischemia weakens the tracheal wall and tracheomalacia develops.

Answer 10

D. The correction factor for a 70/30 heliox is the oxygen flow multiplied by 1.6 (10 L/min X 1.6 = 16 L/min.)

Answer 11

D. Vibratory PEP aids in secretion removal.

Answer 12

B. An inhalation challenge uses bronchoprovocative stimulus (e.g., methacholine), to test the hyperactiveness of the airway. Patients with asthma demonstrate an excessive response to various doses of this substance.

Answer 13

B. A PaO2 of 150 mm Hg is above the normal range of 75 - 100 mm Hg; therefore, hyperoxemia is present.

Answer 14

B. Changing to a full face mask will direct humidified gas from the machine through the nose and mouth.

Answer 15

C. The patient has some degree of upper airway obstruction cause by some type of viral illness. The barky cough is a classic finding for patients experiencing croup.

Answer 16

D. Exhaling into the device will disperse the powder throughout the device and the moisture in the exhaled air can make the medication occlude the device.

Answer 17

A. Application of PEEP minimizes the potential for end-expiratory alveolar collapse and then maintains the alveoli in an open position because it exceeds the force of surface tension.

Answer 18

A. A nasopharyngeal airway is the least invasive device to use to prevent upper airway obstruction in a conscious patient.

Answer 19

B. A low volume alarm with the audible noise from the mouth indicates a leak.

Answer 20

D. Given a plateau pressure of greater than 30 cm H2O, the next step in the ARDSnet protocol is to decrease the tidal volume in 1 mL/kg PBW increments (to a minimum of 4 mL/kg of PBW) until plateau pressure is less than 30 cm H2O.

Answer 21

B. As inhaled nitric oxide breaks down, methemoglobin is formed. This may lead to methemoglobinemia.

Answer 22

B. The arterial level of CO2 reflects the alveolar CO2 and is the best indication of the adequacy of ventilation.

Answer 23

A. Vibrating mesh nebulizers place only the aerosolized medications into the circuit.

Answer 24

A. An arterial carbon dioxide tension of less than 35 mm Hg reflects alveolar hyperventilation as it results in a decreased arterial carbon dioxide tension in the blood.

Answer 25

B. The signs and symptoms are consistent with pulmonary embolism.

Answer 26

A. An ECG is required to rule out an acute myocardial infarction or arrhythmia before considering other diagnoses.

Answer 27

A. Though there is evidence of auto-PEEP in the flow-time graphic, the patient's normal pH and stable hemodynamics indicate no intervention is currently needed.

Answer 28

C. Pulse oximetry to monitor the SpO2 in a patient with pulmonary edema is essential to track the patient's status. As furosemide will impact fluid levels, monitoring the patient's electrolyte levels is essential to ensuring a correct sodium level.

Answer 29

D. Orthopnea is defined as the shortness of breath while lying flat.

Answer 30

C. Given its strong alpha-adrenergic vasoconstrictive properties, racemic epinephrine is the first choice to help reduce the glottic edema that has occurred in this patient.

Answer 31

A. Sedation is required to eliminate excessive activity so the patient's cardiopulmonary status can be properly evaluated and treated.

Answer 32

D. A leak is the likely cause for the difference of 400 mL and is one of the reasons for checking spirometers with a calibrated syringe.

Answer 33

C. Maintaining peak pressure when the circuit is capped indicates a tight circuit without leaks.

Answer 34

D. HFCWO provides an effective method to loosen and mobilize airways secretions.

Answer 35

B. Room air is used for the low calibration of an oxygen analyzer and should be set at 21%.

Answer 36

D. Blocked air-entrainment ports prevent air from being added to the inspired gas flow and results in a higher FIO2.

Answer 37

B. Pulse oximetry gives a rapid response to changes in oxyhemoglobin saturation and is the most accurate of the options given.

Answer 38

B. FEV1 is the best indicator of reversible airway obstruction in response to inhaled bronchodilators.

Answer 39

A. Subcutaneous emphysema may indicate the presence of a pneumothorax. A chest radiograph is the most appropriate initial diagnostic test when a pneumothorax is suspected.

Answer 40

C. Although the patient has a mild respiratory acidosis, the values are acceptable for this patient.

Answer 41

D. These findings are consistent with a pleural effusion.

Answer 42

D. There has been an increase in the patient's heart rate of greater than 20/min, signaling a tachycardic reaction to the medication. Termination of the treatment is advisable.

Answer 43

C. The patient has a tension pneumothorax. Inserting a needle in the chest is the quickest action based on the vital signs.

Answer 44

D. Diuretics may cause fluid shifts and excretion of certain electrolytes in the urine. Therefore, electrolytes should be monitored to detect electrolyte imbalances (particularly in sodium, potassium, and calcium) as these can be life threatening.

Answer 45

A. The patient is experiencing respiratory alkalosis. Decreasing the tidal volume will reduce the overall minute ventilation and help reduce the pH.

Answer 46

C. The flow to the mask is insufficient and will result in dilution of both the oxygen and helium concentrations with air. Increasing the flow will ensure the patient receives the desired gas mixture

Answer 47

D. Bronchitis is characterized by chronic cough and sputum production.

Answer 48

A. An excess in interstitial fluid can impair oxygen diffusion into the capillaries and increase the P(A-a)O2.

Answer 49

D. The ventilatory parameters and the accompanying ABG analysis results indicate the patient is ready for extubation.

Answer 50

C. Universal precautions should be used when obtaining an ABG sample.

Answer 51

A. An AHI of 28 is categorized as moderate to severe sleep apnea. PAP therapy is the treatment of choice.

Answer 52

D. Handwashing before and after use prevents contamination of equipment and transmission of microorganisms.

Answer 53

B. To reduce complications of trauma, the catheter should be lubricated with a water-soluble lubricant to aid catheter passage through the nostril.

Answer 54

A. The patient exhibits oxyhemoglobin desaturation with exercise and should have oxygen administered with activity.

Answer 55

D. The data suggests a low cardiac index and cardiogenic shock. An inotropic agent should be used to increase myocardial contractility, which in turn, should increase blood pressure.

Answer 56

D. Auto-PEEP is caused by gas trapping. Expiratory flow will not return to baseline because expiration has not completed before the next breath is delivered.

Answer 57

B. Changing to levalbuterol (Xopenex) may decrease the incidence of tachycardia and palpations.

Answer 58

D. Difficulty withdrawing blood through an arterial catheter is a sign of malfunction.

Answer 59

A. Mallampati score IV is characterized by the visualization of only the hard palate. None of the soft palate is visible.

Answer 60

B. A 40% air-entrainment mask entrains air at a ratio of 3 parts air to 1 part oxygen. To determine the total flow provided with a 40% mask and 12 L/min, use the following formula to solve for x, with x being oxygen flow in L/min: 3x = air entrained 3x + x = total flow 3(12) + 12 = total flow = 48 L/min.

Answer 61

C. The most common cause of issues with the light source of bronchoscopes is the connection port.

Answer 62

D. For a patient who has been receiving mechanical ventilation for a long period of time, an abrupt loss of ventilation may lead to anxiety and dyspnea. Initiating pressure support is most likely to lead to successful weaning.

Answer 63

C. The lack of a plateau and upward sloping shape of the curves demonstrate impairment of exhalation due to an obstructive process or airways collapse.

Answer 64

A. A malfunctioning exhalation valve can cause a significant leak and prevent the development of normal pressures during the inspiratory phase of ventilation.

Answer 65

B. The FEV1 and FEV1/FVC values are within normal ranges. The patient should be able to deep breathe and cough after surgery.

Answer 66

B. Right heart failure inhibits venous return and results in edema in the periphery.

Answer 67

C. The flow control valve in conjunction with the gas flow into the bag regulates the filling of the bag. With the flow control valve open, the gas going into the bag will immediately leave the bag through the open-flow control valve.

Answer 68

C. MIP is an indication of respiratory muscle strength. Vital capacity provides information regarding respiratory reserve. Both provide data about the need for ventilatory support in a patient with neuromuscular disease.

Answer 69

B. An apnea monitor is indicated when an infant is asleep or when not being observed; therefore, it should be used during naps and at night.

Answer 70

A. The site must be heated for 2-5 minutes to facilitate capillary dilatation. Once dilatation occurs, transcutaneous values will stabilize.

Answer 71

C. To attempt to compensate by blowing off CO2, there is an increase in rate and depth of breathing. This is called Kussmaul's breathing and is the result of diabetic ketoacidosis.

Answer 72

B. Keeping the current invasive procedure in mind, the diminished breath sounds over the affected area and an increased heart rate are consistent with a pneumothorax.

Answer 73

C. An ABG will indicate the patient's ventilatory status. Hemoximetry (CO-oximetry) will indicate the patient's carboxyhemoglobin level, which is essential in CO poisoning, in addition to true oxygen saturation.

Answer 74

B. The description suggests obstruction of the catheter due to kinking or mucous, resulting in significant back pressure causing the supply tube to pop off.

Answer 75

A. Based on NAEPP guidelines, the patient meets criteria for step 2 and requires the addition of an inhaled corticosteroid.

Answer 76

D. A right-sided pneumothorax will result in diminished breath sounds on the right and possibly a tracheal shift to the left.

Answer 77

B. Although a pressure-volume loop can identify the presence of air trapping by looking at the shape of the curve, the amount of air trapping cannot be determined.

Answer 78

D. Bag-valve-mask resuscitation is required for a patient in severe respiratory distress.

Answer 79

D. Intubation of the right mainstem bronchus most likely explains the asymmetrical chest movement and decreased breath sounds. The best corrective action is to assess the depth of the endotracheal tube insertion.

Answer 80

B. Vital capacity is performed by having the patient inhale to total lung capacity and maximally exhale to residual volume.

Answer 81

A. The high-pitched squeal indicates that the oxygen or air source is disconnected or below a critical point.

Answer 82

A. Propofol is a sedative and will not be useful for analgesia. (u) B. Midazolam HCl (Versed) is an anxiolytic agent and will not be useful for analgesia. (u) C. Lorazepam (Ativan) is an anxiolytic agent and will not be useful for analgesia. (c) D. Fentanyl citrate (Sublimaze) is an analgesic agent and will be helpful to reduce musculoskeletal pain.

Answer 83

A. The patient appears to have an obstructed tracheostomy tube and is exhibiting respiratory distress with oxygen desaturations. The tube should be replaced immediately.

Answer 84

C. Right-sided atelectasis causes diminished breath sounds on the right and the trachea is pulled in the direction of the atelectasis.

Answer 85

C. A nonrebreathing mask with high-flow oxygen will ensure that each breath contains an FIO2 approximating 1.00, and is most likely to increase this patient's oxygenation.

Answer 86

(c) A. The patient has allergic rhinitis and, at most, mild persistent asthma. A leukotriene inhibitor, such as montelukast (Singulair), are indicated to control mild asthma and allergic rhinitis. (h) B. An IgE immunoglobulin antagonist, such as omalizumab (Xolair), is indicated for severe allergic asthma and carries significant risk. (u) C. Beta-adrenergic agonists are rescue drugs. They should not be used to control asthma and should have no role in the treatment of allergic rhinitis. (u) D. Anticholinergics do not play a role in the treatment of allergic rhinitis.

Answer 87

B. Given the tracheostomy was placed 24 hours ago, the tract has likely not epithelialized. Creation of a false tract and malposition can occur if an attempt is made to blindly reinsert the tracheostomy tube. The correct course of action is to occlude the stoma and ventilate with a bag-valve-mask resuscitator while preparations are made to reintubate by the mouth or nose.

Answer 88

C. A hemoximeter (CO-oximeter) can directly measure various forms of hemoglobin saturation, including oxyhemoglobin, carboxyhemoglobin, and methemoglobin. In a patient with suspected smoke inhalation, elevation in the carboxyhemoglobin level can be expected.

Answer 89

D. Fowler's position elevates the head of the bed to an angle between 45 and 60 degrees. This will relieve the dyspnea and alleviate the patient's distress.

Answer 90

A. The expiratory flow does not return to baseline prior to the start of the next breath. This indicates auto-PEEP is present.

Answer 91

B. The pH is greater than 7.45, which indicates alkalemia. The PCO2 is decreased, which indicates respiratory alkalosis. The HCO3- is normal, so no compensation has occurred. The PO2 is in the 60-80 mm Hg range, which indicates mild hypoxemia.

Answer 92

D. The current tidal volume is less than 6 mL/kg of PBW; increasing it to 7 mL/kg of PBW should correct the respiratory acidosis.

Answer 93

C. An HHFNC will provide a consistent FIO2 along with heat and humidity. This should help treat the patient's hypoxemia.

Answer 94

D. A patient who demonstrates patient-ventilator dyssynchrony associated with air trapping will often benefit from an increase in the set (extrinsic) PEEP level. Increasing the set PEEP to be closer to, but slightly below, the total PEEP level minimizes the effort required to trigger the ventilator.

Answer 95

B. Calculation of the C(a-v̄)O2 is as follows: C(a-v̄)O2 = CaO2 - Cv̄O2 Cv̄O2 = (Hb x 1.34) x Sv̄O2 + (Pv̄O2 x 0.003) Cv̄O2 = (10 x 1.34) x 60% + (30 x 0.003) Cv̄O2 = 13.4 x 0.60 + 0.09 Cv̄O2 = 8.04 + 0.90 Cv̄O2 = 8.13 CaO2 - Cv̄O2 = 12 - 8.13 C(a-v̄)O2 = 3.87

Answer 96

A. The patient became tachycardic, tachypneic, and hypoxic, all indicating intolerance of the SBT. The patient should be returned to the previous ventilation settings.

Answer 97

D. A needle thoracentesis should be performed first to help diagnose the cause of the pleural effusion.

Answer 98

A. Dexmedetomidine (Precedex) will sedate the patient, but will not address the patient's pain or dyspnea postextubation. B. Atropine is an anticholinergic that can be used to decrease secretions, but will not address the patient's pain or dyspnea post extubation. (c) C. Morphine will alleviate pain and dyspnea associated with a terminal extubation. D. Furosemide (Lasix) is not indicated in this situation as it will not address the patient's pain or dyspnea.

Answer 99

A. The graphic shows that the volume isn't returning to baseline and a leak is present.

Answer 100

C. The patient is already on a minimal level of PSV and demonstrates acceptable ABG analysis and pulmonary mechanics results.

Answer 101

C. Crepitus may be associated with a pneumothorax due to the presence of subcutaneous emphysema.

Answer 102

C. The patient should first be placed in high Fowler's position.

Answer 103

B. In an optimally exposed chest radiograph, vertebrae are visible while maintaining visible lung markings.

Answer 104

C. Biologic indicators, or spore tests, indicate whether a highly resistant microorganism has been killed within the package. This is the most accepted method for monitoring effectiveness of heat/stem sterilization.

Answer 105

D. Vital capacity is the maximum volume exhaled after a maximum inhalation.

Answer 106

B. Vocal fremitus is transmission of the spoken voice to the chest wall, detectable by auscultation or palpation. It is increased with lung consolidation.

Answer 107

A. Facial burns with oropharynx edema indicate upper airway burns and the potential for worsening edema and airway obstruction. Intubation is necessary to ensure airway patency.

Answer 108

C. The goal of CPAP intervention is to completely eliminate apnea and hypopnea episodes, standard protocol is to incrementally increase the CPAP level until this occurs.

Answer 109

A. Overnight oximetry may be considered a screening tool for a more detailed polysomnography study.

Answer 110

B. Coached coughing and deep breathing are the best methods for mobilizing secretions in a young healthy adult.

Answer 111

B. Hemoptysis is bleeding from an airway source. Bronchoscopy may help localize the site of the bleeding.

Answer 112

C. Air in the syringe will affect the results.

Answer 113

C. Continuous positive airway pressure provides constant positive airway pressure during the entire respiratory cycle.

Answer 114

B. Providing sedation and analgesia is standard in any protocol for discontinuing mechanical ventilation during end of life care.

Answer 115

B. The increase in PEEP will increase FRC, decrease the intrapulmonary shunt, and address the hypoxemia.

Answer 116

C. Breathing in fast and deep is the proper method of administration for umeclidinium/vilanterol (Anoro Ellipta).

Answer 117

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.

Answer 118

D. A Stow-Severinghaus blood gas electrode is used in transcutaneous monitors.

Answer 119

A. A PICC is the best choice for long-term IV access and allows for blood sampling.

Answer 120

(c) A. Since the PaO2 is adequate, it is now appropriate to decrease the FIO2. (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.

Answer 121

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.

Answer 122

(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.

Answer 123

(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.

Answer 124

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.

Answer 125

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/Q̇ scan, 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.

Answer 126

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.

Answer 127

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.

Answer 128

(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.

Answer 129

(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.

Answer 130

(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 FIO2 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.

Answer 131

(c) A. VC ventilation terminates inspiration after delivering a preset volume.

Answer 132

(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.

Answer 133

B. Relative humidity increases as a gas cools. When the relative humidity is at 100%, the gas is unable to hold more water vapor and it condenses into liquid.

Answer 134

(c) C. PAO2 = FIO2 (PB - PH2O) - PaCO2 R PAO2 = 1.0 (747 - 47) - 38 0.8 PAO2 = 700 - 48 PAO2 = 652 mm Hg P(A-a)O2 = 652 - 152 P(A-a)O2 = 500 mm Hg

Answer 135

(u) A. Increasing the flow to 7 L/min may result in patient discomfort and may not provide a high enough concentration of oxygen. (c) B. The patient's SaO2 of 83% indicates that a nonrebreathing mask is needed to provide a high FIO2. (u) C. The patient's PaCO2 indicates adequate ventilation. There are no indications to initiate mechanical ventilation. Less invasive treatments for the patient's hypoxemia should be attempted first. (u) D. A CPAP level of 3 cm H2O is unlikely to improve the patient's hypoxemia.

Answer 136

(u) A. Secretions is an indication for fiberoptic bronchoscopy in the mechanically ventilated patient. (u) B. Elevated airway pressures are generally required to ventilate around the scope inside the airway. (u) C. Loss of consciousness will not directly impact adequate ventilation if compensatory measures are taken with ventilator settings. (c) D. Placing the scope in the artificial airway may obstruct the tube, especially if the scope is too large for the artificial airway.

Answer 137

(u) A. Sedating the patient will probably improve the patient's synchrony with the ventilator, but will not resolve the problem of the excessive inspiratory time due to low flow. (u) B. Decreasing the tidal volume may result in an inadequate minute ventilation, and the problem will not be resolved. (h) C. Increasing the pressure limit will not address the problem of inadequate flow and may increase the possibility of pulmonary overdistention. (c) D. Increasing the flow will more adequately meet the patient's inspiratory flow demand.

Answer 138

(u) A. Increasing the set inspiratory flow will lead to an even higher resistance in the small artificial airway. (h) B. The tidal volume is currently set at 6 mL/kg of PBW. Raising the tidal volume will not reduce the resistance of the small tube and increases the potential for barotrauma. (u) C. Though there may be some indication for a bronchoscopy with increased peak airway pressure, it would delay replacement of too small of an endotracheal tube based on the patient's size. (c) D. The small size of the endotracheal tube causes an increase in airway resistance causing an increase in the work of breathing. Using a larger diameter endotracheal tube will decrease the airway resistance, which will make the work of breathing easier.

Answer 139

(c) A. Repositioning may have caused displacement of the tracheostomy tube. Placing the patient supine will allow better access and ability to evaluate and correct the problem. (u) B. Tube integrity and position should be assessed before it is removed. (u) C. Instilling normal saline will not help the patient's respiratory distress. (u) D. The patient should be placed supine, and the tube should be evaluated before suction is attempted.

Answer 140

(u) A. Progressive bradycardia may result from an acute hypoxemia clinical event. (c) B. Stimulation of vagal receptors in the tracheobronchial tree may cause a rapid slowing of the heart rate. (u) C. Mucosal trauma will result in bleeding and not a decrease in the heart rate. (u) D. Hypercapnia initially causes an increased respiratory rate.

Answer 141

(c) D. The treatment for carbon monoxide poisoning is a high concentration of oxygen (as close as possible to 100%) administered by nonrebreathing mask.

Answer 142

(u) A. Protein is 7% of surfactant. (u) B. No significant glucose content exists in surfactant. (c) C. Phospholipid is 85% of surfactant. (u) D. No significant independent polysaccharide exists in surfactant.

Answer 143

(u) A. A right-to-left shunt is an anatomic shunt and is not diagnosed with a V̇/Q̇ scan. (c) B. This is the classic description of a pulmonary embolism where the alveolar unit is normally ventilated, but pulmonary capillary blood flow is impeded by the presence of a clot. (u) C. The consolidated alveolar units associated with pneumonia will inhibit ventilation and perfusion will be normal. (u) D. A hemothorax will cause compression of the alveolar units and decrease ventilation.

Answer 144

(u) A. A pulse oximeter will only provide the clinical team with an indication of the patient's oxygenation status, not ventilation status. (u) B. A colorimetric CO2 detector is used to conform tracheal placement of an ETT. It does not monitor ventilation. (c) C. Capnometry can be performed noninvasively through a cannula to monitor the patient's ventilatory status. (u) D. A transcutaneous oxygen monitor will only monitor the patient's oxygenation status, not ventilation status.

Answer 145

(u) A. Levalbuterol (Xopenex) is a SABA. It is not the next step in asthma treatment. (u) B. Umeclidinium/vilanterol (Anoro Ellipta) is a LABA/LAMA. It is not the next step in asthma treatment. (c) C. According to national asthma guidelines, a LABA/ICS, such as fluticasone/salmeterol (Advair Diskus), should be initiated as the next step in this patient's asthma treatment. (u) D. Azithromycin (Zithromax) is an antibiotic, and not a standard of care in asthma treatment.

Answer 146

(h) A. There is neither evidence of increased secretions, nor the patient's inability to cough effectively. Therefore, suctioning this patient is not indicated. (c) B. The treatment should be discontinued because the patient is demonstrating severe respiratory distress of unknown etiology. Determining the cause of the distress is of the utmost importance. (h) C. Decreasing the peak pressure will not identify the cause of the distress. Continuing the treatment, even at a lower pressure, may worsen the patient's condition. (h) D. Temporarily stopping the treatment will not determine the cause of the respiratory distress.

Answer 147

(c) A. Low PCWP and CVP coupled with a low urine output is characteristic of hypovolemia. (u) B. A fluid overloaded patient would be characterized by a high PCWP and CVP. (u) C. The urine output value is markedly low. The expected urinary output for a clinically stable patient is 0.5 mL/kg/hr. (u) D. There is insufficient information to make this conclusion.

Answer 148

(u) A. Nausea and insomnia are common side effects of nicotine replacement therapy regardless of the route of administration. (u) B. While nausea and insomnia are common side effects of nicotine replacement therapy, they may be resolved with a lower dose. (c) C. Switching to a lower-dose nicotine patch should be the first step to address the common side effects of nausea and insomnia. (u) D. An antiemetic will not address the insomnia, and lowering the dose of nicotine should be tried before adding another medication to the regimen.

Answer 149

(u) A. Systolic and diastolic pressures will increase if the bed is raised, not lowered, relative to the transducer. (u) B. Changes in the level of the bed relative to the transducer will make both systolic and diastolic pressures move the same direction. (c) C. A fluid-filled transducer catheter system is zeroed to the patient's position. Lowering the patient relative to the height of the transducer will result in both a lower systolic and diastolic blood pressure reading proportionate to the change in patient position. (u) D. Changes in the level of the bed relative to the transducer will make both systolic and diastolic pressures move the same direction.

Answer 150

(u) A. In some cases, repetitive cleaning and sterilizing may shorten the life of the equipment. (c) B. Cleaning and sterilization are essential to limiting the transmission of organisms related to reusable respiratory care equipment. (a) C. Although cleaning and sterilizing equipment may prevent contamination of other equipment, the primary goal is to limit transmission of infection to patients. (a) D. Although cleaning and sterilizing equipment may protect medical personnel, the primary goal is to limit transmission of infection to patients.

Answer 151

(c) A. Per CDC guidelines, an initial step in managing disasters is to initiate a triage process. (u, e) B. Turning away patients with chronic disease is unethical. (u) C. Having oxygen available for anyone to use could be problematic. (u) D. While this could be helpful, it is not the most immediate response needed in a disaster situation.

Answer 152

(u) A. If an appropriate size catheter is unable to remove the secretions, a smaller catheter would be less likely to help in this situation. (u) B. While a larger endotracheal tube may allow suctioning with a larger bore suction catheter, it is not without risk. Changing the HME to heated humidifier should be tried first. (c) C. A heated humidifier can deliver more humidity than an HME, which may help with thick secretions. (u) D. There is no indication for dornase alfa (Pulmozyme) at this time.

Answer 153

(c) C. Dishwashing soap is recommended for cleaning home CPAP masks and tubing.

Answer 154

(c) 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 expired values for carbon dioxide.

Answer 155

A. Based on the oxyhemoglobin dissociation curve, an SpO2 of 75% is approximately a PaO2 of 47 mm Hg for a patient with a normal pH.

Answer 156

(c) A. A CBC 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.

Answer 157

(a) A. Although the patient's PaO2 is slightly high, the patient's respiratory alkalosis should be addressed first. (c) B. Decreasing the set inspiratory pressure should result in a decreased tidal volume and minute ventilation, resulting in an improvement of the respiratory alkalosis. Additionally, the current exhaled tidal volume is greater than 8 mL/kg of ideal body weight and may be potentially harmful. (a) C. While decreasing the mandatory rate will potentially correct the respiratory alkalosis, the high tidal volume needs to be addressed first. (h) D. Reducing inspiratory time will not improve the respiratory alkalosis and may worsen oxygenation.

Answer 158

(u) A. The patient is using HFCWO. Adding another form of airway clearance will not significantly improve the care. (u) B. N-acetylcysteine has not been shown to be beneficial for altering airway secretions and carries significant risk of bronchoconstriction. (u) C. The patient is using HFCWO. Adding another form of airway clearance will not significantly improve the care. (c) D. Dornase alfa (Pulmozyme) has been shown to decrease viscosity of sputum in persons with cystic fibrosis and to decrease the frequency of exacerbations requiring hospitalization.

Answer 159

C. 500 mL tidal volume divided by 10 cm H2O (plateau pressure - PEEP) equals 50 mL/cm H2O static compliance.

Answer 160

(u) A. Percutaneous tracheostomy should only be attempted after other, less invasive strategies have failed to provide effective ventilation. (h) B. A head-tilt maneuver is contraindicated, due to manipulation of the cervical spine in a patient with a suspected neck injury. (c) C. An oropharyngeal airway can be inserted using a limited amount of neck movement and it moves the tongue off the posterior wall. (u) D. Using a flow-inflating resuscitator will not relieve the tongue obstruction.

Answer 161

(u) A. In the presence of a left tension pneumothorax, the patient will present with the left side of the chest not moving and the trachea will be deviated to the right. (u) B. A left mainstem intubation will result in the right side of the chest not moving, but the trachea will not be shifted toward the left. (u) C. With right-sided atelectasis, there will be limited movement of the right side of the patient's chest, and the trachea may be deviated to the right. (c) D. A right tension pneumothorax will cause a decrease in movement of the right hemithorax and the increased pressure from the pneumothorax will shift the trachea to the left.

Answer 162

(u) A. It is important to attempt clearance of the secretions first. Administering more medication, even diluted, may not help to clear these secretions. (c) B. Secretions have been mobilized and the airway must be cleared before continuing treatment. (u) C. Increasing the dose of medication will not help to clear the secretions further. (u) D. Pausing the treatment and allowing the airway to be cleared is the most appropriate first step. Notifying the physician of these findings should occur afterwards.

Answer 163

(h) A. VC ventilation may exacerbate a pneumothorax. (u) B. Administration of nitric oxide will not be helpful in the management of a pneumothorax. (u) C. An ABG analysis could be performed to assess overall gas exchange, but will not help with the resolution of the pneumothorax. (c) D. The onset of agitation, tachycardia, oxygen desaturation, and left chest tympany are suggestive of a tension pneumothorax. Needle decompression is recommended.

Answer 164

(c) A. Many patients with known CHF suffer from orthopnea. Sitting them upright in the high Fowler position is the best initial intervention to decrease pulmonary venous return and improve respiratory mechanics. (h) B. Placing a patient with CHF in Trendelenburg position may exacerbate shortness of breath. (u) C. Prone positioning is primarily for intubated patients with refractory hypoxemia due to ARDS. (u) D. Left lateral positioning will result in the same complications as supine positioning.

Answer 165

(u) A. Although the placement of a tracheostomy may be required, other possibilities should be exhausted when it appears the patient may be able to wean if anxiety is controlled. (u) B. A new approach is required, not simply transferring the patient to long-term acute care. (h) C. Discontinuing SBTs and initiating an infusion of midazolam HCl (Versed) will make it more difficult to liberate the patient from mechanical ventilation, exposing the patient to further potential harm. (c) D. Dexmedetomidine (Precedex) can provide effective anxiolysis without suppressing the respiratory drive. This may be used to overcome failure of SBTs due to anxiety when the patient is otherwise physiologically ready for extubation.

Answer 166

(u, e) A. A PaCO2 greater than 60 mm Hg or an increase in PaCO2 of 20 mm Hg or greater from baseline with no respiratory movement supports a diagnosis of brain death. (c, e) B. A PaCO2 greater than 60 mm Hg or an increase in PaCO2 of 20 mm Hg or greater from baseline with no respiratory movement supports a diagnosis of brain death. (u, e) C. Criteria for a determination of brain death have been reached. It is unnecessary to extend the test for a longer period of time. (u, e) D. Results are conclusive, and supportive of a diagnosis of brain death.

Answer 167

(h) A. Changes in the respiratory care plan should not be implemented without a provider's order. (u) B. Changes in the care plan may be discussed by all members of the patient care team; however, changes cannot be implemented without a provider's order. (c) C. Despite notation in the provider's progress notes, treatment changes require a provider's order. (u) D. Changes in the care plan may be discussed with supervisory personnel; however, changes cannot be implemented without a provider's order.

Answer 168

(u) A. Male patients experiencing acute myocardial infarction are typically hypertensive. (u) B. Pedal edema is not an indicator of an acute myocardial infarction. (c) C. An elevated ST interval is a classic sign that a male patient is experiencing an acute myocardial infarction. (u) D. Cardiac murmur is not an indicator of an acute myocardial infarction.

Answer 169

(u) 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 decreased breath sounds on the affected side. (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.

Answer 170

(u) A. High-frequency oscillatory ventilation may be considered for patients with refractory hypoxemia, but should not be considered the first-line treatment for this patient. (h) B. Decreasing PEEP may worsen the patient's hypoxemia. (u) C. There is no indication that the ABG analysis is incorrect. Obtaining a new ABG sample may delay care. (c) D. Patients with severe refractory hypoxemia and high plateau pressures will benefit from lung recruitment.

Answer 171

(c) A. An ECG is required to rule out an acute myocardial infarction or arrhythmia before considering other diagnoses. (u) B. A chest radiograph may be an appropriate diagnostic test after an ECG is performed. (u) C. CT scan of the chest may be an appropriate diagnostic test after an ECG is performed. (u) D. Cardiac ultrasound may be an appropriate diagnostic test after an ECG is performed.

Answer 172

(h) A. Given the significant increase in heart rate, the treatment should not be continued. (u) B. There is no need to increase the inspired oxygen concentration as the oxygen saturation is 94%. (u) C. Having the patient take slower breaths will likely not affect the elevated heart rate. (c) D. Given the increase in heart rate, the treatment should be terminated and the results reported to the physician.

Answer 173

(c) A. In the presence of a flail chest, the findings most likely indicate a pneumothorax requiring needle decompression. (u) B. An echocardiogram does not address the issue of decreased breath sounds. (a) C. Though analgesia is important for patient comfort, needle decompression needs to be performed emergently. (a) D. While a chest CT scan may be helpful, due to the patient's significant compromise, needle decompression is first indicated.

Answer 174

(h) A. Placing an LMA requires extubation and replacement with a less secure airway device which would not be recommended. (h) B. Fiberoptic bronchoscopy requires complete removal of the existing endotracheal tube and then reintubation, which can result in airway loss. (u) C. Magill forceps are typically used for nasal intubation or removal of foreign bodies from the oropharynx and would not be appropriate in this situation. (c) D. An airway exchange catheter allows the therapist to maintain a tract while exchanging the endotracheal tube. This decreases the risk of malposition of the new endotracheal tube, especially if the intubation is difficult or if there is upper airway swelling. In addition, many exchange catheters allow oxygenation by jet ventilation or manual bag-mask ventilation if there is difficulty replacing the tube in order to temporize until a more definitive solution can be achieved.

Answer 175

(c) A. This is a commonly performed method for oxygen titration. (u) B. The patient needs an increase in oxygen. (u) C. Switching to a simple mask will not be helpful. Also, a simple mask requires a minimum oxygen flow of 5 L/min. (u) D. There is no reason to stop the test prematurely.

Answer 176

(c) A. This patient has a respiratory alkalosis. Decreasing the tidal volume will reduce the overall minute ventilation and help reduce the pH. (u) B. There is no need to change from VC to PC ventilation in this patient. A simple change of the tidal volume is the first step to normalize the pH. (u) C. Increasing peak flow will have no effect on the arterial blood gas analysis results. (h) D. The patient has a normal serum bicarbonate level and thus the addition of supplemental bicarbonate is not necessary and will only result in a further increase in the blood pH.

Answer 177

(u) A. Fistulas are abnormal connections between tissues or organs and are rarely caused by arterial punctures. (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.

Answer 178

(c) A. The pH is less than 7.35, which indicates acidemia. The PCO2 is elevated, which indicates respiratory acidosis. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia. (u) B. The pH is less than 7.35, which indicates acidemia. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia. (u) C. The HCO3- is within the normal range, so a metabolic acidosis is not present. The PO2 is in the 40 to 59 mm Hg range, which indicates moderate hypoxemia. (u) D. The pH is less than 7.35, which indicates acidemia.

Answer 179

(u) A. Peripheral perfusion will not be expected to change with the addition of PEEP. (u) B. Tachycardia, not bradycardia, may be an expected adverse effect of increased PEEP. (u) C. Increased FRC is a desired effect of PEEP. (c) D. Hypotension can occur with increasing PEEP as the increase in intrathoracic pressure results in decreased venous return and, in turn, decreased preload.

Answer 180

(c) A. The blood gas values are acceptable for initiating a spontaneous breathing trial. (u) B. The generally accepted standard of care is to perform a spontaneous breathing trial prior to considering extubation. (u) C. Decreasing the mandatory rate will unnecessarily prolong the course of mechanical ventilation. (u) D. Decreasing to less than 5 cm H2O PEEP is not indicated.

Answer 181

(c) A. The evidence suggests a pneumothorax. A chest radiograph is a quick test to identify the presence of pneumothorax. (u) B. The evidence suggests a pneumothorax; a fiberoptic bronchoscopy is not indicated. (u) C. A CT scan of the chest with contrast would be useful to identify pulmonary embolism. The data suggest pneumothorax as the cause of the changes. (u) D. A ventilation/perfusion scan cannot be easily completed on a patient who is receiving mechanical ventilation.

Answer 182

(u) A. Oxygen desaturation may transpire if the patient's ventilator drive and minute ventilation are reduced. The change from VC to PC ventilation increased the patient's minute ventilation. (u) B. Ventilator dyssynchrony can occur if the trigger sensitivity, inspiratory time, or flow make it more difficult for the patient to trigger a mechanical breath, or make it so easy that it will contribute to auto-triggering. This clinical scenario does not provide information that should lead the respiratory therapist to conclude dyssynchrony will occur. (u) C. The risk for atelectasis can occur with hypoventilation. The change from VC to PC ventilation may contribute to hyperventilation, not hypoventilation. (c) D. The increased VT will increase the patient's minute ventilation and may decrease the PaCO2. Respiratory alkalosis may result.

Answer 183

(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 tolerance, easily measured by increased walking distance. (u) C. Pulmonary function results do not normally improve with pulmonary rehabilitation. (a) D. See explanation C.

Answer 184

(c) A. With increasing oxygen requirements and the recent administration of surfactant, a chest radiograph will aid in determining the cause of deterioration. (u) B. Two hours is too early for a second dose of surfactant. (u) C. High-frequency ventilation should not be initiated before obtaining a chest radiograph. (u) D. Inhaled nitric oxide is indicated for persistent pulmonary hypertension. There is inadequate information to make this diagnosis.

Answer 185

(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 volume ventilation between ventilatory support.

Answer 186

(u,e) A. Initiating invasive mechanical ventilation is unethical as the patient has a DNI directive. (u) B. Continuously nebulized albuterol will not provide adequate support for the patient while waiting until her family arrives. (c, e) C. Noninvasive positive pressure ventilation is preferred as an initial mode for treating an acute respiratory failure in patients with acute exacerbations of COPD. As the patient has indicated she does not want to be intubated, this would provide the necessary ventilation while also respecting her wishes. (u) D. Nutritional supplementation may improve respiratory muscle strength in malnourished patients. As the patient is near the end of life, this is not indicated.

Answer 187

(u) A. An HME should be discouraged for NPPV use as it may hamper triggering and increase deadspace. (u) B. An HME should be considered for short-term mechanical ventilation. A patient with ARDS will require long-term mechanical ventilation and humidification. (c) C. An HME should be considered for short-term mechanical ventilation like that used for a patient in PACU. (h) D. An HME is contraindicated in a bronchopleural fistula. The air leak will not allow the HME to collect adequate moisture from the decreased volume exhaled to humidify the inhaled gas.

Answer 188

(c) A. An adequate oxygen supply is necessary to complete the trip. (u) B. The endotracheal cuff should be inflated rather than deflated. (u) C. There is no clinical indication to increase the FIO2. Increasing the FIO2 will affect the O2 supply available for the transport. (u) D. Heated humidification is not necessary in this situation and adds cumbersome equipment to the transport.

Answer 189

(u) A. Condensation in the circuit is likely causing auto-triggering. Decreasing the mandatory rate will not correct the auto-triggering. (u) B. Individuals with congenital central hypoventilation syndrome do not initiate ventilation during sleep and would most likely be unable to trigger the ventilator. (c) C. The patient is dyssynchronous with the ventilator likely due to condensation in the circuit causing auto-triggering. No ventilator setting changes are indicated without having more details. (u) D. Some children with a tracheostomy have cuffed tubes to help compensate for a leak, but information related to this is not known given the information provided.

Answer 190

(u) A. The patient's blood gas values are acceptable. Switching to PC ventilation is not indicated. (u) B. The patient's blood gas values do not indicate the need to increase the spontaneous tidal volume. (h) C. There is insufficient evidence to indicate the patient is ready for extubation. (c) D. With the information provided, this patient qualifies for a spontaneous breathing trial.

Answer 191

(u) A. Nothing in this scenario indicates the titration should be prematurely terminated. (u) B. There is no need for continued observation before modifying the patient's CPAP settings. (u) C. The patient's AHI of 15 will not be corrected by adding 2 L/min of supplemental oxygen. (c) D. Airway patency needs to be re-established by increasing the CPAP level.

Answer 192

(u) A. A nasogastric tube is not necessary for cardioversion. (c) B. A bag-valve-mask resuscitator is required for patient safety as the patient will be sedated and may have a post-event that requires resuscitation. (a) C. The end-tidal CO2 monitor may be helpful to monitor sedation, but is not an integral part of the procedure. (u) D. Blood gas sampling is not a standard of care with cardioversion.

Answer 193

(c) A. Air contains essentially no helium; therefore, it should read zero. (u) B. There is 79% nitrogen in air. (u) C. This implies there is 100% helium in air. (u) D. There is 21% oxygen in air.

Answer 194

(u) A. The patient has chronic respiratory acidosis with an acute process causing further CO2 retention. Noninvasive ventilation is a reasonable first step before a more aggressive step of invasive ventilation. (u) B. Measuring vital capacity will not address the patient's ventilation problem and may result in a delay of care. (u) C. Performing airway clearance will not improve minute ventilation or provide ventilator assistance. (c) D. Blood gas analysis results indicate a need to provide ventilatory assistance. NPPV will address the ventilation problem.

Answer 195

(u) A. A CBG sample only provides an accurate evaluation of ventilation status, not of oxygenation status. (c) B. Pulse oximetry will provide the most rapid assessment of oxygenation status. (a) C. ABG analysis will provide accurate assessment of oxygenation status, but will not provide the most rapid turnaround time for results. (u) D. Transcutaneous monitoring will not provide rapid assessment of oxygenation status due to required calibration and equilibration.

Answer 196

(c) A. A patient with obstructive sleep apnea typically has an irregular breathing pattern. (u) B. Evaluation of peripheral perfusion would not be helpful in this patient's assessment. (u) C. Evaluation of breath sounds would not be helpful to assess for sleep-disordered breathing. (u) D. While the cardiac rate will likely vary with obstructive sleep apnea, it is not diagnostic.

Answer 197

(c) A. The APGAR scoring system consists of the following: Score 0 1 2 Appearance pale or blue acrocyanosis completely pink Heart rate absent < 100 per minute > 100 per minute Reflex irritability no response grimace cry, cough, sneeze Muscle tone limp some flexion active motion Respiration absent slow, irregular good cry The score for 1 minute is 6: central cyanosis = 0, pulse of 105 = 2, sneeze = 2, some flexion = 1, irregular respiratory rate = 1. The score for 1 minute is 3: central cyanosis = 0, pulse of 80 = 1, grimace = 1, limp = 0, slow respiratory rate = 1.

Answer 198

(c) A. Albuterol is a fast-acting beta2-agonist and is the appropriate treatment for acute bronchospasm. (u) B. Ipratropium (Atrovent) is useful only as an adjunct to albuterol and only in the early phases of treatment. (u) C. Salmeterol (Serevent) is a long-acting beta2-agonist that has a long onset of action and will not be useful for an acute exacerbation. (u) D. Tiotropium (Spiriva) is a long-acting bronchodilator and is not useful for an acute asthma exacerbation.

Answer 199

(u) A. The patient's SpO2 is adequate at rest, so he does not require O2 when not exercising or exerting himself. (u) B. The patient needs more than 1 L/min because 86% is not a sufficient SpO2. (u) C. The patient's SpO2 is adequate at rest. He does not require O2 when not exercising or exerting himself. (c) D. The patient's SpO2 is adequate with 2 L/min during exercise, and is adequate at rest without O2 supplementation.

Answer 200

(u) A. The device should be calibrated at the site of use before proceeding to quality control assessment. (u) B. Changes in barometric pressure can introduce measurement errors. (u) C. Electrodes do not need to be replaced prior to use of a new analyzer. (c) D. Regardless of where they are manufactured, new blood gas analyzers must be calibrated at the site of use before analyzing blood.

Answer 201

(u) A. The right radial artery should not be punctured when there is insufficient collateral circulation through the ulnar artery. (u) B. Procedures should be avoided on a shunted extremity when alternative sites are available to protect the patency of the shunt for dialysis. (c) C. The right brachial artery is the appropriate alternative site from which to obtain an arterial blood gas sample.

Answer 202

(c) A. FIO2 is impacted by both the flow into the bag and the presence of a reservoir. With oxygen flow set at 15 L/min 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 concentration. (u) C. Bag size does not have a primary impact on oxygen concentration. A PEEP valve is a threshold resistor and has no effect on oxygen concentration. (u) D. Bag size does not have a primary impact on oxygen concentration.

Answer 203

(u) A. Breath-holding will not decrease the trapped air causing the auto-PEEP. (h) B. Adding mechanical deadspace will not affect the time available for exhalation and may increase the arterial carbon dioxide. (c) C. Decreasing the mandatory rate will increase expiratory time. Allowing more time to exhale will reduce air trapped in the lungs at the end of exhalation, or the auto-PEEP. (h) D. Decreasing the inspiratory flow will decrease expiratory time, allowing less time for air to escape. This will not reduce auto-PEEP and has the potential to worsen air-trapping.

Answer 204

(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. There is no reason to titrate the FIO2 in this instance as the oxygen saturation is adequate at this level of support. (h) D. The patient is alert and ready for extubation. Maintaining mechanical ventilation exposes the patient to nosocomial infections and delays discharge.

Answer 205

(u) A. 5 cm H2O PEEP will not result in either the best SpO2 or static compliance. (u) B. 10 cm H2O PEEP may lead to a marginally acceptable SpO2, but not the best compliance. (c) C. This change will lead to the highest compliance with acceptable systemic blood pressure and SpO2. In the absence of cardiac output measurements; compliance, blood pressure, and SpO2 are the only useful data for determining optimal PEEP. (u) D. The application of 20 cm H2O PEEP will decrease the static compliance and blood pressure, suggesting the lung is overexpanded.

Answer 206

(c) A. Due to the allergic component to this patient’s disease, NAEPP guidelines recommend the addition of a leukotriene receptor antagonist, such as montelukast (Singular), as part of the step-up approach to therapy in an uncontrolled patient, especially those with an allergic component. (u) B. A short-acting anticholinergic is not part of the NAEPP guidelines for stepwise therapy, and is unlikely to improve the patient's long-term control of her asthma symptoms. (u) C. Antibiotic therapy is not a standard of care for the treatment of asthma. (u) D. If the patient's symptoms do not improve, a systemic corticosteroid may be needed to gain control of the patient's asthma symptoms. However, a leukotriene modifier should be used first due to the patient's history of moderate, persistent asthma with an allergic component.

Answer 207

(c) A. Cisatracurium (Nimbex) is a nondepolarizing skeletal muscle relaxant that may be administered to patients prior to endotracheal intubation or during mechanical ventilation. (h) B. Morphine is an opioid that acts upon receptors in the brain and spinal cord to reduce the feeling of and emotional response to pain. (a) C. Midazolam HCl (Versed) is a benzodiazepine that can be used as an anxiolytic and amnestic. It does not have any significant neuromuscular-blocking effects. (u) D. Succinylcholine chloride (Anectine) is a depolarizing skeletal muscle relaxant whose onset of paralysis is very rapid (less than 1 minute after IV administration) and effects are very short (approximately 4 to 6 minutes). It is not an effective agent for skeletal muscle paralysis because it will not sustain paralysis.

Answer 208

(u) A. Hypertonic saline is used for mucus clearance. It will not treat the lung infection. (c) B. Tobramycin (TOBI) is an inhaled antibiotic, and is the standard of care to treat lung infections in patient with cystic fibrosis. (u) C. Budesonide is an inhaled steroid used to decrease inflammation. It will not treat the lung infection. (u) D. N-acetylcysteine is a mucolytic and is not indicated for patients with cystic fibrosis.

Answer 209

(u) A. Increased oxygen requirements and an elevated PaCO2 indicate a need to change therapy. (c) B. The patient's condition continues to deteriorate, based on increased oxygen requirements and an elevated PaCO2, indicating the need for assisted ventilation. (u) C. The patient continues to be hypoxemic despite increased supplemental oxygen. Decreasing the FIO2 does not address the ventilatory failure. (u) D. There is no indication for vibratory PEP.

Answer 210

(h) A. Sedating the patient will depress respirations and worsen the degree of hypoxemia. (h) B. The patient is able to maintain adequate ventilation; therefore, intubation is not indicated. (c) C. In the presence of CHF and subsequent pulmonary edema, mask CPAP can be used to recruit collapsed alveoli, increase lung volumes by increasing transpulmonary pressure, and correct hypoxemia. (h) D. Administering an FIO2 of 1.0 may transiently improve oxygenation; however, it places the patient at risk for oxygen toxicity and absorption atelectasis.

Answer 211

(u) A. Although a larger endotracheal tube may be indicated when high cuff pressures are needed to obtain minimum occlusion volume, the recurrent aspiration and abdominal distention indicate a possible connection between the trachea and the esophagus. (h) B. Cuff pressures of 30-34 cm H2O are above the recommended range, and use of a higher cuff pressure may cause tissue necrosis. (c) C. Long-term use of high cuff pressures can increase the risk of developing a tracheoesophageal fistula. The recurrent aspiration and abdominal distention indicate a possible connection between the trachea and the esophagus. (u) D. There are no indications of upper or lower airway inflammation, so a glucocorticosteroid should be not administered.

Answer 212

(h) A. A nonrebreathing mask is not indicated and may produce hyperoxygenation resulting in respiratory depression in a patient with chronic hypercarbia and hypoxemia. (u) B. There is no indication for NPPV for a patient in a compensated acid-base state. (h) C. Excessive oxygen may suppress the patient's respiratory drive. (c) D. A nasal cannula provides a variable oxygen concentration.

Answer 213

(u) A. Mallampati score I is characterized by complete visualization of the soft palate, uvula (including the tip), fauces, and tonsillar pillars. (u) B. Mallampati score II is characterized by visualization of the soft palate, fauces, and most of the uvula (but notably with the tip obscured). (c) C. Mallampati score III is characterized by the visualization of the soft palate, including the base of the uvula only. (u) D. Mallampati score IV is characterized by the visualization of the hard palate only. None of the soft palate is visible.

Answer 214

(u) A. Although the patient's PaO2 is high and decreasing the FIO2 is warranted, the swelling of the patient's lips and burns on the face and neck increases the risk of a compromised airway. Emergency intubation is indicated. (u) B. Although aerosolized racemic epinephrine may reduce the patient's upper airway swelling, emergency intubation is indicated due to the patient's swollen lips and burns on the face and neck. (c) C. The burns on the patient's face and the swelling of her lips indicate the need for emergency intubation to protect the patient's airway. (u) D. Emergency intubation is indicated due to the patient's swollen lips and burns on the face and neck.

Answer 215

(u) A. Clubbing does not involve the joints. (c) B. Clubbing causes an increased angle between the nail bed and the finger, as well as an increase in the diameter of the terminal portion of the finger. (u) C. Discoloration does not occur with clubbing of the digits. (u) D. The symmetry of the fingers is not an accurate assessment of digital clubbing.

Answer 216

(c) A. The therapist should suspect the regulator setting has been switched to continuous mode rather than pulse dose. (u) B. These units do not have an oxygen sensor to calibrate. (u) C. Replacing the nasal cannula may be considered after confirming the regulator setting is set to pulse dose. (u) D. Increasing the flow does not affect the pulse mode selected.

Answer 217

(u) A. End-tidal CO2 tensions will not rise until the ventilatory impairment is severe. (u) B. While PaCO2 provides data regarding ventilation, vital capacity measurements are less invasive and can provide trending information earlier in the progression of the disease. (c) C. Guillain-Barré syndrome is a neurological disease that causes weakness of respiratory muscles and ascending paralysis. Serial measurements of vital capacity will reveal progressive neuromuscular ventilatory impairment. (u) D. Peak flow is used to monitor airways obstruction in patients with asthma, not neurological diseases, like Guillain-Barré syndrome.

Answer 218

(c) A. Peak flow is the maximum flow during a forced exhalation. (u) B. Vital capacity is the volume measured from maximal inhalation to maximal exhalation. (u) C. FEV1 is the volume exhaled in the first second of a forced vital capacity maneuver. (u) D. V̇E is the volume exhaled from a person's lungs per minute.

Answer 219

(c) B. AASM guidelines classify obstructive sleep apnea by an AHI of 5 or greater.

Answer 220

(u) A. Allergic rhinitis is often associated with nasal symptoms of runny nose and congestion, not fever and sputum production. (u) B. A viral respiratory tract infection is often associated with a nonproductive cough. (u) C. Congestive heart failure is often associated with shortness of breath and nonproductive cough. (c) D. These signs and symptoms are often associated with bacterial pneumonia.

Answer 221

(u) A. There is no indication for nasal CPAP in a well-oxygenated patient. (c) B. The FIO2 should be decreased to minimize the risk of retinopathy of prematurity. (u) C. There is no evidence of neonatal RDS; therefore, surfactant is not indicated.

Answer 222

(u) A. The patient is showing signs of excess fluid, which cannot be treated by changing the patient's IV fluid to D5W. (h) B. The patient is showing signs of fluid overload. Administering an additional bolus of normal saline may increase the risk of respiratory distress and cause harm to the patient. (h) C. Administering albumin will increase the volume of blood, which could be harmful to a patient showing signs of fluid overload. (c) D. The faint crackles heard in the lung bases and the increase in CVP show that the patient is fluid overloaded. Minimizing the administration of IV fluids will prevent the patient's condition from worsening.

Answer 223

(u) A. Although ABG analysis can evaluate arterial oxygen content, analysis of a mixed venous sample is the best evaluation of tissue oxygenation. (c) B. Analysis of a mixed venous sample from the pulmonary artery catheter is the best method to evaluate tissue oxygenation. (u) C. Serum lactate level is a measure of anaerobic metabolism and does not evaluate tissue oxygenation. (u) D. Cardiac output is used to assess oxygen delivery, but does not provide information regarding the oxygen content of the blood to evaluate tissue oxygenation.

Answer 224

(a) A. Alveolar ventilation can increase without significantly involving accessory muscles. (u) B. The use of accessory muscles is often associated with decreased lung compliance. (c) C. Increased airways resistance requires the use of accessory muscles to move air. (u) D. Increased cardiac output is not associated with the use of accessory muscles.

Answer 225

(u) A. The flow to the mask is too low and should be increased to 15 L/min. Removing the one-way valve will not increase the amount of flow to the mask. (u) B. A simple mask will provide a lower concentration of oxygen. The nonrebreathing mask should continue to be used, but the flow should be increased to 15 L/min. (u) C. The use of a bubble humidifier is not appropriate with a nonrebreathing mask. (c) D. A flow of 10-15 L/min should be used with a nonrebreathing mask. A flow of less than 10 L/min may cause the reservoir bag to deflate during inspiration, reduce the concentration of oxygen delivered to the patient, and may worsen the patient's work of breathing due to inadequate flow to the mask.

Answer 226

(u) A. The third intercostal space in the mid-clavicular is more appropriate for a pneumothorax. (c) B. 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. (u) C. The second intercostal space in the mid-clavicular line is more appropriate for a pneumothorax. (u) D. The fourth intercostal space in the mid-axillary line is too high to drain a hemothorax.

Answer 227

(u) A. A liquid oxygen system is expensive and requires regular refills. (u) B. E cylinders require regular replacement and supply can be depleted. (c) C. An oxygen concentrator is the most cost-effective option as it does not require refills or replacements. (u) D. Delivering transtracheal oxygen has no impact on the economics of the delivery system.

Answer 228

(c) A. The correct negative pressure to use when suctioning the airway of a infant is -80 to -100 mm Hg. (h) B. A negative pressure of -120 mm Hg is likely to damage airway mucosa. (h) C. A negative pressure of -150 mm Hg is likely to damage airway mucosa. (u) D. It is the therapist's responsibility to know the recommended safe suction pressures for the various patient populations.

Answer 229

(u) A. The resulting minute ventilation of 2.4 L/min is inadequate for this patient. (c) B. Using the predicted or PBW formula for women (45.5 kg + 2.3 kg for each inch over 5 ft), the patient's PBW is 50 kg (110 lb). Tidal volume is 8 mL/kg of PBW, which is appropriate. (a) C. This tidal volume is 12 mL/kg of PBW, which is too large. (u) D. This tidal volume is 10 mL/kg of PBW, which is too large.

Answer 230

(u) A. No causal relationship between the use of aerosolized pentamidine isethionate (NebuPent) and tachycardia has been established. (u) B. No causal relationship between the use of aerosolized pentamidine isethionate (NebuPent) and bradycardia has been established. (c) C. Bronchospasm is the most frequently reported adverse effect associated with the use of aerosolized pentamidine isethionate (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.

Answer 231

(u) A. Dornase alfa (Pulmozyme) is not available in DPI form. (u) B. Dornase alfa (Pulmozyme) is not available in MDI form. (u) C. An ultrasonic nebulizer may alter the configuration of the medication. (c) D. A vibrating mesh nebulizer will not alter the configuration of the medication and will not increase volume delivery to patient.

Answer 232

(c) D. Minute ventilation = VT x RR = 450 mL/breath x 12 breath/min = 5400 mL/min = 5.40 L/min.

Answer 233

(u) A. The conversion factor for a 60/40 heliox mixture is 1.4. (u) B. The conversion factor for a 70/30 heliox mixture is 1.6. (c) C. The conversion factor for an 80/20 heliox mixture is 1.8. (u) D. This conversion factor does not exist for a heliox mixture.

Answer 234

(c) A. Evaluation of MIP is to determine the strength of the muscles used for inspiration. (u) B. Evaluating a patient's MIP does not provide information about a patient's oxygenation status. Evaluation of maximum inspiratory pressure is to determine the strength of the muscles used for inspiration. (u) C. Although a poor MIP measurement may be a result of poor ventilation, evaluation of MIP does not provide information about a patient's ventilation status. (u) D. An abnormally low MIP measurement may result in an abnormal V̇/Q̇ ratio by altering a patient's ability to ventilate. However, evaluation of MIP does not determine a patient's V̇/Q̇ ratio.

Answer 235

(u) A. The set inspiratory time will not directly impact the work of breathing, and lengthening it may make the patient less comfortable. (u) B. Ramp time is designed to slowly increase CPAP as the patient falls asleep for increased comfort. (a) C. Increasing PEEP may help with work of breathing, but it more directly impacts oxygenation. (c) D. Increasing pressure support directly impacts the patient's work of breathing.

Answer 236

(u) A. A chest radiograph provides only anatomic abnormality information, not evaluation of functional status. (u) B. Furosemide (Lasix) is a diuretic and administration will not treat the increased airways resistance or bronchospasm. (h) C. Information from an ABG analysis will not assist in the treatment of the increased airways resistance or bronchospasm. (c) D. Ipratropium (Atrovent) treats bronchoconstriction by a mechanism different from albuterol and should decrease airways resistance or bronchospasm.

Answer 237

(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.

Answer 238

(a) A. NPPV is effective in improving ventilation, but it is unlikely that it will be sufficient to meet oxygenation and ventilation requirements of a patient with severe ARDS. (h) B. Drug overdose patients are prone to aspiration. NPPV can lead to gastric insufflation, thus increasing the risk of aspiration. These patients require intubation for airway protection. (h) C. NPPV can lead to gastric insufflation, thus increasing the risk of further aspiration. (c) D. NPPV may lead to reduced mortality in patients with COPD.

Answer 239

(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.

Answer 240

(u) A. The most likely explanation is a right mainstem intubation that can be resolved by withdrawing the endotracheal tube until bilateral breath sounds are heard. (u) B. While a chest radiograph can assist with diagnosing a right mainstem intubation, ventilating only one lung while waiting for a radiograph may compromise the patient's oxygenation. A chest radiograph should be obtained to confirm placement or to diagnose alternative etiologies of unilaterally decreased breath sounds if withdrawing the endotracheal tube fails to resolve the issue. (c) C. This patient most likely has a right mainstem intubation due to advancing the endotracheal tube too deep during intubation. This is easily resolved by withdrawing the endotracheal tube until bilateral equal breath sounds are heard. Diagnosing and resolving this issue early is imperative as a delay in recognizing right mainstem intubation can result in compromised oxygenation from ventilating only one lung. (u) D. While a left pneumothorax is possible, given the timing immediately after intubation makes malposition of the endotracheal tube in the right mainstem more likely.

Answer 241

(u) A. MIP is a measurement that reflects inspiratory muscle strength. (c) B. Spirometry provides detail of a patient's lung condition as well as the patient's ability to cough. (u) C. While a CBC may be obtained prior to surgery, it does not reflect the patient's ability to avoid respiratory complications. (u) D. An ABG analysis may indicate a potential pre-existing lung condition; however, it will not reflect the patient's ability to deep breathe and cough postoperatively.

Answer 242

(u) A. There is insufficient data to indicate increased air trapping. (c) B. An increase in the difference between peak airway pressure and plateau pressure is indicative of increased airways resistance. (u) C. A decrease in inspiratory flow will result in decreased peak airway pressure. (u) D. Based on an unchanging VT and a constant plateau pressure, static compliance has not changed.

Answer 243

(u) A. An N95 mask is required when following CDC airborne precautions. (c) B. According to CDC droplet isolation precautions, a surgical mask is required if the distance between the patient and others is 3 feet or less. (u) C. An air-purifying respirator is required when following CDC airborne precautions. (u) D. A full-face respirator is not needed for droplet precautions.

Answer 244

(h) A. Since the patient continues with refractory hypoxemia, a decrease in the FIO2 setting would be detrimental. (u) B. Given the patient's normal PCO2, increasing the mandatory rate to 20 will not improve the patient's oxygenation. (u) C. There is no indication that changing the mode to SIMV will be beneficial. (c) D. Prone positioning has been shown to improve oxygenation and mortality in patients with severe ARDS by improving V̇/Q̇ mismatch.

Answer 245

A. In the presence of normal vital signs, the SpO2 value may be inaccurate. Therapy should not be initiated before confirming this value. B. The SpO2 value may not be accurate. Recording the value in the medical record may result in unnecessary interventions. (h) C. Obtaining an arterial blood gas sample based on an inaccurate SpO2 value may cause unnecessary harm to the patient. (c) D. The saturation may not be accurate, and should be measured at a different site.

Answer 246

(c) A. A 3-liter syringe provides accurate volumes for calibration and is the gold standard for assessing the volume accuracy of a spirometer. B. A pneumotachometer measures flow and does not directly measure volume. C. A vortex sensor spirometer measures flow integrated with time and is not sufficiently accurate for calibration. D. A Wright respirometer is not sufficiently accurate to be used as a volume standard

Answer 247

A. Thoracentesis is useful to diagnose the origin of a pleural effusion; however, that is not what is indicated in this situation. (c) B. Microbiologic analysis of material obtained during a bronchoscopy with BAL will differentiate between hydrostatic pulmonary edema associated with fluid overload or left ventricular failure, and non-hydrostatic pulmonary edema associated with ARDS. C. Transthoracic needle biopsy is useful in obtaining lung tissue in the diagnosis of lung cancer; however, that is not what is indicated in this situation. D. Transbronchial needle aspiration is useful in the diagnosis of lesions on the periphery of the lung; however, that is not what is indicated in this situation.

Answer 248

(u) A. Radiographic aspects of a pneumothorax are not evident, including the absence of visible lung markings. (u) B. A chest tube is not present on this radiograph. (u) C. A chest tube is not present on this radiograph. Radiographic aspects of a pneumothorax are not evident, including the absence of visible lung markings. (c) D. The entire tracheostomy tube is visible at the clavicles ending in the trachea. Pleural effusion is present in the lower zone of the radiograph noted by obscuring of the heart border, costophrenic angle, and hemidiaphragm.

Answer 249

(c) A. An increase and slant in CO2 are characteristic of emphysema due to prolonged expiration and air trapping. B. Morbid obesity will not have an impact on a capnograph. C. Pulmonary embolism will cause an increase in alveolar dead space resulting in a decrease in the expired CO2 level. D. Mainstem intubation will not have the slant shape to the capnograph.

Answer 250

A. An expiratory flow would not return to zero flow baseline, but vary breath to breath. (c) B. The sawtooth pattern of the flow-volume waveform indicates secretions in the airway. C. In the presence of a system leak, the flow would not return to zero on most if not all breaths. D. An inadequate inspiratory flow rate would be indicated by a scalloping pattern of the flow-volume waveform.

Answer 251

A. A patient in cardiac arrest will have an absent PETCO2. B. Normal exhalation will produce a rectangular waveform that has an abrupt rise in CO2 during phase II followed by a plateau. C. An air leak around the tracheal tube or tracheostomy will result in a waveform with a peaked, triangular appearance. (c) D. Obstructive lung disease shows impaired expiratory air flow with a more rounded ascending phase that never reaches the plateau.

Answer 252

(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 (auto-PEEP).

Answer 253

A. Adjusting the PEEP is not indicated and does not address the dyssynchrony. 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. 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.

Answer 254

(c) A. Though there is evidence of auto-PEEP in the flow-time graphic, the patient's normal pH and stable hemodynamics indicate no intervention is currently needed. B. There is no indication of a need to decrease the FIO2. C. There is no indication to change to VC ventilation. (h) D. An increase in mandatory rate will cause a decrease in expiratory time and will result in increased auto-PEEP.

Answer 255

A. Given the improvement in the flow-volume loop after bronchodilator administration, there is no indication for bronchoscopy. B. NPPV is not useful for reversible airways disease. (c) C. The flow-volume loop obtained after bronchodilator administration demonstrates a significant improvement in expiratory flow. D. This flow-volume loop indicates reversible airway obstruction, and there is no information regarding the presence of hypoxemia to justify the use of supplemental oxygen therapy.

Answer 256

A. The curve is not indicative of a malfunctioning exhalation valve. B. The tracing does not provide data indicating the need for a change in the mode of ventilation. (c) C. The lack of a plateau and upward sloping shape of the curves demonstrate impairment of exhalation due to an obstructive process or airways collapse. D. Calculating the gradient between PaCO2 and PETCO2 will not explain the abnormal shape of the curve.

Answer 257

(c) A. The expiratory flow does not return to baseline prior to the start of the next breath. This indicates auto-PEEP is present. B. A small leak would likely not show up in this graphic. C. If the exhalation valve were faulty (i.e., stuck open), there would be no exhalation flow because the inspiratory flow would travel directly through the circuit. D. An expiratory hold would result in a period of no flow, and the duration of expiration would be extended until the end of the hold. This is not present in the graphic.

Answer 258

(c) A. The graphic shows that the volume isn't returning to baseline and a leak is present. B. The graphic does not show an airway obstruction. C. If the tidal volume is too high, the graphic will show overdistension, i.e. "birds' beak." D. The graphic does not represent secretions in the airway.

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