Respiratory failure

Question 1

Respiratory Failure / Will Kill)
A 68-year-old with COPD exacerbation is found to have a PaO₂ of 50 mm Hg and PaCO₂ of 72 mm Hg. What is the most crucial immediate intervention?
A. Noninvasive or invasive ventilation support
B. IV furosemide
C. Routine laboratory tests
D. High-flow intravenous fluids

Answer 1

Correct Answer: A. Noninvasive or invasive ventilation support
Rationale:
In a patient with both significant hypoxemia (low PaO₂) and hypercapnia (elevated PaCO₂), the immediate concern is respiratory failure. Providing ventilation support—whether noninvasive (e.g., BiPAP) or invasive (endotracheal intubation)—is crucial to improve oxygenation and eliminate excess carbon dioxide. Other options, such as IV furosemide, routine laboratory tests, or high-flow IV fluids, do not address the critical ventilatory failure present in this scenario.

Question 2

Respiratory Failure / Will Harm)
Which iatrogenic error is most likely to harm a patient in acute respiratory failure?
A. Delaying oxygen therapy until ABG results are back
B. Giving low-flow supplemental oxygen
C. Using short-course steroids
D. Ambulation with close monitoring

Answer 2

Correct Answer: A. Delaying oxygen therapy until ABG results are back
Rationale:
Delaying oxygen therapy in a patient with acute respiratory failure can worsen hypoxemia and lead to further deterioration. Immediate oxygen supplementation is essential, even before ABG results are obtained. The other options, such as low-flow supplemental oxygen, short-course steroids, or ambulation with close monitoring, are generally safe or beneficial when appropriately used.

Question 3

7. (Respiratory Failure / Really Common)
   In acute hypoxemic respiratory failure, which monitoring parameter is most commonly used to guide management decisions?
   A. 12-lead EKG
   B. Arterial blood gas (ABG)
   C. Liver function tests
   D. Echocardiography

Answer 3

Correct Answer: B. Arterial blood gas (ABG)
Rationale:
ABG analysis is critical in the management of acute hypoxemic respiratory failure as it provides direct measurements of oxygenation, ventilation (PaCO₂), and acid-base status. This information is essential for guiding therapeutic interventions, such as the need for ventilation support. Other tests like a 12-lead EKG, liver function tests, or echocardiography do not offer the immediate respiratory parameters needed for this clinical decision-making.

Question 4

6. Which of the following best defines respiratory failure?
   A. A condition where oxygen saturation is 95%
   B. Inability to maintain normal gas exchange (PaO₂ <60 mm Hg or PaCO₂ >50 mm Hg)
   C. Mild dyspnea during exercise
   D. Hyperventilation with low CO₂

Answer 4

o Answer: B
o Rationale: Respiratory failure is defined by impaired gas exchange leading to hypoxemia and/or hypercapnia.

Question 5

7. A patient with COPD develops worsening dyspnea and confusion. Which parameter “will kill your patient” if not corrected promptly?
   A. Elevated PaCO₂ causing respiratory acidosis
   B. Mild tachypnea
   C. Slightly increased respiratory rate
   D. Normal oxygen saturation

Answer 5

o Answer: A
o Rationale: Severe hypercapnia and acidosis can depress the central nervous system and lead to respiratory arrest.

Question 6

8. What is “really common” as a cause of respiratory failure in hospitalized patients?
   A. Trauma-induced apnea
   B. Pneumonia leading to hypoxemia
   C. Asthma only
   D. Cardiac arrhythmia

Answer 6

o Answer: B
o Rationale: Pneumonia is one of the most common causes of acute respiratory failure.

Question 7

9. Which intervention is key in managing acute respiratory failure?
   A. Immediate initiation of high-dose diuretics
   B. Airway stabilization and oxygen therapy
   C. Exclusive use of bronchodilators
   D. Avoiding positive-pressure ventilation.

Answer 7

o Answer: B
o Rationale: Ensuring a patent airway and supporting oxygenation are the first priorities (the “A” and “B” in ABCs)

Question 8

10. In respiratory failure, which nonpharmacologic therapy is “really common” for improving oxygenation?
    A. Prone positioning
    B. Complete bed rest
    C. Fluid restriction
    D. High-dose corticosteroids

Answer 8

o Answer: A
o Rationale: Prone positioning is commonly used in ARDS to improve oxygenation.

Question 9

A 72-year-old man with COPD presents with increasing dyspnea and confusion. His ABG shows pH 7.28, PaCO₂ 68 mmHg, and PaO₂ 55 mmHg on room air. What is the most likely diagnosis?
A) Type 1 respiratory failure
B) Type 2 respiratory failure
C) Acute respiratory distress syndrome (ARDS)
D) Pulmonary embolism

Answer 9

Answer: B
Rationale: Type 2 respiratory failure (hypercapnic) is defined by PaCO₂ >45 mmHg and pH <7.35 due to alveolar hypoventilation, often seen in COPD exacerbations.

Question 10

A 60-year-old woman with pneumonia presents with dyspnea and SpO₂ of 85% on room air. ABG shows pH 7.40, PaCO₂ 38 mmHg, and PaO₂ 55 mmHg. What type of respiratory failure does she have?
A) Type 1 respiratory failure
B) Type 2 respiratory failure
C) Type 3 respiratory failure
D) Type 4 respiratory failure

Answer 10

Answer: A
Rationale: Type 1 respiratory failure (hypoxemic) is defined by PaO₂ <60 mmHg with normal or low PaCO₂, commonly caused by pneumonia, ARDS, or PE.

Question 11

Which of the following is the most appropriate initial intervention for a patient with type 1 respiratory failure due to pulmonary edema?
A) High-flow nasal cannula oxygen
B) Non-invasive positive pressure ventilation (NIPPV)
C) Intubation with mechanical ventilation
D) Diuretics and afterload reduction

Answer 11

Answer: D
Rationale: Pulmonary edema is commonly managed with diuretics and afterload reduction (e.g., nitroglycerin), while oxygen therapy supports ventilation.

Question 12

10. In respiratory failure, which nonpharmacologic therapy is “really common” for improving oxygenation?
    A. Prone positioning
    B. Complete bed rest
    C. Fluid restriction
    D. High-dose corticosteroids

Answer 12

o Answer: A
o Rationale: Prone positioning is commonly used in ARDS to improve oxygenation.

Question 13

A 40-year-old man with Guillain-Barré syndrome develops progressive respiratory distress. Which of the following ABG findings would most indicate the need for mechanical ventilation?
A) pH 7.45, PaCO₂ 40 mmHg, PaO₂ 70 mmHg
B) pH 7.30, PaCO₂ 55 mmHg, PaO₂ 60 mmHg
C) pH 7.40, PaCO₂ 40 mmHg, PaO₂ 50 mmHg
D) pH 7.48, PaCO₂ 30 mmHg, PaO₂ 65 mmHg

Answer 13

Answer: B
Rationale: Hypercapnic respiratory acidosis (PaCO₂ >50 mmHg with pH <7.35) suggests impending respiratory failure, requiring mechanical ventilation.

Question 14

A 62-year-old man with congestive heart failure presents with acute respiratory distress. He is tachypneic and hypoxic. What diagnostic tool would best assess his respiratory failure cause?
A) Pulmonary function test
B) Echocardiogram
C) Chest X-ray
D) Arterial blood gas

Answer 14

Answer: C
Rationale: Chest X-ray is the first-line imaging to evaluate pulmonary edema, pneumonia, or lung collapse in respiratory distress

Question 15

A 50-year-old patient with obesity-hypoventilation syndrome presents with morning headaches and daytime sleepiness. ABG shows pH 7.34, PaCO₂ 55 mmHg, and PaO₂ 60 mmHg. What is the best long-term management?
A) Continuous positive airway pressure (CPAP)
B) Bi-level positive airway pressure (BiPAP)
C) High-flow nasal oxygen
D) Endotracheal intubation

Answer 15

Answer: B
Rationale: Obesity-hypoventilation syndrome (OHS) leads to chronic hypercapnia and benefits most from BiPAP to support ventilation.

Question 16

Which of the following conditions most commonly causes type 2 respiratory failure?
A) Pulmonary embolism
B) ARDS
C) COPD
D) High-altitude exposure

Answer 16

Answer: C
Rationale: COPD exacerbations often result in alveolar hypoventilation, leading to hypercapnic respiratory failure (type 2).

Question 17

Which intervention is most appropriate for a patient with respiratory failure due to opioid overdose?
A) High-flow oxygen
B) Non-invasive ventilation
C) Naloxone administration
D) Inhaled bronchodilators

Answer 17

Answer: C
Rationale: Opioid overdose leads to decreased respiratory drive (won’t breathe) and is best treated with naloxone.

Question 18

A patient in respiratory failure has a chest X-ray showing bilateral opacities without cardiogenic pulmonary edema. What is the most likely diagnosis?
A) ARDS
B) Pulmonary embolism
C) COPD exacerbation
D) Pneumothorax

Answer 18

Answer: A
Rationale: ARDS is diagnosed based on bilateral lung opacities on imaging, respiratory failure, and lack of cardiac failure.

Question 19

Which of the following is a common complication of prolonged mechanical ventilation?
A) Pulmonary embolism
B) Tracheomalacia
C) Hypercapnia
D) Pneumothorax

Answer 19

Answer: D
Rationale: Barotrauma from mechanical ventilation increases the risk of pneumothorax.

Question 20

Which factor increases the risk of ventilator-associated pneumonia (VAP)?
A) Early extubation
B) Head of bed elevation
C) Frequent sedation interruptions
D) Prolonged intubation

Answer 20

Answer: D
Rationale: Longer intubation times increase the risk of VAP due to bacterial colonization.

Question 21

Which of the following best defines acute hypercapnic respiratory failure?
A) PaCO₂ >50 mmHg and pH <7.35
B) PaCO₂ <35 mmHg and pH >7.45
C) PaO₂ <60 mmHg on room air
D) Normal PaO₂ with low SaO₂

Answer 21

Answer: A
Rationale: Type 2 respiratory failure is defined as PaCO₂ >50 mmHg with respiratory acidosis.

Question 22

A patient with myasthenia gravis is at risk for respiratory failure due to:
A) Airway obstruction
B) Reduced central respiratory drive
C) Neuromuscular weakness
D) V/Q mismatch

Answer 22

Answer: C
Rationale: Neuromuscular weakness (can’t breathe) leads to type 2 respiratory failure in myasthenia gravis.

Question 23

A patient with severe ARDS is placed on mechanical ventilation. What strategy reduces ventilator-induced lung injury?
A) High tidal volume ventilation
B) Permissive hypercapnia
C) Immediate neuromuscular blockade
D) High oxygen fraction (FiO₂ >90%)

Answer 23

Answer: B
Rationale: Permissive hypercapnia with low tidal volumes reduces barotrauma in ARDS.

Question 24

Which of the following conditions can cause both type 1 and type 2 respiratory failure?
A) Guillain-Barré syndrome
B) Pneumothorax
C) ARDS
D) Pulmonary embolism

Answer 24

Answer: A
Rationale: Guillain-Barré syndrome can cause hypoxemia (type 1) and hypercapnia (type 2) due to respiratory muscle paralysis.

Question 25

A 68-year-old man with COPD is admitted for worsening dyspnea. He is somnolent with a respiratory rate of 10 breaths per minute. ABG shows pH 7.25, PaCO₂ 72 mmHg, and PaO₂ 58 mmHg. What is the next best step? A) Intubation and mechanical ventilation B) Supplemental oxygen at 10 L/min via nasal cannula C) Noninvasive positive pressure ventilation (BiPAP) D) IV corticosteroids and nebulized albuterol

Answer 25

Answer: C Rationale: BiPAP is preferred for acute hypercapnic respiratory failure due to COPD exacerbation unless the patient is in severe distress or has altered mental status, requiring intubation.

Question 26

A 45-year-old woman presents with acute respiratory distress. She has a history of opioid use. ABG shows pH 7.22, PaCO₂ 78 mmHg, and PaO₂ 65 mmHg. What is the most appropriate next step? A) Start high-flow oxygen B) Administer naloxone C) Intubate immediately D) Obtain a CT scan of the chest

Answer 26

Answer: B Rationale: Opioid overdose leads to central respiratory depression (won’t breathe), causing hypercapnic respiratory failure, which is reversed with naloxone

Question 27

A patient with ARDS is placed on mechanical ventilation. Which setting adjustment is most appropriate to prevent ventilator-induced lung injury? A) Increase tidal volume to 10 mL/kg B) Set FiO₂ at 100% C) Use low tidal volume ventilation (6 mL/kg) D) Maintain PEEP at 0 cm H₂O

Answer 27

Answer: C Rationale: Low tidal volume ventilation (6 mL/kg) reduces barotrauma and improves survival in ARDS.

Question 28

A 70-year-old woman with a history of congestive heart failure presents with acute hypoxemic respiratory failure. Chest X-ray shows bilateral pulmonary edema. Which intervention is most appropriate? A) Intubation and mechanical ventilation B) Noninvasive positive pressure ventilation (NIPPV) C) High-dose corticosteroids D) Nebulized bronchodilators

Answer 28

Answer: B Rationale: NIPPV (e.g., BiPAP) reduces the need for intubation in acute cardiogenic pulmonary edema by improving oxygenation and decreasing work of breathing

Question 28

A 55-year-old man with severe pneumonia has been on mechanical ventilation for 7 days. He suddenly develops fever, increased secretions, and worsening oxygenation. What is the most likely diagnosis? A) Pulmonary embolism B) Ventilator-associated pneumonia (VAP) C) ARDS D) Pneumothorax

Answer 28

Answer: B Rationale: New fever, increased secretions, and worsening oxygenation after 48 hours of intubation suggest ventilator-associated pneumonia (VAP).

Question 29

A 65-year-old man with end-stage COPD presents with dyspnea and respiratory acidosis. He refuses intubation. What is the best next step? A) Provide palliative care only B) Offer noninvasive ventilation (BiPAP) C) Administer IV corticosteroids D) Increase oxygen to 100% FiO₂.

Answer 29

Answer: B Rationale: BiPAP is the best option for hypercapnic respiratory failure in a patient who refuses intubation

Question 30

A 50-year-old man is found unconscious. His ABG reveals pH 7.15, PaCO₂ 90 mmHg, and PaO₂ 60 mmHg. What is the best next step? A) BiPAP B) Endotracheal intubation C) High-flow nasal oxygen D) Nebulized bronchodilators

Answer 30

Answer: B Rationale: Severe hypercapnia with respiratory acidosis and altered mental status requires immediate intubation.

Question 31

Which intervention is most appropriate for preventing ventilator-associated pneumonia (VAP)? A) Administer prophylactic antibiotics B) Routine endotracheal suctioning C) Elevate the head of the bed D) Frequent deep sedation.

Answer 31

Answer: C Rationale: Elevating the head of the bed (>30 degrees) reduces the risk of aspiration and VAP

Question 32

Which of the following is a major cause of type 1 (hypoxemic) respiratory failure? A) Myasthenia gravis B) Neuromuscular blockade C) ARDS D) Opioid overdose

Answer 32

Answer: C Rationale: ARDS causes severe V/Q mismatch and leads to type 1 respiratory failure.

Question 33

A 78-year-old woman with COPD is admitted for respiratory failure. She has been on 2 L of oxygen at home. ABG on 6 L of oxygen shows pH 7.29, PaCO₂ 65 mmHg, and PaO₂ 140 mmHg. What is the most likely cause of her worsening condition? A) Oxygen-induced hypercapnia B) Pulmonary embolism C) Acute respiratory distress syndrome (ARDS) D) Myasthenia gravis exacerbation

Answer 33

Answer: A Rationale: In COPD, excessive oxygen can suppress hypoxic drive, leading to CO₂ retention and worsening hypercapnic respiratory failure

Question 34

Hypoxemia (PaO₂ <60 mmHg), normal or low PaCO₂ → Causes: ARDS, pneumonia, PE

Answer 34

Type 1 respiratory failure

Question 35

Hypercapnia (PaCO₂ >50 mmHg), respiratory acidosis → Causes: COPD, opioid overdose, neuromuscular disorders

Answer 35

Type 2 respiratory failure

Question 36

BiPAP for COPD and CHF exacerbations →

Answer 36

Prevents intubation in hypercapnic or hypoxemic failure

Question 37

Indication for intubation

Answer 37

Intubation for respiratory acidosis with altered mental status

Question 38

ARDS management

Answer 38

Low tidal volume ventilation (6 mL/kg), permissive hypercapnia, and high PEEP

Question 39

Head of bed elevation, daily sedation breaks, early extubation when possible

Answer 39

VAP prevention

Question 40

High FiO₂ in COPD can suppress hypoxic drive and worsen hypercapnia

Answer 40

Oxygen-induced hypercapnia

Question 41

ARDS / Will Kill) A 58-year-old with septic shock develops bilateral infiltrates and refractory hypoxemia. Which hallmark complication leads to high mortality if not corrected? A. Mild alveolar edema B. Persistent hypoxemia with multi-organ failure C. Unilateral consolidation D. Bronchospasm alone

Answer 41

Correct Answer: B. Persistent hypoxemia with multi-organ failure Rationale: In ARDS, refractory hypoxemia can quickly progress to multi-organ failure if not aggressively managed. This systemic involvement is the primary contributor to the high mortality associated with ARDS. Mild alveolar edema, unilateral consolidation, or bronchospasm alone do not encapsulate the full severity of the condition.

Question 42

15. (ARDS / Will Harm) Which ventilator strategy is most harmful if used in ARDS management? A. Low tidal volumes (4–6 mL/kg IBW) B. High tidal volumes (>10 mL/kg) C. Adequate PEEP for alveolar recruitment D. Prone positioning

Answer 42

Correct Answer: B. High tidal volumes (>10 mL/kg) Rationale: Using high tidal volumes in ARDS can lead to ventilator-induced lung injury by overdistending the already injured alveoli. In contrast, low tidal volumes (4–6 mL/kg IBW), adequate PEEP for alveolar recruitment, and prone positioning are part of lung-protective strategies that improve outcomes in ARDS patients

Question 43

16. (ARDS / Really Common) In moderate to severe ARDS, which nonpharmacologic intervention is commonly used to improve oxygenation? A. Prone positioning B. Immediate extubation C. Routine bronchoscopy D. Fluid overload

Answer 43

Correct Answer: A. Prone positioning Rationale: Prone positioning is a widely recognized nonpharmacologic intervention for improving oxygenation in moderate to severe ARDS. It enhances ventilation-perfusion matching and reduces ventilator-induced lung injury. Immediate extubation, routine bronchoscopy, or fluid overload are not beneficial in this setting and may worsen the patient’s condition.

Question 44

ARDS / Pathophysiology) ARDS is primarily characterized by: A. Cardiogenic pulmonary edema B. Diffuse alveolar damage with increased capillary permeability C. Isolated bronchospasm D. Focal neoplasm of the lung

Answer 44

Correct Answer: B. Diffuse alveolar damage with increased capillary permeability Rationale: ARDS is defined by diffuse alveolar damage that leads to increased capillary permeability and subsequent noncardiogenic pulmonary edema. This distinguishes it from conditions like cardiogenic pulmonary edema or isolated bronchospasm, and it is not related to focal neoplastic processes.

Question 45

For lung-protective ventilator strategies, what is the goal tidal volume for a patient in acute respiratory distress syndrome? A. 4–6 ml/kg of ideal body weight B. 6–8 ml/kg of ideal body weight C. 2–4 ml/kg of ideal body weight D. 8–10 ml/kg of ideal body weight

Answer 45

Correct Answer: A. 4–6 ml/kg of ideal body weight Rationale: Lung-protective ventilator strategies in ARDS aim to minimize ventilator-induced lung injury. This is achieved by using low tidal volumes—typically 4–6 ml/kg of ideal body weight—to reduce overdistension of the alveoli while maintaining adequate ventilation.

Question 46

Hypoxemia in acute respiratory distress syndrome is from an intrapulmonary shunt. How is this treated? A. Increase FiO2 B. Decrease minute ventilation C. Decrease tidal volume D. Increase peak end expiratory pressure

Answer 46

Correct Answer: D. Increase peak end expiratory pressure (PEEP) Rationale: In ARDS, hypoxemia primarily results from an intrapulmonary shunt due to alveolar collapse and fluid-filled alveoli. Increasing PEEP helps by recruiting these collapsed alveoli, thereby reducing the shunt fraction and improving oxygenation. While increasing FiO₂ may provide some benefit, it is less effective if alveoli remain collapsed, making PEEP the preferred intervention in this scenario.

Question 47

On CT scan, what differentiates acute respiratory distress syndrome (ARDS) from pneumonia? A. Consolidation only in the bases of the lungs with ARDS B. Consolidation throughout with ground-glass appearance with ARDS C. Kerley B lines present in pneumonia but not ARDS D. Enlarged mediastinum appreciated for pneumonia

Answer 47

B. Consolidation throughout with ground-glass appearance with ARDS

Question 48

You have a patient who is being mechanically ventilated. As the advanced practice registered nurse, you know there are different modes for managing respiratory failure. What mode would you want to use to have complete control of the patient’s breathing? A. Pressure control B. Pressure-regulated volume control C. BiPAP D. Synchronized intermittent mandatory ventilation

Answer 48

B. Pressure-regulated volume control

Question 49

21. ARDS is characterized by which of the following pathophysiologic features? A. Increased lung compliance and reduced edema B. Diffuse alveolar damage, increased permeability, and noncardiogenic pulmonary edema C. Isolated bronchospasm D. Focal consolidation in one lung lobe

Answer 49

o Answer: B o Rationale: ARDS is defined by diffuse alveolar damage, increased capillary permeability, and resultant pulmonary edema not due to cardiac failure.

Question 50

22. Which factor “will kill your patient” in ARDS if not managed appropriately? A. Mild cough B. Refractory hypoxemia and multi-organ failure C. Occasional desaturation D. Low-grade fever o

Answer 50

Answer: B o Rationale: Refractory hypoxemia leading to multi-organ dysfunction is the primary cause of death in ARDS.

Question 51

23. What is a “common” initial nonpharmacologic management strategy in ARDS? A. High tidal volume ventilation B. Low tidal volume mechanical ventilation C. Unmonitored oxygen therapy D. Immediate extubation

Answer 51

o Answer: B o Rationale: Low tidal volume ventilation is standard care in ARDS to minimize ventilator-induced lung injury.

Question 52

24. Which complication “will harm your patient” if a patient with ARDS is ventilated with high tidal volumes? A. Improved oxygenation B. Ventilator-induced lung injury (barotrauma) C. Enhanced lung compliance D. Reduction in inflammatory cytokines

Answer 52

o Answer: B o Rationale: High tidal volumes can cause barotrauma, worsening lung injury.

Question 53

25. In ARDS, which adjunctive therapy may be used in refractory hypoxemia? A. Prone positioning B. Increased tidal volume C. Fluid overload D. Routine use of bronchodilators only

Answer 53

o Answer: A o Rationale: Prone positioning improves oxygenation in ARDS by redistributing ventilation.

Answer 54

Answer: C Rationale: A PaO₂/FiO₂ of 120 indicates moderate ARDS. Low tidal volume ventilation and prone positioning can improve oxygenation.

Question 55

A 72-year-old man with COPD presents with increasing dyspnea and confusion. His ABG shows pH 7.28, PaCO₂ 68 mmHg, and PaO₂ 55 mmHg on room air. What is the most likely diagnosis? A) Type 1 respiratory failure B) Type 2 respiratory failure C) Acute respiratory distress syndrome (ARDS) D) Pulmonary embolism

Answer 55

Answer: B Rationale: Type 2 respiratory failure (hypercapnic) is defined by PaCO₂ >45 mmHg and pH <7.35 due to alveolar hypoventilation, often seen in COPD exacerbations.

Question 56

A 60-year-old woman with pneumonia presents with dyspnea and SpO₂ of 85% on room air. ABG shows pH 7.40, PaCO₂ 38 mmHg, and PaO₂ 55 mmHg. What type of respiratory failure does she have? A) Type 1 respiratory failure B) Type 2 respiratory failure C) Type 3 respiratory failure D) Type 4 respiratory failure

Answer 56

Answer: A Rationale: Type 1 respiratory failure (hypoxemic) is defined by PaO₂ <60 mmHg with normal or low PaCO₂, commonly caused by pneumonia, ARDS, or PE.

Question 57

Which of the following is the most appropriate initial intervention for a patient with type 1 respiratory failure due to pulmonary edema? A) High-flow nasal cannula oxygen B) Non-invasive positive pressure ventilation (NIPPV) C) Intubation with mechanical ventilation D) Diuretics and afterload reduction

Answer 57

Answer: D Rationale: Pulmonary edema is commonly managed with diuretics and afterload reduction (e.g., nitroglycerin), while oxygen therapy supports ventilation.

Question 58

4. A 40-year-old man with Guillain-Barré syndrome develops progressive respiratory distress. Which of the following ABG findings would most indicate the need for mechanical ventilation? A) pH 7.45, PaCO₂ 40 mmHg, PaO₂ 70 mmHg B) pH 7.30, PaCO₂ 55 mmHg, PaO₂ 60 mmHg C) pH 7.40, PaCO₂ 40 mmHg, PaO₂ 50 mmHg D) pH 7.48, PaCO₂ 30 mmHg, PaO₂ 65 mmHg

Answer 58

Answer: B Rationale: Hypercapnic respiratory acidosis (PaCO₂ >50 mmHg with pH <7.35) suggests impending respiratory failure, requiring mechanical ventilation.

Question 59

5. A 50-year-old patient with obesity-hypoventilation syndrome presents with morning headaches and daytime sleepiness. ABG shows pH 7.34, PaCO₂ 55 mmHg, and PaO₂ 60 mmHg. What is the best long-term management? A) Continuous positive airway pressure (CPAP) B) Bi-level positive airway pressure (BiPAP) C) High-flow nasal oxygen D) Endotracheal intubation

Answer 59

Answer: B Rationale: Obesity-hypoventilation syndrome (OHS) leads to chronic hypercapnia and benefits most from BiPAP to support ventilation.

Question 60

A patient with ARDS is intubated. Which ventilatory strategy is most appropriate? A) High tidal volume ventilation (10-12 mL/kg) B) Low tidal volume ventilation (6 mL/kg) with high PEEP C) Permissive hypercapnia and FiO₂ 100% D) No PEEP and aggressive fluid resuscitation

Answer 60

Answer: B Rationale: Low tidal volume ventilation reduces ventilator-induced lung injury in ARDS, and high PEEP prevents alveolar collapse.

Question 61

A patient with ARDS is on mechanical ventilation with low tidal volume settings. However, their PaO₂/FiO₂ ratio remains <100 despite high PEEP. Which next step could help improve oxygenation? A) Increase tidal volume B) Prone positioning C) Bronchodilator therapy D) Lower respiratory rate

Answer 61

Answer: B Rationale: Prone positioning can drastically improve oxygenation by enhancing ventilation-perfusion matching in severe ARDS.

Question 62

Which factor is most critical for improving long-term outcomes in survivors of severe ARDS? A) Early initiation of high-dose steroids B) Routine use of noninvasive ventilation C) Aggressive fluid resuscitation D) Adequate nutrition and physical rehabilitation

Answer 62

Answer: D Rationale: Appropriate nutrition, rehabilitation, and supportive care to prevent deconditioning enhances post-ICU recovery in ARDS survivors.

Question 63

normal/low PCWP, PaO₂/FiO₂ ratio <300, bilateral infiltrates, treat with low tidal volumes, high PEEP, prone positioning in severe cases.

Answer 63

ARDS

Question 64

A patient presents with severe dyspnea, diffuse pulmonary infiltrates, and hypoxia refractory to oxygen therapy. BNP is normal. What is the most likely diagnosis? A) Cardiogenic pulmonary edema B) Pulmonary embolism C) Acute respiratory distress syndrome (ARDS) D) Pneumonia

Answer 64

Answer: C Rationale: Normal BNP and refractory hypoxia with diffuse infiltrates suggest ARDS rather than cardiogenic pulmonary edema.

Question 65

Which of the following is a hallmark feature of ARDS on chest X-ray? A) Unilateral consolidation B) Bilateral diffuse infiltrates C) Pleural effusion D) Perihilar "batwing" appearance.

Answer 65

Answer: B Rationale: ARDS presents with bilateral diffuse infiltrates on chest X-ray, often appearing as "white-out" lungs

Question 66

Which ventilatory strategy is recommended for ARDS to minimize ventilator-induced lung injury? A) Low tidal volume (6 mL/kg) ventilation B) High tidal volume (12 mL/kg) ventilation C) No PEEP and high FiO2 D) CPAP only

Answer 66

Answer: A Rationale: Low tidal volume ventilation reduces volutrauma and barotrauma in ARDS

Question 67

A patient with ARDS is on mechanical ventilation. Their PaO₂/FiO₂ ratio is 80. How would you classify their ARDS severity? A) Mild B) Moderate C) Severe D) Not ARDS

Answer 67

Answer: C Rationale: PaO₂/FiO₂ ratio <100 indicates severe ARDS.

Question 68

Which of the following best differentiates ARDS from cardiogenic pulmonary edema? A) Pulmonary capillary wedge pressure (PCWP) B) Chest X-ray C) BNP levels D) Clinical presentation

Answer 68

Answer: A Rationale: PCWP is normal or low in ARDS but elevated in cardiogenic pulmonary edema.

Question 69

A patient with ARDS has a PaO₂/FiO₂ ratio of 150. How would this be classified? A) Mild ARDS B) Moderate ARDS C) Severe ARDS D) Not ARDS

Answer 69

Answer: B Rationale: PaO₂/FiO₂ ratio between 100-200 indicates moderate ARDS.

Question 70

Which intervention is most effective in improving oxygenation in severe ARDS? A) Prone positioning B) Diuretics C) Noninvasive ventilation D) Bronchodilators

Answer 70

Answer: A Rationale: Prone positioning improves ventilation-perfusion matching and lung recruitment in severe ARDS.

Question 71

What is the most common direct cause of ARDS? A) Sepsis B) Pneumonia C) Pancreatitis D) Blood transfusion

Answer 71

Answer: B Rationale: Pneumonia is the most common direct cause of ARDS.

Question 72

A 45-year-old man with pancreatitis develops respiratory failure. His chest X-ray shows diffuse infiltrates, and he is hypoxic despite high-flow oxygen. Which of the following is the most likely diagnosis? A) Cardiogenic pulmonary edema B) Pulmonary embolism C) ARDS D) COPD exacerbation

Answer 72

Answer: C Rationale: Pancreatitis is a common non-pulmonary cause of ARDS.

Question 73

Which of the following is contraindicated in the management of ARDS? A) Low tidal volume ventilation B) High PEEP C) Routine corticosteroids D) Prone positioning

Answer 73

Answer: C Rationale: Routine corticosteroids are not recommended in all cases of ARDS unless there is a strong indication.

Question 74

Which laboratory finding is most consistent with ARDS? A) High BNP B) Low pulmonary capillary wedge pressure C) Increased left ventricular ejection fraction D) Hyperchloremic metabolic acidosis

Answer 74

Answer: B Rationale: ARDS is a noncardiogenic cause of pulmonary edema, so PCWP is normal or low.

Question 75

Which of the following pathophysiologic processes contributes most to ARDS? A) Pulmonary capillary hypertension B) Increased alveolar capillary permeability C) Hypovolemia D) Right ventricular failure

Answer 75

Answer: B Rationale: Increased capillary permeability leads to pulmonary edema in ARDS.

Question 76

A 50-year-old man with ARDS remains hypoxic despite high FiO₂. What is the best next step? A) Increase FiO₂ to 100% B) Start diuretics C) Prone positioning D) Give IV steroids

Answer 76

Answer: C Rationale: Prone positioning improves ventilation-perfusion mismatch in ARDS.

Question 77

Which of the following best predicts mortality in ARDS? A) PaO₂/FiO₂ ratio B) WBC count C) Serum creatinine D) Sputum culture results

Answer 77

Answer: A Rationale: Lower PaO₂/FiO₂ ratio correlates with worse outcomes in ARDS

Question 78

Which of the following is a late complication of ARDS? A) Pulmonary fibrosis B) Hyperkalemia C) Upper GI bleeding D) Seizures

Answer 78

Answer: A Rationale: Some ARDS patients develop pulmonary fibrosis, leading to chronic respiratory failure.

Question 79

What is the primary cause of hypoxemia in ARDS? A) Hypoventilation B) V/Q mismatch and shunting C) Hypercapnia D) Bronchospasm

Answer 79

Answer: B Rationale: Intrapulmonary shunting and ventilation-perfusion mismatch cause refractory hypoxemia in ARDS.

Question 80

A patient with ARDS has a pH of 7.28 and a PaCO₂ of 60 mmHg. What is the best intervention? A) Increase tidal volume B) Increase respiratory rate C) Decrease PEEP D) Decrease FiO₂

Answer 80

Answer: B Rationale: Increasing respiratory rate improves CO₂ clearance in ARDS patients with respiratory acidosis.

Question 81

A patient with severe ARDS is not improving despite lung-protective ventilation. What is the next step? A) ECMO B) High-dose steroids C) Beta-blockers D) CPAP

Answer 81

Answer: A Rationale: Extracorporeal membrane oxygenation (ECMO) is used in refractory severe ARDS.

Question 82

6. A 62-year-old man with congestive heart failure presents with acute respiratory distress. He is tachypneic and hypoxic. What diagnostic tool would best assess his respiratory failure cause? A) Pulmonary function test B) Echocardiogram C) Chest X-ray D) Arterial blood gas

Answer 82

Answer: C Rationale: Chest X-ray is the first-line imaging to evaluate pulmonary edema, pneumonia, or lung collapse in respiratory distress.

Question 83

Which of the following conditions most commonly causes type 2 respiratory failure? A) Pulmonary embolism B) ARDS C) COPD D) High-altitude exposure

Answer 83

Answer: C Rationale: COPD exacerbations often result in alveolar hypoventilation, leading to hypercapnic respiratory failure (type 2).

Question 84

Which intervention is most appropriate for a patient with respiratory failure due to opioid overdose? A) High-flow oxygen B) Non-invasive ventilation C) Naloxone administration D) Inhaled bronchodilators

Answer 84

Answer: C Rationale: Opioid overdose leads to decreased respiratory drive (won’t breathe) and is best treated with naloxone.

Question 85

A patient in respiratory failure has a chest X-ray showing bilateral opacities without cardiogenic pulmonary edema. What is the most likely diagnosis? A) ARDS B) Pulmonary embolism C) COPD exacerbation D) Pneumothorax

Answer 85

Answer: A Rationale: ARDS is diagnosed based on bilateral lung opacities on imaging, respiratory failure, and lack of cardiac failure.

Question 86

Which of the following is a common complication of prolonged mechanical ventilation? A) Pulmonary embolism B) Tracheomalacia C) Hypercapnia D) Pneumothorax

Answer 86

Answer: D Rationale: Barotrauma from mechanical ventilation increases the risk of pneumothorax

Question 87

Which factor increases the risk of ventilator-associated pneumonia (VAP)? A) Early extubation B) Head of bed elevation C) Frequent sedation interruptions D) Prolonged intubation

Answer 87

Answer: D Rationale: Longer intubation times increase the risk of VAP due to bacterial colonization.

Question 88

Which of the following best defines acute hypercapnic respiratory failure? A) PaCO₂ >50 mmHg and pH <7.35 B) PaCO₂ <35 mmHg and pH >7.45 C) PaO₂ <60 mmHg on room air D) Normal PaO₂ with low SaO₂

Answer 88

Answer: A Rationale: Type 2 respiratory failure is defined as PaCO₂ >50 mmHg with respiratory

Question 89

A patient with myasthenia gravis is at risk for respiratory failure due to: A) Airway obstruction B) Reduced central respiratory drive C) Neuromuscular weakness D) V/Q mismatch

Answer 89

Answer: C Rationale: Neuromuscular weakness (can’t breathe) leads to type 2 respiratory failure in myasthenia gravis.

Question 90

Which of the following conditions can cause both type 1 and type 2 respiratory failure? A) Guillain-Barré syndrome B) Pneumothorax C) ARDS D) Pulmonary embolism

Answer 90

Answer: A Rationale: Guillain-Barré syndrome can cause hypoxemia (type 1) and hypercapnia (type 2) due to respiratory muscle paralysis.

Question 91

A patient with severe ARDS is placed on mechanical ventilation. What strategy reduces ventilator-induced lung injury? A) High tidal volume ventilation B) Permissive hypercapnia C) Immediate neuromuscular blockade D) High oxygen fraction (FiO₂ >90%)

Answer 91

Answer: B Rationale: Permissive hypercapnia with low tidal volumes reduces barotrauma in ARDS.

Question 92

A 68-year-old man with COPD is admitted for worsening dyspnea. He is somnolent with a respiratory rate of 10 breaths per minute. ABG shows pH 7.25, PaCO₂ 72 mmHg, and PaO₂ 58 mmHg. What is the next best step? A) Intubation and mechanical ventilation B) Supplemental oxygen at 10 L/min via nasal cannula C) Noninvasive positive pressure ventilation (BiPAP) D) IV corticosteroids and nebulized albuterol

Answer 92

Answer: C Rationale: BiPAP is preferred for acute hypercapnic respiratory failure due to COPD exacerbation unless the patient is in severe distress or has altered mental status, requiring intubation.

Question 93

A 45-year-old woman presents with acute respiratory distress. She has a history of opioid use. ABG shows pH 7.22, PaCO₂ 78 mmHg, and PaO₂ 65 mmHg. What is the most appropriate next step? A) Start high-flow oxygen B) Administer naloxone C) Intubate immediately D) Obtain a CT scan of the chest

Answer 93

Answer: B Rationale: Opioid overdose leads to central respiratory depression (won’t breathe), causing hypercapnic respiratory failure, which is reversed with naloxone

Question 94

A patient with ARDS is placed on mechanical ventilation. Which setting adjustment is most appropriate to prevent ventilator-induced lung injury? A) Increase tidal volume to 10 mL/kg B) Set FiO₂ at 100% C) Use low tidal volume ventilation (6 mL/kg) D) Maintain PEEP at 0 cm H₂O

Answer 94

Answer: C Rationale: Low tidal volume ventilation (6 mL/kg) reduces barotrauma and improves survival in ARDS.

Question 95

A 55-year-old man with severe pneumonia has been on mechanical ventilation for 7 days. He suddenly develops fever, increased secretions, and worsening oxygenation. What is the most likely diagnosis? A) Pulmonary embolism B) Ventilator-associated pneumonia (VAP) C) ARDS D) Pneumothorax.

Answer 95

Answer: B Rationale: New fever, increased secretions, and worsening oxygenation after 48 hours of intubation suggest ventilator-associated pneumonia (VAP)

Question 96

A 70-year-old woman with a history of congestive heart failure presents with acute hypoxemic respiratory failure. Chest X-ray shows bilateral pulmonary edema. Which intervention is most appropriate? A) Intubation and mechanical ventilation B) Noninvasive positive pressure ventilation (NIPPV) C) High-dose corticosteroids D) Nebulized bronchodilators

Answer 96

Answer: B Rationale: NIPPV (e.g., BiPAP) reduces the need for intubation in acute cardiogenic pulmonary edema by improving oxygenation and decreasing work of breathing.

Question 97

A 65-year-old man with end-stage COPD presents with dyspnea and respiratory acidosis. He refuses intubation. What is the best next step? A) Provide palliative care only B) Offer noninvasive ventilation (BiPAP) C) Administer IV corticosteroids D) Increase oxygen to 100% FiO₂

Answer 97

Answer: B Rationale: BiPAP is the best option for hypercapnic respiratory failure in a patient who refuses intubation.

Question 98

A 50-year-old man is found unconscious. His ABG reveals pH 7.15, PaCO₂ 90 mmHg, and PaO₂ 60 mmHg. What is the best next step? A) BiPAP B) Endotracheal intubation C) High-flow nasal oxygen D) Nebulized bronchodilators Answer: B Rationale: Severe hypercapnia with respiratory acidosis and altered mental status requires immediate intubation.

Question 99

Which of the following is a major cause of type 1 (hypoxemic) respiratory failure? A) Myasthenia gravis B) Neuromuscular blockade C) ARDS D) Opioid overdose

Answer 99

Answer: C Rationale: ARDS causes severe V/Q mismatch and leads to type 1 respiratory failure.

Question 100

Which intervention is most appropriate for preventing ventilator-associated pneumonia (VAP)? A) Administer prophylactic antibiotics B) Routine endotracheal suctioning C) Elevate the head of the bed D) Frequent deep sedation .

Answer 100

Answer: C Rationale: Elevating the head of the bed (>30 degrees) reduces the risk of aspiration and VAP

Question 101

A 78-year-old woman with COPD is admitted for respiratory failure. She has been on 2 L of oxygen at home. ABG on 6 L of oxygen shows pH 7.29, PaCO₂ 65 mmHg, and PaO₂ 140 mmHg. What is the most likely cause of her worsening condition? A) Oxygen-induced hypercapnia B) Pulmonary embolism C) Acute respiratory distress syndrome (ARDS) D) Myasthenia gravis exacerbation Answer: A Rationale: In COPD, excessive oxygen can suppress hypoxic drive, leading to CO₂ retention and worsening hypercapnic respiratory failure.

Question 102

Hypercapnia (PaCO₂ >50 mmHg), respiratory acidosis → Causes: COPD, opioid overdose, neuromuscular disorders

Answer 102

Type 2 respiratory failure →

Question 102

Hypoxemia (PaO₂ <60 mmHg), normal or low PaCO₂ → Causes: ARDS, pneumonia, PE

Answer 102

Type 1 respiratory failure →

Question 103

Prevents intubation in hypercapnic or hypoxemic failure

Answer 103

BiPAP for COPD and CHF exacerbations →

Question 104

Intubation is for

Answer 104

respiratory acidosis with altered mental status

Question 105

ARDS management

Answer 105

→ Low tidal volume ventilation (6 mL/kg), permissive hypercapnia, and high PEEP

Question 106

Head of bed elevation, daily sedation breaks, early extubation when possible

Answer 106

VAP prevention →

Question 107

High FiO₂ in COPD can suppress hypoxic drive and worsen hypercapnia

Answer 107

Oxygen-induced hypercapnia →