TMC PRACTICE3

Question 1

A 95-kg (209-lb) patient receiving mechanical ventilation has the following ventilator settings and arterial blood gas results:

Vent settings: VC SIMV, Vt 750 mL, Set rate 4, Patient’s rate 0, FIO2 0.55

Blood gas: pH 7.26/PaCO2 56 torr/Pa02 92 torr/HCO3 22/Sa02 96%

Which of the following should you recommend?

A. Increasing the Inspiratory time
B. Increasing the tidal volume to 800mL
C. Decreasing the FIO2 to 0.50
D. Increasing the SIMV rate

Answer 1

D IS THE CORRECT ANSWER. MODE IN THIS CASE DOES NOT MATTER, SIMV WILL DELIVER MACHINE BREATHS REGARDLESS IF THE PATIENT IS BREATHING OR NOT. The blood gas indicates uncompensated respiratory acidosis. To correct a high PacO2 and low pH, the best option is to increase the rate.

Question 2

A patient receiving BiPAP for acute respiratory failure has a Pa02 of 48 torr on 65% FIO2 with IPAP= 20 cm H20 and EPAP= 5 cmH20. To raise this patient’s Pa02, which change should you recommend?

A. Increasing the FIO2 to 0.80
B. Increasing IPAP to 25 cm H20
C. Increasing EPAP to 10 cm H20
D. Decreasing IPAP to 15 cm H20

Answer 2

C IS THE CORRECT ANSWER. This patient has a shunt, indicating the need for a higher EPAP (PEEP on invasive). BE SURE TO ALWAYS MAKE SURE YOU KEEP ADEQUATE DELTA P WHEN ADMINISTERING NIPPV!

Question 3

Which site is most preferred when checking the pulse of an unresponsive patient?

A. Brachial artery
B. Jugular vein
C. Carotid artery
D. Radial artery

Answer 3

C FOR CAROTID! Correct! The carotid artery is the best site to check for an unresponsive patient

Question 4

48 year old female brought into the ER status post MVA
Imagining shows significant head trauma, 6 broken ribs, subdural hematoma, and a cervical spine fracture.
CT Scan shows lacerated liver and pleural effusion.

Data: HR 130bpm
BP 87/58 mmHg
CVP 2mmHg
ICP 17 mmHg
Hb 10.2 g/dL

What would you recommend ?

A.Administer Mannitol
B. Infuse IVF ( IV fluids) at a rapid rate
C. Insert Chest tubes
D. Administer Dobutamine

Answer 4

THE CORRECT ANSWER IS B INFUSE IVF RAPIDLY THIS PATIENT HAS OBVIOUSLY SUSTATINED MULTIPLE TRAUMA , WHAT IS OF GREATEST CONCERN IS THE POTENTIAL INTERNAL TRAUMA THAT CANT BE READILY VISUALIZED , ADDIONALLY THE PATIENT IS HYPOTENSIVE SUGGESTING SIGNIFICANT FLUID LOSS OR SHOCK.

Question 5

Succinylcholine ( Anectine) is contraindicated in patients with acute burn injuries due to which of the following reasons?

A. May cause prolonged neuromuscular paralysis
B. Can cause acute metabolic acidosis
C. Increased risk of severe hyperkalemia
D. High risk of altering the AC membrane

Answer 5

THE CORRECT ANSWER IS C! ANECTINE CAN CAUSE HYPERKALEMIA AND PROMOTE MOTOR NEURON DAMAGE WHEN USED IN BURN PATIENTS.

Question 6

When transporting critically ill patients in unpressurized aircraft, it is often necessary to make which adjustment to maintain adequate oxygenation?

A. Increase the FIO2
B. Decrease minute volume
C. Decrease the FIO2
D. Increase the minute ventilation

Answer 6

A IS THE CORRECT ANSWER! According to Dalton’s law, the ambient P02 drops the altitude increases, due to the fall in the Barometric pressure. At 10,000 feet, a patient breathing room air may need an FIO2 of 30% to maintain the same P02

Question 7

If the number of ICU ventilators needed to support patients in respiratory failure after a chemical disaster is insufficient to meet the need, what should your initial response be?

A. Contact other local facilities and arrange for patient transfers
B. Call and order additional backup ventilators from the vendor
C. Use available in-house anesthesia and/or transport ventilators
D. Assign patients without equipment to triage priority “black”

Answer 7

C IS CORRECT! The first option should always be to use the maximum amount of equipment you have available! Anesthesia vents, LTV’s, transport vents, anything that will meet the need until other equipment is available!

Question 8

At the onset of adult mouth-to-mouth or mouth-to-mask ventilation for an adult, which type of breathing should you provide?

A. Two normal breaths
B. Four fast, shallow breaths
C. Four slow, deep breaths
D. One very slow breath

Answer 8

A IS THE CORRECT ANSWER AND A MASSIVE AMOUNT OF FIST BUMPS TO ALL OF YOU! According to AHA guidelines, after assessing for a pulse and giving about 2 minutes of compressions, if appropriate, you should give two normal breaths, each lasting about 1 second.

Question 9

What is the initial energy range for biphasic defibrillation of ventricular fibrillation?

A. 120-200 joules
B. 200-280 joules
C. 280-360 joules
D. 360-440 joules

Answer 9

A IS THE CORRECT ANSWER! The initial energy for fibrillation using the typical biphasic device is 120-200 joules or as per manufacturer’s recommendations (OLDER MONOPHASIC DEFIBS USE 360 JOULES). If the recommended device dosage is unknown, apply the maximum energy. Subsequent shocks should be given after each 2-minute cycle with equivalent dosage.

Question 10

After two attempts of ventilating an infant in respiratory arrest, you still cannot deliver breaths. At this point, what should you do?

A. Apply back blows, followed by chest thrusts
B. Try to ventilate again with smaller puffs
C. Apply 6-10 strong abdominal thrusts
D. Provide external cardiac compressions

Answer 10

A IS CORRECT! Apply back blows followed by chest thrusts. Airway obstruction is the culprit here, what do we do as RT’s?! We are the airway! To hopefully clear or at least dislodge the obstruction, apply back blows and chest thrusts.

Question 11

When auto-PEEP is present, what is the lung capacity that increases?
A. Vital capacity
B. Inspiratory capacity
C. Total lung capacity
D. Functional residual capacity

Answer 11

What is PEEP considered in the lungs….. its the FRC, the residual pressure (volume) left on exhalation……..SO IF THE PATIENT IS AUTO PEEP’N THIS ADDS TO THE FRC (THE AIRTRAPPING) OF WHAT THE PATIENT CAN’T GET OUT. SO IF YOU LOOK AT YOUR GRAPHICS INSTEAD OF THE PRESSURE DROPPING TO LETS SAY THE SET 5 ON END EXHALATION ITS NOW 6, 7, OR 8. SO AUTO PEEP INCREASES THE FRC, ANSWER D

Question 12

A patient is being mechanically ventilated and you notice an increase in the assist rate followed by a rise in the PIP. A decline in the exhaled tidal volume is often most associated with which of the following?
A. Auto-PEEP
B. Mode dyssynhrony
C. Subcutaneous empysema
D. Air leak

Answer 12

THE ANSWER IS A.

Question 13

Symptoms of chronic hypoventilation include of the following?
I. Fatigue
II. Morning Headache
III. Hypoxemia
IV. Insomnia

a. I and II
b. II and III
c. III and IV
d. I and IV

Answer 13

THE ANSWER IS A…

Question 14

A patient is receiving CPAP via mask with 9 cmH20 with 80% oxygen. You have received the recent ABG results on the above settings that reveal: pH 7.37/CO2 37/ O2 55/HCO3 22. What is the most appropriate action?
A. Increase the FiO2 to 0.9
B. Intubate and mechanically ventilate
C. Increase to a CPAP of 12 cmH20
D. Switch to bilevel positive pressure ventilation

Answer 14

THE ANSWER IS C. FIRST ABG IS IT A VENTILATION OR AN OXYGENATION PROBLEM. OXYGENATION RIGHT BECAUSE OUR ACID BASE BALANCE IS BALANCED. THIS LETS US KNOW THAT WE DON’T NEED BILEVEL OR TO INTUBATE. NOW WE HAVE AN OXYGENATION ISSUE. WHEN DO WE INCREASE OXYGEN OR PEEP THE 60% RULE. SO HERE WE ARE GOING TO CHOOSE TO INCREASE TO CPAP 12 BECAUSE IT OBVIOUSLY ISN’T ENOUGH WITH A PAO2 IOF 55.

Question 15

A patient with chronic hypercapnic respiratory failure is currently being ventilated on NIPPV during noctural hours only with the following settings IPAP 10 EPAP 5. The patient is noted to be short of breath with a spontaneous RR of 28bpm. Which of the following actions below should help alleviate this problem?
A. Intubate and mechanically ventilate
B. Increase the IPAP to 12
C. decrease the EPAP to 3
D. Maintain current settings

Answer 15

THE ANSWER IS B. THE 10/5 IS JUST THE PATIENT’S BASELINE SETTINGS AT NIGHT. WHEN HE IS WELL. NOW THAT HE IS HAVING SYMPTOMS OR DISTRESS WE WANT TO USE THEM AS OUR MINIMUM AND INCREASE THEM. HE NEEDS MORE SUPPORT. YOU WILL NOT INTUBATE 95% OF THE TIME WITHOUT A BLOOD GAS (KEY HINT IN NBRC WORLD) SO WE ARE GOING TO INCREASE THE INSPIRATORY PRESSURE TO HELP WITH SOB IN HOPES TO HELP WITH DEMAND.

Question 16

During a ventilator check in the ICU, you observe the following settings and monitored parameters on a 70-kg (154-lb) patient receiving ventilatory support:

Volume Control SIMV, Rate of 10, Patient rate of 38, Vt 600mL, PEEP 8 cm H20, Minute ventilation 10 L/min

Which of the following actions would you recommend at this time?

A. Switch to A/C mode
B. Decrease the mandatory rate
C. Add pressure support
D. Increase the PEEP level

Answer 16

C IS THE CORRECT ANSWER. The key problem is the patient’s rapid spontaneous rate and low spontaneous tidal volume. If this is occurring, the first step should be to add pressure support

Question 17

A 150 lb patient is breathing at a rate of 20 bpm , with a VT 550mL ,what is his estimated alveolar ventilation per min?

A. 11
B. 8
C. 3
D.14

Answer 17

THE CORRECT ANSWER IS B 8.00L/MIN THE FORMULA FOR ALVEOLAR VENTILATION IS VE= F X ( VT-VD) IN THIS CASE THE PHYSIOLOGIC DEADSPACE IS ESTIMATED AT 1ML LB IBW OR 150ML SUBSTITING THE PATIENTS VALUES FOR F, VT AND ESTIMATED VD, YOU MUST COMPUTE 20 X (550-150) = 800 OR 8L/MIN

Question 18

THE CORRECT ANSWER IS B 8.00L/MIN THE FORMULA FOR ALVEOLAR VENTILATION IS VE= F X ( VT-VD) IN THIS CASE THE PHYSIOLOGIC DEADSPACE IS ESTIMATED AT 1ML LB IBW OR 150ML SUBSTITING THE PATIENTS VALUES FOR F, VT AND ESTIMATED VD, YOU MUST COMPUTE 20 X (550-150) = 800 OR 8L/MIN

Answer 18

THE CORRECT ANSWER IS B : 375 VT=8.25/22= 375mL

Question 19

The best way to control secretions is:

A. Sodium bicarbonate
B. Mucomyst
C. Recombinant human DNAse
D. Good hydration
E. All of the above

Answer 19

THE CORRECT ANSWER IS D! GOOD HYDRATION!!! REMEMBER THIS !!! SODIUM BICARBONATE ONLY INCREASES THE MUCUS pH AND DECREASING VISCOSITY, RECOMBINANT DNASE IS ANOTHER NAME FOR PULMOZYME GIVEN MAINLY TO CF PATIENTS , AND MUCOMYST DISSOLVES THE DISULFIDE BONDS.

Question 20

The results of a CT scan shows pleural effusion with a 15% collapse of in the right lung, which of the following is most appropriate recommendation?

A. Percutaneous lung biopsy
B. Lasix IV
C. Chest tube in 2nd interspace , anterior chest
D. Thoracentesis on right lung.

Answer 20

THE CORRECT ANSWER IS D! ANY PLEURAL EFFUSION 20% THEN IS CONSIDERED A HEMOTHORAX AND LIKELY A CHEST TUBE NEEDS TO BE IN PLACE.

Question 21

In analyzing overnight oximetry data, a desaturation event represents a decrease in Sp02 of what amount?

A. 2% or more
B. 3% or more
C. 4% or more
D. 5 % or more

Answer 21

THE CORRECT ANSWER IS C; MOST SLEEP DISORDER SPECIALISTS AGREE THAT A DESATURATION EVENT REPRESENTS A DECRASE OF SATURATION OF 4% OR MORE , THE TOTAL NUMBER OF THESE DESATURATIONS EVENT PER HR OS THE OXYGEN DESATURATION INDEX ( ODI).

Question 22

To remove accumulations of subglottic secretions from above the cuff of intubated patients, you should recommend which of the following?

A. IPV- intrapulmonary percussive ventilation
B. Use of a tracheal tube with suction port above the cuff
C. Aggressive tracheal suctioning with saline lavage
D. Frequent oropharyngeal suctioning with a Yankauer tip.

Answer 22

THE CORRECT ANSWER IS B. THE USE OF A TRACHEAL TUBE WITH SUCTION PORT ABOVE THE CUFF! A COMMON ISSUE WITH INTUBATED PATIENTS IS LEAKAGE OF SUBGLOTTIC SECRETIONS PAST THE TRACHEAL TUBE CUFF. THESE SECRETIONS CAN CONTAMINATE THE LOWER RESPIRATORY TRACT AND CAN CONTRIBUTE AND LEAD INTO VAP( VENTILATOR ASSISTED PNEUMONIA).

Question 23

Which of the following bronchial hygiene techniques is most suitable for small infants?

A. Postural drainage, percussion and vibration
B. Positive expiratory pressure
C. Aggressive suctioning with a 14Fr catheter
D. High Frequency Oscillation

Answer 23

THE CORRECT ANSWER IS A. OF THE CHOICES AVAILABLE THE BRONCHIAL HYGINE TECHNIQUE THAT IS MOST SUITABLE FOR SMALL INFANTS IS PD,PERCUSSION AND VIBRATION. PEP AND HFO ARE GENERALLY NOT USED ON INFANTS, AND AGGRESSIVE SUCTIONING ESP WITH A LARGE LAVAGE CATH WOULD BE POTENTIONALLY HARMFUL.

Question 24

A patient with congestive heart failure is coughing up large quantities of pink, frothy sputum. ABG values on simple mask 02 at 7 L/min are as follows:

pH 7.44
PaCO2 29 torr
HCO3 20 mEq/L
BE -3 mEq/L
Pa02 46 torr
Sa02 76%

Which of the following treatments would you recommend?

A. Nonrebreathing mask at 12 L/min and postural drainage therapy
B. Intermittent positive-pressure breathing (IPPB) with compressed air
C. Starting intrapulmonary percussive ventilation to clear secretions
D. Mask continuous positive airway pressure (CPAP) with 80% FIO2

Answer 24

D IS CORRECT! The frothy, pink sputum is usually an indication of acute pulmonary edema. This blood gas shows a compensated respiratory alkalosis secondary to severe hypoxemia (due to the edema). Therefore, oxygenation should be your main concern as well as maintaining alveolar inflation.

Question 25

Data for a 63-kg (140-lb) patient receiving ventilatory support with a 10 cm H20 PEEP are as follows: Vent Settings: VC SIMV, rate of 10, Vt of 600mL, PEEP of 5 cmH20, FIO2 of 70% Blood Gases: pH of 7.45/PaCO2 36 torr/Pa02 55 torr/HCO3 25/Sa02 100% Which of the following changes should you recommend at this time? A. Lower the Vt B. Increase the rate C. Increase PEEP D. Decrease the FIO2

Answer 25

THE ANSWER IS C! The goal of PEEP is to achieve adequate oxygenation with a safe FIO2. This patient is clearly shunting somewhere, indicating the need for an increase in PEEP. Also, ARDS protocol states that from FIO2 60% and up, the PEEP should be adjusted 2-3 cmH20.

Question 26

Which of the following best describes the way a patient should perform incentive spirometry? A. The patient should exhale maximally and hold it for at least 5 seconds B. The patient should inhale normally and hold it for several seconds C. The patient should hold a maximum inspiratory capacity (IC) breath for at least 5 seconds D. The patient should repeat maximum inspiratory and expiratory efforts for 10-15 seconds

Answer 26

C IS CORRECT! The patient should hold a maximum inspiratory capacity breath for at least 5 seconds.

Question 27

All of the following are needed for an effective cough except: A. A closed glottis B. Compression phase C.Explosive exhalation D. Low inspiratory volumes

Answer 27

THE CORRECT ANSWER IS D. THE EFFECTIVENESS OF A COUGH REQUIRES PROPER INTEGREATION OF 3 PHASES , INSPIRATORY COMPOMENT, COMPRESSION PHASE AND EXPLOSIVE EXHALTION. ENERGY IS TRANSFERED TO THE MUCOUS AND IT IS EXPELLED FROM THE AIRWAY. STRONG ABDOMINAL MUSCLES TO GENERATE LARGE VOLUMES WITH GLOTTIS CLOSURE WILL GENERATE HIGH INTRA-ALVEOLAR PRESSURES AND A GOOD COUGH.

Question 28

A. Suction at a pressure of -40 to-60 , limit time 30 seconds B. Suction at a pressure of -80 to -100, limit time of 10-15 seconds C.Suction at a pressure -100 to -120 ,continue to suction until you see secretions in ETT D. Suction at a pressure -60 to -80, limiting time to less than 10-15 seconds.

Answer 28

THE CORRECT ANSWER IS D. THE NORMAL SUCTION PRESSURE FOR INFANTS IS -*60 TO -80 MMHG, THE PATIENT SHOULD BE PREOX FOR A LEAST A MINUTE AND THE TOTAL SUCTION SHOULD BE LIMITED TO NO MORE THAN 10-15 SECONDS ON EACH ATTEMPT.

Question 29

You are preparing to intubate a patient who is 45kg. In preparing for direct laryngoscopy , you are able to visualize the hard palate, the base of the vallecula , This observation is consistent with a Mallampati score of? A. 3 B. 4 C. 2 D. 1

Answer 29

THE CORRECT ANSWER IS A : MALLAMPATI SCORE OF 3 IS CONSISTENT WITH HARD PALATE, SOFT PALATE AND BASE VISUALIZATION OF THE VALLECULA.

Question 30

A patient receiving pressure control ventilation at a rate of 10 bpm, has an I;E ratio 1:3 . what is the inspiratory time? A. 1.8 sec B. 1.0 sec C. 1.5 sc D. 2.0 sec

Answer 30

THE CORRECT ANSWER IS 1.5 sec. Total cycle time = 60/10 Total cycle time = 6 secs I -time = total cycle time / sum of IE ratio. I - time = 6/ 4 I-time = 1.5 secs

Question 31

``` 45 year old female patient is receiving SIMV VC ventilation Data: Fi02 45% Mandatory rate: 6 Total rate: 32 VT set: 450mL VT spont: 180mL ``` Several weaning attempts over the last 3 days have been made unsuccessful. which of the following would be most effective at improving weaning and decrease work of breathing? A. APRV B. NAVA C. Inverse IE D. PAV

Answer 31

**NAVA- Neurally Adjusted Ventilator Assist, PAV-Proportional Assist Ventilation** THE CORRECT ANSWER IS D! PAV PROPORTIONAL ASSIST VENTILATION IS A SUPERIOR METHOD OF INCREASING THE SIZE OF SPONTANEOUS VT AND DECREASED WOB,WHICH WORKS SIMILAR TO PSV, PAV ALSO ASSIST THE PATIENT AT VARYING LEVELS FOR EACH BREATH.

Question 32

62 year old male patient with asthma is admitted to the ICU with severe bilateral pneumonia BP 200/125mmHg Nipride( Nitroprusside) IV ordered and given. Which of the following you expect to increase? A. Distribution of gases throughout the lungs B. Pulmonary shunting C. V/Q mistmach D. Mean Pulmonary Arterial Pressure.

Answer 32

THE CORRECT ANSWER IS C! NIPRIDE WILL ULTIMATELY DILATE THE PULMONARY VESSELS, WHICH WILL LEAD INTO INCREASED BLOOD FLOW AROUND THE ALVEOLI ( PERFUSION) HOWEVER THE PNEUMONIA WILL CONTINUE TO LIMIT THE AMOUNT OF GAS THAT REACHES THE ALVEOLI ( VENTILATION ) ANY V/Q MISMATCH WILL BE INCREASED WITH THE ADMINISTRATION OF NIPRIDE.

Question 33

You receive a patient from a nursing home with a bacterial pneumonia. The patient has a 8.0 tracheostomy in place. You notice the tissue around the trach are ecchymotic and there is yellow pus like drainage . What would you recommend? A. Increase tracheostomy care frequency B. Close the trach site and switch to oral intubation C. Apply viscous lidocaine to site D. Switch to a Jackson trach tube

Answer 33

THE CORRECT ANSWER IS A! THE DEVELOPEMENT OF ECCYMOSIS AND PUS AROUND THE TRACH INDICATES AND SUGGEST THAT BETTER AND MORE FREQUENT TRACH CARE SHOULD BE PERFOMED.

Question 34

To reduce the chance of VAP , which of the following is most important? A.Use the inspiratory/expiratory filters on ventilator circuit B. Heated wires in ventilator circuit C. Single use sterile suction cathether D. Larger water reservoir on the ventilato

Answer 34

THE CORRECT ANSWER IS B: HEATED WIRES IN A VENT CURCUIT WILL HELP PREVENT FORMATION OF CONDENSTATION , TOO MUCH CONDENSATE IN A VENT CIRCUIT WILL INCREASE THE CHANCE OF NOSOCOMIAL INFECTION AND VAP.

Question 35

A 5'9" 160 lbs male is receiving AC/VC ventilation on these settings: ``` Fi02 65% Mandatory rate 16 VT 400mL PEEP 18 I:E ratio 1:2 ``` The resident orders a decrease in peak inspiratory flow which of the following best explains the effect on this change to the patient? A. Decreased Mean airway pressure B. Improves pulmonary compliance C. Decreases Pulmonary Vascular Resistance D. Improves gas distribution

Answer 35

THE CORRECT ANSWER D! DECREASED PEAK INSPIRATORY FLOW WILL PROLONG I-TIME WHICH WILL PROMOTE BETTER DISTRIBUTION OF GASES IN THE LUNGS.

Question 36

Patient receiving volume-limited ventilation with a VT of 600mL and 10cmH20 PEEP, has a peak pressure of 45cmH20 and a plateau pressure of 30 cmH20 . What is this patients static compliance? ( mL/cmH20) A. 13 B. 15 C.20 D.30

Answer 36

THE CORRECT ANSWER IS D 600/ (30-10) = 30 mL/cmH20

Question 37

All of the following are associated with patient being at risk of malnutrition except: A. Recent weight gain B. Being significantly underweight C. Having poor dietary habits D. Inability to prepare own food

Answer 37

THE CORRECT ANSWER IS A ANY PATIENT WHO IS SIGNIFICANTLY UNDERWEIGHT ,HAS RECENTLY LOST A SIGNIFICANT AMOUNT OF WEIGHT OR HAS POOR DIETARY /INADEQUATE FOOD INTAKE /OR UNABLE TO PREPARE HIS OR HER OWN FOOD IS AT HIGH RISK FOR MALNUTRITION, WEIGHT GAIN IS NOT NORMALLY ASSOCIATED WITH MALNUTRITION

Question 38

A patient undergoing CPAP titration during sleep exhibits 3 obstructive events during a 5 minute observation interval at a pressure of 8cmH20, What would be the appropriate action at this time? A. Switch the patient to BiPAP with IPAP 12 EPAP 8 B. Increase the CPAP to 10 for 5 minutes and continue to observe C. Discontinue the titration trial and place the patient on Nasal 02 at 2Lpm D. Decrease the CPAP to 6cmH20 for minutes and continue observation.

Answer 38

THE CORRECT ANSWER IS B IN ANY OF THE FOLLOWING EVENTS OCCUR DURING CPAP TITRATION OBSERVATION INTERVAL UP TO MAX PROTOCOL PRESSURE , TYPICALLY 20CMH20 , YOU SHOULD INCREASE CPAP LEVEL BY AT LEAST 1CMH20 : > 2 OBST APNEAS, > 3 HYPOPNEAS, > 5 RERA's > 3 MIN OF LOUD SNORING.

Question 39

24 year old male has sustained facial bone fractures causing morphological changes to his face, to protect his airway intubation has been ordered. As the RT to intubate you should anticipate which of the following intubation technique and devices? A. Airway exchange catheter B. Direct Laryngoscopy C. Nasal Intubation D. Bronchoscopy assisted intubation

Answer 39

THE CORRECT ANSWER IS D! DUE TO MORPHOLOGICAL FACIAL CHANGES - ANATOMICAL THE PATH OF THE ETT IS UNPRECDICTABLE IN SUCH CIRCUMSTANCE WILL BE CONSIDERED A DIFFICULT INTUBATION OR COMPLICATED , THEREFORE THE USE OF A BRONCHOSCOPE TO INTUBATE IS INDICATED FOR THIS PATIENT.

Question 40

Which of the following conditions is associated with jugular venous distention? A. Septic shock B. Pneumonia C. Cor Pulmonale D. Pneumothorax

Answer 40

THE CORRECT ANSWER IS C COR PULMONALE WHICH IS RIGHT HEART FAILURE DUE TO CHRONIC LUNG DISEASE.

Question 41

A patient has a PCWP of 18mmHg , all the following are potential causes for this finding except: A. Hypovolemia B. Mitral Valve Stenosis C. PEEP D. Left Ventricular failure

Answer 41

THE CORRECT ANSWER IS A: HYPOVOLEMIA RECALL THIS QUESTIONS STATES EXCEPT!! THE PCWP IS 18MMHG THAN THE NORMAL PCWP WHICH IS 4-12 MMHG, ALL OF THE CAUSES LISTED EXCEPT HYPOVOLEMIA CAN INCREASE PCWP , HYPOVOLEMIA TENDS TO LOWER ALL VASCULAR PRESSURES.

Question 42

Which of the following aspects of a patients social life history is most important in the diagnosis of lung disease? A. Marital Status B. Cultural background C. Education D. Occupational History

Answer 42

THE CORRECT ANSWER IS D: OCCUPATIONAL HISTORY , MANY LUNG DISEASES ARE ASSOCIATED WITH INHALATION OF DUST OR TOXIC CHEMICALS IN THE WORK SETTING.

Question 43

Upon reviewing the results of the attending physician physical exam of a patients chest you note a dull percussion note and bronchial breath sounds LLL, all of the following are potential problems except? A. Infiltrates B. Atelectasis C. Consolidation D. Pneumothrorax

Answer 43

THE CORRECT ANSWER IS D; RECALL AND READ CAREFULLY FOR THOSE EXCEPT WORDS!! A PATIENT WITH A DULL PERCUSSION NOTE AND BRONCHIAL BREATH SOUNDS ON THE CHEST EXAM MOST LIKELY HAS EITHER PULMONARY INFILTRATES , ATELECTASIS OR CONSOLIDATION ON THE AFFECTED AREA. PTX RESULTS IN HYPERRESONANT PERSUCUSSION NOTE.

Question 44

During the interview of your patient you determine that she is disoriented to time, place and person. What might explain this findings? A. Respiratory Alkalosis B. Severe Hypoxemia C. Metabolic Acidosis D. Hyperthermia

Answer 44

THE CORRECT ANSWER IS B SEVERE HYPOXEMIA : AN ABNORMAL SENSORIUM IS OFTEN CAUSED BY A LACK OF ADEQUATE OXYGENATION TO THE BRAIN, SEVERE HYPOXEMIA REDUCES THE OXYGEN AVAILABLE TO THE BRAIN AND LEADS TO CONFUSION. AN ABNORMAL SENSORIUM IN ANY PATIENT SHOULD BE ASSUMED TO BE CAUSE BY HYPOXIA UNTIL PROVEN OTHERWISE.

Question 45

A patient has a 7mm ID trach tube , what size suction catheter should you use? (Fr) A. 14 B. 12 C.10 D. 8

Answer 45

THE CORRECT ANSWER IS B 12Fr. Cath size (Fr) =(3 x ETT ID)/2 so therefore 3x7 /2 21/2=10.5 ROUND UP TO 12

Question 46

What inspiratory flow is needed for a patient receiving volume-limited ventilation at a rate 20bpm , I:E ratio of 1:2 and VT 500mL? (L/min) A. 60 B.50 C.40 D.30

Answer 46

THE CORRECT ANSWER IS D! Ve = 10L/min, % I-time =33%, Vinsp =Ve / %I-time = 10/33= 30L/min

Question 47

A patient has a VT 450mL and an arterial PC02 ( PaC02) of 60torr and a mixed expired PC02 (PEC02) of 30 torr , What is the deadspace? ( mL) A. 300 B. 225 C. 150 D. 200

Answer 47

THE CORRECT ANSVWER IS 225mL USING THE PHYSIOLOGIC DEADSPACE FORMULA VD= VT X PaC02- PeC02/ PaC02. 450mL x ( 60-30)/60 450mL x (30/60) Vd= 225mL

Question 48

You would recommend consideration of all of the following imaging modalities for diagnosing a patient suspected of having a pulmonary embolism except? A. V/Q scan B. AP Chest Xray C. CT Scan D. Pulmonary Angiography

Answer 48

THE CORRECT ANSWER IS B: AP CHEST XRAY IS NOT USEFUL IN DETECTING A PE. PULMONARY ANGIOGRAPHY HAS BEEN THE GOLD STANDARD,ALONG WITH V/Q SCANNING AND CT, ALSO TRANSTHORACIC US HAVE BECOME ACCEPTED NON INVASIVE TOOLS FOR DIAGNOSING PE.

Question 49

``` A 150 lbs patient has a VT of 600mL and an arterial PC02 of 50 torr and a mixed expired PC02 ( PEC02) of 35 torr , what is the patient's physiologic deadspace? (mL) A. 200 B. 300 C.180 D.350 ```

Answer 49

THE CORRECT ANSWER IS C VD= 600 X ( 50-35) /50 = 180mL

Question 50

A patient has a FRC of 3800mL , a VT of 400mL and an ERV of 1300mL what is the RV? (mL) A. 2500 B. 3500 C.2200 D. 1500

Answer 50

THE CORRECT ANSWER IS A RV= FRC- ERV THEREFORE FRC 3800- ERV 1300 = RV OF 2500mL

Question 51

``` A 5 foot 4 inches tall 110lb woman with normal lungs has a VT 480mL and is breathing at a rate of 14/min , what is her approx. alveolar ventilation? ( L/min) A. 6.72 B. 3.42 C. 5.18 D.15.4 ```

Answer 51

THE CORRECT ANSWER IS C! ASSUME NORMAL DEADSPACE 1mL /lb x 110 = 110mL VA= 14x (480-110) = 5180 or 5.18L/min

Question 52

``` A patient has a TLC of 5500mL and a VC of 4000mL and an IC 3000mL. What is his functional residual capacity (FRC)? (mL) A. 2500 B. 1500 C.1000 D. 7000 ```

Answer 52

THE CORRECT ANSWER IS A FRC= TLC-IC THEREFORE TLC 5500- IC 3000 = 2500mL

Question 53

Patient has been admitted to ICU after discovering a 2.8cm mass in his larynx . the patient is scheduled for surgery but is demonstrating a moderate level of respiratory distress. Which of the following would be most helpful for this patient? A. 0.5ml of 2.25% racemic epi B. 02 by NRB C. Tracheostomy D. 80/20% HeliOx

Answer 53

THE CORRECT ANSWER IS D RESPIRATORY DISTRESS BEING EXPERIENCED BY THIS PATIENT IS DUE TO INCREASED AIRWAY RESISTANCE BROGUHT ON BY A FIXED UPPER AIRWAY OBSTRUCTION SINCE MASS CANT BE REMOVED OR REDUCED THE USE OF HELIOX WILL EASE THE WOB, HELIUM IS LESS DENSE THAN NITROGEN AND THEREFORE IS EASIER TO BREATHE IN AND OUT PASS THE FIXED OBSTRUCTION

Question 54

``` 60 year old patient is 4 hrs post myocardial revascularization Sv02 decreased from 71% to 63% Sp02 is unchanged CVP 10mmHg PAP 35/16mmHg ``` As the RT for this patient you can conclude which of the following is most likely to decrease? A. 02 consumption B. Ca02 C. Cardiac Index D. Pulmonary Vascular Resistance

Answer 54

THE CORRECT ANSWER IS C DECRASED VENOUS SATURATION IN THE PRESENCE OF STEADY ARTERIAL SATURATION SUGGEST THAT 02 CONSUMPTION AT THE TISSUE LEVEL IS INCREASING. THIS IS ALSO MANIFEST BY DECREASE IN VENOUS OR 02 CONTENT AS THE GRADIENT BETWEEN Ca02 and Cv02 INCREASES , IT MEANS 02 CONSUMPTION IS INCREASING AND CARDIAC OUTPUT AND INDEX IS DECREASING.

Question 55

Which of the following methods is most effective and most rapid for weaning patients from mechanical ventilation? A. SBT B. APRV C.SIMV D. PS

Answer 55

THE CORRECT ANSWER IS A SBT: SPONTANEOUS BREATHING TRIALS)! THE ARE THE MOST EFFECTIVE WAY TO WEAN PATIENTS OFF THE VENT.

Question 56

32 year old male with a Pa02/Fi02 ratio of 150 without any previous cardiac history is in ICU being monitored by PAC - pulmonary arterial cath. Hemodynamics: ``` PAP 25mmHg CVP 13 torr PCWP 7 mmHg HR 124 BP 95/56 mmHg ``` What would you recommend? A. Romazicon ( Flumazenil) B. Sildenafil ( Revatio) C. Inhaled epoprosternol ( Flolan) D. Protonix( Pantaprazole)

Answer 56

THE CORRECT ANSWER IS C : EXCESSIVE PAP IS CAUSING INTRA CARDIAC SHUNTING, THIS CAN BE RESOLVED BY GIVING FLOLAN WHICH WILL SELECTIVELY DILATE PULMONARY VESSELS AND LOWER PAP.

Question 57

COPD patient in ICU being monitored with a balloon tipped flow directed pulmonary arterial catherer showing the following hemodynamic data: CVP 9 torr PAP 15 torr PCWP 9 torr CO 4.8L/min Which of the following would most likely represent the patients condition? A. Cor pulmonale B. Pulmonary Hypertension C. Pulmonary Air Embolism D. Left heart Failure

Answer 57

THE CORRECT ANSWER IS A! HEMODYNAMICS SHOW RIGHT HEART ISSUE , CVP IS ELEVATED WHILE PAP IS NORMAL

Question 58

54 Year old patient is on AC VC status post MVA ,pulmonary compliance has decreased slowly over the last week, Inverse IE ration ventilation has been instituted Echocardiogram with bubble study confirms a PFO ( Patent Foramen Ovale) This patient is on PEEP 20 and Fi02 of 60% What should you do next? A. Schedule surgery for PFO closure in 48 hrs B. Perform a V/Q scan C. Begin iNO therapy( nitric oxide) D. Administer Nipride

Answer 58

THE CORRECT ANSWER IS C FOR ALL OPTIONS IN THIS SCENARIO iNO WOULD BE THE MOST BENEFICIAL TO THE PATIENT WHILE THE PFO SHOULD BE SURGICALLY REPAIRED , NITRIC OXIDE WOULD KEEP THE PULMONARY PRESSURE DOWN AND DECREASE NEGATIVE EFFECTS OF THE PFO

Question 59

While reviewing the lab chemistry of a patient in metabolic acidosis due to renal failure, which electrolyte would you expect to be abnormally high? A. Glucose B. Bicarbonate C. Chloride D. Potassium

Answer 59

D IS CORRECT! Metabolic acidosis increases H+ levels outside the cells. In an effort to buffer this acidosis, intracellular K+ ions are exchanged with extracellular H+, producing hyperkalemia. The first step here is to correct the metabolic acidosis (This actually came from a patient case a month ago in the ED at Albany Medical Center, I had a doctor explaining to me the major care plan going forward)

Question 60

78 year old male is 6hrs post op for mitral valve replacement . The following data is gathered from this patient. Patient is receiving AC VC with Fi02 100% PEEP 18cmH20 ``` HR 124 bpm BP 98/52 mmHg CVP 6 torr PAP 75/46 mmHg PCWP 18mmHg CI 1.7 L/min/m2 ``` ABG: 7.37, PaC02 44, Pa02 62, HC03 24, BE -1 Which condition must you conclude from the following data given: A. Cor pulmonale B. Hypervolemia C. Left heart failure D. Decreased Pulmonary Vascular Resistnace

Answer 60

THE CORRECT ANSWER IS C LEFT HEART FAILURE : HEMODYNAMIC DATA SUGGESTS WITH AN INCREASED PCWP WITH LOW CARDIAC INDEX SUGGEST BLOOD IS HAVING DIFFICULTY TRANSIOTING TO THE LEFT HEART,THIS IS MOST LIKELY SOME SORT OF FAILURE ASSOCIATED WITH NEW MITRAL VALVE.

Question 61

A patient is receiving a treatment with 2.5mg of albuterol and 3mL of normal saline in the emergency department. The heart rate prior to therapy is 80/min; at the end of therapy, the heart rate is 128/min. Which measure should you recommend? A. Adding Acetylcysteine (Mucomyst) to the treatment B. Decreasing the dosage of albuterol C. Increasing the amount of saline per treatment to 5 mL D. Changing to ipratropium bromide (Atrovent)

Answer 61

B IS THE CORRECT ANSWER! And some of you I see have thought about this, ATROVENT IS NOT A RESCUE DRUG! The significant increase in heart rate (more than 20 from baseline) indicates that albuterol is provoking systemic side effects on this patient, specifically the heart. The best option is to decrease the dosage of albuterol. Word to the wise, KNOW YOUR DOSAGES FOR THE BOARD EXAMS!

Question 62

``` As you review the medical record of a 64 year old patient with history of cirrhosis admitted to ICU for hematemesis and ventilatory difficulty. An EGD ( esophagogastroduodenoscopy) confirms erosive gastritis. ``` Data: Hb: 7.6 g/dL RBC 2.5 g/dL WBC 10K uL Platelets 82K uL What would you recommend for prophylaxis for this patient? A. Methylene blue via NG tube B. Lovenox C. Protonix D. Dobutrex

Answer 62

THE CORRECT ANSWER IS C: PROTONIX ( PANTAPRAZOLE) IN PRESENCE OF ERROSIVE GASTRITIS , STOMACH ACID SHOULD BE CONTROLLED AND REDUCED USING PROTONIX.

Question 63

A physician orders 3 L/min 02 via simple mask to a 33-year-old postoperative female patient with moderate hypoxemia while breathing room air (Pa02= 55 torr), which of the following is the correct action at this time? A. Carry out the physician's prescription exactly as written B. Recommend a flow of at least 5 L/min C. Recommend that the mask be changed to a cannula at 2 L/min D. Do not apply the oxygen until contacting the medical director

Answer 63

B IS CORRECT, A SIMPLE MASK REQUIRES AT LEAST A FLOW OF 5 L/MIN TO PREVENT CO2 REBREATHING!

Question 64

Which of the following should you do to properly perform nasotracheal suctioning on an adult patient? 1. Lubricate the catheter 2. Apply suction for less than 15 seconds 3. Pre-oxygenate and post-oxygenate the patient 4. Have the patient exhale and then hold their breath A. 1 and 4 only B. 1, 2 and 3 C. 3 and 4 only D. 1, 3 and 4

Answer 64

B IS THE CORRECT ANSWER. Always pre-oxygenate before naso-tracheal suctioning as you could stimulate a vagal response in which the patient's heart rate could drop as well as their oxygen saturation. Always lubricate as well, this makes a really unpleasant procedure more...bearable I guess I could say!

Question 65

A 18 month old patient has been admitted to the PICU with croup and the doctor has asked you to start the patient on a Heliox mixture of 80/20. You use a oxygen flow meter and set the flow meter to 14 LPM. What is the actual flow?

Answer 65

SO YOU MUST KNOW THE FACTOR FOR 80/20- FACTOR 1.8 ( I TEACH PEOPLE EASY WAY TO REMEMBER THIS ONE 80/20 HAS AN 8 AND SO DOES 1.8). ANSWER: 14 (FACTOR)= ACTUAL FLOW FACTOR=1.8 14(1.8)=25.2 I will write it a few other ways since people aren't familiar with (_) so, 14 x 1.8 = 25.2 or 14 * 1.8 = 25.2 NOW WHY IS THE FLOW HIGHER? BECAUSE HELIOX IS LESS DENSE THAN OXYGEN IT FLOWS FASTER THAN OXYGEN!

Question 66

Patient in the CCU has a stroke volume of 55mL, BSA of 2.3, HR of 80, and BP of 106/72. What is the patients Cardiac Output?

Answer 66

CO=SV x HR = 55ml x 80 beats = 4,400 ml/beat......aka 4.4L/beat

Question 67

Patient in bed 2 is s/p a CABG X2 with a cardiac output of 5.5 L/min and has a heart rate of 93 beats /min. He is 67 cm and has a dry weight of 75 kg. What is the patient's stroke volume? Is it within normal limits?

Answer 67

SV=CO/HR= 5,500/93 = 59.1 ml/beat;low

Question 68

What is the equation for Stroke Volume? | What is the normal value range that you learned?

Answer 68

CO/HR. NORM 60-90

Question 69

What is the equation for Cardiac Output?

Answer 69

CARDIAC OUTPUT= STROKE VOLUME X HEART RATE

Question 70

You are reviewing your orders and notices that the doctor has ordered an actual flow of 18LPM of a 80/20 heliox mixture. What should you set your flow meter to?

Answer 70

10

Question 71

``` A doctor ordered 5L/min of Heliox 70/30 mixture. What is the actual gas flow? A. 2.8 B. 3.1 C. 8 D. 9 ```

Answer 71

NEED TO KNOW THE FACTOR HOWEVER THIS IS A 70/30 MIXTURE SO THE FACTOR IS 1.6. ORDERED FLOW (FACTOR) = ACTUAL FLOW. 5 (1.6) = 8

Question 72

Which of the following bronchial hygiene techniques is most suitable for small infants? A. Postural drainage, percussion and vibration B. Positive expiratory pressure C. Aggressive suctioning with a 14F catheter D. High frequency oscillation

Answer 72

A IS THE BEST ANSWER HERE. Before I go further, high frequency oscillation is indicated when an infant (pre term or term) or young children are in respiratory failure that is not responsive to conventional ventilation. THIS WILL NOT AID IN THE REMOVAL OF SECRETIONS. Postural drainage and percussion with vibration can be very effective for clearing secretions out of small children and infants (if you do it just right, they will fall asleep on you!)

Question 73

The administration of which aerosolized drug is most appropriate to thin secretions and help in the removal of a mucus plug? A. Albuterol B. Ipratropium Bromide C. Acetylcysteine D. Racemic Epinephrine

Answer 73

Ah our friend Mucomyst (As some RT's refer to it at Albany, Puke-O-Myst because of the smell), C IS CORRECT! This drug actually breaks up the disulfide bonds (small bonds that hold the secretions together in a thick, sticky mess) and can help thin secretions in patients with mucus plugs

Question 74

What is the Dynamic Compliance (Cdyn) for a patient with the following ventilator information: Vt 640mL, Pplat 44 cmH20, PIP 58 cmH20, and 8 of PEEP?

Answer 74

DYNAMIC COMPLIANCE= Cdyn= VT/PIP-PEEP. Cdyn=640/58-8 640/50=13

Question 75

What is the Static Compliance (Cs) for a patient with the following ventilator information: Vt 640mL, Pplat 44 cmH20, PIP 58 cmH20, and 8 of PEEP

Answer 75

EQUATION FOR STATIC COMPLIANCE: Cs= VT/ PLAT-PEEP. Cs= 640/44-8 = 640/36 = 18

Question 76

A doctor has ordered 12L/min of Heliox 80/20 mixture. What is the actual gas flow?

Answer 76

CORRECT 12 X 1.8 = 21.6. 1.8 IS THE FACTOR FOR 80/20 MIXTURE!

Question 77

A patient has an oxygen consumption of 300mL/min, an arterial 02 content of 18 mL/dL and a mixed venous 02 content of 12 mL/dL. What is the cardiac output for this patient? A. 6L/min B. 5L/min C. 3L/min D. 8L/min

Answer 77

THE CORRECT ANSWER IS B! A NORMAL C(a-v)O2 IS ABOUT 5mL/dL. CO= VO2/ C(a-v)02 x10. 300/ (18-12)x10. 300/60 = 5L/min

Question 78

``` Patient has a cardiac output of 4L/min and a HR of 80 bpm. What is his stroke volume? (ml/min) A. 60 B. 30 C. 50 D. 20 ```

Answer 78

THE CORRECT ANSWER IS C!! SV =CO/HR. 4000ml/80 =50ml/beat

Question 79

A patient has a minute volume of 8.25L/min and his breathing at a rate of 22/min. What is his average VT? (mL) A. 375 B. 400 C. 475 D. 400

Answer 79

THE CORRECT ANSWER A !

Question 80

A patient receiving volume limited ventilation with a VT of 400mL , inspiratory flow of 75 L/min and 6 PEEP, peak pressure of 45 cmH20 and a plateau pressure of 30cmH20. Whats is the airway resistace? (cmH20/L/sec) A. 12 B. 14 C. 17 D. 20

Answer 80

THE CORRECT ANSWER IS A! AIRWAY RESISTANCE FOR ORALLY INTUBATED PATIENTS RANGE FROM 10-15cmH20 EXPECT HIGHER COMPUTED VALUES IN PATIENTS WITH AIRWAY OBSTRUCTION. Raw= PIP-Pplat/V Raw= 45-30/(75 L/min / 60 sec) Raw= 12cmH20/L/sec

Question 81

``` A patient has a cardiac output of 6.1L/min and a body surface area of 2.3m2 what is his/her cardiac index? (L/min/m2) A. 3 B. 5 C. 4 D. 6 ```

Answer 81

THE CORRECT ANSWER IS A! FOR ADULTS THE NORMAL CARDIAC INDEX WILL ALWAYS BE < THE CARDIAC OUTPUT ABOUT 1/2 AS MUCH FOR THE AVERAGE SIZE ADULT

Question 82

Patient has a VT of 400mL and is breathing at 14/min. What is her minute volume? (L/min) A. 9.0 B. 5.6 C. 7.8 D. 6.0

Answer 82

THE CORRECT ANSWER B! AVERAGE MINUTE VOLUME IS 4-10L/MIN FOR MOST ADULTS VE=F X VT 14x 400 VE= 5600 or 5.6 L/min

Question 83

You palpate the patient's neck and notice the trachea is shifted to the patient's left. Which of the following conditions could explain this following? A. Left ventricular enlargement B. Left upper lobe collapse C. Right lower lobe collapse D. Pleural effusion on the left

Answer 83

B IS CORRECT HERE. Volume loss in the upper lobe will pull the trachea TOWARD the collapsed lung. In this case the trachea has shifted to the left, indicating that either volume loss has occurred on the left or a space-occupying lesion (tension-pneumothorax, effusion or tumor) on the right is pushing the trachea to the left.

Question 84

A 6 ft 4 in 200lbs man with normal lungs has a VT of 680mL and is breathing at a rate of 15 bpm. What is his approximate alveolar ventilation? (L/min) A. 6.8 B. 9.8 C. 7.2 D. 8.0

Answer 84

``` THE CORRECT ANSWER IS C! VA= F X( VT-VD) 15 x (680-200) 15x 480 VA= 7200 or 7.2 L/min ```

Question 85

A doctor orders 0.25mL of 2.25% racemic epi in 3mL NS via SVN for a child with croup. How many mg of racemic epi are you delivering? A. 6.8mg B. 5.6 mg C. 0.75mg D. 12.0mg

Answer 85

THE CORRECT ANSWER IS B ! **1ml of a 1% solution (1:100)=10mg of solute** 10x 2.25=22.5mg/mL. 22.5mg/mLx 0.25mL=5.6mg

Question 86

You come upon an elderly patient who is unresponsive and is not breathing. You had heard from the nurse that she had discussed with her physician about placing a do not resuscitate (DNR) order in her chart. What should you do? A. Check the patient's chart for a DNR order/advance directive B. Immediately call a code and begin resuscitation efforts C. Contact the nurses' station and ask how to proceed D. Call a "slow code" (i.e., apply basic CPR, but not ACLS)

Answer 86

B IS CORRECT. The patient is the most important subject of this question. At this point, it appears that the DNR order is in question, meaning the chart is not in front of us to determine a patient's wishes. Therefore we must not wait, call the darn code and begin resuscitation efforts right away. If the patient is truly DNR, it can be dealt with fairly quickly after the code has been called.

Question 87

A patient's bedside spirometry results (as compared to normal) are as follows: FVC decreased, FEV1 normal, and FEV1% increased. What is the most likely diagnosis? A. An obstructive disorder B. Poor patient effort C. A restrictive disorder D. Within normal limits

Answer 87

C IS THE CORRECT ANSWER! A patient with a decreased FVC, normal FEV1 and increased FEV1% is a classic pattern exhibited by patients with a restrictive pulmonary disorder-decreased volumes with normal flows!

Question 88

An AP x-ray of a 3-year old child with wheezing and stridor shows an area of prominent subglottic edema, but the lateral neck x-ray appears normal. What is the most likely problem? A. Croup B. Foreign body C. Epiglottitis D. Cystic Fibrosis

Answer 88

A IS CORRECT! On X-rays, the area of edema is BELOW the vocal chords. This should immediately send up red flags to think about the possibility of croup. Foreign bodies WILL NOT SHOW UP AS EDEMA. You will actually see a foreign body outline (such as a gumdrop or marble). SUBGLOTTIC EDEMA is the key to this question. Also the position of the X-rays might give you a clue. An A-P is taken from the front where a lateral is taken from the side.

Question 89

On reviewing an ECG printout, you note widened QRS complexes. Which of the following is the most likely cause of this problem? A. Atrial fibrillation B. First-degree heart block C. Sinus arrhythmia D. Bundle branch block

Answer 89

D IS MOST CORRECT! QRS complexes appear wider than normal (more than 0.12 seconds on ECG paper) in PVCs, bundle branch blocks, V-Fib and hyperkalemia as well

Question 90

To assess the level of pain that a 2 year old child is experiencing during a procedure, you would do all of the following except: A. Look for facial grimacing B. Ask for the mother's judgement C. Use a numeric pain scale D. Observe for crying

Answer 90

C IS CORRECT HERE. A numeric pain scale is not useful for young children or patients who cannot express themselves. In order to assess a young child's pain, you must get input from a family member. If a family member is not present, look for grimacing or crying

Question 91

You note on inspection of an anterior-posterior (AP) chest radiograph that the right hemidiaphragm is elevated above normal. Which of the following is the most likely cause of this abnormality? A. Right-sided pleural effusion B. Right tension pneumothorax C. Right phrenic nerve paralysis D. Right lower lobe pneumonia

Answer 91

C IS CORRECT! I picked this question up when I was working in the pulmonary lab with one of our pulmonologists at Fletcher Allen in Vermont, I had not seen this case before or since. An elevated diaphragm means the phrenic nerve is paralyzed on the affected side. Hyperinflated lungs will show the opposite, a flattened diaphragm!

Question 92

Patient currently on mechanical ventilation in ICU with the current data: ``` AC-VC actual rate: 20 VT 900 Set rate 10 Fi02 35% ABG: 7.54/20PaC02/125/17/99% ``` Based on this information you should suggest the following A. Add 5+ PEEP B. Add Deadspace C. Change to SIMV mode with a set rate of 10bpm D. Set the Fi02 to 25%

Answer 92

THE CORRECT ANSWER IS C: CHANGE TO THE SIMV MODE WITH A SET RATE OF 10 . THE ABG INDICATES A PARTIALLY COMPENSATED RESPIRATORY ALKALOSIS, MOST LIKELY THE RESULT OF THE PATIENT INTIATING 10 MACHINE BREATHS ABOVEE THE SET RATE. BY CHANGING TO A MOVE OF SIMV THE SPONT INITIATED BREATHS WILL NOT BE DELIVERED AT THE SET VT, BUT RATHER THE PATIENT WILL RECIEVE ONLY WHAT THE HE OR SHE CAN DRAW FROM THE CIRCUIT ON SUCH BREATHS. AS A RESULT THE PATIENTS MINUTE VOLUME WILL BE REDUCED.

Question 93

All of the following are proper patient instructions for positive expiratory pressure (PEP) except: A. Take in a breath that is larger than normal, but don't fill the lungs completely B. Exhale forcefully and maintain expiratory pressure of at least 20 cm H20 C. After 10 to 20 breaths, perform 2 to 3 huff coughs and rest as needed D. Repeat the cycle four to eight times, not to exceed 20 minutes

Answer 93

THE CORRECT ANSWER IS B. This is another question with the word "except" in it. BE ON THE LOOKOUT FOR THESE TYPES OF QUESTIONS AS THEY WILL APPEAR ON THE BOARD EXAMS! Patients performing PEP therapy should be instructed to sit comfortably and take a moderately deep breath. After the deep breath, they should exhale actively, but not forcefully. This expiration should last about 3 to 4 times longer than inspiration. Perform this procedure for 10-20 breaths followed by a good cough and some rest. Repeat for 4 to 5 sets, but do not exceed 20 minutes.

Question 94

A patient receiving NPPV therapy for acute respiratory failure has a Pa02 of 48 torr on 65% Fi02 IPAP 20 cmH20 EPAP 5 cm H20 MD wants to you to increase his Pa02 What would you recommend? A. Increase Fi02 to 80% B. Increase IPAP to 25 C. Increase EPAP to 10 D. Decreasing IPAP to 15

Answer 94

THE CORRECT ANSWER IS C : INCREASING EPAP TO 10CMH20 . THIS PATIENT HYPOXEMIA IS DUE TO SHUNTING Pa02 50 IF SHUNTING IS PRESENT WHEN ADMINISTERING NPPV FOR ACUTE RESPIRATORY FAILURE INCREASE THE EPAP WHILE BEING SURE TO KEEP THE deltaP >5 cm H20.

Question 95

Early in a spontaneous breathing (weaning trial), you observe a 170-lb, 6-foot-tall male patient breathing at a rate of 35/min with a minute ventilation of 8.75 L/min. Which of the following conclusions can you draw from this finding? A. The patient's alveolar ventilation is normal for his size and weight B. The patient is in acute hyperemic respiratory failure C. The patient cannot sustain prolonged spontaneous ventilation D. The patient has weakened respiratory muscle strength

Answer 95

C IS CORRECT! If we do the math out, this patient has a tidal volume of 250mL (8750mL/35 breaths per minute=250 mL/breath) and a rapid shallow breathing index (RSBI) of 140 (35/0.25=140). When a RSBI exceeds 105 early in SBTs, the attempt is likely to fail.

Question 96

A patient with acute bronchitis is receiving mechanical ventilation , wheezes bilaterally , rhonchi over central airways. Secretions are thick and creamy. Peak pressure is 45 cmH20 and plateau pressure 20 cmH20 . All of the following would be useful to treat the patients condition except: A. Albuterol B. Atrovent C. Mucomyst D. Pavulon

Answer 96

THE CORRECT ANSWER IS D: PAVULON IS A NON DEPOLIRIZING NEUROMUSCULAR BLOCKING AGENTS THAT WILL NOT ACHIEVE BRONCHODILATION OR CLEAR AIRWAY. IN FACT PAVULON CAN CAUSE RELEASE OF HISTAMINE WHICH YOU ALL KNOW CAN CAUSE BRONCHOSPASM.

Question 97

An adult male requires postural drainage of the posterior basal segments bilaterally. To properly position this patient, you should: 1. Elevate the foot of the bed 30 degrees 2. Keep the bed flat but put a pillow under the patient's hips 3. Have the patient lie supine with a pillow under the hips 4. Have the patient lie prone with a pillow under the hips A. 1 and 2 only B. 3 and 4 only C. 1 and 4 only D. 2 and 3 only

Answer 97

C IS THE CORRECT ANSWER AND MANY FIST BUMPS ALL AROUND! To drain the posterior basal segments, place the patient in a prone Trendelenburg position (30 degrees, remember that for the boards!), with a pillow under the hips

Question 98

During a patient ventilator check in the ICU, you observe the following settings and monitored parameters on a 70kg patient receiving ventilator support: ``` SIMV 10 Mandatory rate 37 VT 600 PEEP 8+ Ve: 10L/min CVP 4 PAP 25/8 PCWP 12 ``` Which of the following action would you recommend at this time? A. Switch to AC/VC B. Decrease mandatory rate C.Add Pressure Support D.Increase PEEP

Answer 98

THE CORRECT ANSWER IS C: ADD PRESSURE SUPPORT!!!, THE KEY PROBLEM IS THE PATIENTS RAPID SPONTANEOUS RATE AND LOW SPONT VT. THE SPONT VT = TOTAL MIN VOL-SET MIN VOL/ TOTAL RATE- SET RATE = 10000-6000/38-10 =4000 /28= 142mL.TO INCREASE THE SPONT VT , YOU SHOULD ADD PS . THIS WILL INCREASE THE EFFICIENCY OF SPONT VENTAND ALLOW FOR A LOWER SPONT RATE OF BREATHING. IN FACT YOU CAN JUDGE THE EFFECT OF PS BY RESULTING DECREASE IN RATE. A GOOD RULE OF THUMB IS TO PROVIDE SUFFICIENT PS TO ASSURE SPONT RATE.

Question 99

Upon exam of an acutely dyspneic and hypotensive patient, you note the following (all limited to the left hemithorax): reduced chest expansion, hyper resonance to percussion, absence of breath sounds and tactile fremitus, and a tracheal shift to the right. These findings suggest: A. Left-sided pneumothorax B. Left-sided consolidation C. Left lobar obstruction or atelectasis D. Left sided pleural effusion

Answer 99

A IS THE CORRECT ANSWER! Just for future reference, if the pneumothorax is large enough, it may disrupt cardiac function and the patient's blood pressure may fall.

Question 100

Data for a 63kg patient receiving mechanical ventilation: SIMV 10 VT 600mL Fi02 70% PEEP 5+ ABG: 7.45/36PaC02/55/25/100% A. Lower VT B. Increase RR C.Increase PEEP D. Decrease the Fi02

Answer 100

THE CORRECT ANSWER IS C : INCREASE PEEP. THE GOAL OF PEEP IS TO ACHIEVE ADEQUATE YGENATION WITH A SAFE FI02,IN THIS CASE THE FI02 IS DANGEROUSLY HIGH BUT SHUNTING PERSISTS GIVENT HE Pa02 OF 55 TORR FOLLOWING THE 60/60 RULE THE PEEP SHOULD BE INCREASED.