TMC PRACTICE4

Question 1

A nurse is concerned that a patient with a neuromuscular disorder under her care cannot develop a good cough. Which of the following would you recommend as best able to aid this patient in clearing secretions?

A. Combining mechanical insufflation-exsufflation with suctioning
B. Applying forward waist flexion to aid expiratory flow
C. Implementing positive expiratory pressure (PEP) therapy
D. Employing the forced expiratory technique

Answer 1

THE ANSWER IS A! This is a fancy term for the cough-assist device, which I will say is very effective, especially on vented neuromuscular patients. The device gives the patient a positive pressure breath, followed by a negative airway pressure maneuver. This will help move secretions to the trachea from the lungs, where they can then be suctioned out.

Question 2

Which of the following are possible complications of postural drainage, percussion and vibration?

1. Pulmonary barotrauma
2. Acute hypotension during procedure
3. Dysrhythmias
4. Fractured ribs

A. 1 and 3 only
B. 1, 2 and 3
C. 1, 2, 3, and 4
D. 2, 3 and 4

Answer 2

D IS THE CORRECT ANSWER! In addition to these complications can be vomiting and aspiration and bronchospasm. Always assess your patient before, during and after every treatment and procedure…always!

Question 3

A 55 year old patient receiving mechanical ventilation has to following ventilator settings and ABG:

SIMV 4
VT 750
Spont RR: 0
Fi02 55%

ABG: 7.25/56 PaC02/ 92/22/96

Which of the following would you recommend ?

A. Increase Ti
B. Increase VT to 800mL
C. Decrease the Fi02 to 50%
D. Increase the SIMV rate

Answer 3

THE CORRECT ANSWER IS D. THE ABG INDICATES UNCOMPENSATED RESPIRATORY ACIDOSIS . AS A RESULT THE PATIENTS MINUTE VENTILATION SHOULD BE INCREASED BY INCREASING THE SIMV RATE.

Question 4

A doctor institutes volume control ventilation for an 80kg ARDS patient. Which of the following is the maximum pressure you should aim to achieve for this patient?

A. 50cm H20 peak pressure
B. 30cm H20 plateau pressure
C. 40cm H20 peak pressure
D. 50cm H20 plateau pressure

Answer 4

THE CORRECT ANSWER IS B!! ACCORDING TO THE ARDS.NET PROTOCOL TARGET VT IS 4-6ML/KG WITH A MAX PLATEAU PRESSURE OR ALEVOLAR PRESSURE OF 30CMH20 THE VENTILATOR RATE SHOULD INITIALLY BE SET TO MATCH THE PRIOR VE BUT CAN BE INCREASED AS NEEDED UP TO MAX OF 35BPM.

Question 5

To obtain the most effective ventilation , a patient with severe emphysema should be instructed to:

A. Inhale slowly
B. Exhale slowly
C. Hold every third breath
D. Breathe as deeply as possible

Answer 5

THE CORRECT ANSWER IS B . PATIENTS WITH EMPHYSEMA TEND TO HAVE HIGHLY COMPLIANT AIRWAYS, AS A RESULT TO HELP PREVENT AIRWAY PRESSURE COLLAPSING AND AIR TRAPPING THEY SHOULD BE INSTRUCTED TO EXHALE SLOWLY AND PERHAPS THROUGH PURSED LIPS.

Question 6

Patient in Respiratory Failure has the following ABG: On a 8L/min Simple 02 Mask

7.19/68 PaC02/85/28/96

The MD orders intubation and mechanical ventilation. Which of the following modes of support are appropriate for this patient?

I. CMV with a rate of 12
II. SIMV with a rate of 12
III CPAP of 10cmH20

A. I and II only
B. II and III
C. I or III only
D. I, II, or III

Answer 6

THE CORRECT ANSWER IS A: THE MODE OF VENTILATORY SUPPORT INITIALLY CHOSEN DEPENDS MAINLY UPON PATIENTS UNDERLYING PATHOPHYIOLOGIC PROBLEMS. WHEN A PATIENTS RESPIRATORY FAILURE IS ASSOCIATED WITH HYPERCAPNIA DUE TO INADEQUATE AVEOLAR VENTILATION AS IN THIS CASE , EITHER THE CMV OR SIMV MODE WITH SAME RATE MAY BE USED.

Question 7

The Fellow Resident ask you to decrease the PaC02 of a patient receiving HFOV , you should consider all the following adjustments except?

A. Increasing the power/amplitude
B. Decreasing frequency
C. Deflating the ETT cuff
D. Decreasing the bias flow

Answer 7

THE CORRECT ANSWER IS IS D : DECREASING THE BIAS FLOW. INCREASING THE HFOV POWER/AMPLITUDE IS USUALLY THE FIRST STEP TO INCREASE C02 ELIMINATION , DECRASEING THE FREQUENCY CAN ALSO LOWER THE C02 - NOTE THAT FREQUENCY CHANGES DURING HFOV AFFECT C02 ELIMINATION IN A MANNER OPPOSITE TO THAT OBSERVED DURING CONVENTIONAL MECHANICAL VENT. IF HYPERCAPNIA IS SEVERE DESPITE THE USEOF THE MAX POWER /AMPLITUDE AND LOWER FREQUENCY SETTINGS, YOU CAN ALSO CONSIDER CREATING A CUFF LEAK TO EHNANCE C02 REMOVAL. DECREASING BIAS FLOW TENDS TO LOWER THE Pmean AND NEGATIVELY AFFECT OXYGENATION.

Question 8

Normal L/S ratio

A. 1:3
B.2:0
C. 3:1
D. 2:1

Answer 8

THE CORRECT ANSWER IS D. NORMAL L/S RATIO IS 2:1

Question 9

Normal Urine Protein -mg/dL

A. >150
B. > 100
C. 160

Answer 9

THE CORRECT ANSWER IS C. ANYTHING ABOVE 100 IT STATES YOUR PATIENT HAS SOME TYPE OF RENAL DYSFUNCTION

Question 10

Normal DLCO : CO/min/mmHg

A. 20
B. 10
C. 25
D. 30

Answer 10

THE CORRECT ANSWER IS C

Question 11

As an RT which electrolyte may decrease and most monitor while giving excessive Albuterol treatments?

A. Calcium
B. Chloride
C. Magnesium
D. Sodium

Answer 11

THE CORRECT ANSWER IS C: LOW MAG CAN CAUSE TORSADE DE POINTES,ATAXIA,HYPOKALEMIA, MUSCULAR TREMORS AND SEIZURES. ALSO LOW LEVELS OF MG BY GIVING EXCESSIVE ALBUTEROL INTERFERES WITH THE EFFECTS OF PTH ( PARATHYROID HORMONE) LEADING INTO HYPOCALCEMIA. SO WHEN YOU ARE GIVING “EXCESSIVE “ AMOUNTS OF ALBUTEROL THINK OF ALL THESE FACTORS.

Question 12

A 4 month old who is newly diagnosed with CF is need a diagnostic bronchoscopy. Which of the following drugs would produce anesthesia for this procedure?
A. Morphine
B. Chloral hydrate
C. Pancuronium
D. Fentanyl

Answer 12

WHAT DID THE ANSWER ASK FOR? Anesthesia. CORRECT SO WHICH OF THESE DRUGS WOULD DO THAT? THE CORRECT ANSWER FOR A 4MONTH OLD FOR A BRONCH OR EVEN AN ADULT WOULD BE D. FENTANYL
MORPHINE AND FENTANYL ARE THE BIGGEST DRUGS USED IN PEDS AS A COMBO SEDATIVE/ANALGESIA. FENTANYL IS USED MOST COMMONLY IN ALL AGE GROUPS FOR INVASIVE PROCEDURES LINE PLACEMENTS, BRONCHS, SCOPES ETC. YESTERDAY I DID A BRONCH AND MY PT MATTER OF FACT RECEIVIED 200MCG OF FENTANYL DURING THE PROCEDURE! ALSO, IN NEO/PEDS YOU ARE RARELY EVER GOING TO USE A PARALYTIC. THIS IS RARELY GOING TO BE AN ANSWER.

Question 13

You have been resuscitating a newborn, following 30 seconds of positive pressure ventilation using 100% oxygen the heart rate is noted to be 12 in a 15 second period. Which of the following is he next step in the resuscitation?
A. Continue ventilation and monitor the heart rate
B. Intubate and administer epinephrine via the ETT
C. Begin chest compressions
D. stimulate the neonate

Answer 13

THE ANSWER IS C! HR

Question 14

Normal Phosphorous level -mg/dL

A. 10-15
B. 25-45
C. 50-55
D. 0-10

Answer 14

THE CORRECT ANSWER IS B ! DECREASED LEVELS ARE CONSISTENT WITH DIABETES,HYPOKALEMIA VOMITING. INCREASED LEVELS ARE ASSOCIATED WITH RENAL FAILURE AND LIVER CIRROHSIS

Question 15

Normal Lactate level - mg/dL

A. 0-20
B. 0-10
C. 5-22
D. 24-26

Answer 15

THE CORRECT ANSWER IS C: 5-22mg/dL LACTATE LEVELS ARE USED IN CONJUNCTION WITH ABGS TO DETERMINE HYPOXEMIA AND IF AFFECTS THE ACID BASE STATUS

Question 16

88 year old female in a nursing home was admitted to the ER with pneumonia . Per your assessment Vitals: 103.2
Dry mucous membranes
urine output 10mL/hr for the past 2 hours
Mild hypotension 100/56
Increased hematocrit obtained from CBC
You should recommend to the ER MD all the following except?

A. IVF
B. IV Lasix
C. Minimizing insensible water loss
D. Documenting fluid intake/output every hour

Answer 16

THE CORRECT ANSWER IS B : IV LASIX /DIRUERTIC . DEHYDRATION VERY COMMON IN THE ELDERLY DUE TO IMPROPER FLUID INTAKE AND ALTERED FLUID METABOLISM. BE ON GUARD!! COMMON SIGNS OF DEHYDRATION ARE DRY MUCOUS MEMBRANES, DECREASED URINE OUTPUT, HYPOTENSION, DECRESED SKIN TURGOR, INCREASE HCT COUNT AND THICK /TENACIOUS SECRETIONS, DECREASED CVP AND PCWP.

Question 17

A 1350g neonate is being ventilated at a peak pressure of 32 cm H20 and a PEEP of 6, FiO2 75%, with a RR of 60 bpm. While perfoming a ventilator assesment you note that the heart sounds are distant and have shifted to the left. A CXR is obtained and reveals what appears to be a batwing in the patient's thorax. Which of the following is the most probable diagnosis?
A. Pneumonia
B. Pneumomediastinum
C. Pneumo pericardium
D. Pulmonary interstitial emphysema

Answer 17

THE ANSWER IS B. PNEMOMEDIASTINUM. THE “BATWING” IS THE THYMUS GLAND, WHICH IS OUTLINE BY THE FREE AIR IN THE MEDIASTINUM. THE THYMUS GLAND IS MISREAD A LOT ON NEO CXR USE CATION!. SO MANY PEOPLE FOCUSED ON THE BATWING INSTEAD OF THE KEYS IN THE QUESTION LETS BREAK IT DOWN. THE HIGH PRESSURES OF THE VENT ALONG WITH THE SHIFT OF THE HEART SOUNDS INDICATE AN AIR LEAK. tHE CXR CONFIRMS THIS. THE THYMUS GLAND ALSO LOOKS LIKE A BUTTERFLY

Question 18

A pediatric patient has been mechanically ventilated for 8 days for treatment following a trauma. The patient’s lung compliance has begun to worsen. CXR reveals diffuse atelectasis throughout bilateral lung fields. Patient’s current ventilator setting are as follows:
Assist control/VC 450 x 15 55% compliance of 30
Which of the following is the most appropriate recommendation?
A. Initiate CPT
B. Initiate bronchodilators
C. InitiatE PEEP
D. Initiate antibiotic therapy

Answer 18

THE ANSWER IS C ! WORSENING COMPLIANCE AND INCREASING ATELECTASIS ON THE CXR INDICATES A LOSS OF SURFACE TENSION PROBABLY SECONDARY TO THE ONSET TO ARDS,. THE INITIATION OF PEEP WILL PREVENT THE COLLAPSE OF ALVEOLI, IMPROVING BOTH COMPLIANCE AND ATELECTASIS.

Question 19

You are atttending a delivery of a baby born via cesarean section. The newborn is brought to the warmer and is dried, postioned, and suctioned. The initial assesment reveals the babies HR is 86 bpm with a weak respiratory effort. Which of the following would you do next?
A. Begin Chest compressions
B. Bag and mask ventilation
C. Immediatly Intubate and mechanically ventilate
D. Administer epinipherine

Answer 19

THE ANSWER IS B! REMEMBER IN NRP YOU HAVE PRIMARY AND SECONDARY ASSESSMENT. YOU WANT TO DO THE FOLLOWING STEPS IN PRIMARY ASSESSMENT: WARM, DRY, STIMULATE GOAL HR. EVEN IF THE HR IS 40 AT BIRTH YOU DO NOT DO CHEST COMPRESSIONS UNTIL YOU HAVE DONE 30 SECONDS OF POSITIVE PRESSURE VENTILATON (PPV)

Question 20

What is the minimum liter flow required to reduce CO2 retention in oxyhoods?
A. 4L/min
B. 7L/min edited at 2114 from 6L to 7L I made a typo
C. 10 L/min
D.15L/min
E. Depends on the size of the patient and oxygen requirement

Answer 20

THE ANSWER IS B. SEVEN (7) L/MIN IS THE MINIMUM FLOW REQUIRED FOR OXYHOODS. THIS IS A COMMON QUESTION ON THE NPS. USUALLY PHRASED AS: THE PATIENT IS ON A 40% OXYHOOD SET AT 4L/MIN WITH THE FOLLOWING UAC: 7.30/56/92/27 WHAT SHOULD YOU DO? ANSWER INCREASE THE FOLLOW TO WASH OUT THE CO2 BUILDING UP IN THE HOOD! SHOULD BE AT 7 MINUMUM!!

Question 21

I have a:

• stenotic pulmonary valve and artery
• Enlarged aorta with overridding ASD
• Right ventricular hypertrophy

What am defect am I?

Answer 21

TETRALOGY OF FALLOT DEFECTS ACCOUNT FOR ~10% OF CHD AFFECTING BOTH SEXES EQUALLY. iT IS THE MOST COMMON POST INFANCY HENCE WHY I HAVE FOCUSED ON IT TONIGHT WITH THE CXR AND THIS POST, AND IT IS COMPRISED OF 4 ANOMALIES AS THE NAME IMPLIES (TETRA MEANS FOUR) #1 RIGHT VENTRICULAR HYPERTROPHY #2 THE AORTA IS ENLARGED AND DISPLACED TO THE RIGHT SUCH THAT IT “OVERRIDES” THE VSD #3 A LARGE MALALIGNMENT VENTRICULAR VSD OF THE CONAL SEPTUM #4 STENOSIS OF THE RIGHT VENTRICULAR OUTFLOW TRACT (THE INFUNDIBULAR STENOSIS) WITH ASSOCIATED PULMONARY VALVE STENOSIS

Question 22

All of the lung volumes can be measured by spirometry except:

A. Tidal volumes.
B. Inspiratory reserve volume.
C. Expiratory reserve volume.
D. Residual volume.

Answer 22

D IS THE CORRECT ANSWER! WHEN DOING A SPIROMETRY TEST YOU ARE ASKING THE PATIENT TO BLOW INTO A FIXED ORIFICE TO MEASURE LUNG CAPACITY. THE FURTHEST THAT ANYONE CAN EVER (EVER!!) EXHALE IS TO THEIR EXPIRATORY RESERVE VOLUME. THE RESIDUAL VOLUME IS WHATEVER IS LEFT OVER IN THE LUNGS TO KEEP THEM OPEN. THIS AMOUNT OF AIR CANNOT BE EXHALED, THERE IS A SEPARATE TEST TO DETERMINE WHAT RESIDUAL VOLUMES ARE IN THE LUNGS! (BODY BOX, HELIUM DILUTION, ETC.)

Question 23

Patient in ICU due to failing mitral valve and excessive pulmonary arterial pressure, 23 hours prior iNO was started at 20ppm and currently patient has been weaned to 14ppm

In preparation for mitral valve replacement the anesthesiologist ask you to set the same dose of iNO in the OR.
Which of the following will most helpful in keeping the NO delivery consistent?

A. Use the vent in the OR
B. Tranfer and use the same iNO tank
C.Test and Calibrate the OR oxygen mixture
D. Raise the iNO to 20ppm in the OR and titrate slowly to 14 ppm

Answer 23

THE CORRECT ANSWER IS B: AN INHALED NITRIC OXIDE SYSTEM IS VERY CAREFULLY CALIBRATED WITH THE VENTILATOR, IF SYSTEM IS MOVED TO THE OR AND USED IN CONJUCTION WITH A DIFFERENT VENT THE ABILITY TO VENTILATE THE PATIENT MAY CHANGE AND IT MAY TAKE HOURS TO CALIBRATE CORRECTLY. THEREFORE THE SAME VENT AND NO SYSTEM COMBINATION SHOULD BE USED TO TAKE PATIENT TO THE OR, IS MORE EFFECTIVE AND CONSISTENT.

Question 24

A patient with heart failure is receiving volume cycled ventilation and has a pulmonary artery catheter in place The ventilator peak pressure is 45cmH20 and plateau at 25cmH20 , PAP 42/33 mmHg PCWP 28mmHg

Lungs: Dependent crackles and wheezing
Which of the following would your recommend?

A. Administer Albuterol
B. Decreasing Mean Airway Pressure
C. IV Lasix
D. Removing PAC it is malfunctioning

Answer 24

THE CORRECT ANSWER IS C: THE DIAGNOSIS OF HEART FAILRE AND INCREASED PAP AND PCWP SUGGEST THAT THIS PATIENT IS IN CHF, IN ORDER TO ALLEVIATE THE BACKUP OF FLUID IN THE LUNGS THE THERAPY PLAN SHOULD INCLUDE A DIRUETIC OR A POSITIVE INOTROPIC DRUG SUCH AS DIGOXIN OR DOPAMINE.

Question 25

A 5'8" 170 lbs ( 70kg) 45 year old male near drowning victim is slowly deteriorating 6 days after the incident CXR: Diffuse infiltrates with possible honeycomb pattern Pa02/Fi02 150 Which setting is most appropriate for this patient? A. SIMV 8 900 50% 0 PEEP B. SIMV 12 750 60% +5 C. AC 10 600 100% 5+ D. AC 18 350 60% +5

Answer 25

THE CORRECT ANSWER IS D: BASED ON IBW AND BEGINNING STAGES OF ARDS, ARDS PROTOCOL STATES AND SUGGEST VT 4-6ML/KG IBW , MANDATORY RATE 12-24 AND PEEP AT LEAST 10CMH20.

Question 26

A patient with neuromuscular disease has been on vent support for 5 months via tracheostomy .At this point she requires only nighttime ventilatory support Which of the following artificial airways should you recommend? A. Tracheostomy button B. Bivona tracheostomy tube C. Cuffed fenestrated tracheostomy tube D. Uncuffed standard tracheostomy tube

Answer 26

THE CORRECT ANSWER IS C: FOR A PATIENT WITH A TRACHEOSTOMY ON A LONG TERM MECH VENT WHO STILL REQUIRES INTERMITTENT SUPPORT A CUFFED ,FENESTRATED TRACHEOSTOMY TUBE IS REQUIRED FOR AN IDEAL AIRWAY.

Question 27

An 8 hour old 28 week gestational age neonate is being maintained in an oxygen hood with an Fi02 of 65%. The Neonatologist believes that the patient has Infant Respiratory Distress Syndrome,based on the following results what would you recommend? ABG: 7.36/ 44 PaC02/52/25/0 A. Increase the 02 hood to 100% B. Start iNO stat C. Start Survanta D. Start HFV

Answer 27

THE CORRECT ANSWER IS C: SURVANTA THE ACID BASE BALANCE FOR THIS INFANT IS WITHIN NORMAL RANGE THEREFORE MECHANICAL VENTILATION IS NOT WARRANTED. BUT THIS PATIENT HAS REFRACTORY HYPOXEMIA Pa02

Question 28

58 year old female is 4 days status post gastric bypass surgery V/Q scan shows batwing pattern Vitals: BP 140/92 Sp02 86% Fi02 30% What would you recommend for this patient? A. Warfarin B. Enoxaprin C. Protonix D. Recombinant tPA

Answer 28

THE CORRECT ANSWER IS B: ENOXAPRIN IS APPROPIATE MEDICATION FOR TREATMENT OF VENOTHROMBEMBOLITIC DISEASE , WARFARIN SHOULD BE ONLY USED WHEN PRECEEDED BY HEPARIN ANTICOAG THERAPY

Question 29

45 year old male presents to the ER with difficulty swallowing , double vision, and droopy facial muscles Edrophonium is given and patient states he feel somewhat better. Serial VC done per RT 1100 1.7L 1700 1.1L 2100 0.8L ABG: 7.41/39 PaC02/80/24/1 What would you recommend? A. Vital signs q2h B. Administer Tensilon and monitor C. NPPV D. Intubate and place on mechanical ventilation

Answer 29

THE CORRECT ANSWER IS D: SIGNS OF DROOLING, DOUBLE VISION, DROPPY FACIAL MUSCLES INDICATES NEUROMUSCULAR DISEASE AND ONE THAT COMES TO MIND IS MYSTHENIA GRAVIS. FOR PATIENTS PRESENTING IN THIS CONDITION YOU MUST MONITOR THE MIP AND VC FOR THESE PATIENTS CLOSELY. ONCE THE VC FALLS BELOW 1.0L EVEN IF YOU HAVE A NORMAL ABG YOU MUST INTUBATE AND INSTUTE MECHANICAL VENTILATION, THE POINT IS TO TAKE OVER VENTILATIONS BEFORE THE ACID BASE STATUS DETIRIOTES FURTHER

Question 30

A physician ask your recommendation regarding sedation for a mechanically ventilated patient in the ICU. You should consider recommending all the following to calm the patient except: A. Nembutal B. Propofol C. Lorazepam D. Nimbex

Answer 30

THE CORRECT ANSWER IS D: NIMBEX - COMMON SEDATIVES USED TO CALM PATIENTS IN THE ICU INCLUDE BENZODIAZIPINES SUCH AS ATIVAN , BARBITUATES LIKE PHENOBARB - NEMBUTAL AND PROPOFOL. NIMBEX IS A NEUROMUSCULAR BLOCKING AGENT NOT A SEDATIVE.

Question 31

A young patient with a history of chronic lung disease is being evaluated for cystic fibrosis. Which of the following findings are consistent with that diagnosis? 1. Reduced FVC 2. Increased airflow rates 3. High ratio of RV to TLC 4. Increased pulmonary diffusing capacity A. 1 and 3 B. 2 and 4 C. 1 and 4 D. 1, 3 and 4

Answer 31

A IS THE CORRECT ANSWER! Cystic fibrosis is characterized by reduced FVC and a high ratio of RV to TLC related to air trapping as well as reduced airflow rates and reduced TLC. Hypoxemia is often present, and compensatory respiratory acidosis may occur with chronic disease.

Question 32

When administering a 12-Lead ECG (Sometimes known as an EKG), where is lead V2 applied? A. 4th intercostal space on the left side of the sternum B. 4th intercostal space on the right side of the sternum C. 5th intercostal space at the midclavicular line D. 5th intercostal space at the anterior axillary line

Answer 32

A IS CORRECT! YOU ALL KNOW YOUR ECG'S! Quick fun fact, this is the most viewed lead on heart monitors simply because it gives a great picture of the heart

Question 33

A patient's external pulse oximeter is showing a decrease in SpO2 to 80% although the patient does not appear to be in respiratory distress. The first step should be to A. Request arterial blood gases. B. Reposition the pulse oximeter. C. Replace the pulse oximeter. D. Place the pulse oximeter on the opposite side

Answer 33

B IS CORRECT! GREAT JOB EVERYONE, START WITH THE SIMPLEST TASK FIRST, THEN PROCEED TO TROUBLESHOOT AFTER THAT!

Question 34

The best test to separate asthma from COPD is A. The 6-minute walk B. FEV1/FVC. C. DLCO. D. Bronchodilator challenge

Answer 34

C IS THE CORRECT ANSWER. BOTH OF THESE DISEASES (ASTHMA AND COPD) ARE OBSTRUCTIVE DISEASES. ONLY THE DLCO (diffusing capacity or transfer factor of the lung for carbon monoxide, CO) TEST CAN PREDICT COPD. IF THERE IS A DECREASE IN THE DLCO, COPD IS EXPECTED. CARBON MONOXIDE HAS A VERY HIGH DIFFUSION FACTOR, HIGHER THAN OXYGEN. BY USING A SMALL AMOUNT OF GAS SENT ACROSS THE ALVEOLAR MEMBRANE, YOU CAN SEPARATE COPD FROM ASTHMA, BOTH CAN HAVE SIMILAR FEV1/FVC RATIOS. **When we are talking about DLCO, the alveoli are the topic of discussion, in asthma and COPD, constricted airways can be relaxed with bronchodilators, but because of the chronic nature of COPD, the alveoli are over distended and some may be destroyed such as emphysema, this would cause a decrease in DLCO, with asthma there is no destruction of alveoli, the disease affects specifically the airways**

Question 35

Normal Pulmonary Function Tests with a reduced DLCO would be most suggestive of: A. Asthma B. Pulmonary Emboli C. COPD D. Interstitial Lung Disease

Answer 35

B IS THE CORRECT ANSWER HERE! THE KEYWORD IN THIS QUESTIONS IS NORMAL PFT RESULTS. THIS IS TRICKY TO PICK OUT. A PATIENT MAY HAVE NORMAL LUNGS, BUT IF THEY HAPPEN TO HAVE A PULMONARY EMBOLI (OR BLOOD CLOT IN THE LUNGS), THIS WILL SHOW A DECREASE THE DLCO IN THE LUNGS, OR THE ABILITY FOR CARBON MONOXIDE TO DIFFUSE ACROSS THE ALVEOLAR CAPILLARY MEMBRANE. BE ON THE LOOKOUT FOR THIS TYPE OF QUESTION, PULMONARY EMBOLI IS NOT SOMETHING WE USUALLY THINK ABOUT WITH PFT'S.

Question 36

A ventilatory limitation to exercise may be characterized by all of the following except: A. A reduced VO2max B. Gas exchange abnormalities C. Normal ventilatory reserve D. Normal 02 pulse

Answer 36

C IS CORRECT ! SOMEONE WITH A NORMAL VENTILATORY RESERVE WILL NOT HAVE AN ABNORMAL VENTILATORY LIMITATION!

Question 37

The technologist is performing pulmonary function tests on a 40-year-old patient with asthma. Findings could include: 1. increased or normal FVC. 2. decreased FEV1, FEV1/FVC, and DLCO. 3. decreased or normal FEV1, FEV1/FVC, and RAW (resistance). 4. increased FRC and RAW. Which of these findings are consistent with asthma? A. 1 and 3 B. 2 and 4 C. 1 and 4 D. 1, 2, and 4

Answer 37

D IS CORRECT! These findings are consistent with asthma: Increased or normal FVC, increased FRC and RAW, and decreased FEV1, FEV1/FVC, and DLCO. Asbestosis: Decreased FVC, FRC, and DLCO and decreased or normal FEV1, FEV1/FVC, and RAW. Bronchitis: Increased FRC and RAW and decreased FVC, FEV1, FEV1/FVC, and DLCO. Emphysema: Increased FRC and RAW and decreased FVC, FEV1, FEV1/FVC, and DLCO. Sarcoidosis: Decreased FVC, FRC, and DLCO and decreased or normal FEV1, FEV1/FVC, and RAW.

Question 38

Hemodynamics: Patient in ICU with the following data: CVP 5 torr PAP: 21 torr PCWP 8 torr CO: 5L/M Where is the problem for this patient? A. Right heart B. Lungs C. Left heart D. Fluid overload

Answer 38

THE CORRECT ANSWER IS B: LUNGS PAP IS CLEARLY ELEVATED HERE ,NORMAL PAP IS 9-18 WITH A MEAN OF14 , COMMONLY YOU WILL SEE AN ELEVATED PAP IN YOUR COPD PATIENTS. ELEVATED PAP IS ALSO CALLED RIGHT VENTRICULAR AFTERLOAD, BE ON GUARD WITH THESE TERMS FOR THE EXAM. SOME LUNG ISSUES CAN BE: PE, PULMONARY HYPERTENSION, AIR EMBOLISM AND INCREASED PVR.

Question 39

58 year old female with a history of COPD , patient was intubated due to pulmonary bacterial infection, patient is being weaned of ventilator but has been unsuccessful then after 2 weeks a tracheostomy is placed Which of the following will decrease work of breathing and wean this patient off mechanical ventilation? A. PC Ventilation B. PAV C. NAVA D. Inverse I:E ratio

Answer 39

THE CORRECT ANSWER IS B: PAV PROPORTIONAL ASSIST VENTILATION WHICH IS USEFUL TO DECREASE WORK OF BREATHING DURING WEANING ATTEMPTS , PAV WORKS LIKE PSV THAT FLEXES WITH EACH VENTILATION ATTEMPT

Question 40

Which of the following is the 1st step in respiratory care protocol application? A. Observe universal precautions B. Review medical records C. Check physician order to RTP D. Perform initial patient evaluation

Answer 40

THE CORRECT ANSWER IS C: BEFORE ANYTHING YOU MUST CHECK MD'S ORDER WRITTEN FOR RTP

Question 41

Hemodynamic data shows: CVP: 7 torr PAP 19 torr PCWP 16 torr Cardiac Index: 1.8 Where or what is the issue here? A. Right heart failure B. Dehydration C. CHF D. Left heart issue

Answer 41

THE CORRECT ANSWER IS D: LEFT HEART! PCWP IS ELEVATED , IF YOU SEE PCWP OUT OF RANGE IN THE HIGH SIDE IT STATES PATIENT IS IN LEFT HEART FAILURE SOME LEFT HEART ISSUES INCLUDE CHF,AND MITRAL VALVE STENOSIS

Question 42

45year old male in MICU with the current data , resident is asking you have is going on with this patient CVP 2 torr PAP: 10 torr PCWP: 6 torr CO: 3.8 L/M What is the issue here? A. Dehydration B. Left heart failure C. Air embolism D. Increased PVR

Answer 42

THE CORRECT ANSWER IS A : DEHYDRATION. CLEARLY THE CVP IS RIGHT AT THE LOWER END, THERES NOT ENOUGH WATER IN THE RIVER , PATHOLOGIES INCLUDE INTERNAL HEMORRHAGING,ETC THE BOTTOM LINE IS PATIENT NEEDS IVF OR BLOOD STAT.

Question 43

While obtaining an arterial sample for analysis using a point-of-care analyzer, you should do all of the following except: A. Analyze the sample within 3 minutes B. Place the sample in an ice slush C. Thoroughly mix the sample D. Prevent sample exposure to air

Answer 43

I think I may have gotten some of you with the "except" part of this question. B IS THE CORRECT ANSWER. The procedure used for point-of-care analysis is similar to that used when preparing a sample for central lab analysis. The only acceptable answer is B simply because you would not be placing a blood gas sample on ice before analyzing the sample. Keep in mind as well, a point-of-care blood gas analyzer is also known as an I-Stat (be on the lookout for fancy names for pieces of equipment)!

Question 44

``` You are caring for a 56 year old patient in the MICU who has developed ARDS. The doctor has asked the respiratory therapist for the best ventilator adjustment to reduce the patient's intrapulmonary shunting. What should the RT recommend? A. Increasing the inspiratory time B. Increasing the sigh volume C. Decrease the respiratory rate D. Increase the PEEP ```

Answer 44

THE answer is D! THERAPEUTIC PEEP INCREASES A PTs FRC. THIS INCREASED LUNG VOLUME enables better ventilation and perfusion matching as a result intrapulmonary shunting past under ventilated alveoli is reduced. **INCREASING I-TIME and SIGH VOLUME IMPROVES alveolar filling and may help to increase oxygenation. However, they don't increase FRC and therefore do not reduce shunting!**

Question 45

Which of these conditions is associated with JVD( Jugular Vein Distention) A. Pneumonia B. Cor Pulmonale C. Simple Pneumothorax D. Septic Shock

Answer 45

THE CORRECT ANSWER IS B: COR PULMONALE WHICH IS RIGHT HEART FAILURE DUE TO CHRONIC LUNG DISEASE. RIGHT HEART FAILURE OCCURS WHEN CHRONIC HYPOXEMIA ELEVATES THE PVR AND PUTS A STRAIN ON THE RIGHT VENTRICLE TO PUMP BLOOD THROUGH THE CONSTRICTED PULMONARY CAPILLARIES RIGHT HEART FAILURE CAUSES VENOUS BLOOD TO BACK UP INTO THE NECK VEINS OR JUGULAR.

Question 46

he best way to avoid ABG errors associated with blood metabolism is to? A. Analyze the sample immediately B. Place the sample in ice C. Keep the sample at body temperature D. Use dry Lithium heparin

Answer 46

THE CORRECT ANSWER IS A ABG ERRORS CAUSE BY BLOOD METABOLISM ARE TIME AND TEMP DEPENDENT. IF NOT RUNNING THE ABG RIGHT AWAY PLACE ON ICE RIGHT AWAY

Question 47

You can use a fluid column pressure manometer for all of the following purposes except: A. To measure atmospheric pressure B. To measure static pressures C. To calibrate other manometers D. To measure rapid pressure changes

Answer 47

Great job! D IS CORRECT! Fluid column pressure manometers are used to calibrate static or slowly changing pressures and to calibrate other pressure measuring devices!

Question 48

67 year old male patient having difficultly weaning from SIMV VC after a 7 day bout of markedly increase airway resistance, your patient is receiving 2800kcal/day by nasogastric tube. Failure in weaning is most likely related to which of the following? A. production of C02 B. altered respiratory quotient C. excessive 02 consumption D. INR of 2.0 sec

Answer 48

THE CORRECT ANSWER IS A , A 2800KCAL/DAY IS EXCESSIVE CALORIC INTAKE WHEN THIS EXCEEDS C02 PRODUCTION WILL INCREASE WHICH CAN COMPLICATE WEANING PATIENTS OFF MECH VENTILATION

Question 49

A patient is required transport to another hospital for complex radiological testing. As the RT you must assess this patient that is hemodynamically monitored on a quadruple lumen balloon tipped PAC . Which of the following must you constantly monitor during the movement and transport? A. PCWP B. Cardiac Index C. Sv02 D. PAP

Answer 49

THE CORRECT ANSWER IS D. MONITORING PAP WILL HELP TO CONSTANT MONITORING OF THE PAC PLACEMENT, MOVING PATIENTS CAN EASILY RESULT IN MAL POSITIONING OF THE PAC

Question 50

52 year old male brought into the ER with generalized muscle weakness to rule out myasthenia gravis, Tensilon administered and within minutes patients show signs of cholinergic crisis. Which of the following steps should you anticipate? A. NPPV B. IV Mestinon C. Administration of Narcan D. Administration of Atropine

Answer 50

THE CORRECT ANSWER IS D ; ATROPINE IS USED TO COMBAT THE EFFECTS OF AN ANTICHOLINERGIC CRISIS BROUGHT ON BY TENSILON

Question 51

Which of the following values in a typical high-frequency oscillation ventilator is used to regulate the mean airway pressure? A. Limit valve B. Flush valve C. Dump valve D. Control valve

Answer 51

D IS CORRECT, EXCELLENT! MEAN AIRWAY PRESSURE IN A HFOV TYPICALLY IS REGULATED BY A PNEUMATIC VALVE (CONTROL VALVE) THAT PROVIDES VARIABLE RESISTANCE TO OUTFLOW OF GAS FROM THE CIRCUIT. FYI, the limit valve is opened when airway pressure meets or exceeds the ventilator's maximum pressure alarm setting. The dump valve is used when either airway pressure rises above 60cmH20 or falls below 5cmH20

Question 52

A COPD patient being mechanically ventilated appears to be developing auto PEEP. Which of the following should you recommend to improve this situation? A. Decrease I:E ratio B. Adding an Inspiratory Hold C. Using Inverse I:E ratio D. Using a decelerating flow pattern

Answer 52

THE CORRECT ANSWER IS A: DECREASE I:E RATIO DUE TO HIGH EXPIRATORY FLOW RESISTANCE COPD PATIENTS ARE MOST LIKELY TO DEVELOP AUTO PEEP DURING MECHANICAL VENTILATION. IF THE ISSUE HERE IS BRONCHOSPASMS THEN GIVE A BRONCHODILATOR, BY DECREASING THE IE RATIO FIRST SHORTENS THE INSPIRATION BY USING HIGHER FLOWS AND OR LOWER VT OR LENGHTENING THE EXPIRATORY TIME BY USING LOWER RATES OR SWITCHING TO SIMV MODE ANOTHER ALTERNATIVE IS TO APPLY EXTERNAL PEEP IN AN AMOUNT LESS THAN THE AUTO PEEP LEVEL. THIS WILL HELP SMALL AIRWAY CLOSURE DURING EXHALATION THAT CAN CAUSE MORE AIR TRAPPING.

Question 53

Patient currently in HFJV with the following data: ``` FiO2 60% pH 7.35 PaO2 84 PaCO2 55 Hb 8gm CaO2 12 vol% CvO2 7.5 vol% SaO2 91% ``` What do you recommend for this patient ? 1. Add PEEP 2. Increase FiO2 3. PRBC's 4. Increase amplitude A. 1 and 3 B. 3 and 4 C. 1 and 4 D. 1 and 2

Answer 53

THE CORRECT ANSWER IS B : PATIENTS HEMOBLOBIN IS BELOW NORMAL AND PRBC'S NEEDS TO BE GIVEN PATIENT NEEDS VOLUME STAT!!, INCREASING THE AMPLITUDE WILL ALLOW TO BLOW OFF THAT HIGH PaC02 . AT THIS POINT CHOOSING TO INCREASE PEEP AND Fi02 WILL NOT CORRECT THE MAIN ISSUE HERE WHICH IS VENTILATION AND OBVIOUSLY PATIENT IS ANEMIC, THOSE 2 ISSUES MUST BE ADDRESSED IMMEDIATELY THAN CORRECTING OXYGENATION ISSUES.

Question 54

A physician specifies in her respiratory orders the following objective for a patient with an artificial airway: "to overcome the patient's humidity deficit." Which of the following devices should you select for this patient? A. Small volume jet nebulizer B. Large-reservoir heated jet nebulizer C. Unheated passover humidifier D. Vibrating mesh nebulizer

Answer 54

B IS CORRECT! GREAT JOB! THE KEY COMPONENT OF THIS QUESTION IS IDENTIFYING THE HEATED PORTION OF THE NEBULIZER!

Question 55

CVP: 10 torr PAP: 14 torr PCWP: 9 C.I. 3 Where or what's the problem here? A. Left heart B. Fluid overload C. Right heart D. Dehydration

Answer 55

THE CORRECT ANSWER IS C; RIGHT HEART THE CVP IS CLEARLY ELEVATED 2-6 TORR IS NORMAL ANYTHING ABOVE CLEARLY STATES RIGHT HEART ISSUES

Question 56

``` A patient that is 5'6" 142 lbs ( 65kg) has undergone left sided pneumonectomy and is receiving AC/VC settings are Fi02 50% Mandatory rate: 16 Vt 300mL PEEP +3 ``` ABG: 7.33/49 PaC02/75/24/-1 What should do first as an RT: A. Increase PEEP to 5 B. Increase Fi02 to 60% C. Increase rate to 18 D. Increase VT to 600mL

Answer 56

THE CORRECT ANSWER IS C THIS PATIENTS ABG SHOWS HYPOVENTILATION SLIGHT BUT PRESENT WITH HYPOXEMIA FOR THE THESE TWO ISSUES VENTILATION MUST BE CORRECTED FIRST THE BEST APPOACH IS TO INCREASE VT THIS WILL ALLLOW FOR A MINOR ADJUSTMENT FOR ARTERIAL C02 WHILE KEEPING THE MEAN AIRWAY PRESSURE TO A MININUM A VT OF 600ML SEEMS APPROPIATE FOR THIS PATIENTS AND THE IBW BUT IF Y0U TAKE A CLOSER LOOK AT THE SCENARIO REVEALS THAT PATIENT HAS UNDERGONE A LEFT PNEUMONECTOMY THIS SHOULD ALERT YOU NOT TO INCREASE THE VT AND CHOOSE INCREASE RR TO 18 TO BLOW OFF THE C02.

Question 57

You are preparing the ventilator for a patient who is having a right sided pneumonectomy, the ventilator delivered tidal volume should be: A. Less than normal based on patient's ideal body weight B. Larger than normal based on ideal body weight C. The same volume as delivered before surgery D. Same as normal based on ideal body weigh

Answer 57

ANSWER IS A.... BECAUSE THIS PT HAS HAD A PNUEMONECTOMY they SHOULD HAVE ABOUT 1/2 OF THE NORMAL FOR 2 LUNGS. GIVING tHE SAME OR LARGER WITH ONE LUNG CoULD CAUSE OVERDISTENTION and BAROTRAUMA

Question 58

``` You have noticed over the course of your shift that a patient who has been receiving constant volume ventilation has had an increased in peak pressures from 23 to 46. What could have caused this change? I. Airway resistance decreased II. Lung compliance increased III. Airway resistance increased IV. Lung complaince decreased a. III only b. IV only c. III and IV d. I and II ```

Answer 58

THE ANSWER IS C! WITHOUT HAVING BOTH THE PEAK AND PLATEAU PRESSURES THERE IS NO WAY TO KNOW MORE SPECIFICALLY WHAT HAS CAUSED THE PEAK PRESSURE TO INCREASE. ......IF EITHER THE LUNG COMPLIANCE HAD INCREASED OR THE AIRWAY RESISTANCE HAD DECREASED THE PEAK PRESSURES WOULD HAVE DECREASED. WITH AN INCREASE IN RESISTANCE (BRONCHOSPASM/SECREATIONS) CAUSES THE PEAK PRESSURE TO RISE, .A DECREASE IN LUNG COMPLIANCE (PULMONARY EDEMA, PLUERAL EFFUSION, PNA, ETC) CAUSES THE PLATEAU PRESSURE TO RISE. THIS IN TURN DRIVES UP THE PEAK PRESSURE.

Question 59

29 year old male status post boat accident in the lake arrives intubated to the ED, 40 cc of lake water has been suctioned from his lungs Patient has experienced long bone fractures 24 hrs after surgery lungs reveal good ventilation but poor perfusion per VQ scan ``` CXR: Batwing pattern Meds: Coumadin Temp: 38 degrees RR 18 HR 120 BP 126/80 INR: 1.0 Lactate Level 15mg/dL ``` What is the most appropriate action to take or intervention? A. Increase Coumadin level B. Administration of IV Dextrose C. Perform a pulmonary compliance study D. Check Troponin and CK-MB

Answer 59

THE CORRECT ANSWER IS A INCREASE COUMADIN LEVEL FOR THIS PATIENT BATWING PATTERN IS CONSISTENT WITH A PE AND PATIENT HAS SUFFERED A LONG BONE FRACTURE AS WELL,NORMAL THERAUPEUTIC LEVEL FOR INR IS 1.5 TO 2.6

Question 60

While you assist the pulmonary physician on a bronchoscopy, you notice frank blood entering the in-line specimen jar Which of the following should you suggest to instill down the bronchoscope? A. Lidocaine B. Activase -(tPA) C. ice Saline D. Epinephrine

Answer 60

THE CORRECT ANSWER IS D: EPIPNEPHRINE WILL BE THE 1ST LINE OF DEFENSE TO ADMINISTER DOWN THE BRONCHOSCOPE, EPI IS AN ALPHA DRUG WHICH PROMOTES CONSTRICTION OF BLOOD VESSELS WHICH MAY HELP STOP BLEEDING

Question 61

A neonatal intensive care unit nurse calls you to check an infant on a transcutaneous PO2/PCO2 monitor due to a rapid rise in PtCO2 an concurrent fall in PtCO2 below 10 torr. What is the most likely cause of this problem? A. The presence of peripheral vasoconstriction B. A defective sensor or sensor membrane C. Interference due to bright ambient lighting D. Air leakage around the sensor's fixation ring

Answer 61

D IS THE CORRECT ANSWER. Air leaks will always cause a fall in PtCO2. If you apply a big picture analysis to this question, you can imagine the monitor showing ambient levels of the partial pressures of gas (P02=150 torr, PC02= 0 torr). The most common cause of these findings is air leakage around the sensors adhesive ring. To correct the issue, simply replace the fixation ring!

Question 62

You measure an oxygen concentration of 55% being delivered by an air-entrainment mask set to deliver 31% oxygen. Which of the following actions is most appropriate? A. Add an aerosol collar to the mask B. Decrease the oxygen input flow C. Check the entrainment ports D. Increase the oxygen input flow

Answer 62

C IS THE CORRECT ANSWER, FIST BUMPS! BECAUSE AIR-ENTRAINMENT DEVICES MIX AIR AND 02 AT A CONSTANT RATIO, AN ALTERATION IN THE DELIVERED 02% CAN RESULT ONLY FROM A CHANGE IN THE MIXING RATIO. MOST COMMONLY, THIS OCCURS WITH PORT OBSTRUCTION (such as patients pulling the blankets over the entrainment port!), WHICH WILL DECREASE AIR ENTRAINMENT AND RAISE THE DELIVERED 02%

Question 63

A patient receiving control ventilation for ARDS, if the inspiratory pressure is increased while the flow and I-time remains constant , which of the following changes should be anticipated by the RT? A. Decreased in mean airway pressure B. better distribution of gases in the lung C. Increase in VT D. Increase in PaC02

Answer 63

THE CORRECT ANSWER IS C; INCREASE IN VT. IF FLOW AND Ti REMAIN CONSTANT THE PATIENT WILL EXPERIENCE AN INCREASE OF VT IF INSPIRATORY PRESSURE IS INCREASED

Question 64

Patient in the ED RR: 34 Spont VT 900mL Labs: Serum Anion Gap at 20mEq/L Which of the following is consistent with this finding? A. Hypokalemia B.Metabolic Acidosis C.Acute on chronic hypercapnia D. Compensated respiratory Alkalosis

Answer 64

THE CORRECT ANSWER IS B: METABOLIC ACIDOSIS (DKA) ANION GAP THAT HIGH INDICATES DKA

Question 65

THE CORRECT ANSWER IS B: METABOLIC ACIDOSIS (DKA) ANION GAP THAT HIGH INDICATES DKA

Answer 65

D IS THE CORRECT ANSWER, GREAT JOB EVERYONE AND MANY FIST BUMPS TO BE HAD! BECAUSE MOST CROUP TENTS ARE POWERED BY LARGE VOLUME NEBULIZERS, INSUFFICIENT MIST INDICATES NEBULIZER MALFUNCTION. BE ON THE LOOKOUT FOR MALFUNCTIONS WITH CLOGGING OF THE CAPILLARY TUBE THAT FEEDS LIQUID WATER TO THE JET!

Question 66

``` A 165lb pt with a left sided stroke is being mechanically ventilated in the Assist control mode with the following settings: Mv: 8.4 L I:E 1:2 Mechanical deadspace 155mL 35% RR 12 ABG reveals: pH 7.30/ CO2 51/ O2107/HcO3 24 Bases on this information, it would be most approiate to recommend to the doctor: A. Decrease the FiO2 B. Decrease the Mv C. Increase the RR D. Decrease the mechanical deadspace ```

Answer 66

THE ANSWER is D MECHANICAL DEADSPACE. NOW, I SEE THE GREAT DIALOGUE BETWEEN EVERYONE HOWEVER, DECREASING/REMOVING RECOMMEND/FIRST I know we talk about wording being very important but now your guys are over over analyzing like I did in school and getting the easier things wrong. Dont always think the first answer is going to fix the whole problem.

Question 67

An intubated adult patient with severe expiratory airway obstruction requires ventilatory support. Which of the following factors is most important in selecting a ventilator for this patient? A. Ability to compensate for airway interface leaks B. Variable flow control and adjustable I:E ratios C. Ability to run on 12-volt DC (battery) power D. Certification for use during MRI procedures

Answer 67

B IS CORRECT! I THINK YOU ALL UNDERSTAND THIS QUESTION, ESPECIALLY FOLKS WITH OBSTRUCTIVE DISEASES AND VARIABLE I:E RATIOS! GREAT JOB!

Question 68

A fuel cell oxygen analyzer is reading 18% when exposed to ambient air. The initial corrective action should be to? A. Calibrate the sensor B. Check the batteries C. Replace the fuel cell D. Replace the display

Answer 68

THE CORRECT ANSWER IS A THIS SHOULD PROMPT YOU TO CALIBRATE THE SENSOR IT SHOULD BE RECALIBRATED TO 20.9% REPLACE THE SENSOR ONLY IF AN ANALYZER FAILS TO CALIBATE AT 21% AND 100% 02

Question 69

Which of the following when used in conjunction with other labs values would be most helpful in determining the presence of an myocardial infarction that might have occurred within the last 24 hours? A. Creatinine B. CK-MB C. C(a-v)02 D. Anion Gap

Answer 69

THE CORRECT ANSWER IS B; CK-MB IS A CARDIAC ENZYME THAT WILL BE ELEVATED AFTER A MYOCARDIAL INFARCTION

Question 70

Which type of circuit tubing is required for high-frequency oscillation ventilation? A. Wide-diameter, high-compliance tubing B. Narrow-diameter, high-compliance tubing C. Wide-diameter, low-compliance tubing D. Narrow-diameter, low-compliance tubing

Answer 70

THE ANSWER IS D, REMEMBER ABOUT HFOV, YOU MUST THINK ABOUT THE PROPER TRANSMISSION OF BULK GAS FLOW GOING TO AND FROM THE PATIENT. BECAUSE THE GASES FLOW AT SUCH HIGH FREQUENCIES, IT IS CRITICAL THAT THE TUBING BE OF LOW COMPLIANCE IN ORDER TO DELIVER A SPECIFIC VOLUME. MOST HFO VENTILATORS IN THE CLINICAL SETTING CONTAIN NARROW DIAMETER TUBING SPECIFICALLY FOR CONTROLLING LAMINAR FLOW VERSUS TURBULENT FLOW

Question 71

You are assisting an ICU nurse measure a patient's CVP with a strain-gauge pressure transducer. You note that the pressure transducer is positioned well above the middle of the patient's lateral chest wall. What effect, if any, would this have on the CVP measurement? A. No effect B. It would underestimate the CVP C. It would cause dampening of the signal D. It would overestimate the CVP

Answer 71

B IS THE CORRECT ANSWER! WHEN MEASURING RIGHT-SIDED VASCULAR PRESSURE SUCH AS CVP, YOU MUST ENSURE THAT THE BASE OF THE FLUID COLUMN OR PRESSURE TRANSDUCER IS POSITIONED AT THE LEVEL OF THE RIGHT ATRIUM (KNOWN AS THE PHLEBOSTATIC AXIS). OTHERWISE, THE SYSTEM WILL BEHAVE LIKE A U-TUBE MANOMETER AND OVERESTIMATE PRESSURES IF PLACED TOO LOW, AND UNDERESTIMATING PRESSURES IF PLACED TOO HIGH

Question 72

``` A patient that is 5'8" 160lbs 73kg is on AC VC Settings Fi02 70% Mandatory rate : 16bpm VT 400mL PEEP 18+ I:E Ratio 1:2 ``` Resident want to decrease the peak inspiratory flow. Which of the following best explains the affect of this change to the patient? A. Improves pulmonary compliance B. Improves distribution of gases C. Decreases pulmonary vascular resistance D. Decreases mean airway pressure

Answer 72

THE CORRECT ANSWER IS B DECREASE IN PEAK INSPIRATORY FLOW WILL PROLONG INSPIRATORY TIME WHCIH WILL PROMOTE BETTER AND MORE EVEN DISTRIBUTION OF GASES IN THE LUNGS. THE SLOWER THE RATE THE LESS TURBULENT AIR FLOW DELIVERED GASES CAN REACH DISTAL AREAS OF THE LUNGS.

Question 73

How often should ventilators be tested to verify their performance? A. Daily B. Between patient uses C. once a week D. Once a year

Answer 73

THE CORRECT ANSWER IS B ALL VENTS SHOULD BE TESTED BEFORE THE UNIT IS USED ON ANOTHER PT. THESE PROCEDURES SHOULD BE DETAILED IN THE HEALTH CARE FACILITY'S AND PROCEDURES MANUAL.

Question 74

Under ideal conditions, electrochemical oxygen analyzers have an accuracy of? A. +/- 1% B. +/- 2% C. +/- 5% D. +/- 10%

Answer 74

THE CORRECT ANSWER IS B THERE ARE 2 COMMON TYPES OF ELECTROCHEMICAL OXYGEN ANALYZERS THE POLYGRAPHIC WHICH IS CLARK AND THE GALVANIC FUEL CELL UNDER IDEAL CONDITIONS OF TEMP, PRESSURE AND RELATIVE HUMIDITY BOTH TYPES ARE ACCURATE TO WITHIN 2% OF ACTUAL CONCENTRATION

Question 75

``` What would your patient's static compliance be if the corrected tidal volume is 600mL, peak pressure is 65, plateau pressure is 48, and PEEP is 12? A. 9 B. 11 C. 13 D. 17 ```

Answer 75

THE ANSWER IS..... D 17. THESE ARE bIG ON THE TEST Cstat = VT / (Pplat-PEEP).

Question 76

According to ATS recommendations, diagnostic spirometers should be calibrated to within: A. +/- 1.5 cm H20/L/sec resistance B. +/- 3% or 50mL whichever is greater, using a 3 L syringe C. +/- 5% or 100mL whichever is greater using a 3L syringe D. +/- 10% or 500mL whichever is greater using a 5L syringe

Answer 76

THE CORRECT ANSWER IS B 3% OR 50ML ACCORDING TO THE ATS STANDARDS AND RECOMMENDATIONS FOR DIAGNOSTIC SPIROMETERS ARE THAT CALIBRATION CHECKS SHOULD BE WITHIN 3% OR 50ML

Question 77

Which of the following devices would you select to assess the output accuracy of a Bourdon gauge regulator used for 02 transport? A. Mercury manometer B. Clark Electrode C. Paramagnetic oxygen analyzer D. Precision flowmeter

Answer 77

THE CORRECT ANSWER IS D, TO ASSESS THE OUTPUT OR FLOW ACCURACY OF A BOURDON GAUGE REGULATOR USED FOR 02 TRANSPORT YOU SHOULD USE A PRECISION CALIBRATED FLOWMETER

Question 78

A 58Kg female patient is being mechanically ventilated with an SIMV rate of 10, tidal volume of 600mL and 10 of therapeutic PEEP with 35% FiO2. She has a 8 ID trach tube. Her spontaneous RR is 10 with average tidal volume around 350m. The most recent ABG shows pH7.40/42/95/26 What would you recommend? a. reduce the SIMV rate to 3 b. reduce the PEEP to 7 c. Increase the SIMV rate to 12 d. add 10 of pressure support

Answer 78

THE ANSWER IS B.....ABG shows adequate oxygenation so you can safely start reducing the PEEP. Ventilation is not the problem. So now we are working on oxygenation. No indication is present that the problem is increase airway resistance problem so pressure support isn't indicated. She has a size 8 trach already. Her spontaneous rr and TV is adequate

Question 79

How often should a PtC02 electrode be relocated in a neonate? A. Every 2 hrs B. Every 8 hrs C. Once a day D. No need to change

Answer 79

THE CORRECT ANSWER IS A BOTH PtCO2 and 02 ARE HEATED TO 44 DEGREES CELCIUS TO ARTERILIZE THE CAPILLARY BLOOD AS A RESULT OF THE INCREASED TEMP AT THE SIDE THE ELECTRODES MUST BE MOVED FREQUENTLY FOR NEONATES EVERY 2 HRS AND 2- 4HRS FOR ADULTS

Question 80

Which of the following hemoximeter measurements are affected air contamination ? A. HbCO levels B. metHb levels C. Hb02 levels D. Total Hb levels

Answer 80

THE CORRECT ANSWER IS C LEVELS OF HB02 METHB SHB AND TOTAL HB ARE UNAFFECTEFD BY AIR CONTAMINATION AND ADDITIONALLY INADEQUATE MIXING OF EITHER A SYRINGE OR CAPILLARY SAMPLE JUST PRIOR TO ANALYSIS WILL RESULT IN ERRONEOUS TOTAL HB MEASUREMENTS

Question 81

To avoid the preanalytical errors that are associated with air contamination of an ABG sample, all of the following are appropriate except: A. Removing of all air bubbles B. Mixing only after air has been completely removed C. Capping syringe quickly D. Using the minimum amount of heparin

Answer 81

THE CORRECT ANSWER IS D TO AVOID PRE ANALYTICAL ERRORS ASSOCIATED WITH AIR CONTAMINATION OF AN ABG YOU SHOULD FULLY REMOVE ANY AIR BUBBLES,CAP THE SYRINGE QUICKLY AND MIX SAMPLE ONLY AFTER AIR HAS BEEN REMOVED.

Question 82

As you revise the medical record for your patient in MICU with acute on chronic hypercapnia. After 14 days of mechanical ventilation patient was extubated to a 3L NC PMH: Heavy Smoker and has stopped smoking for about 6 weeks Cough: non productive Which of the values will be elevated for this patient? A. COHb B. Monocyte count C.RBC D. Leukocyte Count

Answer 82

THE CORRECT ANSWER IS C RBC! COPD PATIENTS IN RESPONSE TO CHRONIC HYPOXEMIA ARE PRONE TO DEVELOP POLYCYTHEMIA VERA. MONOCYTE AND LEUKOCYTE COUNT DO NOT MAKE ANY SENSE FOR THIS QUESTION AND COHb IS FOUND IN MOST COPD PATIENTS

Question 83

30 year old 5'10 176 lbs( 80 kg) male is admitted to the hospital for influenza like symptoms. After 3 days post admission patient complains to the RT hes having difficulty moving his extremities and describes it as an asecending muscular weakness. Data: Admission 10hrs later VT 6ml/Kg 5ml/Kg VC 25ml/Kg 12ml/Kg MIP -45cmH20 -30cmH20 What would you recommend? A. Give Dopram B. Peform Edrophonnium Test C. Monitor ventilatory mechanics Q4 hrs D. Intubate and place patient on mechanical ventilation

Answer 83

THE CORRECT ANSWER IS D! MUSCLE WEAKNESS AND ASCENDING PARALYSIS INDICATE GBS GILLIAN BARRE SYNDROME THIS PATIENTS NEUROLOGICAL CONDITION MUST BE MONITORED CLOSELY AS WEAKNESS AND PARALYSIS WILL LEAD INTO VENTILATORY FAILURE. VC IS THE MOST IMPORTANT VALUE HERE, IF VC

Question 84

Patient admitted to ICU Data: ``` CVP 1 mmHg Vitals: HR 120 Freq: 22 PCWP 5 mmgHg PAP 10 mmHg CI ( cardiac Index) 1.8L/min/m2 You attempt to get an Sp02 reading for your patient but unable to do so in the fingers so you obtain a reading from the earlobe at 87% ``` ABG: 7.32/28 PaCO2/120/12/-12 gas drawn : NRB @ 15L What would you recommend as the RT for this patient? A. IV Vasopressin B. NPPV C. IV NSS ( normal saline) D.HC03 bolus STAT

Answer 84

THE CORRECT ANSWER IS C LOOK AT YOUR HEMODYNAMIC DATA VERY POOR EH? CVP PCWP PAP CO ALL LOW INDICATING THIS PATIENT IS DEHYDRATED AND NEEDS IV NSS RIGHT AWAY, YES THE ABG LOOKS BAD BUT WE NEED TO ADDRESS THE DEHYDRATION ISSUE FIRST, IF YOU DONT ELECTROLYTES SUCH AS POTASSIUM CAN BE AFFECTED AND CAUSE CARDIAC ARRYTHMIAS

Question 85

38 year old female without any pulmonary history Diagnosed with ALI s/p MVA Resident is asking to extubate this patient 30mins of SBT's are done ``` Data: Pa02/Fi02 ratio : 250 RSBI 190 Sp02 95 on Fi02 50% HR 130 Freq: 23 ``` what would you recommend to this resident A. Liberate patient B. SBT to continue for the next 4 hrs C. Place patient on SIMV/PS D. Keep patient on mechanical ventilation

Answer 85

THE CORRECT ANSWER IS D. LOOK AT THE PF RATIO AND RSBI THESE VALUES ARE SUGGESTING PATIENT IS UNABLE TO MAINTAIN VENTILATION ALONG WITH UNSTABLE VITAL SIGNS.

Question 86

40 year old male admitted to the ER after sustaining spinal cord injury post MVA ,patient remains lethargic and somnolent but awakens with light stimuli, he is alert and oriented x 3 Numbness of upper and lower extremeties. VC 11ml/kg VT 5ml/kg HR 95 bpm RR 32 ABG: 7.33/ PaCO2 48/ 108/24 /0 What would you recommend for this patient? A.NPPV B.Oral intubation C. IV aminophylline D. IV Narcan

Answer 86

THE CORRECT ANSWER IS B! ALL EVIDENCE IN THIS SCENARIO INCLUDES LETHARGY: SOMNOLENCE AND PRESENCE OF SPINAL CORD INJURY WHICH SUGGEST PATIENTS INABILITY TO PROTECT THEIR OWN AIRWAY. ORAL INTUBATION IS INDICATED HERE TO PROTECT THAT AIRWAY AND AVOID ASPIRATION OF GASTRIC CONTENTS INTO THE LUNGS. **bottom line is if you have a pt with spinal cord injury U MUST PROTECT THE AIRWAY.** **what does X3 mean? Alert and oriented x 3 is to name, place, and time (date

Question 87

Patient with terminal cancer in ICU is experiencing increased work of breathing and dyspnea. Nurse attempts to establish an IV and fails to do so , at this time patient is refusing the IV. MD wants your expertise in how to deliver an aerosolized medication to relive her dyspnea. What do you recommend? A. Ativan B. Xopenex C. Lasix D. Morphine

Answer 87

THE CORRECT ANSWER IS D: MORPHINE MAY BE GIVEN TO RELIEVE PAIN AND DYSPNEA ESP IN TERMINAL PATIENTS NOTE: DYSPNEA IS THE UNCOMFORTABLE FEELING ASSOCIATED WITH SOB AND INCREASED WOB. MORPHINE ONLY RELIEVES THE DISCOMFORT ,IT DOES NOT RELIEVE DYSPNEA OR HER WOB IN THIS CASE.

Question 88

``` 56 year old male status post bariatric surgery On AC VC Mandatory rate 12 VT 550ml PEEP 5 Fi02 40% ``` ABG: 7.36/ PaC02 45/81/24/0 MD states patient is ready to wean What would you recommend? A. Place on SIMV B. Place on APRV with a P-high of 30 cmH20 C. Decrease PEEP to 3 D. Start SBT's

Answer 88

THE CORRECT ANSWER IS D! SBT's ARE THE MOST APPROPRIATE ACTION TO TAKE. NO INDICATION FOR SIMV OR PEEP OF 3. AND APRV WITH A P-high OF 30 cmH20 IS NOT UTILIZED FOR WEANING. ** D because the clue is post bariatric surgery, process of extubation is fast**

Question 89

``` What inspiratory flow is needed for a patient receiving volume limited ventilation at a rate of 15 bpm I:E 1:3 VT 600mL (L/min) A. 45 B. 39 C. 36 D. 40 ```

Answer 89

THE CORRECT ANSWER IS 36L/min ``` 9.0/.25= 36 L/ min Vinsp = Ve/% I-time ``` Ve is 15 x 600 VT which = 9000ml /min or 9.0L/min the Ti = .25 or 1:3 so then you divide 9.0/0.25= 36 L/min or IT=TCT/tot parts of I:E TCT=60sec/RR Tct=60sec/15=4 IT=4/4(total parts from I:E)=1s Flow=.600L/1x60sec=36L/m one cycle time = I + E. To find the length of the cycle time, divide 60 seconds by the rate. In this case, 60/15 = 4, so each complete cycle of I + E = 4 seconds. We know there is a 1:3 ratio, so if total cycle time is 4 seconds, I time has to be 1 second.

Question 90

Patient with acute on chronic hypercapnea to receive NPPV to help avoid mechanical ventilation and ventilator failure. Which one is most appropriate? A. IPAP 12 EPAP 3 B. IPAP 10 EPAP 5 C. IPAP 16 EPAP 10 D. IPAP 20 EPAP 12

Answer 90

THE CORRECT ANSWER IS B ! IPAP OF 10-12 AND EPAP OF 4-6 cmH20 IS A GOOD START FOR MOST PATIENTS !

Question 91

``` Patient in ICU with bilat pneumonia on AC/VC on day number 5 CBC 11K SBT's started with Fi02 40% PS 5 PEEP +5 after 45mins the HR 135 RSBI 140 VT spont 250ml Sp02 92% ``` What would recommend ad the ICU Respiratory Therapist? A. Place back on full ventilator support B. Increase PS to 10 C.Continue with current therapy and recheck vitals in 10 mins D. Increase PEEP and sedate

Answer 91

THE CORRECT ANSWER IS A! WITH AN RSBI THAT HIGH INDICATES PT IS EXHIBITING INCREASED WOB TO WEAN THIS PT OFF THE VENT. MUST RETURN TO PREVIOUS SETTINGS TO REST. SHOULD ATTEMPT WEANING THE NEXT DAY.

Question 92

NEW FOR 2015 ( CHANGES IN VT 6-10mL/Kg) ACCS HAS ESTABLISHED THIS NEW WAY TO CALCULATE FOR VT EXPERIMENTAL QUESTION FOR THE BOARD USE THE ABOVE VT TO ESTABLISH SETTINGS FOR THIS QUESTION: 60Y male 5'10" 229 lbs ( 104kg) in PACU not arousing that well s/p abdominal surgery History of DVT - on anticoag therapy Fellow Resident wants your expertise in now to ventilate this patient: A. SIMV 12 550 PS 10 +5 B. SIMV 10 850 PS 12 +8 C. AC 6 550 +10 D. AC 12 820 +5

Answer 92

THE CORRECT ANSWER IS A LETS BREAK THIS QUESTION DOWN, FIRST LOOK AT THIS PATIENT WEIGHT, HES OBESED THEREFORE DO NOT USE IBW TO CALCULATE HIS VT PATIENT SHOULD WEIGH 176 LBS APROX 80 KG USING 6-10ML/KG THE RADE SHOULD BE 480-800ML SO THERE ARE 2 SUITABLE OPTIONS HERE NOW INTIAL PEEP SHOULD RANAGE FROM 0-9 SO THIS LEAVES WITH ONE OPTION SIMV 12 550 PS 10 +5 PS 10 MAY BE EXCESSIVE BUT NOT HARMFUL FOR PTS AND IT WILL HELP DECREASE WOB AND CIRCUIT RESISTANCE

Question 93

25 year old male was rescued from his home after burning down, patient found by Firefighters on the floor facing down under a pile of debris. Patient rushed to the ER and admitted Patient has suffered a change in condition at this time and is experiencing refractory hypoxemia CXR: Bilat infiltrates Which of the following strategies is the most appropriate? A. Inverse IE ratio ventilation B. Flow rate > 60L/min C. VT 6ml/Kg of IBW D. Keep Plateau pressures

Answer 93

THE CORRECT ANSWER IS C REFRACTORY HYPOXEMIA IS ASSOCIATED WITH ALI A KEY STRATEGY IN PREVENTING FURTHER INJURY IS TO MINIMIZE ALVEOLAR STRETCHING BY KEEPING LOW TIDAL VOLUMES. USE THE ARDS.NET PROTOCO

Question 94

45 year old Female 5'9" 95kg on APRV following ventilator failure brought on by Pulmonary Hypertension. T-high 3.5 secs T-low 1.0 secs P-high 42 cmH20 P-low 3 cm H20 Physiological Findings: ``` Exhaled VT 1000ml PCWP 13 Cardiac Index 1.6L/min/m2 PAP 17mmHg CVP 8mmHg ``` What should the RT next do of the following? A. Increase P-low B.increase T-low C.Decrease P-high D. Decease T-high

Answer 94

THE CORRECT ANSWER IS C : DECREASE THE P-high. BASED ON IBW VT 1000ml IS TOO HIGH. APRV DOES NOT INCLUDE VT IN SETTINGS. VT IS DETERMINED BY THE DIFFERENCE IN P-high and P-low. DELIVERED VT CAN BE LOWERED BY DECREASING THE P-high.

Question 95

ICU patient with history of Myasthenia Gravis on mechanical ventilation on SIMV/VC mode.Which of the following would be least likely to decrease work of breathing? A. NAVA B. PS C. PAV D. Flow triggering

Answer 95

THE CORRECT ANSWER IS A! THE KEY WORD HERE IS LEAST!!!! NAVA IS A METHOD OF VENTILATION TRIGGERING THAT RELIES ON THE ELECTRICAL IMPULSE PRODUCED WHEN THE DIAPHGRAM CONTRACTS, USING NAVA ON PATIENTS WITH MG IS LESS EFFECTIVE TO DECREASED THEIR WORK OF BREATHING,.

Question 96

Patient with ALI on mechanical ventilation after inhalation of Kerosene In ICU Vent: AC/PC Mandatory rate 24 Fi02 60% PEEP 16+ HR 128 BP 85/60 Meds: IV Levophed, Wafarin INR 1.5 Platelets 80K U/L What would you recommend for this patient? A. DC IV Levophed B. Transfuse platelets STAT C. Place ART line D. increase Fi02 to 70%

Answer 96

THE CORRECT ANSWER IS C! PLACE AN ART LINE PATIENT IS CURRENTLY ON ANTICOAGULANT THERAPY. INR IS NOT OPTIMAL AT THIS POINT PT ALSO HAS A DX OF ALI IN WHICH WILL REQUIRE ABGS DONE PERIODICALLY TO WEAN PT. PLACING AN ART LINE WILL HELP PT NOT TOO BLEED PLUS OTHER LABS CAN BE OBTAINED THRU THE ART LINE WITHOUT PUNCTURING PT MULTIPLE TIMES.

Question 97

A male weighing 480 lbs ( 218kg) is on mechanical ventilation on AC/VC mode after recovering bariatric surgery. Which of the following will anticipate to see? A. high airway pressures B. Auto PEEP C. Decreased Plateau pressures D. Increased pulmonary compliance

Answer 97

THE CORRECT ANSWER IS A!OBESE PATIENTS OFTEN REQUIRE HIGH PIP TO OVERCOME THE POOR COMPLIANCE BROUGHT BY THE ADIPOSE TISSUE.

Question 98

Chest xray LLL infiltrate for a 60 year old female s/p gallbladder surgery ``` Data: RBC 7.0 Hb 17g/dL Vitals : temp 39.3 Leukocytes: 32K Creatinine 160 U/L INR 1.0 ``` What would recommend for this patient? A. PRBC's ( packed red blood cells) B. KCL C. Antimicrobial Therapy D. Leukotriene Modifier

Answer 98

THE CORRECT ANSWER IS C ! GOOD JOB EVERYONE . PRESENCE OF INCREASED WBC OR LEUKOCYTES SUGGEST A BACTERIAL INFECTION AND ANOTHER CLUE GIVEN HER LLL INFILTRATES!!!

Question 99

43 year old patient on AC/PC ventilation in response to ALI by inhalation of gasoline Vent settings: ``` Pressure limit : 34 cmH20 Mandatory rate: 18 delta P: 20 PEEP 15 ABG: 7.31/ 51 PaCO2/ 56 /28/0 ``` MD orders APRV P-high 30 P-low 3 IE ratio 4:1 This change will have which of the following effects? A. increased venous return B. decreased percent shunt C. increased FEV1/FVC ratio D. decreased pulmonary residual volume

Answer 99

THE CORRECT ANSWER IS B! AS APRV IS INTRODUCED TO THE PATIENT THE GREATER DELTA P WHICH INCREASED FROM 20 TO 27 CM H20 WILL RESULT IN AN EXPASION OF THE ALVEOLAR SURFACE THIS WILL LEAD INTO INCREASED GAS EXCHANGE AND RESULT IN DECREASE A-aD02 AND DECREASED PULMONARY SHUNTING .

Question 100

A physician is about to perform cardioversion on a patient with unstable atrial flutter who is receiving 02 via a non-rebreather mask. After the initial shock has been delivered, the patient's Sp02 drops to 85%, respirations become slow and shallow, and the heart rate drops to 82/min with normal sinus rhythm (NSR). What should the next immediate action be? A. Open the airway and provide manual ventilation with 100% 02 B. Administer 2mg of Naloxone (Narcan) C. Quickly deliver another synchronized shock D. Intubate and place on mechanical ventilation

Answer 100

A IS THE BEST CHOICE! The keyword in this question is IMMEDIATE, keep an eye out for these types of questions.