Standardized TMC-Like Exam Part 4

110. Data for a 55 kg (121 lb) patient receiving ventilatory support are: Mode Press Limit Rate FIO2 PEEP Ventilator Settings Press Ctrl A/C 25 cm H2O 18 0.35 0 cm H2O pH PaCO2 HCO3 PaO2 SaO2 Blood Gases 7.54 24 mm Hg 22 mEq/L 75 mm Hg 93% Which of the following changes would be appropriate at this time? A. increasing the pressure limit B. increasing the rate C. decreasing the pressure limit *D. decreasing the rate General Feedback: The patient has acute respiratory alkalosis (excessive ventilation). Ventilation is adjusted by altering the minute volume (VE) to achieve a PaCO2 with a normal pH. To decrease the VE during pressure control ventilation, one can decrease the rate and/or decrease the pressure limit. Here the rate is slightly high but the pressure limit is within the normal range (20 - 30 cm H2O), so the best choice would be to decrease the rate. 111. Which of the following diuretics would you recommend for a patient in acute cardiogenic pulmonary edema? *A. furosemide (Lasix) B. spironolactone (Aldactone) C. chlorothiazide (Diuril) D. acetazolamide (Diamox) General Feedback: For rapid diuresis, a loop diuretic like furosemide (Lasix) is indicated. Thiazide diuretics like chlorothiazide and potassium-sparing agents like spironolactone simply cannot produce as much urine as fast as can the loop diuretics. Acetazolamide has weak diuretic properties but is seldom used exclusively for this purpose. 112. The following four patients all exhibit acceptable ABGs during a spontaneous breathing trial. Cuff Leak Test A B C D Pass Fail Pass Pass Gag Reflex Max Exp Pressure Absent Present Present Absent 0 cm H2O 20 cm H2O 70 cm H2O 0 cm H2O Which one of these patients would you recommend be extubated? A. A B. B *C. C D. D General Feedback: Extubation should be considered only if the patient 1) can maintain acceptable ABGs during a spontaneous breathing trial; 2) can pass a cuff leak test (indicating minimal risk for upper airway obstruction); 3) is at minimal risk for aspiration (e.g., has positive gag reflex; can raise head on command); and 4) can adequately clear pulmonary secretions (e.g., exhibits deep cough on suctioning and/or has an MEP > 60 cm H2O or a peak cough flow > 60 L/min). Only patient C meets these criteria. 113. A doctor wants an outpatient with idiopathic pulmonary hypertension to self-administer an inhaled pulmonary vasodilator. Which of the following drugs would you recommend? A. epoprostenol (Flolan) B. diltiazem (Cardizem) *C. iloprost (Ventavis) D. bosentan (Tracleer) General Feedback: Pulmonary vasodilators administered via the inhalation route currently include three prostacyclins: epoprostenol (Flolan), treprostinil (Tyvaso) and iloprost (Ventavis). Only treprostinil (Tyvaso) and iloprost (Ventavis) are approved for administration via the inhalation route, typically for use by outpatients. Inhaled epoprostenol (Flolan) is used off-label in the acute care setting as an alternative to inhaled nitric oxide therapy and typically administered via continuous nebulization using an IV drip into a jet nebulizer. Both diltiazem (Cardizem; a calcium channel blocker) and bosentan (Tracleer; an endothelin receptor antagonist) are used to treat pulmonary hypertension, but are administered orally. 114. Clinical signs and a chest X-ray confirm that a patient receiving volume control SIMV has suffered a tension pneumothorax. Which of the following actions would you recommend to treat this problem? A. lowering the peak inspiratory pressure B. obtaining a stat arterial blood gas *C. performing a tube thoracostomy D. switching to pressure control SIMV General Feedback: A tension pneumothorax is a medical emergency. Treatment always involves decompression of the pleural space by either needle or tube thoracostomy chest tube insertion). Lowering the peak pressure will help prevent worsening of the problem, but does nothing to treat it. Likewise obtaining an ABG it is not a priority and will not help resolve the pneumothorax. 115. An 8-hour-old, 28-week gestational age neonate is being maintained in an oxygen hood with an FIO2 of 0.65. The neonatologist believes that the patient has infant respiratory distress syndrome (IRDS). Blood gas results are as follows: pH PaCO2 HCO3 BE PaO2 7.36 44 torr 24 mEq/L 0 mEq/L 46 torr You should recommend: A. increasing the O2 hood concentration to 80% B. beginning inhaled nitric oxide (INO) therapy *C. administering pulmonary surfactant D. starting high-frequency ventilation General Feedback: This infant’s acid-base balance is normal; hence mechanical ventilation is not warranted at this time. However, the patient has refractory hypoxemia (PaO2 < 60 with FIO2 > 0.60), probably due to shunting. With the hypoxemia due to shunting, further increases in FIO2 are not warranted. CPAP may be indicated but is not an option here. Surfactant administration is indicated for premature babies for the prevention and treatment of IRDS. Nitric oxide therapy is indicated only for persistent pulmonary hypotension of newborn (PPHN) or for hypoxic respiratory failure when conventional therapies such as mechanical ventilation are not successful. 116. You would recommend against inserting a laryngeal mask airway (LMA): A. in a child who is under three years of age B. in a patient with a Mallampati class 3 airway C. in a patient who has failed standard ET intubation *D. in a patient who is at high risk for aspiration General Feedback: An LMA is used an alternative to ET intubation for emergency ventilatory support and airway control in or out of the hospital. It can provide ventilatory support and/or airway control for patients who are difficult to intubate (Mallampati class 3 or 4), including neonates and small children (sizes 1-2). However, because they cannot prevent aspiration, LMAs are contraindicated in patients at high risk for this problem. 117. A surgeon writes an order for "hyperinflation therapy" for a 28 year old 110 lb female patient having undergone lower abdominal surgery. In evaluating this patient at the bedside, you obtain a vital capacity of 800 mL and an inspiratory capacity of 50% predicted. In addition, her chest X-ray indicates basal atelectasis. What hyperinflation treatment regimen would you recommend? A. incentive spirometry, 4-6 breaths TID B. IPPB q4h at 30 cm H2O with albuterol C. volume-oriented IPPB q2h, VT=800 mL *D. incentive spirometry with 8-10 breaths/hr General Feedback: When hyperinflation therapy is indicated, one should determine the most effective approach. In general, if the patient's post-op vital capacity is > 12-15 mL/kg (or the IC is > than 33% predicted), incentive spirometry should be considered as the initial approach. Values below this range indicate the need for volume-oriented IPPB. 118. Which of the following aerosolized agents would you recommend to facilitate airway clearance in a patient with cystic fibrosis (CF) who cannot tolerate DNase? *A. hypertonic saline B. albuterol (Proventil) C. dexamethasone (Decadron) D. tobramycin (TOBI) General Feedback: DNase is a mucokinetic agent that thins mucus by breaking up the long strains of DNA commonly found in purulent sputum. Unfortunately not all CF patients can tolerate DNase. Although albuterol and tobramycin are used to treat cystic fibrosis, they are not mucokinetic agents, and thus not a substitute for DNase. Hypertonic saline (5-7%) is classified as a mucokinetic, and thins secretions by drawing extra water into the mucus layer lining the airways. 119. A patient receiving mechanical ventilation with active heated humidification has very tenacious secretions. Which of the following actions would you recommend in order to facilitate suctioning of these secretions? A. instill 5 mL normal saline into the ET tube before suctioning B. increase the proximal airway temperature setting to 45 °C C. suction the patient for 20 to 30 seconds on each attempt *D. assure that the patient has adequate systemic hydration General Feedback: The best way to manage thick, tenacious secretions and prevent mucus plugs in intubated patients is to assure adequate systemic hydration. Because saline and mucus do not mix, saline instillation does NOT thin secretions. Moreover, saline instillation can cause desaturation and may dislodge bacterial colonies from the ET tube. The only potential indications for instilling saline are (1) to elicit a cough in a patient who despite intact airway reflexes cannot or will not cough, and (2) to help pass a suction catheter when you suspect partial obstruction of the ET/trach tube. Given that active heated humidification (BTPS conditions) already is being provided, raising humidifier temperature is not indicated and can be hazardous. Likewise extending the suction time beyond 10-15 seconds per attempt increases the likelihood of hypoxemia and atelectasis. 120. An intubated patient in ICU receiving inverse ratio pressure control ventilation needs continuous long-term sedation. Which of the following agents would you recommend for this patient? A. haloperidol (Haldol) B. chlorpromazine (Thorazine) *C. propofol (Diprivan) D. cisatracurium (Nimbex) General Feedback: Common medications used to sedate mechanically ventilated patients include benzodiazepines like midazolam (Versed); hypnotics like propofol (Diprivan); and alpha-2 agonists like dexmetatomidine (Precedex) or clonidine (Catapres). Opioid analgesics like fentanyl (Sublimaze) or remifentanil (Ultiva) also can be used as sedating agents. Haloperidol (Haldol) and chlorpromazine (Thorazine) are neuroleptic/antipsychotic agents, not sedatives. Likewise cisatracurium (Nimbex) is a neuromuscular blocking agent, not a sedative. 121. An intubated and mechanically ventilated patient is restless and fighting the ventilator. IV sedation has not been successful in calming the patient. Which of the following drugs would you recommended to assure patient-ventilator synchrony? A. disopyramide phosphate (Norpace) *B. cisatracurium (Nimbex) C. succinylcholine (Anectine) D. lorazepam (Ativan) General Feedback: Cisatracurium (Nimbex) is a nondepolarizing paralytic agent which can be used to facilitate mechanical ventilation in patients fighting the ventilator who are not responsive to sedatives alone. Because such agents do not affect sensation or the anxiety associated with being paralyzed, patients receiving paralytic agent also should continue to receive sedation. Succinylcholine (Anectine) is a shortacting depolarizing paralytic agent used for special procedures like intubation. Norpace is an antiarrhythmic drug indicated for the treatment of ventricular arrhythmias, such as sustained ventricular tachycardia. 122. A premature 1850 g newborn infant is receiving 40% oxygen in an oxyhood. A chest X-ray shows a ground-glass appearance bilaterally, with air bronchograms. An arterial blood gas reveals the following: pH PaCO2 PaO2 HCO3 BE 7.36 44 torr 45 torr 24 mEq/L 0 mEq/L Which of the following actions is appropriate at this time? A. intubate and initiate 10 cm H2O CPAP B. intubate and initiate mechanical ventilation *C. administer 5 cm H2O nasal CPAP with an FIO2 of 0.50 D. place the neonate in an Isolette with an FIO2 of 0.60 General Feedback: As suggested by the X-ray and blood gas, the likely problem is Respiratory Distress Syndrome. Since the blood gas indicates adequate ventilation but poor oxygenation (P/F ratio of about 100), a trial of noninvasive CPAP is the place to begin. 5 cm H2O is a reasonable starting point, with the FIO2 slightly elevated (0.50) to ensure adequate oxygenation. Intubation is not yet indicated, and raising the FIO2 alone will not help overcome the shunting that occurs in IRDS. 123. A patient is receiving postural drainage and percussion in the Trendelenburg position. Therapy should be terminated if which of the following develops? *A. hemoptysis B. productive coughing C. mild dyspnea D. flushing General Feedback: Active hemoptysis is an absolute contraindication for chest percussion and postural drainage and thus grounds for immediately terminating the therapy. 124. A patient has been experiencing a moderate asthmatic attack for 20 minutes. Which of the following arterial blood gas results would be most consistent with this condition if the patient was breathing room air when the sample was drawn? pH A B C D A. A B. B C. C *D. D 7.09 7.31 7.37 7.51 PaCO2 torr 68 49 41 29 PaO2 torr 49 60 76 54 General Feedback: Early in an asthma attack, the patient tries to compensate for the hypoxemia by hyperventilating (respiratory alkalosis). After a while, however, the patient will fatigue, and the paCO2 will rise up through 40 torr to a respiratory acidosis. 125. Two days after upper abdominal surgery, a patient develops a low-grade fever, dyspnea, tachypnea and signs of infiltrates/consolidation in the lower lobes. The most likely cause of this problem is: A. pleural effusion B. pulmonary edema C. ARDS *D. atelectasis General Feedback: Pulmonary infiltrates frequently develop in patients after major thoracic or upper abdominal surgery, especially if performed under general anesthesia and/or if a pre-existing co-morbidity is present, e.g., COPD, obesity, etc. When accompanied by fever, dyspnea, and tachypnea, the most likely causes are a bacterial or aspiration pneumonia or atelectasis. 126. Which of the following drugs you would NOT recommend for the long-term management of mild persistent asthma in an adult patient? *A. levalbuterol (Xopenex) B. beclomethasone (Vanceril) C. zafirlukast (Accolate) D. cromolyn sodium (Intal) General Feedback: Mild persistent asthma normally is treated with daily dosing of an anti-inflammatory drug. Options include a low-dose inhaled corticosteroid (like beclomethasone), or cromolyn sodium (Intal). Children usually begin with a trial of cromolyn or nedocromil. The leukotriene modifier (Montelukast-Singulair) may also be considered. Levalbuterol (Xopenex) is a short-acting beta agonist used primarily for treating exacerbation of symptoms, i.e., as a reliever or 'rescue' medication. 127. A physician orders intubation and volume control A/C ventilation for a 6 foot 3 inch tall 190 lb (86 kg) adult male patient with ARDS. Which of the following ventilator settings would you aim for to support this patient? A B C D Rate/min 10 8 20 15 VT (mL) 800 1200 900 500 A. A B. B C. C *D. D General Feedback: In adult patients with ARDS, the goal is to achieve a tidal volume of 6 mL/kg of predicted body weight, with a plateau pressure (Pplat) < 30 cm H2O. If Pplat > 30 cm H2O at 6 mL/kg, the VT can be reduced to as low as 4 mL/kg. The respiratory rate should be set to approximate the baseline minute ventilation, with the goal to achieve a pH between 7.20 and 7.45. For a six foot 3 inch tall patient with a predicted body weight of 85 kg, the goal would be a VT of about 500 mL with a rate between 10-20/min. In some cases rates as high as 35/min may be needed to maintain the pH above 7.30. 128. A 53 year-old patient complains that every winter for the past couple of years she develops a chronic cough usually accompanied by thick sputum. This information indicates that the patient probably has which of the following conditions? A. acute asthma *B. chronic bronchitis C. pulmonary fibrosis D. congestive heart failure General Feedback: Chronic bronchitis is defined by its symptoms, i.e., a productive cough for at least three months per year for at least two years. Other common findings that can help confirm the diagnosis include a noisy chest, cyanosis, and (in advanced stages) signs of right heart failure (i.e., peripheral edema, and jugular venous distension). 129. A sleep study conducted on a 38 year old adult male patient reveals the following: an average of 12 apneic periods/hr, each lasting at least 20 seconds. During the apneic episodes, the patient does not make any effort to breathe. The patient also complains of chronic day-time sleepiness. Which of the following is the most likely cause of this patient's problem? A. obstructive sleep apnea *B. central sleep apnea C. chronic hypothyroidism D. high intracranial pressure General Feedback: The most likely cause of this patient's problem is central sleep apnea. Central sleep apnea is characterized by the occurrence of at least 5 or more apneic periods/hr (of 10 seconds or more), during which the patient usually do not make any effort to breathe. Central sleep apnea is most likely due to a defect in the CNS respiratory control mechanism. 130. While assessing a 72 year old patient during therapy, you note a sudden drop in her heart rate to about 38/min, with respirations increasing from about 20/min to over 30/min. Which of the following actions would be appropriate? A. call a Code Blue and initiate CPR B. stop therapy and report the situation to nurse C. request continuous ECG + SpO2 monitoring *D. activate the Rapid Response Team General Feedback: The Rapid Response or Medical Emergency Team should be activated whenever a patient exhibits signs and symptoms of physiologic instability. Common criteria activating the team include one or more of the following: (1) acute change in mental status or overall clinical appearance; (2) heart rate < 40 or > 130, or respiratory rate < 8/min or > 30/min; (3) systolic blood pressure < 90 mm Hg; and (4) SpO2 < 90%, especially with supplemental O2. 131. If the number of ventilators needed to support patients in respiratory failure after a chemical disaster is insufficient to meet the need, your initial response should be to: A. contact other local facilities and arrange for patient transfers B. call and order additional backup ventilators from the vendor *C. enlist non–respiratory personnel to perform manual ventilation D. assign patients without needed equipment to triage priority Black General Feedback: Preparedness planning for the respiratory care department includes estimating the number of patients who may need ventilatory support, determining number of staff members required to meet patient needs, and having in place a staff emergency call-back procedure. Should the available equipment and personnel not be able to meet patient needs, the first step would be to enlist non– respiratory personnel to perform manual ventilation using disposable BVMs. Once adequate immediate patient support is ensured, you can attempt to get additional backup equipment and/or make arrangements to transfer patients to other facilities. 132. After two attempts at securing the airway and ventilating an infant in respiratory arrest, you still cannot confirm adequate air movement. You suspect foreign body airway obstruction. At this point you should: A. apply six to ten strong abdominal thrusts B. try to ventilate again with smaller puffs *C. apply back blows, followed by chest compressions D. go on to provide external cardiac compressions General Feedback: If two attempts to secure an airway and ventilate a victim fail, an obstructed airway is likely. For adults/children, an obstructed airway is addressed via abdominal thrusts (the Heimlich maneuver). For infants, you deliver repeated cycles of 5 back blows (slaps) followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive. Abdominal thrusts are not recommended for infants because they may damage the infant's relatively large and unprotected liver. Chest compressions may also be used for pregnant women and markedly obese persons. Regardless of procedure, you should follow it by a manual check/removal of obstructing material. 133. A patient receiving airway pressure release ventilation (APRV) needs transport to/from the imaging center for a lengthy catheterization procedure. Which of the following would be the optimal plan to manage this patient throughout the transport and procedure? A. use a transport ventilator capable of full support and assist-control ventilation *B. set up and apply the equivalent ventilator and mode in the receiving location C. bag the patient on 100% oxygen during transport and throughout the procedure D. recommend against transporting this patient due to the complexity of management General Feedback: For patients requiring mechanical ventilation, the ideal plan is to have equipment available at the receiving location that is capable of delivering ventilatory support equivalent to that being delivered at the patient's origin. Occasionally patients may require modes of ventilation or ventilator settings not reproducible at the receiving location or during transportation. Under these circumstances, the origin location must trial alternate modes of mechanical ventilation before transport to ensure acceptability and patient stability with this therapy. 134. At the end of each graded step of a cardiopulmonary exercise test, you normally would measure which of the following? A. physiologic deadspace B. intrapulmonary shunt *C. Borg exertion rating D. pulmonary diffusing capacity General Feedback: Toward the end of each graded interval of an exercise test, you typically measure the patient's blood pressure, heart rate, SpO2, Borg exertion rating, and symptoms (if any). You sometimes may need to draw an ABG specimen (for blood gas values and lactate levels) at each step in the protocol. 135. A surgical resident has asked that you assist her in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action? A. remove the oral tube before the tracheotomy is performed B. withdraw the oral tube 2-3 inches while the incision is made *C. remove the oral tube just prior to tracheostomy tube insertion D. replace the oral tube with an esophageal obturator airway General Feedback: If an endotracheal tube is in place during a tracheotomy, it should not be removed until just prior to the insertion of the tracheostomy tube, as this ensures a patent airway and provides additional stability to the trachea during the procedure. Once the stoma is created and the tracheostomy tube is selected and prepared for insertion, the endotracheal tube may be removed. 136. You assist a physician insert a pulmonary artery catheter via the subclavian venous route on a patient receiving volume control ventilation in the coronary care unit. Soon thereafter, the ventilator high pressure alarm begins sounding on each breath and the patient appears in acute respiratory distress. Which of the following would you recommend at this time? A. Taking a 12-lead ECG B. Withdrawing the catheter 2-3 cm C. Switching to pressure control *D. Obtaining a STAT chest x-ray General Feedback: One of the complications of pulmonary artery catheter insertion via the subclavian venous route is pneumothorax. The patient’s sudden development of respiratory distress and rising airway pressures are consistent with possible development of a tension pneumothorax. Although bedside assessment might indicate this as the cause of the problem, a STAT chest x-ray is needed to confirm it. In the interim, the patient should be ventilated with lower volumes/pressures and— if the situation worsens—a needle thoracostomy or chest tube may have to be inserted. 137. An adult patient has pneumonia and an empyema in the right pleural space. To assist the physician with thoracentesis of the affected lung, how should the patient be positioned? A. Lying down with the bed flat and the affected lung down B. Lying down with the bed flat and the affected lung up C. In semi-Fowler's position with the head and neck hyperextended *D. Sitting up straight and leaning forward on the overbed table General Feedback: In general, a patient undergoing thoracentesis should be in an upright sitting position, leaning forward with arms and head supported. This position can be achieve by having the patient sit on the side of the bed and lean forward onto an overbed table, or by sitting backwards on an armless chair, leaning forward on the chair back 138. Which of the following would you recommend to a home care patient for processing non-disposable respiratory therapy equipment? A. the equipment should be soaked in vinegar and then rinsed after each use B. the equipment should undergo sterilization at least once per week *C. the equipment should be washed, rinsed and air-dried after each use D. the equipment should undergo pasteurization at least once per week General Feedback: The best way to minimize the risk of infection in the home care setting is to use disposable respiratory therapy equipment. If non-disposable equipment must be used, it should be washed, rinsed (ideally with sterile water) and air-dried between uses. If high-level disinfection is required, the equipment should be immersed in an EPA-approved disinfectant. With the exception of bleach (sodium hypochlorite), common household products like vinegar are not recommended. Sterilization generally is not needed in the home setting. 139. A home care patient requires a higher FIO2 and as a result, the physician has ordered a change from an O2 concentrator to O2 cylinders. The patient should be told the following to ensure a safe environment: A. clean the O2 outlet every day by wiping it off with alcohol *B. secure the cylinder to a stand or chain it to the wall C. lay the cylinder on its side so that is cannot be tipped over D. 'wye' the cylinder and concentrator together to get the needed FIO2 General Feedback: The same basic safety rules used for managing cylinders in hospitals apply in the home. O2 cylinder should always be secured in a cylinder stand or chained to a wall to help prevent accidents. 140. A patient asks you if there are any over-the-counter (OTC) medications available to help her quit smoking. Which of the following would you suggest she discuss with her doctor? A. Buproprion (Zyban) B. Nicotine inhaler (Nicotrol) C. Varenicline (Chantix) *D. Nicotine gum (Nicorette) General Feedback: Varenicline (Chantix), buproprion (Zyban), and the 4 mg/cartridge nicotine inhaler (Nicotrol) are all prescription medications. On the other hand, nicotine gum (Nicorette) can be purchased without prescription (over-the-counter).