Patient Assessment
The respiratory therapist notes a respiratory rate of 34/min in the patient's chart. The patient’s breathing pattern is best described by which of the following?
Tachypnea
Rationale: While a patient with a respiratory rate this high may be hyperventilating, that can only be determined by observing ABGs and a PaCO2 <35 torr. From the information given, we can determine the patient is tachypneic (rate >25/min.)
A patient with asthma is being discharged from the hospital. Which of the following medications should be recommended to help prevent further attacks?
A. Theophylline (Aminophylline)
B. Albuterol (Ventolin)
C. Ipratroprium bromide (Atrovent)
D. Montelukast (Singulair)
D. Montelukast (Singulair)
Rationale: Leukotrienes occur naturally in leukocytes and produce allergic and inflammatory responses, such as bronchoconstriction and mucosal swelling. Montelukast is a leukotriene modifier that blocks the response and controls asthma attacks.
Which of the following is the most appropriate ventilator VT setting for a female patient who is 5 ft, 5 in tall and weighs 85 kg (187 lb)?
A. 350 mL
B. 450 mL
C. 600 mL
D. 700 mL
B. 450 mL
Rationale: The ventilator VT should be set at 6 to 8 mL/kg of ideal body weight. Calculation of ideal body weight is as shown:
Male: 106 + (6 × [(height in inches – 60])
Female: 105 + (5 × [height in inches – 60])
In this problem, the woman is 65 inches tall.
105 + (5 × [65 – 60]) = 105 + 25 = 130 lb
In other words, you add 5 lb for every inch over 5 ft to a base of 105 lb to obtain the ideal body weight. To change pounds to kilograms, divide by 2.2:
130/2.2 = 59 kg
Using 6 to 8 mL/kg of ideal body weight, the most appropriate volume is 450 mL.
A chest x-ray reveals that a patient has consolidation in the left upper lobe. For selective suctioning of the left mainstem bronchus, the respiratory therapist should recommend which of the following?
A coude-tip catheter:
is a catheter in which the tip is angled to the left for selective suctioning of the left mainstem bronchus
During O2 rounds, the respiratory therapist notices that the bed sheet is pulled over the entrainment port of a patient's air entrainment mask. Which of the following are true statements regarding this situation?
A. The FIO2 will decrease.
B. The FIO2 will increase.
C. The total flow will increase.
D. The FIO2 will remain unchanged.
B. The FIO2 will increase.
Rationale: If the entrainment port is occluded, less room air can be entrained to mix with the O2; therefore, FIO2 increases. Because room air entrainment decreases, the total overall flow also decreases.
Laboratory results indicate that a patient's sputum sample has an elevated eosinophil count. This is indicative of which of the following?
Asthma
Rationale: Most asthma is related to an allergic response to inhaled antigens. When mast cells are stimulated, several chemical mediators are released, resulting in bronchoconstriction. One of those mediators is eosinophil chemotactic factor of anaphylaxis (ECF-A). Thus, a high eosinophil count can be found in both sputum and blood.
To determine the causative organism for a patient’s pneumonia bronchoalveolar lavage (BAL) is performed. How much saline is generally instilled into the lungs for this procedure?
A. 25 mL
B. 50 mL
C. 100 mL
D. 200 mL
C. 100 mL
Rationale: BAL is the instillation of approximately 100 mL of normal saline through the bronchoscope's suction channel to the affected area. The tip of the scope is positioned into a fourth-generation bronchus and the saline instilled in 20 mL increments five separate times.
These data are collected from a sedated, paralyzed patient on volume-controlled ventilation in the assist-control mode:
Mode: Assist-control
Rate10 breaths/min
VT 500 mL (0.5 L)
FIO20 .40
ABGs pH7.29 PaCO2 50 mm Hg PaO2 77 mm Hg
HCO3 27mEq/LBE+3 mEq/L
Which of the following ventilator settings would decrease the patient's PaCO 2 to 40 mm Hg?
A. VT = 600 mL; rate = 12 breaths/min
B. VT = 700 mL; rate = 15 breaths/min
C. VT = 650 mL; rate = 8 breaths/min
D. VT = 625 mL; rate = 10 breaths/min
D. VT = 625 mL; rate = 10 breaths/min
Desired VE = [VE (current) × PaCO2 (current)]/PaCO2 (desired) = (5 L × 50) /40
= 250/40 = 6.25 L (desired VE)
A VT of 625 mL (0.75 L) and a rate of 10 breath/min is a VE of 6.25 L.
After a patient is intubated, the CO2 detector on the proximal end of the ET tube reads 2%. Which of the following should the respiratory therapist do at this time?
A. Leave the tube at this position.
B. Withdraw the tube completely and attempt intubation again.
C. Withdraw the tube 2 cm.
D. Advance the tube 2 cm
B. Withdraw the tube completely and attempt intubation again.
Rationale: Exhaled air contains approximately 5% to 6% CO2. If the ET tube is in the trachea or anywhere in the airway, CO2 is in the exhaled air passing through the detector, which shows a reading of 5% to 6%. If the tube is in the esophagus, the reading is less than 5%. One exception to this is when a patient is in full cardiac arrest and the exchange of gases is greatly diminished. In this case, even if the ET tube is in the trachea, the CO2 detector may read zero.
A 57-year-old patient with severe COPD enters the emergency department with shortness of breath. Room air ABG levels are as follows:
pH: 7.44
CO2: 49 mmHg
HCO3: 37 mEq/L
PaO2: 42 mmHg
A. Nonrebreathing mask at 15 L/min
B. 40% air entrainment mask
C. Nasal cannula at 2 L/min
D. 28% air entrainment mask
D. 28% air entrainment mask
Rationale: A high-flow O2 device such as an air entrainment mask should be used if the patient's RR is above 25 breaths/min because it will deliver more consistent O2 concentrations to the patient than a low-flow device (e.g., cannula). Although the RR is not given in this question, you should assume it is high because ABG levels reveal that this patient is hyperventilating. A patient with severe COPD normally has a PaCO2 in the range of 50 to 60 mm Hg, or even much higher in some cases, with a pH range of 7.30 to 7.40. We know that this patient's PaCO2 must be quite high because the >HCO3 is so high (37 mEq/L), compensating for the respiratory acidosis. It may seem strange to see a PaCO2 above the normal range (35 to 45 mm Hg) and yet call it hyperventilation. Normally, we would interpret this PaCO2 as hypoventilation, but this patient has a different set of “normal” ABG levels. Because the patient has a high PaCO2 whenever he hyperventilates, the PaCO2 is higher than normal for patients without severe COPD. This patient is hyperventilating in response to a lower level of hypoxemia than he normally has, which generally is in the range of 50 to 65 mm Hg.
During a pulmonary assessment, the patient tells the respiratory therapist that he has been coughing up green, foul-smelling secretions. This suggests to the therapist that the patient most likely has which of the following?
A. Pleural effusion
B. Pulmonary edema
C. Viral infection
D. Pseudomonas infection
D. Pseudomonas infection
Rationale: Pseudomonas species infections characteristically result in the production of green, foul-smelling sputum.
The physician wants to add a medication to a cystic fibrosis patient’s aerosol therapy treatment that will help reduce the viscosity of his pulmonary secretions. Which of the following would be the most appropriate drug to recommend?
A. Atrovent
B. Serevent
C. Pulmozyme
D. Albuterol
C. Pulmozyme
Rationale: Pulmonzyme is a mucolytic that thins thick secretions seen with cystic fibrosis patients.
The respiratory therapist is assessing a ventilator-dependent patient's ability to be weaned. The weaning protocol states that the patient can be weaned when the patient's spontaneous tidal volume is at least 3 mL/lb of the patient's ideal body weight, which is 60 kg (132 lb). The therapist measures the patient's spontaneous minute ventilation (VE) to be 8 L/min and the respiratory rate to be 20 breaths/min. What is the most appropriate recommendation?
Proceed with the weaning
Rationale: For weaning to be initiated, the patient's VT needs to be at least 3 mL/lb of the ideal body weight. In other words, the VT must be at least three times his weight. The patient weighs 132 lb; therefore, his spontaneous VT must be at least 396 mL for weaning to be appropriate. His measured minute ventilation (VE) is 8 L/min with a respiratory rate of 20 breaths/min. To determine his VT, VE must be divided by rate:
8/20 = 0.4 L (400 mL)
This indicates that initiating weaning is appropriate.
While manually ventilating an intubated apneic patient with a manual resuscitator, very little resistance is found when the bag is compressed, and the patient's chest rises only minimally. Which of the following may be the cause of this problem?
A. Excessive ET tube cuff pressure
B. Exhalation valve jammed in the closed position
C. Patient's lungs are noncompliant
D. Leak through the bag intake valve
D. Leak through the bag intake valve
Rationale: Three possible causes are a leak through the exhalation valve, bag intake valve, or around the ET tube or tracheostomy tube cuff.
The respiratory therapist is delivering a 80/20 heliox mixture through an oxygen flowmeter to an asthmatic patient. The flow is set at 15 L/min. The flow the patient is receiving is?
A. 8 L/min.
B. 15 L/min.
C. 24 L/min.
D. 27 L/min
D. 27 l/min
Rationale: Since a heliox mixture is much lighter than oxygen, an oxygen flowmeter won't read accurately with this mixture running through it. An 80/20 heliox mixture is 1.8 times less dense than oxygen, so multiply 1.8 times the flow to get the correct flow reading; 1.8 × 15 = 27 L/min. Note: The flow correction factor for a 70/30 heliox mixture is 1.6.
A 37-year-old patient receiving volume-controlled ventilation is recovering from gallbladder surgery and is receiving continuous IV infusions. Blood chemistry results reveal decreased BUN and Hb levels. The patient's urine output has remained at 50 mL/h for the past 4 hours. Assessment of this patient most likely reveals which of the following?
A. Inspiratory stridor
B. Hypotension
C. Auscultation of fine crackles
D. Increased CL
C. Auscultation of fine crackles
Rationale: The decreased Hb level may be the result of overhydration via the continuous IV fluids. Note that the urine output has not increased over the past 4 hours, even with continuous infusion of fluids, and the BUN level has decreased. These findings are consistent with overhydration, which can result in fine crackles being auscultated in the lungs.
A patient's systemic vascular resistance (SVR) increases from 15 to 24 mm Hg/L/min. The respiratory therapist should recommend administration of which of the following medications?
A. Epinephrine
B. Dopamine
C. Sodium nitroprusside
D. Dobutamine
C. Sodium nitroprusside
Rationale: An increased SVR indicates high blood pressure or hypertension. A commonly used antihypertensive drug is sodium nitroprusside (Nipride).
The following data are collected from a patient on volume-controlled ventilation:
Time PIP Plateau Pressure VT
0800 29 cm H2O 13 cm H2O 600 mL
0900 36 cm H2O 13 cm H2O 600 mL
1000 40 cm H2O 13 cm H2O 600 mL
1100 42 cm H2O 13 cm H2O 600 mL
On the basis of these data, you conclude that:
Airway resistance is increasing
Rationale: The data in this question show a stable plateau pressure with increasing peak pressures over 3 hours on a ventilator VT of 600 mL. Because plateau pressure is used to determine static compliance, and it is unchanged, then static compliance is unchanged. Peak pressure is used to calculate dynamic compliance, which is a measurement of airway resistance. As peak pressures increase, dynamic compliance decreases, which means airway resistance (Raw) is increased. Raw increases as a result of H2O in the ventilator tubing, secretions in the airway, bronchospasm, or mucosal edema. To help decrease Raw, determine the cause and treat it. For example, you can drain H2O from tubing, suction the patient, or recommend administration of a bronchodilator or a corticosteroid (for mucosal edema).
During manual ventilation, minimal resistance is found during compression of the bag, with little rise in the patient's chest. Which of the following should the respiratory therapist do to correct this problem?
A. Increase oxygen flow to the bag.
B. Inflate the cuff on the patient's ET tube.
C. Decrease flow to the bag.
D. Allow a longer time between bag compressions.
B. Inflate the cuff on the patient's ET tube.
Rationale: If the ET tube cuff is not inflated, gas being compressed from the bag will leak around the cuff, most likely from the patient's mouth. With a leak that large, the bag will not pressurize when compressed and, because little air is entering the patient's lungs, the chest will rise very little.
A patient has shortness of breath on a 60% aerosol mask. The following data are obtained:Pulse112 beats/min Respiratory rate34 breaths/min
ABGs pH7.27 PaCO253 mm Hg PaO2 68 mm Hg.
On the basis of this information, which of the following should be recommended at this time?
A. Place the patient on CPAP and 60% O2.
B. Intubate the patient and institute mechanical ventilation.
C. Increase levels to 70% O2.
D. Place the patient on a nonrebreathing mask.
B. Intubate the patient and institute mechanical ventilation.
Rationale: These ABG levels reveal acute respiratory acidosis, also referred to as acute ventilatory failure, which is evidenced by the elevated PaCO2 value. It must be treated by increasing alveolar ventilation with mechanical ventilation.
The respiratory therapist has been administering PEP therapy at 10 cm H2O to a patient with cystic fibrosis. Secretion clearance has not improved. Which of the following should the therapist recommend at this time?
A. Discontinue the therapy.
B. Decrease the PEP level to 5 cm H2O.
C. Increase the PEP level to 15 cm H2O.
D. Increase the PEP level to 25 cm H2O.
C. Increase the PEP level to 15 cm H2O.
Rationale: Normal PEP levels for treatment of retained secretions are 10 to 20 cm H2O. If secretion removal is not improving, the PEP level should be increased, generally in 5-cm H2O increments.
The physician wants to paralyze an agitated, combative asthmatic patient who is being mechanically ventilated. Which of the following would be the most appropriate drug to utilize at this time?
A. vecuronium (Norcuron)
B. succinylcholine (Anectine)
C. d-tubocurarine (Curare)
D. midazolam (Versed)
A. vecuronium (Norcuron)
Rationale: Vecuronium is the most appropriate neuromuscular agent to use in this scenario. Succinylcholine is a neuromuscular blocker used for short-term paralysis (5 min), such as prior to endotracheal intubation. D-tubocurarine is an old neuromuscular blocker not used anymore for this purpose. Although Versed (a sedative) should be administered prior to the neuromuscular blocker, it's not the correct answer to this question, since the question asks which neuromuscular blocker should be used.
A ventilator patient's cardiac index decreases from 3.5 to 2.2 L/min/m2. This may occur in which of the following situations?
A. Decreased vascular resistance
B. Hypervolemia
C. Excessive level of PEEP
D. Dopamine administration
C. Excessive level of PEEP
Rationale: Cardiac index is determined by dividing the patient's cardiac output by body surface area. It is simply a reflection of the patient's cardiac output. A decreasing cardiac index indicates that the cardiac output has decreased. Applying an excessive amount of PEEP to the airway results in compression of the superior and inferior venae cavae, restricting venous blood return back to the heart. With less blood flow returning to the right side of the heart, less blood is pumped to the left side of the heart and out to the body, resulting in decreased cardiac output.
The most effective method for determination of ET tube location after intubation is which of the following?
A. Auscultation of breath sounds
B. Direct visualization during intubation
C. Observance on chest x-ray
D. Listening for air flow at the tube outlet
C. Observance on chest x-ray
Rationale: Be sure to read the question carefully. The most effective method is always to see the tube and not simply hear air flow. If the question states that you have just intubated the patient when it is indicated to determine tube placement immediately, the correct answer is to auscultate breath sounds.
A patient’s PaO2 is 80 torr on a nonrebreathing mask, but the patient complains he can't tolerate wearing the mask. Which of the following should the respiratory therapist recommend?
A. Change to a nasal cannula at 8 L/min.
B. Replace with a face tent.
C. Use a high-flow nasal cannula.
D. Reduce the flow to the nonrebreathing mask.
C. Use a high-flow nasal cannula.
Rationale: This patient requires a high level of oxygen and a high flow nasal cannula is capable of delivering O2 levels of greater than 90% with flows of up to 60 L/min.