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Transcript
Practice RRT Examination
1.
Shortly after the respiratory therapist caps a patient's tracheostomy tube, the patient
appears agitated, and the respiratory rate and heart rate have increased. The SpO2
has fallen from 97% to 93%. Which of the following should the therapist do first?
A. Ask the patient to speak.
B. Inflate the pilot balloon of the tracheostomy tube.
C. Remove the tracheostomy and insert another.
D. Increase the FIO2.
EXPLANATIONS:
(c) A. If the patient can speak, then the patient needs to be reassured that it is difficult
to breathe around the tube, but it is OK. The respiratory therapist should remove the
cap if the patient does not speak and the condition does not improve.
(h) B. If the balloon were inflated, the patient would not be able to breathe.
(h) C. This is unnecessary in this situation.
(u) D. This may help the situation, but it would not correct the problem.
The respiratory therapist is reviewing the most recent report from a patient's PA
chest radiograph. The right heart border can be identified and the right diaphragm is
obscured. How should the patient be positioned for postural drainage and
percussion over the affected area?
2
A. supine with pillow under the knees
B. lying on left side with head down 15 degrees and rotated 1/4 turn backward
C. in a semi-Fowler's position
D. in a prone position with head down 25 degrees
EXPLANATIONS:
(u) A. Supine with a pillow under the knees drains the anterior segments of the upper
lobe.
(u) B. Lying on left side with head down 15 degrees and twisted 1/4 turn backward
drains the right middle lobe.
(u) C. A semi-Fowler's position drains the apical segments of the upper lobes.
(c) D. The obscured right diaphragm indicates a process in the right lower lobe. Lying
in prone position with head down 25 degrees drains the posterior basal segments of
the lower lobes.
3
A patient's fluid balance is relevant because it provides information about
I. renal function.
II. congestive heart failure.
III. pulmonary hypertension.
IV. pulmonary edema.
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. A major component of renal function is maintenance of fluid balance.
Therefore, impaired function would be monitored by using fluid balance
measurements.
II. True. Careful fluid balance is essential to the appropriate management of any
patient in whom there is difficulty with spontaneous maintenance of fluid and
electrolytes.
III. False. There is little relationship between fluid balance and secondary pulmonary
hypertension.
IV. True. See statement II.
(u) A. Incomplete and incorrect response included.
(c) B. Correct response.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
4
Which of the following would the respiratory therapist use to confirm the presence of
auto-PEEP during volume-controlled ventilation?
A. square-wave inspiratory flow
B. end-expiratory hold
C. plateau pressure
D. PSV mode
EXPLANATIONS:
(u) A. Auto-PEEP is not detected during the inspiratory phase.
(c) B. Auto-PEEP is detected at the end of the expiratory phase. Expiratory hold
permits pressure to be equilibrated throughout the ventilator circuit and the patient's
airway, allowing estimation of alveolar pressure.
(u) C. Plateau pressure is an end-inspiratory measurement. See explanation A.
(u) D. Auto-PEEP cannot be accurately detected during expiratory hold in a
spontaneously breathing patient.
5
A 34-week gestational age infant is receiving mechanical ventilation and the chest is
being transilluminated. The transillumination device produces a small halo
appearance at the point of contact with the skin. Which of the following does this
indicate?
A. pneumothorax
B. pneumomediastinum
C. pneumopericardium
D. normal lung appearance
EXPLANATIONS:
(u) A. When there is excessive air or fluid present, light transmission will be
increased. Transillumination of the air-filled chest in the neonate with a pneumothorax
results in lighting up the affected side of the chest.
(u) B. Transillumination will light up the chest in patients with pneumomediastinum.
See explanation A.
(u) C. Transillumination is not used to determine pneumopericardium.
(c) D. The halo appearance is produced by a normal, inflated lung absorbing the light.
6
The respiratory therapist is called to deliver a second dose of 5 mg aerosolized
albuterol to a patient with acute asthma. The patient had wheezing audible without a
stethoscope after the first treatment 20 minutes ago. Auscultation now demonstrates
no wheezing with very decreased breath sounds. The patient is receiving oxygen by
nasal cannula at 3 L/min and the SpO2 is 88%. Which of the following has MOST
likely occurred?
A. The albuterol reversed the bronchospasm.
B. The airways obstruction has worsened.
C. The SpO2 value was inaccurate.
D. The first treatment was ineffective.
EXPLANATIONS:
(u) A. Reversal of bronchospasm would result in improved breath sounds. The
decreased breath sounds are caused by lack of air exchange from worsened
bronchospasm.
(c) B. This patient is not ventilating enough to produce wheezing. The decreased
breath sounds and absent wheezing reflect the lack of air exchange.
(u) C. The patient's SpO2 is likely low because of inadequate air exchange.
(u) D. This patient is not ventilating enough to produce wheezing. The decreased
breath sounds and absent wheezing reflect worsening of the patient's bronchospasm,
regardless of the previous treatment.
7
A patient receiving aerosolized bronchodilator treatments with a small volume
nebulizer develops a tracheal infection involving Escherichia coli. Which of the
following is the most likely cause of the infection?
A. failure to change the tubing frequently
B. inadequate handwashing techniques
C. placing unsterile water in the nebulizer
D. contamination of disposable equipment
EXPLANATIONS:
(u) A. Failure to change the tubing frequently would most probably result in multiple
organism contamination of the tubing.
(c) B. Escherichia coli, a gram-negative organism generally found in the intestine, is
primarily transmitted by infrequent or inadequate handwashing.
(u) C. Using unsterile water would rarely result in gram-negative contamination.
(u) D. The possibility of contamination of disposable equipment by Escherichia coli is
remote.
8
A 42-year-old patient is receiving volume-controlled ventilation in the assist/control
mode with an FIO2 of 0.45, a tidal volume of 800 mL, and a mandatory rate of 10. The
patient is anxious and has a total respiratory rate of 30/min. Arterial blood gases are:
Which of the following drugs should the respiratory therapist recommend?
A. aerosolized lidocaine (Xylocaine)
B. oral pyridostigmine bromide (Mestinon)
C. morphine sulfate
D. intravenous naloxone (Narcan)
EXPLANATIONS:
(u) A. Aerosolized lidocaine is a topical anesthetic. It is used rarely to treat bronchial
reactivity. It would not treat the patient's anxiety.
(h) B. Oral pyridostigmine bromide is an orally active cholinesterase inhibitor that is
useful in the treatment of myasthenia gravis. It would not treat the patient's anxiety.
(c) C. Morphine sulfate would likely reduce the anxiety the patient is experiencing.
This would also reduce the total respiratory rate reducing minute ventilation and may
correct the hyperventilation.
(u) D. Naloxone is a narcotic antagonist used to reverse the effects of narcotics
(opiates). It would not treat the patient's anxiety.
9
While following a patient-driven protocol, the respiratory therapist has observed the
patient successfully self-administer two consecutive hand-held nebulizer treatments.
The therapist should
A. allow the patient to begin a self-treatment program.
B. delay initiation of self-treatment until the following day.
C. contact the supervisor for approval before proceeding.
D. delegate the patient's respiratory care to nursing.
EXPLANATIONS:
(c) A. An objective of a patient-driven protocol is to have the patient or family member
become responsible for the care, if possible.
(u) B. An objective of a patient-driven protocol is to expedite care by implementing
decisions in a timely manner.
(u) C. The staff therapist at the bedside should have the authority to make this
decision. Supervisory time is best spent solving non-routine problems.
(u) D. The respiratory therapist remains responsible for the patient's care. It would be
inappropriate to delegate respiratory care.
10
A 21-year-old patient was involved in a motorcycle crash. The chest radiograph
reveals fractured left ribs 4-8, and the patient is currently receiving an FIO2 of 0.40 by
air-entrainment mask. The following data are obtained:
Which of the following should the respiratory therapist recommend?
A. Administer an FIO2 of 0.40 with 5 cm H2O mask CPAP.
B. Administer an FIO2 of 1.0 by nonrebreathing mask.
C. Intubate and institute 5 cm H2O CPAP.
D. Intubate and institute mechanical ventilation.
EXPLANATIONS:
(c) A. Administering CPAP by mask would noninvasively enhance end-expiratory
alveolar stability, increasing the FRC and PaO2.
(h) B. Any unnecessary increase in the FIO2 would increase the likelihood of
absorption atelectasis.
(h) C. There is no indication for endotracheal intubation at this time.
(h) D. There is no indication for endotracheal intubation and mechanical ventilation at
this time.
11
The respiratory therapist is preparing to assist with a bronchoscopic biopsy of a
patient with a solitary pulmonary nodule. The therapist should assure that which of
the following tests have been performed?
A. arterial blood gas
B. electrolytes and creatinine
C. cardiac enzymes
D. PT and PTT
EXPLANATIONS:
(u) A. Arterial blood gas analysis may be helpful but it is not critical prior to the
performance of bronchoscopic biopsy. See explanation D.
(u) B. Electrolytes and creatinine may be helpful but it is not critical prior to the
performance of bronchoscopic biopsy. See explanation D.
(u) C. Cardiac enzymes are not needed for pre-bronchoscopic assessment. See
explanation D.
(c) D. Coagulation studies are required prior to procedures where bleeding may occur.
12
A patient is receiving 80%/20% heliox using a standard oxygen flowmeter. Which of
the following is the correction factor to determine the accurate flow?
A. 1.4
B. 1.6
C. 1.8
D. 2.4
EXPLANATIONS:
(u) A. See explanation C.
(u) B. See explanation C.
(c) C. The correction factor for 80% / 20% heliox is 1.8.
(u) D. See explanation C.
13
A patient with COPD is receiving oxygen, 2 L/min by nasal cannula, at home. The
patient's SpO2 is usually 90%. When visiting the patient, the respiratory therapist
finds the oxygen set at 4 L/min, the patient lethargic, and his oxygen saturation is
95%. Which of the following should the therapist do immediately?
A. Obtain a blood gas sample and notify the physician.
B. Contact the physician and request hospital admission.
C. Change the oxygen flow to 2 L/min and observe the patient.
D. Discontinue oxygen until the patient's mental status improves.
EXPLANATIONS:
(h) A. Assuming an accurate SpO2, an arterial blood gas is unnecessary and would
delay intervention, possibly leading to acute ventilatory failure.
(h) B. Physician notification is unnecessary and hospital admission may be harmful
because it delays immediate care.
(c) C. This patient needs an adequate PaO2 but not high enough to blunt the hypoxic
drive.
(h) D. Discontinuing O2 therapy would lead to hypoxemia.
14
A 36-year-old patient is diagnosed with asthma and primary pulmonary
hypertension. A diagnostic workup reveals the following:
The physician asks the respiratory therapist to improve the patient's pulmonary
status. Which of the following gas mixtures should the therapist administer?
A. NO, 10 ppm
B. He/O2, 80%/20%
C. NO, 20 ppm
D. He/O2, 70%/30%
EXPLANATIONS:
(c) A. PVR is normally 90-200 dynes.sec.cm-5 and 420 is significantly elevated. NO may
provide pulmonary vasodilation and reduce this level. The optimum level of NO for
pulmonary vascular dilatation is 10 ppm.
(u) B. Helium/oxygen is indicated for increased airways resistance. The Raw is normal,
therefore a helium/oxygen mixture is not indicated.
(h) C. PVR is normally 90-200 dynes.sec.cm-5 and 420 is significantly elevated. NO may
provide pulmonary vasodilation and reduce this level. However, 20 ppm is in the toxic
range, NO should be started at a dose lower than 20 ppm.
(u) D. Helium/oxygen is indicated for increased airways resistance. The Raw is normal,
therefore a helium/oxygen mixture is not indicated.
15
A 62-kg (136-lb) patient is receiving pressure-controlled ventilation. The following
data are available:
The respiratory therapist should recommend decreasing the
I. FIO2.
II. peak pressure.
III. mandatory rate.
IV. inspiratory time.
A. I and II only
B. I and IV only
C. II and III only
D. III and IV only
EXPLANATIONS:
I. False. The PaO2 and FIO2 are satisfactory. A change in FIO2 would not address the
respiratory alkalosis.
II. True. Decreasing the peak pressure should result in a decreased tidal volume and
minute ventilation, resulting in an improvement of the respiratory alkalosis.
III. True. Decreasing the mandatory rate would decrease the minute ventilation,
resulting in an improvement of the respiratory alkalosis.
IV. False. Reducing inspiratory time would not improve the respiratory alkalosis, but
would worsen the I:E ratio.
(u) A. Incomplete and incorrect response included.
(u) B. Incorrect response.
(c) C. Correct response.
(u) D. Incomplete and incorrect response included.
16
During which of the following should apnea monitoring be implemented for an
infant?
I. night time
II. breast feeding
III. naps
A. I only
B. I and II only
C. I and III only
D. II and III only
EXPLANATIONS:
I. True. The infant should be monitored during any sleep or when not being directly
observed.
II. False. The infant should be monitored during any sleep. Infants are usually awake
and being directly observed during feeding.
III. True. The infant should be monitored during any sleep or when not being directly
observed.
(u) A. Incomplete response.
(u) B. Incomplete and incorrect response included.
(c) C. Correct response.
(u) D. Incomplete and incorrect response included.
17
The respiratory therapist performs an assessment prior to initiating aerosol therapy
and chest physiotherapy. The therapist notices the patient has a rapid respiratory
rate and is using accessory muscles to breathe. During the interview, the patient
states, "I seem to breathe fast and lift my shoulders a lot, but I feel like I am getting
enough air." The therapist can conclude that the patient likely has
A. dyspnea on exertion.
B. orthopnea.
C. increased work of breathing.
D. hypopnea.
EXPLANATIONS:
(u) A. Dyspnea on exertion is the subjective sensation of difficulty breathing during
exercise. This symptom has not been described.
(u) B. Orthopnea is sleeping in the upright position due to difficulty breathing. This
symptom has not been described.
(c) C. This patient describes an increased respiratory rate and the use of accessory
muscles. These findings are directly related to the increased work of breathing.
(u) D. Hypopnea is shallow breathing. This symptom has not been described.
18
A patient appears to be a candidate for rapid weaning after recovering from a drug
overdose. While receiving an FIO2 of 0.30 during volume-controlled ventilation, blood
gas values are:
While fulfilling a weaning order, the respiratory therapist changes the mandatory rate
from 15 to 10 and the mode to SIMV. The therapist should also
A. adjust the low minute-volume alarm.
B. increase the FIO2 to 0.35.
C. perform deep tracheal suctioning.
D. place the patient in a supine position.
EXPLANATIONS:
(c) A. Changes in ventilator settings require appropriate adjustments to alarms to
facilitate safe patient care.
(u) B. The patient is adequately oxygenated and there is no reason to believe this
would change.
(u) C. Suctioning should be related to a need to clear secretions, not ventilator
settings.
(u) D. There is no need for a change in patient positioning at this time.
19
Characteristics associated with point-of-care data entry such as hand-held systems
include
I. standardizing documentation.
II. measuring the quality of patient care.
III. monitoring charge capture.
IV. evaluating clinician productivity.
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. Standardization of documentation, monitoring charge capture, and
evaluation of clinician productivity are easily accomplished with computerized handheld systems.
II. False. The quality of patient care is a subjective measurement.
III. True. See statement I.
IV. True. See statement I.
(u) A. Incomplete and incorrect response included.
(u) B. Incomplete and incorrect response included.
(c) C. Correct response.
(u) D. Incomplete and incorrect response included.
20
The respiratory therapist is evaluating a 15-year-old patient with cystic fibrosis. The
patient self-administers 5 mL of 10% acetylcysteine (Mucomyst) with a
bronchodilator by aerosol q.i.d., followed by chest physiotherapy. In the past 6
months, the patient has required frequent hospitalization for exacerbations of the
disease. The patient currently still has shortness of breath. Which of the following
should the therapist recommend for discharge planning?
A. Increase the treatment frequency to q4h.
B. Change the postural drainage positions.
C. Add a PEP device to the nebulizer.
D. Follow treatments with a heated aerosol face mask.
EXPLANATIONS:
(u) A. Increased frequency would stress patient compliance and interfere with
normal activities.
(u) B. There is no evidence that altering positions would reduce the frequency of
exacerbations.
(c) C. PEP would help with secretion clearance, is self-administered, and may reduce
exacerbations.
(u) D. Heated aerosol has not been shown to augment the effect of mucolytics or
enhance secretion clearance.
21
A patient is homebound and has arranged his 75 feet of oxygen tubing to allow
kitchen activity. During a visit to the patient, the respiratory therapist finds the
oxygen concentrator running, but it is producing inadequate flow through the nasal
cannula. Which of the following would most likely resolve this problem?
A. Install an air intake bacteria filter.
B. Disconnect the inline bubble humidifier.
C. Change to a back-pressure compensated flowmeter.
D. Install and use a separate 220-volt electrical circuit.
EXPLANATIONS:
(u) A. A missing bacteria filter would not impede gas flow.
(u) B. Appropriately installed bubble humidifiers do not impede gas flow.
(c) C. Excessive connecting tubing creates increased resistance to gas flow, resulting
in back pressure to the gas source. Using a back-pressure compensated (Thorpe
tube) flowmeter would give accurate readings.
(u) D. Inadequate household current is not a cause of the problem. The concentrator
can only operate on the voltage for which it was designed.
22
The respiratory therapist is assisting a physician during an intubation procedure.
After several unsuccessful attempts, interrupted by bag-valve-mask ventilation, blind
intubation is performed. The therapist reports a color change of the CO2 detector
after six breaths. The most appropriate action for the therapist to perform NEXT is to
A. secure the endotracheal tube.
B. auscultate the chest.
C. prepare for reintubation.
D. obtain an arterial blood gas.
EXPLANATIONS:
(u) A. The endotracheal tube should not be secured until proper placement has been
confirmed. A main stem intubation would result in the presence of exhaled CO2.
(c) B. Auscultating the chest is appropriate to determine the presence of bilateral
breath sounds.
(h) C. There is no indication for reintubation. The presence of exhaled CO2 after six
breaths eliminates the possibility that the CO2 detected was from the stomach which
can occur during bag-valve-mask ventilation.
(u) D. The endotracheal tube position should be assessed prior to obtaining an arterial
blood gas. Improper position could result in erroneous data.
23
An 18-month-old infant is to receive 30% oxygen by mist tent. While performing a
routine equipment check, the respiratory therapist notices the oxygen analyzer
inside the tent reads 25%. After calibrating the oxygen analyzer, it still indicates 25%.
The therapist should
A. change oxygen analyzers.
B. check the air inlet for an obstruction.
C. check the oxygen inlet for an obstruction.
D. add sterile water to the nebulizer reservoir.
EXPLANATIONS:
(u) A. Proper calibration indicates correct functioning of the analyzer. Replacement
not indicated.
(u) B. Obstruction of the air inlet can only increase the FIO2.
(c) C. Obstruction of the oxygen inlet can decrease the FIO2.
(u) D. Adding water to the reservoir will not affect FIO2 inside the tent.
24
A male patient who is 80 kg (176 lb) and 180 cm (5 ft 11 in) is orally intubated with a
7.0 endotracheal tube. Mechanical ventilation was initiated with an HME in the circuit.
It has become increasingly difficult to effectively suction the patient’s secretions
after 7 days. The respiratory therapist should
I. use a smaller suction catheter.
II. replace the HME with a heated humidifier.
III. suggest changing to a larger endotracheal tube.
IV. administer acetylcysteine (Mucomyst).
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. False. If an appropriate size catheter is unable to remove the secretions, a smaller
catheter would be less likely to help in this situation.
II. True. A heated humidifier may be more effective than an HME if the secretions are
thick.
III. True. A 7.0 tube is relatively small for a man of this size. A larger endotracheal
tube would allow for therapeutic bronchoscopy to remove secretions and may also
reduce airways resistance.
IV. True. A mucolytic may help reduce the viscosity of secretions.
(u) A. Incomplete and incorrect response included.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(c) D. Correct response.
25
The respiratory therapist is preparing a disease management plan for a 52-year-old
patient recently diagnosed with COPD. Since the diagnosis, the patient has
complained of shortness of breath during exercise. Which of the following questions
are MOST important for the therapist to ask the patient while teaching energy
conservation skills?
I. "Do you smoke?"
II. "What is your inhaled medication regimen?"
III. "What is your highest level of education?"
IV. "What is your occupation?"
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. The patient's smoking history may indicate the need for smoking cessation
intervention.
II. False. Energy conservation teaches the patient techniques to help deal with his
symptoms in the performance of physical work. Inhaled medications are not directly
related to energy conservation.
III. True. The patient's level of education will influence the selection of instructional
approaches.
IV. True. The therapist needs to know the level of physical activity that is required to
perform the patient's job. This will help the therapist prepare the patient to function at
work.
(u) A. Incomplete and incorrect response included.
(u) B. Incomplete and incorrect response included.
(c) C. Correct response.
(u) D. Incomplete and incorrect response included.
26
A 90-kg (198-lb) patient remains intubated in the PACU following abdominal surgery.
The patient is still somnolent but is making occasional shallow spontaneous
respiratory efforts while receiving ventilation with a bag-valve resuscitator. Which of
the following should the respiratory therapist do?
A. Continue manual ventilation until the patient is awake.
B. Initiate a T-piece weaning trial with 5 cm H2O CPAP.
C. Initiate mechanical ventilation in the SIMV mode.
D. Initiate mechanical ventilation in the pressure-support mode.
EXPLANATIONS:
(a) A. Although this patient could be manually ventilated, it may be for an extended
period of time. This would prevent the therapist from performing other patient care.
(h) B. T-piece ventilation with CPAP requires the patient to have an adequate
spontaneous respiratory rate and tidal volume. A patient who is still under the
influence of general anesthesia would be unable to produce an effective minute
ventilation.
(c) C. Mechanical ventilation in the SIMV mode can provide guaranteed minute
ventilation, while allowing the patient to participate in ventilatory support.
(h) D. Pressure-support ventilation requires the patient to have an adequate
spontaneous respiratory rate. This may not provide an effective minute ventilation for
a patient who is still under the influence of anesthesia.
27
An intubated premature newborn is experiencing increased signs of respiratory
distress. Which of the following tests/procedures would be helpful in diagnosing a
pneumothorax?
A. suction
B. bronchoscopy
C. transillumination
D. capillary blood gas
EXPLANATIONS:
(u) A. Suctioning the newborn would not help diagnose a pneumothorax and would
delay appropriate treatment. This may be helpful if the infant has increased
secretions.
(h) B. A bronchoscopy would not aid in diagnosis of pneumothorax and would be
harmful.
(c) C. Transillumination with a high intensity light source in a dark room can help
identify a pneumothorax.
(u) D. Capillary blood gases would not help diagnose a pneumothorax. This is timeconsuming, invasive, and would delay appropriate treatment.
28
A 43-year-old patient with ARDS is receiving pressure-controlled ventilation. The
PEEP level has changed from 12 cm H2O to 16 cm H2O. During initial assessment, the
respiratory therapist should monitor
A. intake/output.
B. electrolytes.
C. cardiac rhythm.
D. the pressure-volume loop.
EXPLANATIONS:
(u) A. A change in urine output would be delayed based on a reduction in cardiac
output from increasing PEEP.
(u) B. There is no direct association of electrolyte metabolism with PEEP levels.
(u) C. Cardiac rhythm does not necessarily correlate with cardiac output, which is the
parameter that would be affected by any change in PEEP.
(c) D. The pressure-volume loop would demonstrate the change in PEEP level. Any
significant secondary change in compliance or volume may be seen as well.
29
The respiratory therapist is called to check an oxyhood in the NICU. The unit is using
a large volume nebulizer and an air/oxygen blender with a flowmeter. The therapist
notes the pressure pop-off valve on the nebulizer is chattering. Which of the
following actions is required?
A. Increase the flowmeter from 5 to 8 L/min.
B. Check the tubing to the oxyhood for an obstruction.
C. Reposition the capillary tube in the nebulizer.
D. Tighten the high pressure supply line connections to the blender.
EXPLANATIONS:
(u) A. An increase of 3 L/min would increase back pressure and would not correct this
problem.
(c) B. An obstruction to the nebulizer outlet could cause the pressure pop-off valve to
chatter.
(u) C. A malfunctioning capillary tube would affect nebulization, but not the pop-off
valve.
(u) D. The 50 psi gas source does not contribute to activating the pop-off valve.
30
A 58-year-old male patient is 165 cm (5 ft 5 in) tall and weighs 110 kg (242 lb) and is 1
day postoperative open cholecystectomy. The patient is receiving volume-controlled
ventilation guided by a patient-driven protocol. The therapist notes the following:
Which of the following changes in the protocol should the therapist recommend?
A. Reduce the mandatory rate until spontaneous breaths occur.
B. Discontinue use of pressure support with the SIMV mode.
C. Use ideal body weight to calculate the tidal volume setting.
D. Increase the PEEP setting to 10 cm H2O.
EXPLANATIONS:
(h) A. A patient may hypoventilate or become apneic without adequate ventilatory
support. Simply reducing the rate would not allow this to be detected.
(u) B. Pressure support of 5 cm H2O would be insufficient to cause excess ventilation,
and this patient has no spontaneous breathing to contribute to his overventilation.
Pressure support most often is a desirable adjunct to SIMV to overcome resistance of
an artifical airway.
(c) C. Lung volumes are primarily related to a person's height. Therefore, obesity
should not be included as a factor in establishing the tidal volume for mechanical
ventilation. Using ideal body weight removes the unreliable variable of abnormal
nutritional status.
(u) D. There is no evidence showing any clinical value to adjusting PEEP levels based
solely on body weight.
31
A patient who is receiving mechanical ventilation with an FIO2 of 0.70 and a PEEP of 8
cm H2O is monitored with continuous pulse oximetry. The patient's SpO2 decreases
from 96% to 89% when removed from mechanical ventilation for routine suctioning
and bronchial hygiene. Which of the following should the respiratory therapist do?
A. Increase the PEEP to 10 cm H2O.
B. Administer bronchodilators.
C. Perform bedside hemodynamic monitoring.
D. Change to a closed-system suctioning device.
EXPLANATIONS:
(u) A. Increasing the PEEP would not correct desaturation when the patient is
removed from the ventilator.
(u) B. Bronchodilator therapy is not indicated for a patient who desaturates when
mechanical ventilation is interrupted for suctioning.
(u) C. Hemodynamic monitoring is not indicated and does not address the clinical
problem of desaturation.
(c) D. Changing to a closed-system suctioning device may reduce the hypoxemic
episodes.
32
The respiratory therapist is caring for a 75-year-old female who has had a cough
productive of purulent sputum for 5 years. She was diagnosed with a Mycobacterium
avium complex lower respiratory tract infection 3 years earlier. Her chest radiograph
shows ring shadows and dilated and thickened airways, configured like tramlines, in
the right middle lobe. In addition to antibiotic therapy, which of the following should
the respiratory therapist recommend?
A. transtracheal aspiration
B. postural drainage
C. diagnostic bronchoscopy
D. respiratory isolation
EXPLANATIONS:
(u) A. Transtracheal aspiration is used to obtain diagnostic sputum samples. See
explanation C.
(c) B. The history, clinical presentation, and chest radiograph findings suggest
bronchiectasis associated with Mycobacterium avium complex infection. The
treatment of bronchiectasis includes antibiotics and techniques to loosen and
mobilize viscid secretions. Postural drainage enhances sputum mobilization.
(h) C. Diagnostic bronchoscopy may be needed for diagnosis of Mycobacterium
avium complex infection. However, since the patient has already had the diagnosis,
bronchoscopy is not required and may lead to complications.
(u) D. Mycobacterium avium complex is not transmitted from person to person by
inhalation, therefore no respiratory isolation is needed.
33
The respiratory therapist is supervising a respiratory care student for a clinical
rotation in the ICU. The student assesses the cuff of an endotracheal tube to comply
with both the minimal leak and the minimal occlusion techniques. Which of the
following steps are included in this process?
I. Remove all of the air from the cuff.
II. Inflate the cuff with air so no leak is heard at the end of inspiration.
III. Withdraw air from the cuff so a slight leak is heard at the peak of inspiration.
IV. Measure and record the cuff pressure.
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. False. This practice allows secretions trapped above the cuff to be aspirated,
increasing the risk of infection.
II. True. This is appropriate for the minimal occlusion technique.
III. True. This is appropriate for the minimal leak technique.
IV. True. It is appropriate to measure and document the cuff pressure.
(h) A. Incomplete and incorrect response included.
(h) B. Incomplete and incorrect response included.
(h) C. Incomplete and incorrect response included.
(c) D. Correct response.
34
The respiratory therapist is calibrating several gas measurement devices in the ICU.
Air should be used to zero calibrate which of the following?
A. capnograph
B. nitrogen analyzer
C. Clark electrode
D. oxygen analyzer
EXPLANATIONS:
(c) A. A capnograph uses air for zero point calibration because it contains no CO2.
(u) B. A nitrogen analyzer has an air calibration point of 592.8 mm Hg (760 x 78%).
(u) C. A Clark electrode has an air calibration point of 159.6 mm Hg (760 x 21%).
(u) D. An oxygen analyzer reads 21% (or 159.6 mm Hg) in air.
35
The respiratory therapist assigned to a new employee's orientation is describing the
clinical applications of pulse oximetry (SpO2). Which of the following should the
therapist explain are useful applications of pulse oximetry?
I. documenting oxygenation for Medicare reimbursement requirements
II. evaluating the severity of carbon monoxide poisoning
III. preventing retinopathy of prematurity in neonates
IV. monitoring the effectiveness of ventilation
A. I and III only
B. I and IV only
C. II and III only
D. II and IV only
EXPLANATIONS:
I. True. Pulse oximetry is accepted by Medicare to document the need for oxygen.
II. False. Pulse oximetry does not differentiate carboxyhemoglobin from total
oxyhemoglobin.
III. True. Pulse oximetry can be used to monitor a neonate's response to oxygen
therapy and prevent hyperoxia linked to retinopathy of prematurity.
IV. False. Pulse oximetry does not reliably evaluate the effectiveness of ventilation.
PaCO2 monitoring is the only direct technique for monitoring ventilation.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incorrect response.
36
A 54-year-old female with asthma is receiving oxygen by nasal cannula at 4 L/min
and complains of shortness of breath and appears very anxious. Her temperature is
34.6° C (94.3° F), heart rate 115/min and regular, respiratory rate 26/min, and blood
pressure 75/55 mm Hg. The respiratory therapist notices the patient's hands are cool
and clammy. Arterial blood gas results are:
Which of the following could cause the difference in oxygen saturation
measurements?
A. hyperventilation
B. hypoperfusion
C. tachycardia
D. radiated light
EXPLANATIONS:
(u) A. Extreme hyperventilation may contribute to vasoconstriction but would be
insufficient to cause a significant difference between SaO2 and SpO2.
(c) B. A systolic blood pressure below 80 can be associated with hypoperfusion of the
extremities resulting in a falsely low SpO2.
(u) C. Moderate tachycardia does not produce peripheral vasoconstriction sufficient
to cause a falsely low SpO2.
(u) D. Radiated light from extraneous sources, coupled with a loose-fitting probe, can
interfere with the spectrophotometric analysis essential to pulse oximetry, leading to
falsely high, not low, SpO2 readings.
37
The respiratory therapist is assessing a patient with COPD who has been receiving
PEP therapy for 4 days. Which of the following outcomes indicates therapy should
continue?
A. positive subjective response
B. stable vital signs
C. increased exercise tolerance
D. unchanged SpO2 values
EXPLANATIONS:
(c) A. A patient's subjective response is an important indicator for the effectiveness of
PEP therapy.
(u) B. Vital signs are not relevant to the assessment of PEP therapy.
(u) C. Increased exercise tolerance is not relevant to the assessment of PEP therapy.
(u) D. SpO2 values are not reliable indicators for the effectiveness of PEP therapy.
38
Which of the following devices should be used to effectively deliver a 70%
helium/30% oxygen mixture to a patient?
A. simple mask
B. oxygen hood
C. nasal cannula
D. nonrebreathing mask
EXPLANATIONS:
(u) A. A simple mask is not capable of delivering a reasonably accurate percentage
and therapeutic amount of a helium/oxygen mixture.
(u) B. Large volume enclosures are unsatisfactory because helium tends to
concentrate at the top of these devices.
(u) C. Because of dilution with ambient air, low-flow nasal devices are ineffective for
delivering helium/oxygen mixtures.
(c) D. An appropriately fitted nonrebreathing mask does not permit air-entrainment
and will maintain the helium gas concentration.
39
In reviewing the ventilator flow sheet for a patient who is receiving mechanical
ventilation, the following data are noted:
Which of the following should the respiratory therapist conclude?
A. These data are erroneous.
B. Airway resistance is 5 cm H2O/L/sec.
C. A bronchopleural fistula has developed.
D. The patient has significant airway obstruction.
EXPLANATIONS:
(c) A. Dynamic compliance values must be lower than static compliance values
because dynamic values include both airway resistance and elastic recoil. Therefore,
the compliance values must be erroneous.
(u) B. Airway resistance cannot be determined from these data.
(u) C. Static compliance could not be obtained in a patient with a bronchopleural
fistula because of the leak.
(u) D. Dynamic and static compliance are not indicators of airway obstruction.
40
A patient receiving beta-adrenergic aerosol therapy is taking slow, deep breaths with
a pause at the end of each inspiration. Five minutes into the treatment, the patient
complains of lightheadedness, dizziness, and tingling in the fingers. Which of the
following should the respiratory therapist do?
A. Instruct the patient to breathe less deeply.
B. Recommend changing the medication for the next treatment.
C. Discontinue the treatment and notify the physician.
D. Have the patient pause every 1-2 minutes during the treatment.
EXPLANATIONS:
(u) A. The slow, deep tidal volumes and inspiratory hold are causing hyperventilation.
By decreasing the tidal volume, the signs of hyperventilation may resolve, but there
may be less aerosol delivery.
(u) B. Changing the medication is not indicated by these symptoms. The symptoms
noted indicate hypocarbia.
(u) C. It is not necessary to discontinue the treatment, only modify the patient's
breathing pattern.
(c) D. Periodic interruption in therapy should allow normalization of PaCO2 and pH
while maintaining effective medication delivery when the treatment is resumed.
41
A patient receiving mechanical ventilation is being suctioned q4h with a 12 Fr
suction catheter at a pressure of -120 mm Hg. The patient has a 7.0 mm oral
endotracheal tube in place. The amount of secretions seems to be increasing. Which
of the following actions is most appropriate?
A. Suction more frequently.
B. Use a Coudé tip suction catheter.
C. Use a larger suction catheter.
D. Increase the suction pressure to -150 mm Hg.
EXPLANATIONS:
(c) A. Increased amounts of secretions require more frequent intervention. Suctioning
should be done as needed, not on a scheduled basis.
(u) B. Type and size of catheter is not the problem.
(u) C. See explanation B.
(h) D. A pressure of -150 mm Hg is excessive and may cause damage to the
respiratory mucosa.
42
A patient who is receiving mechanical ventilation using PEEP is switched to a
continuous-flow CPAP system for weaning. On initial evaluation, the manometer
shows negative pressure during inspiration and the patient appears agitated and
uncomfortable. Which of the following actions is most appropriate?
A. Hyperoxygenate and suction the patient.
B. Reinstitute mechanical ventilation.
C. Increase CPAP by 2 cm H2O.
D. Increase system flow.
EXPLANATIONS:
(u) A. Hyperoxygenation would not change the negative pressure from inspiratory
effort recorded on the manometer, nor would suctioning.
(u) B. Reinstituting mechanical ventilation would relieve the patient's symptoms, but
would not achieve the goal of weaning.
(u) C. The patient is demonstrating signs of air hunger. Increasing CPAP by 2 cm H2O
would not change the negative pressure on the manometer from the patient's
inspiratory effort.
(c) D. The reason for the negative pressure on the manometer is inadequate flow
during inspiration. Increasing system flow would correct the problem.
43
A 57-year-old male is admitted to the hospital complaining of dyspnea on exertion
and a dry, non-productive cough. He states his symptoms have been worsening for
the past 2 months. The patient's respiratory rate is 28 with fine inspiratory crackles
(rales) throughout his lung fields, but are most noticeable in his lower lobes.
Spirometry shows some restrictive component. Which of the following would the
respiratory therapist recommend?
A. chest radiograph
B. ventilation/perfusion studies
C. exercise stress testing
D. bronchoprovocation studies
EXPLANATIONS:
(c) A. This patient has signs and symptoms of interstitial lung disease. A chest
radiograph would help determine the severity of the disease.
(u) B. Ventilation/perfusion studies would not provide any useful diagnostic
information for this patient.
(u) C. Exercise stress testing would not be performed until the diagnosis of interstitial
lung disease is confirmed.
(u) D. Bronchoprovocation studies are used to determine airway reactivity and
therefore are not indicated in this case.
44
A 60-kg (132-lb) patient is receiving volume-controlled ventilation in the
assist/control mode. Arterial blood gas results and related data are:
Which of the following individual ventilator adjustments could improve the patient's
arterial blood gases?
I. adding 5 cm H2O PEEP
II. increasing the FIO2 to 0.80
III. increasing the mandatory rate to 12
IV. changing to the SIMV mode
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. Adding PEEP may increase the PaO2.
II. True. Increasing the FIO2 would increase the PaO2.
III. True. Increasing the mandatory rate would decrease the elevated PaCO2 and
increase the PaO2.
IV. False. SIMV mode would have no effect on the blood gases since the patient is
apneic.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
45
While assessing a patient who is receiving oxygen at 2 L/min through a transtracheal
catheter, the patient complains the supply tubing keeps popping off of the catheter.
Which of the following actions should the respiratory therapist take to correct this
problem?
A. Decrease the flow of oxygen.
B. Check the catheter for obstruction.
C. Perform endotracheal suctioning.
D. Tape the connection securely.
EXPLANATIONS:
(h) A. Decreasing the flow would not correct the problem and could possibly affect the
patient's oxygenation.
(c) B. The catheter is obviously obstructed with mucus or kinked, resulting in
significant back pressure causing the supply tube to pop off.
(u) C. Endotracheal suctioning would not clear an obstruction in the transtracheal
catheter.
(u) D. Taping the connection would not correct the problem and could be potentially
harmful to the patient.
46
A patient with asthma is receiving a treatment with 2.5 mg of albuterol. During the
treatment, the patient's heart rate increases from 80/min to 138/min. The respiratory
therapist should recommend
A. decreasing the dosage of albuterol.
B. increasing the amount of saline per treatment.
C. changing to ipratropium bromide (Atrovent).
D. adding acetylcysteine (Mucomyst) to the treatment.
EXPLANATIONS:
(c) A. The patient's marked increase in heart rate indicates an adverse reaction to this
dose of medication.
(u) B. The patient has had an adverse reaction to the bronchodilator. An increase in
saline would not reduce the amount of active medication delivered.
(u) C. Atrovent is a secondary bronchodilator in the treatment of asthma. An
adjustment to the dose of albuterol is more appropriate.
(h) D. This patient has had an adverse reaction to the bronchodilator. Aerosolized
acetylcysteine may aggravate airway irritability, resulting in increased bronchospasm.
47
An upright PA chest radiograph reveals a left lower chest density with a concave
superior interface. A left lateral decubitus radiograph shows a density, with a distinct
line from the diaphragm to the apices in the left lung. The most likely diagnosis is
A. pulmonary edema.
B. emphysema.
C. congestive heart failure.
D. pleural effusion.
EXPLANATIONS:
(u) A. The filling of alveolar spaces with fluid would reveal soft, fluffy, and poorly
demarcated lesions that would not change with patient position.
(u) B. Emphysema reveals a hyperinflated thorax with flattened diaphragms and a
generalized increased translucency of the lung fields that would not shift with a
change in patient position.
(u) C. Congestive heart failure would reveal an enlarged heart, a diffuse reticular
pattern, plus accentuated vascular shadows.
(c) D. The presence of a density with a concave superior interface in the dependent
portion of the thorax is consistent with a pleural effusion. Changes in patient position
causes the fluid to shift and the density to be viewed differently on a lateral decubitus
film.
48
A patient is receiving an FIO2 of 0.40 by a heated nebulizer connected to a T-piece.
Five hours later, the FIO2 analyzed at the nebulizer side of the T-piece is 0.45. Which
of the following should the respiratory therapist do to correct the problem?
A. Clear the nebulizer jet.
B. Replace the nebulizer.
C. Empty the condensate from the aerosol tubing.
D. Increase the flow to the nebulizer.
EXPLANATIONS:
(a) A. Clearing the nebulizer jet may improve nebulizer performance, but will usually
not affect FIO2.
(u) B. Replacing the nebulizer is not necessary. Clearing the tubing of condensate
should correct the problem.
(c) C. Condensate in the tubing would cause a higher FIO2 by increasing back
pressure to the air entrainment port, therefore reducing the dilution of oxygen with air.
(u) D. Increasing the flow might increase the delivered FIO2 and would not correct the
problem.
49
A patient complains of dyspnea and has a Raw of 4 cm H2O/L/sec. The respiratory
therapist should suspect the patient may have
A. atelectasis.
B. pneumonia.
C. asthma.
D. pulmonary fibrosis.
EXPLANATIONS:
(u) A. There is relatively little airflow in areas of atelectasis, which results in no
significant change in Raw.
(u) B. Pneumonia often involves only alveoli and small airways that would not affect
Raw as significantly as asthma.
(c) C. Normal airways resistance is 0.5-2.5 cm H2O per liter per second. Asthma
involves large and medium airways and will cause increases in R aw and dyspnea in
proportion to the degree of bronchoconstriction and inflammation.
(u) D. Pulmonary fibrosis is an interstitial disease that does not narrow the airways
and therefore should not cause an increase in Raw.
50
A patient with COPD is experiencing difficulty triggering the ventilator. The
respiratory therapist notes that auto-PEEP is present. Which of the following
changes is indicated?
A. Decrease set PEEP to approximate the sensitivity setting.
B. Increase set PEEP to a level near the total PEEP.
C. Increase inspiratory time.
D. Decrease expiratory time.
EXPLANATIONS:
(u) A. Sensitivity is automatically related to set PEEP, so changing set PEEP would
not affect sensitivity to inspiratory efforts.
(c) B. Increasing PEEP to a level near total PEEP would optimize the ability of the
ventilator to sense the patient trigger effort.
(u) C. Increasing inspiratory time would allow less time for exhalation and potentially
create more auto-PEEP, thus making triggering more difficult.
(u) D. Decreasing expiratory time would allow less time to exhale and potentially
create more auto-PEEP thus making triggering more difficult.
51
Which of the following policies should the respiratory therapist recommend to
minimize infection risks associated with patients receiving mechanical ventilation?
A. Disinfect the external surfaces of ventilators daily.
B. Change ventilator circuits every 48 hours.
C. Change HMEs every 48 hours.
D. Replace bacterial filters daily.
EXPLANATIONS:
(c) A. The CDC recommends daily disinfection of external ventilator surfaces to
minimize the risk of infection.
(u) B. Changing ventilator circuits and HMEs every 48 hours tends to increase
infection risks for patients due to interruption of the circuits and possible
contamination.
(u) C. See explanation B.
(u) D. Replacing bacterial filters daily tends to increase infection risks for patients due
to interruption of the circuits and possible contamination.
52
After attaching a cardiac monitor to a patient's chest, the respiratory therapist notes
the ECG recording contains artifact. Which of the following could cause artifact in
this situation?
I. inadequate electrode contact
II. improper electrode placement
III. the patient scratching the electrodes
IV. disconnected leads
A. I and III only
B. I and IV only
C. II and III only
D. II and IV only
EXPLANATIONS:
I. True. Poor electrode contact could produce artifact.
II. False. Improper electrode placement could produce inappropriate complexes for
the lead displayed but not artifact.
III. True. The patient scratching or moving the electrodes could cause artifact.
IV. False. Disconnected leads would produce no variability in electrical charge or a
flat line, which is different than artifact.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incorrect response.
53
A 24-year-old female presents with seasonal nasal stuffiness and occasional
episodes of daytime dyspnea and cough. Which of the following drug classifications
should the respiratory therapist recommend to control the patient's symptoms?
A. leukotriene inhibitor
B. IgE immunoglobulin antagonist
C. beta-adrenergic agonist
D. short-acting antihistamine
EXPLANATIONS:
(c) A. The patient has allergic rhinitis and, at most, mild persistent asthma.
Leukotriene inhibitors, such as montelukast (Singulair), are indicated for control of
mild asthma and allergic rhinitis.
(h) B. IgE immunoglobulin antagonist, such as omalizumab (Xolair), is indicated for
severe allergic asthma and carries significant risk.
(u) C. Beta-adrenergic agonists are rescue drugs and are not used to control asthma
and would have no role in the treatment of allergic rhinitis.
(u) D. Short-acting antihistamines produce too many side effects to be useful in the
control of asthma or allergic rhinitis.
54
The respiratory therapist attended the birth of a full-term neonate. Vital signs are:
Which of the following should be the initial treatment?
A. manual ventilation with 100% O2
B. endotracheal intubation
C. oxyhood with 100% O2
D. chest compressions
EXPLANATIONS:
(c) A. According to NRP guidelines, manual positive pressure ventilation is indicated
in this situation.
(h) B. According to NRP guidelines, endotracheal intubation is not indicated at this
time and could cause delay in proper therapy.
(h) C. Spontaneously inhaled oxygen is not sufficient. See explanation A.
(h) D. According to NRP guidelines, chest compressions are not indicated for a heart
rate greater than 60/min while providing positive pressure ventilation with 100%
oxygen.
55
A patient with a history of chronic bronchitis complains of shortness of breath
following chest surgery. The patient is receiving 30% O2 by mask. Rhonchi in the
right lower lobe are heard on auscultation. Which of the following should the
therapist recommend?
A. PEP with incentive spirometry
B. ultrasonic nebulizer therapy
C. acetylcysteine (Mucomyst) therapy
D. chest percussion
EXPLANATIONS:
(c) A. Deep breathing, accompanied by PEP therapy, would provide optimal bronchial
hygiene to clear secretions.
(u) B. Ultrasonic nebulizer therapy may produce bronchospasm and has little benefit.
(u) C. Acetylcysteine (Mucomyst) therapy may produce bronchospasm and is not
indicated.
(h) D. Chest percussion would be contraindicated in a patient following chest surgery
because of chest tubes and incisional pain.
56
A patient is using a demand oxygen conserver with a nasal cannula. The patient
complains the device is not triggering on inspiration. To evaluate why it is not
functioning properly, the respiratory therapist should determine whether the
I. device is providing continuous flow.
II. patient is inspiring through his nose.
III. tubing is free from plugs.
IV. humidifier is securely attached.
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. If the device failed to sense the patient's inspiratory effort, it would default to
a continuous flow mode. This would cause the device to no longer be an oxygenconserver and would cause the patient's oxygen supply to deplete sooner.
II. True. The device sensor responds only to decreased nasal pressure.
III. True. Obstructed tubing would not allow the device to sense inspiratory effort.
IV. False. There is no place to connect a humidifier to an oxygen conserver, nor are
they used with the device.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
57
A patient with cystic fibrosis was involved in a motor vehicle crash and is being
monitored for possible increases in intracranial pressure. Airway clearance has been
ordered per protocol. Which of the following are appropriate for this patient?
I. postural drainage and percussion
II. oscillatory PEP
III. in-exsufflator
IV. high frequency chest vest
A. I and II only
B. I and III only
C. II and IV only
D. III and IV only
EXPLANATIONS:
I. False. Postural drainage and percussion in a head-down position are
contraindicated in a patient with possible increased ICP.
II. True. Oscillatory PEP, administered through the Acapella and Flutter ® valves, is an
acceptable airway clearance technique because it does not require a head-down
position.
III. False. An in-exsufflator is primarily used for patients with neuromuscular
diseases. It may cause airway collapse in patients with obstructive disease. The inexsufflator may agitate the patient and may increase intracranial pressure.
IV. True. A high frequency chest vest is an acceptable airway clearance technique for
this patient because it does not require a head-down position.
(h) A. Incomplete and incorrect response included.
(h) B. Incorrect response.
(c) C. Correct response.
(h) D. Incomplete and incorrect response included.
58
While manually ventilating an intubated patient during transport, the respiratory
therapist observes a significant decrease in SpO2. Which of the following should the
therapist do first?
A. Continue ventilation since desaturation is expected during transport.
B. Instill saline down the endotracheal tube to dislodge a mucus plug.
C. Verify that the resuscitator bag is connected to oxygen.
D. Reposition the oximeter probe.
EXPLANATIONS:
(u) A. Significant desaturation is not expected under any circumstances.
(u) B. A mucus plug may cause decreases in saturation, but would take time to
remove, if this were the problem.
(c) C. During transport, the oxygen tubing may have become disconnected and the
lack of oxygen would cause a decrease in SpO2.
(u) D. Repositioning the probe would not change the SpO2 and is not the first action to
take.
59
The respiratory therapist is assigned to implement a protocol system for delivery of
respiratory care. Which of the following are the most appropriate indicators to
measure protocol program outcomes?
I. diagnosis
II. length of stay
III. therapy ordered
IV. hospital unit
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. Matching therapy ordered and the length of stay to the diagnosis serves as a
measure of therapeutic effectiveness.
II. True. See explanation I.
III. True. See explanation I.
IV. False. Although in some cases you may wish to evaluate outcomes on a particular
unit, this element is not a primary indicator for measuring the effectiveness of
respiratory care.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
60
A 23-year-old, 80-kg (176-lb) 178-cm (5-ft 10-in) male is admitted to the intensive care
unit, and mechanical ventilation is initiated. Ventilator settings are:
The high pressure alarm is sounding frequently, and wide fluctuations are noticed on
the pressure manometer. The most appropriate action would be to
A. sedate the patient.
B. decrease the tidal volume.
C. increase the pressure limit.
D. increase the flow.
EXPLANATIONS:
(u) A. Sedating the patient would probably improve the patient's synchrony with the
ventilator, but would not resolve the problem of the excessive inspiratory time due to
low flow.
(u) B. Decreasing the tidal volume may result in an inadequate minute ventilation, and
the problem would not be resolved.
(h) C. Increasing the pressure limit would not address the problem of inadequate flow
and may increase the possibility of pulmonary overdistention.
(c) D. Increasing the flow would more adequately meet the patient's inspiratory flow
demand.
61
At 1 minute after birth a neonate has the following:
acrocyanosis
slow, irregular respiratory effort
heart rate of 102/min
sneezes with the use of a nasal catheter
partial flexion of the extremities
The Apgar score for this neonate is
A. 3.
B. 5.
C. 7.
D. 9.
EXPLANATIONS:
(u) A. See explanation C.
(u) B. See explanation C.
(c) C. Correct answer. See chart below.
(u) D. See explanation C.
62
The following data are obtained:
What is the P(A-a)O2?
A. 200 torr
B. 350 torr
C. 500 torr
D. 550 torr
EXPLANATIONS:
(u) A. See explanation C.
(u) B. See explanation C.
(c) C. PAO2 = FIO2 (PB - PH2O) - PaCO2
R
PAO2 = 1.0 (747 - 47) - 38
0.8
PAO2 = 700 - 48
PAO2 = 652 torr
P(A-a)O2 = 652 - 152
P(A-a)O2 = 500 torr
(u) D. See explanation C.
63
While counseling a patient during a smoking cessation session, the patient
expresses concern about weight gain. The respiratory therapist should address the
patient's concern by explaining that this is partially the result of
A. decreased metabolism.
B. increased loss of self-control.
C. reliance on nicotine replacement therapy.
D. lack of available aversive conditioning.
EXPLANATIONS:
(c) A. Metabolism decreases when nicotine is withdrawn. If dietary intake remains
unaltered and exercise is not included, there may be a resulting weight gain.
(u) B. This message would be considered negative feedback. It would be more
important to encourage someone who is trying to eliminate an addiction.
(u) C. Nicotine replacement therapy will often reduce the withdrawal symptoms but
should not be considered a reliable way to prevent weight gain.
(u) D. It is not conclusive that any of these methods actually work. Usually
incorporated into a smoking cessation program is positive reinforcement or a reward
system.
64
The respiratory therapist takes over bag-valve ventilation during resuscitation of a
71-year-old patient with COPD. The therapist notes increasing resistance to
ventilation, decreased chest excursion, and absence of breath sounds on the right.
The therapist should
A. insert a nasogastric tube.
B. perform a needle thoracostomy.
C. increase ventilatory pressures.
D. reposition the endotracheal tube.
EXPLANATIONS:
(u) A. The patient has a tension pneumothorax, and a nasogastric tube would not
help.
(c) B. The patient has a tension pneumothorax, and a needle thoracostomy is
indicated.
(h) C. The patient has a tension pneumothorax, and increasing ventilating pressures
may worsen the situation.
(u) D. Repositioning the endotracheal tube would not correct the tension
pneumothorax.
65
Which of the following are clinical signs and symptoms of a pneumothorax when
detected on the affected side of the chest?
I. diminished breath sounds
II. hyperresonance on percussion
III. increased chest motion
IV. increased vocal fremitus
A. I and II only
B. I and IV only
C. II and III only
D. III and IV only
EXPLANATIONS:
I. True. A pneumothorax causes the lung on the affected side to collapse,
decreasing breath sounds on that side.
II. True. A pneumothorax will result in air in the intrapleural space, which causes a
hyperresonant percussion sound on the affected side.
III. False. Collapse of the affected lung may result in decreased movement on the
affected side, not increased movement.
IV. False. Increased vocal fremitus is a sign of consolidation and is not consistent
with pneumothorax.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incorrect response.
66
A patient with a unilateral lung transplant requires independent lung ventilation
postoperatively. The transplanted lung is receiving a mandatory rate of 8, tidal
volume 200 mL, FIO2 0.70, and PEEP 5 cm H2O. The native lung is supported with
CPAP 5 cm H2O at an FIO2 of 0.70. The chest radiograph shows slight hyperinflation
of the transplanted lung and infiltrates in the native lung. The PETCO2 is 67 torr and
the SpO2 is 92% . Which of the following should the respiratory therapist recommend
increasing?
A. CPAP to the native lung to 10 cm H2O
B. mandatory rate to the transplanted lung to 12
C. tidal volume to the transplanted lung to 625 mL
D. tidal volume to the native lung to 600 mL
EXPLANATIONS:
(c) A. Increasing the CPAP should help reduce atelectasis and may improve
ventilation.
(h) B. Increasing the mandatory rate to the transplanted lung may cause or increase
auto-PEEP resulting in worsened hyperinflation.
(h) C. The tidal volume is too high for one lung.
(h) D. The tidal volume is too high for one lung.
A patient who is apneic is receiving mechanical ventilation. The PaCO2 can be
67
increased by increasing the
A. inspiratory time.
B. mechanical dead space.
C. tidal volume.
D. respiratory rate.
EXPLANATIONS:
(u) A. Increasing the inspiratory time has no effect on PaCO2.
(c) B. Adding mechanical dead space increases rebreathed volume, elevating PaCO 2.
(u) C. Increasing the tidal volume results in increased minute ventilation, lowering
PaCO2.
(u) D. Increasing the respiratory rate results in increased minute ventilation, lowering
PaCO2.
68
A patient having a severe asthmatic episode requires volume-controlled ventilation.
The high pressure limit alarm is sounding frequently, and the patient is very agitated
with a respiratory rate of 36/min. Bilateral breath sounds with minimal wheezing are
noted. Which of the following should the respiratory therapist recommend?
A. midazolam HCl (Versed)
B. budesonide (Pulmicort)
C. morphine sulfate
D. cromolyn sodium (Intal)
EXPLANATIONS:
(c) A. Midazolam will relieve the patient's anxiety.
(u) B. Budesonide is not usually needed for status asthmaticus requiring ventilatory
support since systemic steroids are the primary anti-inflammatory drug used.
(h) C. Morphine sulfate will sedate the patient, but also depress respiration.
(u) D. Cromolyn sodium is not used for status asthmaticus requiring ventilatory
support since systemic steroids are the primary anti-inflammatory drug used.
69
A patient with a persistent dry cough suddenly starts producing copious amounts of
pus-like, yellow, mucoid sputum. Which of the following actions should the
respiratory therapist take?
A. Request an order for aerosolized acetylcysteine (Mucomyst).
B. Notify the physician a draining lung abscess is suspected.
C. Obtain an order for postural drainage and percussion.
D. Perform nasotracheal suctioning.
EXPLANATIONS:
(u) A. Aerosolized Mucomyst may precipitate bronchospasm and may increase
secretions, possibly making it difficult for the patient to clear all the secretions.
(c) B. Sputum, secondary to a lung abscess, is characterized by its sudden onset and
production of pus-like, yellow, mucoid sputum.
(h) C. There is no indication for postural drainage and percussion. There is the
potential for contaminating the rest of the lungs with the infected secretions.
(u) D. Nasotracheal suctioning is traumatic and could cause vomiting. Suctioning
would only be indicated if the patient were unable to clear the secretions.
70
A patient with bronchiectasis has received postural drainage. Based on the results of
auscultation, sputum production, and the chest radiograph, the therapy was deemed
ineffective. Which of the following should the respiratory therapist recommend?
A. volume-oriented IPPB therapy
B. incentive spirometry
C. turning and mobilization
D. PEP and increased hydration
EXPLANATIONS:
(u) A. Secretion clearance would not improve directly with hyperinflation maneuvers.
(u) B. Secretion clearance would not improve directly with hyperinflation maneuvers.
(u) C. Since postural drainage has failed, there is no reason to anticipate turning and
mobilization, a similar procedure, would be effective.
(c) D. These are secondary methods for secretion clearance and would be indicated
when postural drainage is ineffective.
71
The respiratory care department has been cited by JCAHO for deficiency in its
quality control program. Which of the following should the therapist include as
essential elements for the mechanical ventilator component of the program?
I. the preventative maintenance schedule
II. testing of mechanical ventilator alarm systems
III. the purchasing records for the ventilators
IV. departmental policy and procedures for setting alarms
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. Documentation of all methods and intervals for inspecting, testing, and
maintaining "critical" equipment is required.
II. True. All ventilator alarms must be identified, tested, and documented.
III. False. Purchase records are not required as part of the quality control program for
ventilators.
IV. True. Quality control programs include an institutional review of departmental
policies for the setting of ventilator alarms.
(u) A. Incomplete and incorrect response included.
(c) B. Correct response.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
72
A 32-year-old female is 167.6 cm (5 ft 6 in) tall and weighs 56.8 kg (125 lb). She has a
diagnosis of heroin overdose and is receiving volume-controlled ventilation. Chest
radiograph reveals bilateral infiltrates consistent with pulmonary edema. An arterial
blood gas is obtained 30 minutes later. Ventilatory data and blood gas results are:
Which of the following changes should the respiratory therapist recommend?
A. increasing the FIO2 to 0.80
B. pressure-controlled ventilation at 35 cm H2O
C. increasing the tidal volume to 700 mL
D. increasing the mandatory rate to 20
EXPLANATIONS:
(u) A. Increasing the FIO2 may possibly help oxygenation, but the main problem is the
high peak inspiratory pressure increasing the risk of barotrauma. See explanation B.
(c) B. A change to pressure-controlled ventilation is indicated because of the high
peak inspiratory pressure. Using the plateau pressure as a starting point for set
inspiratory pressure is reasonable as it should allow minute ventilation to remain
relatively unchanged.
(u) C. Increasing the tidal volume would increase the peak inspiratory pressure
further, risking barotrauma.
(u) D. Given the normal acid-base status, an increase in mandatory rate is not
indicated. It does not address the problem of the high peak inspiratory pressure. See
explanation B.
73
The major component of pulmonary surfactant is
A. protein.
B. glucose.
C. phospholipid.
D. polysaccharide.
EXPLANATIONS:
(u) A. Protein is 7% of surfactant.
(u) B. No significant glucose content exists in surfactant.
(c) C. Phospholipid is 85% of surfactant.
(u) D. No significant independent polysaccharide exists in surfactant.
74
A 32-year-old patient is ordered to receive home O2 therapy, postural drainage and
aerosolized bronchodilators by MDI. Which of the following should the therapist do
to provide education to the patient and family?
A. Minimize confusion in presenting the education program by delivering needed
materials in varied formats.
B. Administer formal written evaluations to monitor the cognitive, affective, and
psychomotor domains.
C. Monitor environmental factors that could impede the educational process.
D. Standardize the education program, regardless of age differences between the
patient and his family.
EXPLANATIONS:
(u) A. Multiple formats (e.g. video and written materials) may be more confusing.
Finding the most appropriate format for the individual learning needs will maximize
understanding and performance.
(u) B. Demonstrations by performance check lists are generally used for affective and
psychomotor domains. Return demonstrations are more reliable for cognitive skills.
(c) C. This facilitates the educational program. The environment needs to be
conducive to the learning experience for the program to be successful.
(u) D. The educational presentation should be age-specific because different age
groups learn with different methods.
75
Which pharmacological agent should the respiratory therapist recommend for a
patient with a temperature of 40° C (104° F)?
I. acetaminophen
II. ibuprofen
III. furosemide (Lasix)
IV. dopamine HCl
A. I and II only
B. I and IV only
C. II and III only
D. III and IV only
EXPLANATIONS:
I. True. Acetaminophen reduces elevated temperatures.
II. True. Ibuprofen, like other NSAIDs, reduces fever.
III. False. Furosemide is a diuretic and does not treat fever. It may produce harm by
causing hypovolemia beyond insensible loss from sweating.
IV. False. Dopamine HCl is an inotrope and can improve cardiovascular performance,
but does not lower fever.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(h) C. Incomplete and incorrect response included.
(h) D. Incorrect response.
76
A patient has been receiving volume-controlled ventilation for 24 hours with an FIO2
of 0.80. The following arterial blood gas results are obtained:
During a routine patient assessment, the respiratory therapist also notices patientventilator asynchrony. Which of the following should the therapist recommend?
I. PEEP
II. pressure support
III. SIMV
IV. inspiratory hold
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. True. PEEP would be facilitative in reducing the P(A-a)O2 gradient.
II. True. Pressure support would reduce the effort associated with the spontaneous
breaths and help to synchronize the patient's breathing pattern with the ventilator.
III. True. SIMV would help to synchronize the patient's breathing pattern with the
ventilator.
IV. False. Inspiratory hold would do little to reduce patient/ventilator asynchrony
and/or improve oxygenation.
(c) A. Correct response.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(u) D. Incomplete and incorrect response included.
77
A patient is receiving mechanical ventilation with the following parameters:
The physician requests adding pressure support to augment the patient's
spontaneous breathing efforts. The therapist should recommend titrating the set
inspiratory pressure to achieve a
A. spontaneous VT of 6-8 mL/kg.
B. total respiratory rate of 6/min.
C. spontaneous VT greater than 800 mL.
D. static compliance less than 0.05 L/cm H2O.
EXPLANATIONS:
(c) A. Pressure support is useful to augment a patient's spontaneous breathing
efforts. It should be titrated until the spontaneous VT and respiratory rate are near
normal.
(u) B. Since the mandatory rate is already 6/min this cannot be achieved by changing
pressure support. See explanation A.
(u) C. A spontaneous VT of 800 is excessive. See explanation A.
(u) D. An objective of a low compliance is undesirable and is not a goal of pressure
support.
78
The respiratory therapist discovers a patient with severe peripheral vascular disease
has QRS complexes on the monitor, but no palpable pulse. The automated blood
pressure is 40/0 mm Hg. Which of the following is the most appropriate?
A. Check pulses with a Doppler.
B. Perform cardiac compressions.
C. Obtain an arterial blood gas sample.
D. Insert a temporary pacemaker.
EXPLANATIONS:
(u) A. A Doppler may be able to detect a pulse in a patient with severe hypotension,
but it would not help correct the problem. See explanation B.
(c) B. The patient has PEA (pulseless electrical activity) requiring immediate cardiac
compressions.
(u) C. Obtaining an arterial blood gas sample in a patient with severe hypotension
may be extremely difficult and will delay appropriate treatment. See explanation B.
(h) D. A temporary pacemaker is indicated for a patient without electrical activity. See
explanation B.
79
An 8-year-old boy with cystic fibrosis has copious tenacious purulent secretions. He
is receiving 2.5 mg albuterol (Ventolin) every 4 hours and dornase alpha (DNase)
once a day. Laboratory results on a sputum sample indicate the patient has a
Pseudomonas infection. Which of the following is appropriate?
A. Increase albuterol (Ventolin) to 5 mg every 4 hours.
B. Change dornase alpha (DNase) to every 4 hours.
C. Administer 3 cc of 10% acetylcysteine (Mucomyst) every 4 hours.
D. Add 300 mg aerosolized tobramycin (TOBI) twice a day.
EXPLANATIONS:
(u) A. This dosage of Ventolin is too high and would not treat the Pseudomonas
infection.
(u) B. DNase is normally given only once a day and would not treat the Pseudomonas
infection.
(u) C. Mucomyst could possibly cause bronchospasm and would not treat the
Pseudomonas infection.
(c) D. TOBI is the correct treatment for Pseudomonas infection in cystic fibrosis.
80
The respiratory therapist is preparing equipment for a bronchoscopy. The chest
radiograph shows consolidation in the right lower lobe. The physician states the
main purpose of the procedure is to obtain a deep sputum sample for culture and
sensitivity. To obtain this sample, the therapist should select a
A. hollow needle.
B. shielded brush.
C. flexible forceps.
D. suction catheter.
EXPLANATIONS:
(u) A. A hollow needle is used to biopsy lesions and does not allow collection of an
uncontaminated sputum sample.
(c) B. A shielded brush should be used to collect sputum samples when the objective
is to obtain an uncontaminated sample.
(u) C. Flexible forceps are used to obtain tissue samples. They are not appropriate for
obtaining sputum samples.
(u) D. A suction catheter cannot be passed through the tip of the flexible fiberoptic
bronchoscope to obtain the sample.
81
The respiratory therapist is reviewing a chest radiograph for a patient with a
hemothorax. In which of the following locations should a properly placed chest tube
be seen?
A. second intercostal space in the mid-clavicular line
B. third intercostal space in the mid-clavicular line
C. third intercostal space in mid-axillary line
D. fifth intercostal space in mid-axillary line
EXPLANATIONS:
(u) A. The second intercostal space in the mid-clavicular line is more appropriate for a
pneumothorax.
(u) B. The third intercostal space is more appropriate for a pneumothorax.
(u) C. The third intercostal space in the mid-axillary line is too high to drain a
hemothorax.
(c) D. The fifth intercostal space in the mid-axillary line is appropriate for draining fluid
from the chest. A tube placed any higher than the thorax may not adequately drain the
fluid.
82
A patient has received chest physiotherapy and bronchodilator therapy for 48 hours.
Sputum production has decreased, but the patient is now coughing up blood-tinged
secretions. Breath sounds are decreased and crackles (rales) are present in the left
lower lobe. Which of the following diagnostic studies should the respiratory therapist
recommend?
A. coagulation studies
B. chest radiograph
C. arterial blood gas analysis
D. ventilation/perfusion scan
EXPLANATIONS:
(u) A. Bloody secretions associated with pulmonary inflammatory changes are
common and are not indicative of a clotting disorder.
(c) B. A chest radiograph would identify the presence of a localized inflammatory
process.
(u) C. Information from arterial blood analysis is nonspecific and would be of no
diagnostic value in this situation.
(u) D. There is no evidence that this patient has a pulmonary embolus or infarction.
Bloody secretions are more commonly associated with a pulmonary inflammatory
process.
83
The respiratory therapist is using an oxygen calibrated flowmeter to administer a gas
mixture of 70% helium and 30% oxygen. To deliver a flow of 8 L/min of the gas
mixture to the patient, the therapist should set the oxygen flowmeter to
A. 3 L/min.
B. 5 L/min.
C. 8 L/min.
D. 11 L/min.
EXPLANATIONS:
(u) A. See explanation B.
(c) B. The correction factor for a 70%/30% helium/oxygen mixture is 1.6 X the oxygen
flow. 5 L/min X 1.6 = 8 L/min.
(u) C. See explanation B.
(u) D. See explanation B.
84
A 39-year-old patient is admitted to the emergency department with fever, chills, and
productive cough. Serial arterial blood gas results reveal:
Which of the following best explains the oxygenation difference between the two
blood gas results?
A. venous admixture
B. left-to-right shunt
C. hyperventilation
D. hyperoxemia
EXPLANATIONS:
(c) A. Venous admixture occurs in pneumonia due to regional decreases in
ventilation/perfusion. This can lead to a widening A-a gradient.
(u) B. Left-to-right shunt would create arterialization of venous blood, leading to a
decreased A-a gradient.
(u) C. The effect of PaCO2 is relatively small and would not account for this large of an
A-a gradient.
(u) D. Hyperoxemia would be reflected by an elevated PaO2, which is not present in
either set of arterial blood gas results.
85
Which of the following are components of an HFJV system?
I. an exhaled volume spirometer
II. a pressure regulator
III. an oxygen source
IV. an injector line
A. I, II, and III only
B. I, II, and IV only
C. I, III, and IV only
D. II, III, and IV only
EXPLANATIONS:
I. False. Exhaled volume cannot be measured accurately in an HFJV.
II. True. A pressure regulator is required to control inspiratory pressure.
III. True. An oxygen source is required to control FIO2.
IV. True. A jet injector line is needed for introducing pulsatile gas flow directly into the
airways.
(u) A. Incomplete and incorrect response included.
(u) B. Incomplete and incorrect response included.
(u) C. Incomplete and incorrect response included.
(c) D. Correct response.
86
Ten minutes after obtaining an arterial blood sample from a patient's radial artery,
the respiratory therapist checks the puncture site and notes a purple subcutaneous
wheal. Which of the following should the therapist do FIRST?
A. Perform an Allen's test.
B. Immediately notify the shift supervisor.
C. Apply pressure to the puncture site.
D. Recommend subcutaneous epinephrine at the site.
EXPLANATIONS:
(u) A. An Allen's test is performed prior to obtaining an arterial blood sample to check
for collateral blood circulation.
(u) B. The shift supervisor would be notified if the problem persists, but the immediate
action of applying pressure is usually sufficient.
(c) C. Applying pressure is usually all that is required to stop progression of a
hematoma.
(h) D. Epinephrine would not stop progression of a hematoma, but may cause arterial
vasoconstriction and decreased blood flow to the hand.
87
A patient who is postoperative and is still under the effects of anesthesia is snoring
loudly. The SpO2 has been decreasing. The respiratory therapist repositions the
patient's head but the problem persists. Which of the following devices would be the
most appropriate to use next?
A. laryngeal mask airway
B. endotracheal tube
C. nasal cannula
D. nasopharyngeal airway
EXPLANATIONS:
(u) A. A laryngeal mask airway can be used to help relieve airway obstruction but may
be too invasive a procedure to be used as a first-line treatment.
(u) B. An endotracheal tube can be used to help relieve airway obstruction but is too
invasive a procedure to be used as a first-line treatment.
(u) C. A nasal cannula can be used to increase the FIO2, but does not correct the
problem of airway obstruction.
(c) D. A nasopharyngeal airway can be used to relieve the airway obstruction and is
less invasive than a laryngeal mask airway or endotracheal tube.
88
The respiratory therapist is administering an IPPB treatment by mask to a patient
who is unconscious. The machine cycles to expiration before the patient receives an
adequate volume. Which of the following adjustments should the respiratory
therapist make?
A. Increase the cycling pressure.
B. Increase the flow.
C. Decrease the sensitivity.
D. Decrease expiratory time.
EXPLANATIONS:
(c) A. Increasing the cycling pressure would lengthen inspiration and increase tidal
volume.
(u) B. Increasing the inspiratory flow would shorten the length of inspiration and
possibly decrease the tidal volume further.
(u) C. Decreasing the sensitivity would result in more difficulty in triggering
inspiration and would have no effect on extending the inspiratory phase.
(u) D. Decreasing the expiratory time could be detrimental. It would further increase
the respiratory rate and not improve the tidal volume.
89
A patient in respiratory distress is intubated for airway patency after a motor vehicle
crash. During the physical examination, the respiratory therapist observes
asymmetrical chest movement during inspiration, but no crepitus is palpated. Breath
sounds are diminished on the left. Which of the following should the therapist
immediately do?
A. Activate sigh breaths and suction the airway.
B. Decompress the left pleural space with a needle.
C. Stabilize broken ribs in the left chest with weighted bags.
D. Withdraw the endotracheal tube a couple of centimeters.
EXPLANATIONS:
(h) A. These findings indicate a right mainstem intubation. Sigh breaths can be
harmful when a large volume is delivered to a single lung. There are no clinical
findings that indicate the airway needs to be suctioned.
(h) B. This is an invasive procedure and there are no direct signs of a tension
pneumothorax that would warrant this action.
(u) C. There is no direct evidence of broken ribs or flail chest.
(c) D. Intubation of the right mainstem bronchus most likely explains the
asymmetrical chest movement and decreased breath sounds. The corrective action is
to withdraw the endotracheal tube and confirm placement with a chest radiograph.
90
Three liters of air are injected into a water-seal spirometer from a certified-volume
standard syringe. The observed tracing shows 2.6 L. Which of the following should
the respiratory therapist conclude about the disparity?
A. The plunger was pushed too slowly.
B. The difference is within the acceptable error range.
C. The time scale was incorrectly calibrated.
D. There was a leak in the system.
EXPLANATIONS:
(u) A. The flow of gas into the spirometer should not affect the accuracy of its volume.
(u) B. This is outside the 10% acceptable error range.
(u) C. The volume deflection is unaffected by the time scale.
(c) D. A leak is the likely cause for the difference of 400 mL and is one of the reasons
for checking spirometers with a calibrated syringe.
91
A patient with COPD required ventilatory support for an acute exacerbation and was
recently extubated. The patient, receiving 2 L nasal O2, has tachypnea and
paroxysms of cough. The respiratory therapist auscultates coarse rhonchi
bilaterally. The SpO2 is 94%. The most appropriate action is to
A. reintubate the patient.
B. increase O2 to 4 L/min.
C. switch to aerosol mask at 28% oxygen.
D. initiate noninvasive positive pressure ventilation.
EXPLANATIONS:
(h) A. Intubation is an invasive procedure with potential risk to the patient.
Reintubation is not indicated at this time.
(u) B. The oxygenation is adequate and increasing the O2 would not address the
problem of retained secretions.
(c) C. Aerosol therapy should improve the mobilization of secretions.
(h) D. There is no indication for initiating noninvasive positive pressure ventilation.
This does not address the problem of mobilization of secretions.
92
A patient is receiving non-invasive positive pressure ventilation by full-face mask.
Initial measurements are:
IPAP 15 cm H2O
EPAP 5 cm H2O
Oxygen 3 L/min
Measured tidal volume 460-600 mL
Three hours later, the measured tidal volume is 300-400 mL with the same settings.
Which of the following could explain the decreased tidal volume?
I. inadequate oxygen flow
II. gastric distension
III. decreased compliance
IV. reduced fluid retention
A. I and III only
B. I and IV only
C. II and III only
D. II and IV only
EXPLANATIONS:
I. False. Oxygen flow is used to titrate FIO2 and would not significantly alter exhaled
tidal volume.
II. True. Gastric distension occurs commonly with full-face mask ventilation.
III. True. Using a pressure-controlled ventilator, a change in compliance would result
in a change in tidal volume.
IV. False. Although unlikely to have any effect, a large decrease in lung water would
improve compliance and increase tidal volume.
(u) A. Incomplete and incorrect response included.
(u) B. Incorrect response.
(c) C. Correct response.
(u) D. Incomplete and incorrect response included.
93
While checking pressures at several oxygen outlets, the respiratory therapist notes
readings near 26 psig. The hospital uses a cylinder bank bulk oxygen system. Which
of the following should the therapist do first?
A. Check the bank supply lines for a leak.
B. Switch to the back-up bank of cylinders.
C. This situation requires no intervention.
D. Change patients who are receiving oxygen to E cylinders.
EXPLANATIONS:
(u) A. Checking for a leak would delay restoration of line pressure and equipment
operation may be affected.
(c) B. Changing to the back-up bank would restore the system pressure and allow
time for the main system to be refilled.
(h) C. Doing nothing would not solve the problem because most respiratory therapy
equipment requires 50 psi to operate.
(u) D. It would take too much time to connect every patient receiving oxygen to an E
cylinder and would not solve the problem. E cylinders would not provide a significant
duration of adequate pressure to drive the ventilators.
94
A patient with a recent head injury is heavily sedated. The patient is receiving
mechanical ventilation with an FIO2 of 0.50. He has an intracranial pressure of 24 mm
Hg, a pulmonary capillary wedge pressure of 23 mm Hg, and an SaO 2 of 93%. Which
of the following are appropriate recommendations?
I. Elevate the patient's head 30 degrees.
II. Decrease the mandatory rate.
III. Administer furosemide (Lasix).
IV. Initiate 10 cm H2O PEEP.
A. I and III only
B. I and IV only
C. II and III only
D. II and IV only
EXPLANATIONS:
I. True. Elevating the patient's head may augment intracranial venous drainage and
decrease intracranial pressure.
II. False. Decreasing the ventilator rate is contraindicated because increasing PaCO2
may cause an increase in intracranial pressure.
III. True. Administering furosemide would decrease intravascular fluid volume,
decreasing both intracranial and pulmonary capillary wedge pressures.
IV. False. The patient's oxygenation is satisfactory, and applying PEEP would have no
beneficial effect but would further increase intracranial pressure.
(c) A. Correct response.
(h) B. Incomplete and Incorrect response included.
(u) C. Incomplete and incorrect response included.
(h) D. Incorrect response.
95
An AP portable chest radiograph will show a heart shadow larger than a PA film
because
A. the heart is farther away from the film in the AP position.
B. radiation waves pass through the heart at an angle in the PA position.
C. the PA position is taken at maximum inspiration.
D. a larger film is used for the AP position.
EXPLANATIONS:
(c) A. The heart, being anterior in the chest, appears larger on an AP radiograph
because of the increased distance between the heart and the film.
(u) B. The position of the patient does not change the direction of the beam.
(u) C. Both the PA and AP positions are taken at full inspiration, therefore this will not
affect the appearance of the heart size.
(u) D. The size of the film has no effect on the relative size of the heart.
96
A patient was involved in a motor vehicle crash. The patient has been immobilized, is
breathing spontaneously, and is receiving oxygen by nonrebreathing mask. The
patient is responsive and has the following vital signs:
Which of the following should the respiratory therapist recommend?
A. Transport immediately to a trauma center.
B. Intubate and initiate mechanical ventilation.
C. Perform electrical cardioversion.
D. Administer lidocaine HCl (Xylocaine).
EXPLANATIONS:
(c) A. Transporting to a trauma center would allow for proper assessment and
management. See explanation B and C.
(h) B. There is no indication for intubation and mechanical ventilation. The patient is
alert, responsive, able to protect the airway, and has no indication of severe
hypoxemia or severe respiratory distress.
(h) C. There is no indication for emergent electrical cardioversion. The heart rate is
rapid but the patient's cardiovascular status is otherwise stable.
(u) D. There is no role for lidocaine HCl in the treatment of atrial fibrillation.
97
A 21-year-old male patient with a diagnosis of status asthmaticus is intubated and
has been receiving mechanical ventilation. There is a sudden increase in airway
pressures. The patient is hemodynamically stable and breath sounds are clear, but
significantly decreased on the right. Which of the following should the respiratory
therapist recommend?
A. Turn the patient onto his left side.
B. Suction the airway through the endotracheal tube.
C. Order a portable chest radiograph.
D. Decrease the PEEP setting to zero.
EXPLANATIONS:
(u) A. The findings are consistent with a pneumothorax and changing the patient's
position would not address the underlying problem. This would delay diagnosing the
problem.
(u) B. Breath sounds are clear, so there is no indication to suction. The findings are
consistent with a pneumothorax, and suctioning would delay diagnosing the problem.
(c) C. A chest radiograph is the definitive diagnostic procedure to determine the
presence of a pneumothorax. This is appropriate for a stable patient with a
pneumothorax. If the patient were unstable, a needle decompression would be
indicated.
(h) D. Decreasing PEEP may reduce a pleural leak, but it would delay diagnosing the
problem.
98
A patient is receiving mechanical ventilation in the SIMV mode with a mandatory rate
of 12, an FIO2 of 0.80, and 5 cm H2O PEEP. The following arterial blood gas results are
obtained:
Which of the following should the respiratory therapist do?
A. Increase the FIO2 to 1.0.
B. Increase the PEEP to 10 cm H2O.
C. Maintain the present settings.
D. Decrease the mechanical dead space.
EXPLANATIONS:
(u) A. Since this patient has a large shunt, probably due to areas of collapsed lung,
increasing the FIO2 to potentially toxic levels would have little effect and should be
avoided.
(c) B. Increasing the PEEP should increase PaO2 by recruiting alveoli.
(u) C. The present therapy is not addressing the patient's hypoxemia.
(u) D. Decreasing mechanical dead space would have little effect on improving
oxygenation.
99
During the 24 hours following a kidney transplant, a 54-year-old woman has received
3000 mL of intravenous fluids. Blood chemistry results identified decreases in BUN
and hemoglobin values. The urine output has been 30 mL/hr. Which of the following
would assessment most likely reveal?
A. inspiratory crackles
B. chest wall crepitus
C. hyperresonance to percussion
D. bronchial breath sounds
EXPLANATIONS:
(c) A. The decreased laboratory values could indicate that blood has been diluted by
IV fluids. This, coupled with low urine output, could lead to pulmonary edema
manifested by crackles.
(u) B. Chest wall crepitus would not be expected in a patient who is fluid overloaded.
(u) C. Hyperresonance to percussion usually occurs over lung that is overinflated.
(u) D. Bronchial breath sounds occur over lungs that are consolidated.
100
A patient receiving volume-controlled ventilation has the following series of airway
pressures:
Which of the following is true of pulmonary compliance and resistance changes
during this period?
Compliance
Resistance
A. increased
increased
B. increased
decreased
C. decreased
increased
D. decreased
decreased
EXPLANATIONS:
(u) A. Compliance has decreased because Pplat has increased. Resistance has
decreased because PIP - Pplat (P) has decreased.
(u) B. Compliance has decreased because the Pplat has increased.
(u) C. Resistance has decreased because P has decreased.
(c) D. Compliance has decreased because the Pplat has increased. Resistance has
decreased because P has decreased.