SOLUTIONS MANUAL for Clinical Application of Mechanical Ventilation 4th Edition by Chang David. ISBN by StudyGuide

SECTION 1 Test Questions

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CHAPTER 1

Principles of Mechanical Ventilation

1. Mechanical ventilation is used to support , and one of its most frequent uses in an acute care setting is to manage . conditions associated with A. hyperventilation; COPD B. hyperventilation; postanesthesia recovery C. hypoventilation; COPD D. hypoventilation; postanesthesia recovery 2. Dr. Johnson, a resident in the intensive care unit, asks a therapist to outline the strategies to minimize airflow resistance during mechanical ventilation. The therapist should suggest all of the following strategies except: A. maintain a patent airway. B. reduce length of endotracheal tube. C. reduce temperature of inspired gas. D. use largest endotracheal tube possible. 3. The simplified Poiseuille’s Law shows that the work of breathing increases 16 times of an airway is reduced when the by of its original size.

4. Which of the following patient conditions will least likely raise a patient’s airflow resistance? A. Pulmonary embolism B. Bronchiectasis C. Croup D. Chronic bronchitis 5. A therapist is reviewing the chart of a patient who was admitted to the hospital with chronic bronchitis. The chest radiography shows depressed hemidiaphragms, which is consistent with moderate gas trapping. To compensate for this condition, the patient will most likely use a breathing patthan normal. tern that is A. deeper and faster B. deeper and slower C. shallower and faster D. shallower and slower 6. While performing ventilator rounds, a therapist notices that the static compliance of a patient has been reduced. This condition is consistent with all of the following conditions except:

A. diameter; 25%

A. ARDS.

B. diameter; 50%

B. chest wall rigidity.

C. radius; 25%

C. postoperative sedation.

D. radius; 50%

D. atelectasis.

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CHAPTER 1 Principles of Mechanical Ventilation 3

7. During mechanical ventilation rounds, a therapist is trending the patient’s dynamic compliance measurements. The primary purpose of this procedure is to monitor changes in the patient’s:

11. The normal range of dynamic compliand this measance is between urement along with the PIP-PPLAT gradient may be used to evaluate the condition of . a patient’s

A. airway resistance.

A. 10 and 20 mL/cm H2O; airways

B. spontaneous tidal volume.

B. 30 and 40 mL/cm H2O; airways

C. inspiratory pressures.

C. 10 and 20 mL/cm H2O; lung parenchyma

D. lung compliance. 8. Mr. Keelan has a diagnosis of emphysema. During assessment, the therapist should expect to find an abnormally lung compliance along with in. complete A. high; inhalation B. high; exhalation C. low; inhalation D. low; exhalation 9. Dr. Abel asks a therapist to assess the elastic properties of a patient’s lungs. The therapist should trend the patient’s: A. static compliance. B. dynamic compliance. C. airway resistance. D. airway conductance. 10. All of the following statements are true regarding lung compliance except: A. Conditions causing changes in static compliance lead to similar changes in dynamic compliance. B. Bronchospasm reduces dynamic and static compliance.

D. 30 and 40 mL/cm H2O; lung parenchyma 12. The pulmonary measurements for an intubated postoperative patient are as follows: Corrected tidal volume = 900 mL, PEEP = 5 cm H2O, Peak inspiratory pressure = 60 cm H2O, Plateau pressure = 36 cm H2O. Based on this information, the dynamic compliance is about: A. 14 mL/cm H2O. B. 16 mL/cm H2O. C. 18 mL/cm H2O. D. 20 mL/cm H2O. 13. The normal range of static compliance and this measurement is between along with the PIP-PPLAT gradient may be used to evaluate the condition of a patient’s . A. 20 and 40 mL/cm H2O; airways B. 40 and 60 mL/cm H2O; airways C. 20 and 40 mL/cm H2O; lung parenchyma D. 40 and 60 mL/cm H2O; lung parenchyma

C. Atelectasis reduces dynamic and static compliance. D. Static compliance is greater than dynamic compliance.

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4 SECTION 1

Test Questions

14. The pulmonary measurements for a patient are as follows: Corrected tidal volume = 750 mL, PEEP = 8 cm H2O, Peak inspiratory pressure = 58 cm H2O, Plateau pressure = 49 cm H2O. Based on this information, the static compliance is about: A. 12 mL/cm H2O. B. 14 mL/cm H2O. C. 16 mL/cm H2O. D. 18 mL/cm H2O. 15. The volume of air in the conducting airdeadspace and ways is known as under normal conditions it can be estimated to be about mL per pound of ideal body weight. A. anatomic; one B. anatomic; five C. physiologic; one D. physiologic; five

18.

is a condition that may increase the patient’s VD/VT ratio. A. Atelectasis B. Aspiration C. Pulmonary embolism D. Myocardial infarction

19. Ms. Brandon has an admitting diagnosis of ventilatory failure. This condition is based on which of the following statements? A. Consumption of oxygen is less than availability. B. Consumption of oxygen is in excess of availability. C. Production of carbon dioxide is in excess of elimination. D. Elimination of carbon dioxide is in excess of production. 20. Alveolar volume may be increased by the tidal volume or the deadspace volume. A. increasing; increasing

16. Mr. John has a physiologic deadspace to tidal volume (VD/VT) ratio of 60%. This value is than normal and it may . be caused by

B. increasing; decreasing

A. higher; decreased cardiac output

D. decreasing; decreasing

B. higher; atelectasis C. lower; decreased cardiac output D. lower; atelectasis 17. A therapist is asked to calculate the VD/VT for Mr. Goosby, a 19-year-old patient who is being mechanically ventilated following a motor vehicle crash. The following information is available from the chart: PaO2 = 64 mm Hg, PaCO2 = 60 mm Hg, PECO2 =18 mm Hg, Minute ventilation = 16 L, FIO2 = 40%. The calculated VD/VT . is A. 40%

C. decreasing; increasing

21. The physician asks a therapist to calculate the patient’s physiologic shunt. The therapist should use the classic shunt equation with all of the following measurements except: A. CcO2. B. CvO2. C. PaO2. D. CaO2. 22. The gas diffusion coefficient for carbon times dioxide is approximately greater than that for oxygen.

B. 50%

A. 0.8

C. 60%

B. 19

D. 70%

C. 100 D. 200

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CHAPTER 1 Principles of Mechanical Ventilation 5

23. All of the following conditions are likely to impair the gas diffusion rate except: A. epiglottitis. B. higher altitudes. C. emphysema. D. pulmonary edema. 24. All of the following statements are true regarding oxygenation except: A. hypoxemia is present when the arterial oxygen levels drop below normal. B. hypoxia is present when organ and tissues receive inadequate levels of oxygen. C. hypoxia cannot occur with a normal PaO2. D. PaO2 level reflects the amount of available oxygen dissolved in plasma. 25. A patient in the emergency department has a carboxyhemoglobin saturation of 30 vol%. The therapist should expect this condition to cause hypoxia. A. histotoxic B. circulatory C. hypoxic D. anemic 26. Mr. Nix, a spontaneously breathing patient in the ICU, has been receiving 70% oxygen via a non-rebreathing mask. The PaO2 is persistently in the 50s (mm Hg). This finding suggests: A. oxygenation failure. B. oxygen toxicity. C. hyperoxia. D. hypoxia.

27. The arterial blood gas results for Mr. Lowel, a 58-year-old patient with COPD, are as follows: pH = 7.37, PaCO2 = 55 mm Hg, PaO2 = 46 mm Hg, FIO2 = 21%. The therapist should report to the physician that the patient has: A. normal oxygenation status. B. mild hypoxemia. C. moderate hypoxemia. D. severe hypoxemia. 28. When a patient is in oxygenation failure, mechanical ventilation may be used to: A. decrease deadspace volume and improve ventilation. B. decrease deadspace volume. C. provide oxygenation and minimize work of breathing. D. decrease deadspace volume and improve oxygenation. 29. Ms. Ponderosa has an admitting diagnosis of severe anemia. Her physician asks a therapist to evaluate the patient’s oxygenation status. The therapist should because this value measure the represents the total amount of oxygen available to the patient. A. SpO2 B. PaO2 C. CcO2 D. PvO2 30. Dr. Plauche asks a therapist to evaluate his patient in the CCU who has developed oxygenation failure secondary to congestive heart failure. In assessing the patient, the therapist may observe all of the following clinical signs except: A. eucapnia. B. tachycardia. C. dyspnea. D. tachypnea.

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CHAPTER 2

Effects of Positive Pressure Ventilation

1. Movement of air into the lungs following a drop in alveolar pressure below the atmospheric pressure describes:

4. The tidal volume that is delivered to the patient by a pressure greater than the alveolar pressure describes:

A. spontaneous breathing.

B. negative pressure ventilation.

B. negative pressure breathing.

C. positive pressure ventilation.

C. positive pressure breathing.

D. A and B only.

2. During the inspiratory phase of negative pressure ventilation, the pressure in the airways, alveoli, and pleural space:

5. During positive pressure ventilation, the pressure in the airways, alveoli, and pleural space:

A. increases.

B. decreases.

C. remains constant.

D. increases initially and then decreases.

D. decreases initially and then increases.

3. During spontaneous breathing, the alveobarometric preslar pressure is sure at end-inspiration.

6. During the inspiratory phase of positive pressure ventilation, the pressure in the has the highest measurement.

A. higher than

A. trachea

B. lower than

B. segmental bronchi

C. equal to

C. bronchioles

D. not affected by

D. alveoli

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CHAPTER 2 Effects of Positive Pressure Ventilation 7

7. A therapist is assessing the condition of a 20-year-old patient with status asthmaticus who is being mechanically ventilated. The therapist notes that the peak inspiratory pressures as well as the patient’s work of breathing have steadily increased over the last 3 hours. The therapist should initially check the patient’s:

11. Mr. Patton, a patient receiving mechanical ventilation, has a mean airway pressure (mPaw) of 42 cm H2O (normal: <30 cm H2O). This condition may be improved . by A. decreasing the respiratory frequency B. increasing the PEEP

A. endotracheal tube.

C. extending the inspiratory time

B. breath sounds.

D. initiating inverse ratio ventilation

C. tidal volume setting. D. nasogastric tube. 8. Upon entering the patient’s room, the therapist hears a ventilator’s low pressure alarm sounding. The therapist should initially:

12. A patient in the CCU is being mechanically ventilated for two weeks. Which of the following is least likely to cause a reduction in the patient’s cardiac output? A. increased intrathoracic pressure B. increased alveoli pressure

A. check for airflow obstruction.

C. decreased stroke volume

B. check for air leak.

D. increased contractility

C. check for kinking of ventilator circuit. D. suction the endotracheal tube. 9. Under conditions of changing compliance or airway resistance, the tidal volume (VT) delivered by pressure-controlled ventilation is ; and the VT delivered by volume. controlled ventilation is A. generally constant; generally constant B. generally constant; variable C. variable; variable D. variable; generally constant 10. High levels of PEEP are better tolerated by the patient with noncompliant lungs because: A. there is more pressure transmitted to the thoracic cavity.

13. The severity of hemodynamic changes during positive pressure ventilation is least likely to be affected by the: A. inspiratory flow rate. B. level of airway pressures. C. mechanical tidal volume. D. patient’s lung compliance. 14. During positive pressure ventilation, an of blood volume is estimated shifted from circulation. A. 5% to 10%; pulmonary to systemic B. 15% to 20%; pulmonary to systemic C. 5% to 10%; systemic to pulmonary D. 15% to 20%; systemic to pulmonary

B. the pressure is transmitted to the venous system. C. a patient with noncompliant lungs requires less cardiac output. D. the dampening effect of the noncompliant lungs results in less pressure transmitted to the thoracic cavity.

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8 SECTION 1 Test Questions

15. Mr. Ilkerson is being mechanically ventilated. In monitoring his hemodynamic status, the therapist should expect his right ventricular output to be as a result of venous return to the right ventricle. A. increased; increased B. increased; decreased C. decreased; increased D. decreased; decreased 16. In the absence of any pulmonary artery pathology such as pulmonary hypertension, a decreased right ventricular stroke volume usually results in a(n) central venous pressure and a(n) pulmonary artery pressure. A. increased; increased B. increased; decreased C. decreased; increased D. decreased; decreased 17. Ms. Rowland has been receiving mechanical ventilation at pressures above 60 cm H2O. This condition may lead to a(n) right and left ventricular stroke volume and a(n) cardiac output.

19. The hemodynamic effects of PEEP, such as decreased aortic pressure and cardiac output, are results of a(n) intrathoracic pressure and a(n) left and right ventricular stroke volume. A. increased; increased B. increased; decreased C. decreased; increased D. decreased; decreased 20. Mr. Eilman is being mechanically ventilated at pressures above 65 cm H2O. His cardiac output has decreased to 75% of baseline value since initiation of 10 cm H2O of PEEP. The cardiac output may be partially corrected by: A. volume expansion. B. negative inotropic agent. C. diuretics. D. all of the above. 21. The kidneys are highly vascular and at any one time hold approximately of the body’s circulatory blood volume. A. 15% B. 25%

A. increased; increased

C. 35%

B. increased; decreased

D. 45%

C. decreased; increased D. decreased; decreased 18. The compression of pulmonary blood vessels by high levels of PEEP may cause which of the following hemodynamic changes? A. Increased pulmonary artery pressure B. Decreased pulmonary artery pressure C. Decreased central venous pressure D. Decreased pulmonary capillary wedge pressure

22. Mr. Hines is being mechanically ventilated at a peak inspiratory pressure of around 60 cm H2O, and his cardiac output has been decreasing. This condition would cause a(n) blood flow to the kidneys and eventual renal failure and . A. increased; increased glomerular filtration B. decreased; increased glomerular filtration C. increased; fluid retention D. decreased; fluid retention

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CHAPTER 2 Effects of Positive Pressure Ventilation 9

23. In reviewing the chart of a 58-year-old patient, a therapist notices that the urine output is 300 mL in a 24-hour period. This finding implies that the patient’s urine output is and it provides waste removal. A. more than normal; adequate B. within normal limits; adequate C. lower than normal; borderline

27. Ms. Warren has the following laboratory results: prothrombin time: 5 sec, bilirubin level: 60 mg/L, albumin level: 13 g/L. This finding suggests impairment. A. vascular B. cardiac C. hepatic D. renal

D. lower than normal; inadequate 24. Ms. Jones has a diagnosis of renal failure. In reviewing her chart, the therapist should expect all of the following laboratory results to be higher than normal except:

28. A patient has an elevated intra-abdominal pressure secondary to bowel edema. The therapist should monitor the patient’s cardiopulmonary status since this condition may lead to:

A. blood urea nitrogen (BUN).

A. an increased capacity.

B. creatinine.

B. an increased tidal volume.

C. potassium.

C. compression of great vessels in the thorax.

D. bicarbonate. 25. Renal hypoperfusion results in higher drug concentrations in the serum through which of the following mechanisms? A. Decreased GFR B. Decreased renal tubular secretion C. Increased reabsorption D. All of the above. related to 26. Hepatic perfusion is the level of used during positive pressure ventilation. A. directly; PEEP B. inversely; PEEP C. directly; peak inspiratory pressure D. inversely; peak inspiratory pressure

functional

residual

D. all of the above. 29. Mr. Lange, a patient who has been mechanically ventilated for two weeks, develops gastrointestinal complications including stress-related mucosal damage. These complications are least likely caused by: A. positive pressure ventilation with PEEP. B. splanchnic hypoperfusion. C. excessive concentration of oxygen. D. side effects of medications. 30. The caloric cost (nutritional requirement) for a patient with COPD is about times that of a healthy individual because the work of breathing is than normal. A. 0.33; lower B. 0.5; lower C. five; higher D. 10; higher

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10 SECTION 1 Test Questions

31. In reviewing Mr. Johnson’s chart, the therapist notes that the patient is receiving total parenteral nutrition (TPN). This means that Mr. Johnson could be receiving all of his nutritional needs provided by any of the following routes except: A. intravenous. B. intramuscular. C. intestinal. D. subcutaneous. 32. Mrs. Cameron, a patient with COPD and congestive heart failure, is being put on fluid restriction. What type of diet would be appropriate in providing an ideal source of energy for her? A. High glucose diet B. Low glucose diet

34. Mr. Weiseman, a 33-year-old patient with normal cardiopulmonary status, has an admitting diagnosis of traumatic head injury. Sustained respiratory alkalosis is implemented for his condition. Which of the following neurologic changes may result if hyperventilation is maintained beyond a 24-hour period? A. Leftward shift of oxyhemoglobin dissociation curve B. Increased oxygen affinity for hemoglobin C. Cerebral tissue hyperoxia D. A and B only 35. Patients with neurologic impairment due to ventilatory and oxygenation failure will usually describe their headache as in the head.

C. High fat diet

A. coldness

D. Low fat diet

B. pressure

33. Sustained hyperventilation of up to hours may result in respiratory alkalosis. This condition reduces cerebral blood flow and intracranial pressure (ICP) and may be beneficial to patients suffering from . A. 24; blood loss B. 24; head trauma

C. lightness D. dizziness 36. The mental status of Mr. Kingston, a mechanically ventilated patient for the past three weeks, has been declining over the last few days. Which of the following should the therapist evaluate in order to determine the cause of his condition?

C. 48; blood loss

A. Oxygenation status

D. 48; head trauma

B. Ventilatory status C. Acid/base status D. All of the above.

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CHAPTER 3

Classification of Mechanical Ventilators

1. In mechanical ventilation, pressure is required to overcome the: A. airflow resistance. B. lung compliance. C. chest wall compliance. D. all of the above. 2. Compliance is defined as a change in . divided by a change in A. volume; flow B. volume; pressure

5. The system used by the ventilator to govern the drive mechanism is called a(n): A. control circuit. B. flow system. C. fluidic system. D. electric circuit. controller if 6. The ventilator is a the pressure waveform does not change when airflow resistance and compliance are changed.

C. pressure; volume

A. pressure

D. pressure; flow

B. flow

3. Ventilators may be powered by: A. a gas source. B. an electric source. C. a fluidic source. D. A and B only. 4. The system used by the ventilator to convert the input power to ventilatory work is called a: A. reducing valve. B. solenoid valve.

C. volume D. A or B 7. The ventilator is a volume controller if is measured and used as a the feedback signal to control the volume delivered. A. time B. pressure C. flow D. volume

C. drive mechanism. D. flow mechanism. 11

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12 SECTION 1

Test Questions

8. The can be determined if the constant flow rate (L/min) and inspiratory time (sec) are known. A. pressure B. volume C. flow D. time 9. When the ventilator delivers a breath every 5 sec, it is operating under the mode and the breaths are . considered A. SIMV; time-triggered B. SIMV; pressure-triggered C. control; time-triggered. D. control; pressure-triggered 10. A pressure-triggered breath is initiated and delivered by the ventilator when it senses the: A. drop in flow gradient in the ventilator circuit. B. drop in PEEP level in the ventilator circuit. C. patient’s inspiratory effort causing a slight positive pressure change. D. patient’s inspiratory effort causing a slight negative pressure change. 11. A flow-triggered breath is initiated and delivered by the ventilator when it senses the: A. drop in flow gradient in the ventilator circuit. B. drop in PEEP level in the ventilator circuit.

12. If the pressure is not allowed to go above the preset value, it is called: A. pressure-controlled. B. pressure-limited. C. pressure-regulated. D. pressure-cycled. 13. If the inspiratory flow ends when the preset pressure is reached, the inspiration is called: A. pressure-controlled. B. pressure-limited. C. pressure-supported. D. pressure-cycled. variables 14. PEEP and CPAP are because they are pressures measured at . A. pressure; end-inspiration B. pressure; end-expiration C. baseline; end-inspiration D. baseline; end-expiration 15. Volume-controlled ventilation allows the clinician to set the: A. peak inspiratory pressure. B. tidal volume. C. peak flow. D. inspiratory time. 16. During volume-controlled ventilation, the is variable depending on the compliance and airflow resistance characteristics of the patient-ventilator system. A. peak inspiratory pressure

C. patient’s spontaneous positive pressure effort.

B. tidal volume

D. patient’s spontaneous negative pressure effort.

D. inspiratory time

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C. peak flow

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CHAPTER 3 Classification of Mechanical Ventilators 13

17. During pressure-controlled ventilation, the is variable depending on the compliance and airflow resistance characteristics of the patient-ventilator system. A. peak inspiratory pressure C. delivered tidal volume D. inspiratory and expiratory time 18. Dual control within a breath usually refers to a combination of: A. flow and inspiratory time. B. inspiratory time and peak inspiratory pressure. pressure-

D. peak inspiratory pressure and expiratory time. 19. Pressure-regulated volume control is a dual control mode consisting of: A. pressure-controlled, time-cycled modes. B. pressure-limited, time-cycled modes. C. volume-controlled, time-cycled modes. D. volume-limited, time-cycled modes. 20. A mode that automatically compensates for the resistance of the artificial airway is called: A. automatic tube compensation. B. proportional assist ventilation. C. airway pressure release ventilation. D. automode. 21. Airway pressure release ventilation (APRV) with two distinct is a form of pressure levels. A. pressure-controlled ventilation B. volume-controlled ventilation C. continuous positive airway pressure D. positive end-expiratory pressure

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A. low pressure level rises to the high pressure level. B. high pressure level drops to the low pressure level.

B. set tidal volume

C. volume-controlled and controlled ventilation.

22. In APRV, exhalation and removal of CO2 occur when the:

C. high and low pressure levels reach the same level. D. high and low pressure levels reach 10 cm H2O or higher. 23. Which of the following represents the four common pressure waveforms available in mechanical ventilators? A. Descending, Exponential, Rectangular, Sine B. Ascending ramp, Exponential, Sinusoidal, Oscillating C. Rectangular, Exponential, Sinusoidal, Oscillating D. Rectangular, Oscillating

Constant,

Sinusoidal,

24. Which of the following represents the two common volume waveforms available in mechanical ventilators? A. Ascending ramp, Rectangular B. Ascending ramp, Sinusoidal C. Descending ramp, Rectangular D. Descending ramp, Constant 25. Which of the following represents the four common flow waveforms available in mechanical ventilators? A. Descending, Exponential, Rectangular, Sine B. Ascending ramp, Exponential, Sinusoidal, Oscillating C. Rectangular, Ascending ramp, Descending ramp, Sinusoidal D. Rectangular, Oscillating

Constant,

Sinusoidal,

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14 SECTION 1

26.

Test Questions

flow pattern begins with a low flow rate and increases linearly throughout the inspiratory phase of a mechanical breath.

28.

alarms are used to detect improper settings or parameters that are not within acceptable ranges or specifications in the operation of a ventilator.

A. Sine

A. Improper setting

B. Ascending ramp

B. Control circuit

C. Descending ramp

C. Range

D. Constant

D. Safety

27. Loss of electrical or pneumatic power to a ventilator is primarily alerted by the alarms. A. input power B. control circuit C. output

29. High/low pressure and high/low volume alarms. alarms are example of A. high/low limit B. control circuit C. output D. visual

D. audible

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CHAPTER 4

Operating Modes of Mechanical Ventilation

1. The pressure gradient that must be generated between the airway opening and alveoli in order to produce inspiratory flow is known as: A. transairway pressure. B. transthoracic pressure. C. transpulmonary pressure. D. transalveolar pressure. 2. Negative pressure ventilators create a transairway pressure gradient by decreasing alveolar pressure to a level: A. below airway opening pressure. B. below atmospheric pressure.

4. Normally, negative pressure breathing enhances venous return; however, venous return to the right atrium decreases with the use of a negative pressure ventilator because the: A. pressure is applied mechanically. B. patient is in a supine position. C. superior and inferior vena cavae are compressed. D. peripheral vasculature is also affected by the negative pressures. 5. One difficulty that limits ventilation with a chest cuirass is:

C. above airway opening pressure.

A. maintaining an airtight seal around the chest wall.

D. A and B only.

B. maintaining an airway.

3. In regard to the iron lung ventilator, all of the following statements are true except: A. patient’s body is enclosed except the head and neck. B. tidal volume is related to the negative pressure applied. C. an endotracheal tube must be in place. D. negative pressure is generated around the chest during inspiration.

C. the patient’s weak inspiratory effort. D. A and B only. 6. During positive pressure ventilation, a patient is complaining that she is not getting enough air for a larger breath. The therapist should make the adjustment below. A. Decrease the inspiratory flow. B. Increase the inspiratory time. C. Increase the peak inspiratory pressure. D. Increase the tidal volume. 15

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16 SECTION 1

Test Questions

7. In mechanical ventilation, a closed-loop system has a constant input and an output variable. A. The constant input is controlled by the patient. B. The constant input is a servo control. C. The output variable is dependent on the ventilator settings. D. The output variable is dependent on the changing characteristics of the patient. 8. Auto-PEEP increases the work of breath trigger because the patient must overcome the auto-PEEP level plus the: A. peak inspiratory pressure setting. B. positive end-expiratory pressure setting. C. sensitivity setting. D. mean airway pressure setting. 9. Auto-PEEP may be compensated by setlevel slightly the ting a auto-PEEP level. A. PEEP; above

11. Mr. Vicks has been on mechanical ventilation for five days with PEEP levels between 15 and 20 cm H2O. The therapist should monitor the patient closely for the development of the following complications except: A. barotrauma. B. decreased intracranial pressure (ICP). C. decreased renal function. D. decreased venous return. are less likely af12. Patients with fected by the hemodynamic effects of PEEP because the compliance of these patients is very . A. COPD; high B. COPD; low C. ARDS; high D. ARDS; low 13. Dr. Manning has ordered PEEP for a patient with severe refractory hypoxemia. You would initiate and use a PEEP level in order to minimize at or below the incidence of barotrauma.

B. PEEP; below

A. 5 cm H2O

C. PIP; above

B. 10 cm H2O

D. PIP; below

C. 20 cm H2O

10. A patient has developed refractory hypoxemia with a PaO2/FIO2 (P/F) index of 150 mm Hg. The most appropriate intervention for this condition is: A. positive end-expiratory pressure. B. mechanical ventilation. C. oxygen therapy. D. noninvasive positive pressure vent ilation.

D. 30 cm H2O 14. Ms. Dows is receiving a PEEP level of 6 cm H2O while the mandatory frequency is turned off. Since the patient is breathing spontaneously, she is essentially on: A. synchronized intermittent mandatory ventilation (SIMV). B. pressure support ventilation (PSV). C. pressure-controlled ventilation (PCV). D. continuous positive airway pressure (CPAP).

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CHAPTER 4 Operating Modes of Mechanical Ventilation 17

15. CPAP may be preferable over PEEP if the patient is able to sustain a normal: A. pH. B. PaO2. C. PaCO2. D. breathing pattern. 16. The therapist has received an order to start bilevel positive airway pressure (BiPAP) on a patient with end-stage COPD. The therapist should use the following initial settings: A. IPAP = 2 cm H2O, EPAP = 5 cm H2O. B. IPAP = 4 cm H2O, EPAP = 8 cm H2O.

19. Mrs. Smith is being ventilated with an assist/control mode with a mandatory frequency of 12/min. At this setting, the ventilator will trigger one mandatory sec if the patient bebreath every comes apneic. A. 3 B. 4 C. 5 D. 6 20. The major advantage of an assist/control mode of ventilation is that the patient is able to:

C. IPAP = 5 cm H2O, EPAP = 2 cm H2O.

A. acquire a minute volume necessary to normalize the PaCO2.

D. IPAP = 8 cm H2O, EPAP = 4 cm H2O.

B. breathe spontaneously.

17. The ABG report for a 66-year-old patient with COPD in the medical ICU shows: pH = 7.33, PaCO2 = 53 mm Hg, PaO2 = 55 mm Hg, IPAP = 6 cm H2O, EPAP = 4 cm H2O, FIO2 = 30%. The therapist should change the: A. IPAP to 4 cm H2O. B. IPAP to 8 cm H2O. C. EPAP to 3 cm H2O. D. EPAP to 8 cm H2O. 18. Mr. Camper is completely paralyzed and sedated while on a control mode. Which of the following parameters on the ventilator is determined by the patient? A. Tidal volume B. Inspiratory flow rate C. Respiratory frequency D. None of the above

C. determine the mechanical tidal volume. D. all of the above. 21. The major advantage of synchronized intermittent mandatory ventilation (SIMV) over intermittent mandatory ventilation (IMV) is that SIMV: A. lowers the patient’s work of breathing. B. reduces the stacking.

likelihood

breath

C. offers larger minute ventilation than IMV. D. all of the above. 22. Synchronized intermittent mandatory ventilation (SIMV) offers all of the following advantages except: A. avoiding muscle disuse atrophy. B. reducing V/Q mismatch. C. increasing the mean airway pressure. D. providing partial ventilatory support.

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18 SECTION 1

Test Questions

23. A patient with ventilatory failure secondary to muscle fatigue is put on mechanical ventilation. The physician wants to rest her patient on full ventilatory support and then ease into a trial run of partial support. The therapist should use the following modes of ventilation in sequence, from most to least ventilatory support: A. AC; CMV; SIMV. B. CMV; SIMV; AC. C. CMV; AC; SIMV. D. AC; SIMV; CMV. 24. After intubation and initiation of mech anical ventilation, the physician asks you to select a mode of ventilation that can prevent hypercapnia due to inadequate minute volume. The therapist should mode to ensure a choose the stable minute ventilation. A. continuous positive airway pressure (CPAP) B. assist control (AC) C. mandatory minute ventilation (MMV) D. pressure control ventilation (PCV) 25. A medical resident asks the therapist to outline the key features of pressure support ventilation (PSV). The therapist should describe all of the following characteristics of PSV except: A. each breath is patient-triggered. B. spontaneous tidal volume remains constant. C. inspiratory phase is as long as the patient’s inspiratory effort continues. D. inspiratory phase stops when a preset end-flow is reached.

26. When the pressure support level is set appropriately for the patient, all of the following changes should be observed with the exception of: A. increase in spontaneous frequency. B. increase in minute volume. C. increase in spontaneous tidal volume. D. decrease in work of breathing. 27. Pressure support ventilation is initiated with a pressure support level of 15 cm H2O. Which of the following parameters would you monitor in order to ascertain that the pressure support level is adequate? A. spontaneous tidal volume B. spontaneous frequency C. arterial blood gas results D. All of the above 28. After weaning a 40-year-old postoperative patient off the ventilator, the physician asks a therapist to initiate a spontaneous breathing trial with pressure support ventilation. The therapist should titrate is the pressure support level until reached. A. spontaneous tidal volume of >10 mL/kg B. spontaneous rate of >30/min C. SpO2 is >98% D. all of the above 29. With adaptive support ventilation (ASV), the ventilator uses a predetermined setmL/min/kg for adults. If ting of the therapist desires a minute volume of 6 L/min (6,000 mL/min) for a 50-kg patient, the percent minute ventilation selected on the ventilator should be . A. 20; 120% B. 20; 600% C. 100; 120% D. 100; 600%

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CHAPTER 4 Operating Modes of Mechanical Ventilation 19

30. Adaptive support ventilation (ASV) changes the according to the patient’s breathing pattern. A. number of mandatory breaths B. delivered tidal volume C. pressure support level and number of mandatory breaths D. peak inspiratory pressure and pressure support level 31. With increasing patient-triggering efforts during adaptive support ventilation (ASV), the number of mandatory breaths and the pressure support level until a predetermined volume is reached. A. increases; increases

B. high; atelectasis C. low; overdistension D. low; atelectasis 35. Volume-assured pressure support (VAPS) is a mode of ventilation that maintains a stable tidal volume by using: A. inspiratory pressure support vent ilation. C. mandatory minute ventilation.

C. decreases; increases

D. A and B only.

D. decreases; decreases 32. In proportional assist ventilation (PAV) the ventilator changes the pressure support level according to the patient’s: A. volume and flow demand. airflow

A. high; overdistension

B. volume-assisted ventilation.

B. increases; decreases

B. elastance and characteristics.

34. In clinical conditions where the patient’s lung elastance or airflow resistance shows sudden improvement, the pressure provided by proportional assist ventilation and lead (PAV) may become too to of the lungs.

resistance

C. oxygenation requirement. D. A and B only. 33. Proportional assist ventilation (PAV) may be flow assist (FA) or volume assist (VA). In FA, the applied pressure is pro, whereas vided to overcome the in VA, the pressure is used to overcome the patient’s lung (e.g., restrictive lung defects). A. airflow resistance; elastance B. airflow resistance; tubing compliance C. tubing compliance; elastance

36. In volume-assured pressure support (VAPS), the pressure support level should be set to provide a volume that is: A. higher than the preset minimal tidal volume. B. lower than the preset minimal tidal volume. C. the same as the preset minimal tidal volume. D. variable according to the changing compliance characteristics. 37. Volume-assured pressure support (VAPS) when the dehas the capability to livered volume does not meet the preset tidal volume target. A. switch to a pressure-limited breath B. switch to a pressure-controlled breath C. increase the inspiratory time D. increase the inspiratory flow

D. tubing compliance; airflow resistance

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20 SECTION 1

Test Questions

38. All of the following similar modes of ventilation are active during SIMV with the exception of: A. pressure-regulated volume control in Siemens 300 ventilator. B. adaptive pressure ventilation Hamilton Galileo ventilator.

C. auto-flow in Evita 4 ventilator. D. variable pressure control in Venturi ventilator. 39. In conditions of decreasing compliance or increasing airflow resistance, pressureregulated volume control (PRVC) provides volume support by using the lowest the insp pressure possible by iratory flow and the inspiratory time. A. increasing; increasing B. increasing; decreasing C. decreasing; increasing D. decreasing; decreasing 40. Automode provides time-triggered breaths when prolonged apnea is detected in mode(s). A. SIMV; adult B. SIMV; adult, pediatric, or neonatal C. PRVC; adult D. PRVC; adult, pediatric, or neonatal 41. In adaptive pressure control, the dualcontrol mechanism combines the function of volume ventilation via a stable with the function of pressure . ventilation via a A. tidal volume; constant flow B. tidal volume; variable flow C. peak inspiratory pressure; constant flow

42. In volume control plus (VC+), the thera. The is adpist sets the justed automatically by the ventilator to meet the patient’s demand. A. target tidal volume and flow; volume B. target tidal volume and inspiratory time; volume C. target tidal volume and inspiratory time; flow D. flow and inspiratory time; volume 43. When volume support (VS) is used for weaning or postanesthesia awakening, the pressure supthe ventilator port level as the patient assumes a spontaneous tidal volume. A. increases; larger B. increases; smaller C. decreases; larger D. decreases; smaller 44. A nursing student wants to learn the reason for using pressure control ventilation (PCV). The therapist should explain to her that PCV is a mode of mechanical ventilation to reduce the likelihood of . by limiting the A. atelectasis; peak inspiratory pressure B. atelectasis; tidal volume C. barotrauma; peak inspiratory pressure D. barotrauma; tidal volume 45. In APRV, when the high pressure (Phigh) level is dropped or “released” to the low pressure (Plow) level, it simulates a: A. mechanical inspiration. B. mechanical expiration. C. spontaneous inspiration. D. spontaneous expiration.

D. peak inspiratory pressure; variable flow

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CHAPTER 4 Operating Modes of Mechanical Ventilation 21

46. During APRV, the patient is allowed to breathe spontaneously at the: A. high pressure level. B. low pressure level. C. high or low pressure level. D. pressure support level. , the patient spends more time 47. In . at the low pressure level than A. APRV; biphasic PAP B. PCV; APRV C. biphasic PAP; APRV D. PCV; biphasic PAP 48. Dr. Williamson changes the mode of ventilation from SIMV to inverse ratio ventilation (IRV) for a patient with severe refractory hypoxemia. After making the changes on the ventilator, the therapist should monitor the patient for development of all of the following signs except: A. auto-PEEP. B. increase in mean airway pressure. C. increase in central venous pressure (CVP). D. increase in cardiac output. 49. Since IRV tends to increase the mean airway pressure, create auto-PEEP, and increase the incidence of barotrauma, it to reduce is sometimes used with the airway pressures.

50. Automatic tube compensation (ATC) offsets and compensates for the: A. airflow resistance imposed by the artificial airway. B. airflow resistance imposed by the patient. C. volume restriction imposed by the ventilator. D. volume restriction imposed by the patient. 51. Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation in which the patient’s electrical activity of the is used to guide the optimal functions of the ventilator. A. brain B. lungs C. heart D. diaphragm 52. In high-frequency oscillatory ventilation (HFOV), ventilation can be increased the oscillation frequency or by the amplitude of the oscillations. A. increasing; increasing B. increasing; decreasing C. decreasing; increasing D. decreasing; decreasing

A. pressure-controlled ventilation B. volume-controlled ventilation C. airway pressure release ventilation D. servo-controlled ventilation

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CHAPTER 5

Special Airways for Ventilation

1. Mr. Jones, a patient in the emergency department, has a respiratory arrest and an oropharyngeal airway is indicated. Prior to insertion of this airway, the therapist should ascertain that Mr. Jones is because insertion of this airway into his mouth may cause .

3. A therapist is getting ready to place an oropharyngeal airway into Ms. Holland’s mouth to facilitate manual ventilation. In order to estimate the correct size for her, the therapist should measure the distance in mm from the: A. center of her mouth to the angle of the jaw.

A. conscious; vomiting and aspiration B. conscious; upper airway obstruction

B. center of her central incisors to the angle of the jaw.

C. unconscious; vomiting and aspiration

C. corner of her mouth to the earlobe.

D. unconscious; upper airway obstruction

D. A, B, or C.

2. Guedel oropharyngeal airways have for infants to sizes ranging from for extra large adults. A. 55; 120 B. 24; 100 C. 76; 160 D. 76; 100

is a contraindications for using a nasopharyngeal airway. A. Nasal trauma B. Oral trauma C. Fractures of the mandible D. Trimus (lockjaw)

5. The appropriate size of nasopharyngeal airway for average females is a size (4, 6, 8) and average males a size (5, 7, 9). A. 4; 7 B. 5; 6 C. 7; 8 D. 6; 7

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CHAPTER 5 Special Airways for Ventilation 23

6. An esophageal obturator airway is a device that is inserted into . the

10. Prior to insertion of an EOA, the therapist should check the integrity of the cuff ml of air. by inflating it with

A. reusable; trachea

A. 2 to 5

B. reusable; esophagus

B. 5 to 10

C. disposable; trachea

C. 10 to 20

D. disposable; esophagus

D. 20 to 30

7. After proper insertion and placement of the esophageal obturator airway, the therapist should:

11. Arrange the following four steps in the proper sequence in preparing an EOA tube for use:

A. leave the cuff inflated because the EOA is in the trachea.

I. Lubricate tube with a water-soluble lubricant.

B. leave the cuff deflated because the EOA is in the trachea.

II. Inflate and test cuff.

C. leave the cuff inflated because the EOA is in the esophagus. D. leave the cuff deflated because the EOA is in the esophagus. 8. A mask is used in conjunction with the EOA tube to: A. prevent gas leak around the patient’s face during ventilation. B. increase oxygen delivery. C. provide positive end-expiratory pressure during ventilation. D. provide larger tidal volume during ventilation. 9. A student asks the therapist to explain the function of the small holes at the hypopharyngeal level of an EOA. The therapist should explain that these small holes:

III. Insert tube through opening of a mask. IV. Deflate cuff. A. II, IV, I, III B. II, I, III, IV C. IV, I, II, III D. II, III, IV, I 12. Which of the following statements is true regarding the use of EOA? A. The EOA may be removed before the patient regains consciousness. B. The EOA should be used in awake or semiconscious patients. C. The EOA should not be used in children under 16 years old or under 5 ft tall. D. The EOA may be used in patients with known esophageal disease.

A. prevent regurgitation and aspiration. B. provide ventilation to the lungs. C. increase the oxygen level. D. reduce the deadspace volume.

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24 SECTION 1

Test Questions

13. A patient in the emergency department is breathing spontaneously via an EOA. Dr. Koon, the ER physician, wants to begin mechanical ventilation and asks you to replace the EOA with another airway. The therapist should perform: A. endotracheal intubation after removal of the EOA. B. endotracheal intubation with the EOA in place. C. tracheotomy after removal of the EOA. D. tracheotomy with the EOA in place. 14. The major difference between an EOA and an esophageal gastric tube airway (EGTA) is that an EOA has a(n) end and an EGTA has a(n) end. A. closed distal; open distal B. open distal; closed distal C. closed proximal; open proximal

distal end and 17. An EGTA has a port(s) on the mask that it is attached to. A. patent; one B. patent; two C. blind; one D. blind; two 18. A properly inserted laryngeal mask airway (LMA) provides a seal over the , and it necessary for the LMA to enter the larynx or trachea. A. vocal cords; is B. vocal cords; is not C. laryngeal opening; is D. laryngeal opening; is not 19. Most LMAs can withstand positive prescm H2O. For LMAsures of up to Proseal, the operating pressure limit is up to cm H2O.

D. open proximal; closed proximal

A. 10; 20

15. With an EGTA, ventilation holes along the proximal end of the tube are and ventilation is provided through the by a traditional manual resuscitation bag.

B. 20; 30

A. absent; adaptor B. absent; mask

C. 30; 40 D. 40; 50 20. An LMA is suitable for use during resuscipatient with tation in a(n) glossopharyngeal and laryngeal reflexes.

C. present; adaptor

A. conscious; active

D. present; mask

B. conscious; absent

16. Since there are two ports on the mask, the resuscitation bag must be attached to the port. A. EOA; gastric B. EOA; ventilation C. EGTA; gastric D. EGTA; ventilation

C. unconscious; active D. unconscious; absent 21. Since leak may occur during high airway pressure situations with an LMA, patients airflow resistance or with lung compliance should use an endotracheal tube instead of an LMA. A. high; high B. high; low C. low; high D. low; low

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CHAPTER 5 Special Airways for Ventilation 25

22. For most adults, size LMA should be used for female and size for male. A. 3; 4 B. 4; 5 C. 5; 6 D. 6; 7 23. Dr. Kortowitz, a resident in surgical rotation, asks the therapist about the proper way to manage the cuff pressure of an LMA. The therapist should tell the resident that the standard cuff pressure for cm H2O and it is adan LMA is justed accordingly to the intracuff pressure.

26. Dr. John asks a therapist about the complications that may occur during removal of an LMA. The therapist should explain that potential complications include all of the following except: A. regurgitation. B. gastric insufflation. C. laryngeal spasm. D. oxygen desaturation. 27. An esophageal-tracheal combitube (ETC) cuff(s) and it is inserted into has . the A. one; esophagus B. one; trachea

A. 30; increase

C. one; esophagus or trachea

B. 40; increase

D. two; esophagus or trachea

C. 50; decrease D. 60; decrease 24. The LMA is inserted without a laryngoscope through the mouth and it is adpalate to the vanced along the and turned towards the trachea and larynx. A. hard; posterior pharynx B. hard; vocal cords C. soft; posterior pharynx D. soft; vocal cords

28. On the ETC, a proximal latex pharyngeal ml of air, and a PVC cuff holds cuff near the distal end of the tube holds ml of air. A. 15; 15 B. 15; 100 C. 100; 15 D. 100; 100 29. Lumen 1 of the ETC is used to provide ventilation when the tube enters the and the distal cuff seals off . the

25. Most LMAs are disposable. Reusable should be steriLMAs made with . lized by

B. esophagus; trachea

A. silicone; liquid sterilization agent

C. trachea; esophagus

B. silicone; steam autoclave

D. trachea; trachea

C. polyvinyl chloride; liquid sterilization agent D. polyvinyl chloride; steam autoclave

A. esophagus; esophagus

30. Lumen 2 of the ETC is used to provide ventilation when the tube enters the and the proximal cuff seals off . the A. esophagus; esophagus B. esophagus; trachea C. trachea; esophagus D. trachea; trachea

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26 SECTION 1

Test Questions

31. The ETC is inserted a laryngoscope and it is properly inserted once the . black rings on the tube lie

36. A fully inserted left-sided double-lumen endobronchial tube may be used to ventilate the:

A. with; at the lips

A. left lung only.

B. without; opposite the front teeth

B. right lung only.

C. with or without; at the lips

C. left or right lung depending on which lumen is used.

D. with or without; opposite the front teeth 32. After insertion of the ETC, the cuff(s) are inflated immediately. A. distal B. proximal C. distal or proximal D. distal and proximal 33. Since ETC is more likely to enter the during blind intubation, ventilation through the ETC should be provided via lumen first. A. esophagus; 1 B. esophagus; 2

D. left or right lung as long as both cuffs are deflated. (left-sided, right-sided) 37. If the DLT is inserted too far into the mainstem bronchus, atelectasis of the may occur because the DLT tube is likely gone past the upper lobe bronchus. A. left-sided; right upper lobe B. left-sided; left upper lobe C. right-sided; right upper lobe D. right-sided; left upper lobe 38. A double-lumen endobronchial tube is typically used to provide all of the following except:

C. trachea; 1

A. bilateral lung ventilation.

D. trachea; 2

B. independent lung ventilation.

34. If ventilation via lumen 1 of the ETC is poor, lumen 2 should be used to provide ventilation as the distal end of ETC may be in the: A. larynx. B. sinus. C. esophagus. D. trachea. 35. After insertion of an ETC, the therapist has trouble ventilating the patient via lumen 1 and lumen 2. The therapist should immediately check for:

C. healing time for bronchopleural or bronchocutaneous fistulas. D. lung isolation. 39. Mr. Lawson, a patient weighing 60 kg, is undergoing a surgical procedure for the removal of the left lung. You would expect Mr. Lawson to require a double-lumen endobronchial tube ranging in size from: A. 31 Fr to 35 Fr. B. 35 Fr to 41 Fr. C. 46 Fr to 50 Fr. D. 52 Fr to 56 Fr.

A. airway obstruction. B. low lung compliance. C. cuff leak. D. kinking of ETC.

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CHAPTER 5 Special Airways for Ventilation 27

40. When the bronchial tube enters the main stem bronchus, all of the following may be noticeable except:

41. When nitrous oxide is used during anesbethesia, the cuff pressure may . cause of gas diffusion

A. resistance to advancement.

A. decrease; into the cuff

B. increase in expired tidal volume.

B. decrease; out of the cuff

C. unilateral ventilation by observation and auscultation.

C. increase; into the cuff D. increase; out of the cuff

D. increase in peak inspiratory pressure (PIP) with volume-controlled ventilation.

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CHAPTER 6

Airway Management in Mechanical Ventilation

1. Mrs. Weeks, a patient with a C-2 spinal cord injury, has been receiving mechanical ventilation for one week. Since her prognosis is uncertain, her physician asks a therapist to outline the criteria for replacing the endotracheal tube with a tracheostomy tube. The therapist should explain that one criterion is based on an expectation that the patient has a poor prognosis and an artificial airway will be needed for or longer. A. seven days B. 21 days C. one month D. two months 2. Which of the following is not necessarily an indication for an artificial airway?

3. A medical resident is learning to perform intubation and asks a therapist to explain the difference between oral and nasal intubation. The therapist should point out that: A. nasal intubation is easier than oral intubation. B. a nasal endotracheal tube is less comfortable than an oral tube. C. nasal intubation requires a smaller tube and results in higher airflow resistance. D. nasal intubation requires a stylet. 4. A foam cuff is inflated by: A. leaving the pilot balloon port open. B. leaving the pilot balloon port closed.

A. Protection of the airway

C. inserting air with a 10-ml syringe.

B. Institution of mechanical ventilation

D. inserting sterile saline with a 10-ml syringe.

C. Facilitation of deep suctioning D. Oxygenation

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CHAPTER 6 Airway Management in Mechanical Ventilation 29

5. During review of the patient’s medical record before performing elective oral intubation, a therapist notices that the most recent Mallampati Classification is Class 4. The therapist should: A. proceed to perform intubation with a Miller blade. B. proceed to perform intubation with a Macintosh blade. C. seek anesthesia consultation. D. recommend a lateral neck radiograph. 6. A therapist is preparing to intubate a 50-year-old, 78-kg (172-lb), 5 ft 1 in. female patient. Based on the patient’s physical characteristics, the therapist should select laryngoscope blade. a size A. 3, curved B. 3, straight C. 4, curved D. 4, straight

9. During intubation with a Miller blade, the therapist should place the tip of the and use the blade just under the laryngoscope handle to . A. tongue; pry mouth open B. tongue; lift up anteriorly C. epiglottis; pry mouth open D. epiglottis; lift up anteriorly 10. A therapist received a call from the SICU requesting for a Magill forceps. This device is needed to perform a(n): A. oral intubation. B. tracheostomy tube insertion. C. nasal intubation. D. blind intubation. 11. The physician is getting ready to intubate an adult female patient who weighs 60 kg. The therapist should select an endotracheal tube from sizes: A. 5 to 6.

7. The radiopaque line on an endotracheal (ET) tube is intended to allow an accurate assessment of the:

B. 7 to 7.5.

A. depth and position of intubation.

D. 8 to 9.

B. cuff volume of the ET tube. C. size of the ET tube. D. suction catheter inside the ET tube. 8. Endotracheal tubes come in sizes ranging and the numbers refer to from the diameter of the tubes in mm. A. 1 to 4; internal B. 1 to 4; external C. 2 to 10; internal

C. 7.5 to 8.5.

12. If intubation is not successful after , the endotracheal tube and laryngoscope blade should be removed immediately, and the patient should be ventilated with a bag/mask system and 100% oxygen. A. 15 sec B. 30 sec C. 1 min D. 2 min

D. 2 to 10; external

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30 SECTION 1

Test Questions

13. After orally inserting a size 7.5 endotracheal tube through the vocal cords under direct vision, the therapist should advance the tube until the cm mark rests between the patient’s lips. A. 17 to 20 B. 21 to 23 C. 24 to 26 D. 28 to 30 14. Immediately after intubation, the therapist must: A. confirm the endotracheal tube placement with a chest radiograph. B. tilt and place the head into a sniffing position. C. displace the patient’s tongue to the left side. D. inflate the cuff and check for bilateral breath sounds. 15. The vallecula is a structure located between the: A. tongue and epiglottis. B. tongue and vocal cords. C. vocal cords and epiglottis. D. larynx and trachea. 16. After endotracheal intubation and verification of bilateral breath sounds, the therapist should confirm the proper depth of the endotracheal tube by a(n): A. continuous pulse oximetry. B. end-tidal CO2.

17. During endotracheal intubation, inadvertent esophageal placement may be avoided by: A. asking the patient to swallow, as the tube is being inserted. B. turning the patient’s head 45º to the right. C. turning the patient’s head 45º to the left. D. advancing the tube through the vocal cords under direct vision. 18. After intubating a spontaneously breathing patient, the therapist may confirm the proper placement of the endotracheal (ET) tube by assessing all of the following signs except: A. loss of speech. B. air movement at ET tube opening. C. condensation inside the ET tube. D. ability to compress the manual resuscitation bag. 19. A resident asks the therapist whether a patient should be intubated immediately. The therapist should explain that all of the following are indications for rapid sequence intubation except: A. inability to maintain a patent airway with an oropharyngeal airway. B. Glasgow coma scale of 8 or less. C. PaO2/FIO2 ratio > 350 mm Hg. D. deteriorating hemodynamic values and vital signs.

C. chest radiograph. D. arterial blood gas.

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CHAPTER 6 Airway Management in Mechanical Ventilation 31

20. Dr. White, the emergency room physician, asks a therapist to orally intubate a 40-yearold patient in room 2. Since the patient appears to be very agitated and apprehensive about his surroundings, the therapist should request a sedative and a shortacting neuromuscular blocker such as: A. 2 mg of etomidate and 10 mg of succinylcholine. B. 20 mg of etomidate and 100 mg of succinylcholine. C. 2 mg of fentanyl and 10 mg of pancuronium. D. 20 mg of etomidate (Amidate) and 100 mg of pancuronium. 21. Sellick’s maneuver is a technique that aparea plies digital pressure on the to expose the vocal cords in some patients and to . A. carina; open up the trachea B. carina; close off the esophagus C. cricoid; open up the trachea D. cricoid; close off the esophagus 22. The cuff pressure of an endotracheal tube , as excessive should not exceed pressure can occlude capillaries and lead to . A. 25 cm H2O; ischemia B. 40 cm H2O; ischemia C. 25 cm H2O; arrhythmia D. 40 cm H2O; arrhythmia 23. After intubation, the physician asks a therapist to manage the ET tube with the minimal leak technique. To perform this procedure, the therapist should place the diaphragm of the stethoscope:

24. After intubating a patient in the ER, the physician asks a therapist to maintain minimal occlusion volume on the cuff of the endotracheal tube. The therapist should use a: A. large syringe and respirometer. B. large syringe and stethoscope. C. respirometer and stethoscope. D. stethoscope. is performed by inflating the 25. The ET tube cuff until the leak stops, and then removing a small amount of air until a small leak is heard during inspiration. A. minimal occlusion volume B. minimal leak technique C. extubation technique D. blind intubation 26. During suctioning a patient via the ET tube, the therapist notices a sudden drop in heart rate from 120 to 66/min. The most appropriate initial response is to: A. continue to suction since the heart rate is still within normal range. B. withdraw catheter and oxygenate the patient with 100% oxygen. C. stop suction and ask patient to hyperventilate. D. stop suction and notify physician immediately. 27. When suctioning an artificial airway, the respiratory care practitioner must designate a “sterile” hand to handle the: A. ET tube adapter. B. irrigation saline solution.

A. over the apices.

C. ventilator circuit.

B. over the trachea.

D. suction catheter.

C. near the hilar regions. D. between the clavicles.

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32 SECTION 1

Test Questions

28. The proper size of a suction catheter for endotracheal suctioning may be calculated by multiplying the ET tube size by 3 (change from mm to Fr) and dividing the number by 2 (50% of the ET tube internal diameter). Therefore, a size Fr suction catheter should be used for a size 8 ET tube. A. 10 B. 12 C. 14 D. 16 29. For adults, mucosal injury to the upper airways during endotracheal suctioning may be reduced by keeping the vacuum level at or below: A. –40 mm Hg. B. –60 mm Hg. C. –80 mm Hg. D. –100 mm Hg. 30. The advantages of an inline suction system include all of the following except it: A. allows frequent suctioning without the need to disconnect the ventilator circuit. B. removes more secretions than an open suction system. C. provides a stable FIO2 and PEEP levels during suctioning. D. does not require daily change. 31. The small dorsal lumen above the cuff of a special adult endotracheal tube is intended to: A. allow removal of subglottic secretions with a low vacuum pressure. B. increase the tidal volume provided to the patient. C. reduce the cuff pressure. D. prevent endobronchial intubation.

32. A speaking valve is a one-way valve that fits on a tracheostomy tube and it allows only. The exhaled the patient to air goes out through the . A. breathe in; tracheostomy tube B. breathe in; vocal cords C. breathe out; tracheostomy tube D. breathe out; vocal cords 33. To use a speaking valve properly and safely on a: A. fenestrated tracheostomy tube, the cuff must be inflated and the inner cannula must be nonfenestrated. B. nonfenestrated tracheostomy the cuff must remain inflated.

tube,

C. nonfenestrated tracheostomy the cuff must remain deflated.

tube,

D. A and B only. 34. After successfully weaning a patient off the ventilator and placing him on continuous aerosol via T-tube, Dr. Davidson asks a therapist to evaluate the patient for extubation. The therapist should evaluate all of the following except: A. spontaneous minute volume less than 10 L/min. B. absence of stomach distention. C. acceptable blood gases on FIO2 of 60%. D. vital capacity greater than 15 mL/kg. 35. The physician asks a therapist to assess Ms. Land, a 60-kg postoperative patient, for potential extubation. Based on the information below, the therapist should recommend extubation because all of the following criteria for extubation have been met by the patient except: A. vital capacity of 1,000 mL. B. rapid shallow breathing index (f/VT) of 80/min/L. C. PaO2/FIO2 of 150 mm Hg. D. maximal inspiratory pressure of–25 cm H2O.

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CHAPTER 6 Airway Management in Mechanical Ventilation 33

36. A therapist is planning to extubate a patient who has a very weak cough. The best plan is to: A. have a Yankaur (rigid tonsil tip) suctioning device available.

38. Twenty minutes following an uneventful extubation, the patient experiences a barky cough with audible stridor. Initially, the therapist should initiate: A. stat blood gases.

B. place patient in a prone (head-down) position.

B. aerosol therapy with racemic epin ephrine.

C. leave suction catheter tip extended from ET tube and apply continuous suction during extubation.

C. aerosol therapy with albuterol. D. reintubation.

D. instill 3 to 5 mL of sterile saline prior to extubating. 37. Mr. Dover, a 44-year-old postabdominal surgery patient, extubated himself two days following surgery while on mechanical ventilation. The physician asks a therapist to assess this patient for possible reintubation. Based on the clinical predictors for reintubation below, the therapist should recommend that the pabecause he has met tient of the predictors. Mr. Dover’s Clinical Predictors for Reintubation (1) Assist/control rate = 8/min (2) Most recent pH = 7.46 (3) Most recent PaO2/FIO2 = 220 mm Hg (4) Highest heart rate in the past 24 hours = 130/min (5) Patient has no other medical problems. (6) Patient is alert. (7) Patient is in postoperative recovery. A. be reintubated; three B. be reintubated; four C. not be reintubated; three D. not be reintubated; four

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CHAPTER 7

Noninvasive Positive Pressure Ventilation

1. Noninvasive positive pressure ventilation (NPPV) is a technique of providing ventilation:

4. In sleep apnea, an apnea episode is defined as a temporary pause of breathing during sleep that lasts at least:

A. with an endotracheal tube.

A. 5 sec.

B. with a tracheostomy tube.

B. 10 sec.

C. without an endotracheal or tracheostomy tube.

C. 15 sec.

D. A and B only. 2. In the continuous positive airway pressure (CPAP) mode, the ventilator propressure level(s) to the vides patient, whereas in the bilevel positive airway pressure (BiPAP) mode it provides pressure level(s). A. one; one B. one; two C. two; two D. two; three 3. CPAP is the treatment of choice for:

D. 20 sec. 5. The average number of apneas in each hour of sleep during a test is called: A. apnea index. B. hypopnea index. C. apnea-hypopnea index. D. desaturation index. 6. Mr. Jones, a patient in the physician’s office for a sleep study follow-up visit, has 60 episodes of apnea in 6 hours of sleep in the sleep lab. His apnea index and this value is is therefore . considered

A. obstructive sleep apnea.

A. 10; normal

B. central sleep apnea.

B. 60; normal

C. mixed sleep apnea.

C. 10; abnormal

D. hypopnea.

D. 60; abnormal

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CHAPTER 7 Noninvasive Positive Pressure Ventilation 35

7. Hypopnea is defined as a breathing pattern with reduction in airflow . and a A. 10%; 4% desaturation for 5 sec or more B. 30%; 4% desaturation for 10 sec or more C. 10%; 8% desaturation for 5 sec or more D. 30%; 8% desaturation for 10 sec or more 8. Mr. Paulsen, a patient with COPD, is receiving bilevel positive airway pressure (BiPAP) ventilation. In order to increase the level of ventilation, the therapist should:

11. Due to its splinting action, IPAP may be used to relieve: A. deadspace ventilation. B. auto-PEEP. C. central sleep apnea. D. upper airway obstruction. 12. A student asks the therapist to explain how to determine the appropriate IPAP and EPAP settings. The therapist should explain to her that the common titration endpoints for the IPAP and EPAP settings may be determined by evaluating all of the following parameters except: A. PO2. B. PCO2.

A. increase the IPAP level.

C. SpO2.

B. increase the EPAP level.

D. pH.

C. decrease the IPAP level. D. decrease the IPAP and EPAP levels. 9. During noninvasive positive pressure level is controlled ventilation, the by the EPAP setting.

13. CPAP provides positive airway pressure and it include during the any mechanical breaths. A. inspiratory phase; does B. inspiratory phase; does not

A. CPAP

C. expiratory phase; does

B. PEEP

D. entire spontaneous breathing cycle; does not

C. CPAP or PEEP D. auto-PEEP 10. Dr. Weisner asks a therapist to describe the changes in lung volumes during implementation of BiPAP ventilation. The therapist should explain that IPAP is used to regulate the delivered and the EPAP is used to augment the patient’s . A. tidal volume; tidal volume B. inspiratory capacity

reserve

C. tidal volume; capacity

capacity;

functional

vital

residual

14. Which of the following statements is true concerning the use of mechanical ventilation (MV) and continuous positive airway pressure (CPAP)? A. MV imposes more work of breathing on the patient than CPAP. B. CPAP imposes more work of breathing on the patient than MV. C. The work of breathing imposed on the patient is the same during MV or CPAP. D. The work of breathing imposed on the patient is not related to the mode of ventilation.

D. inspiratory reserve capacity; functional residual capacity

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36 SECTION 1

Test Questions

15. While making rounds in the intensive care unit, the therapist notices that the settings on the BiPAP device are: IPAP = 6 cm H2O, EPAP = 6 cm H2O. Based on this observation, the patient is receiving:

19. As an alternative to traditional mechanihas been used cal ventilation, successfully in the management of acute respiratory failure and acute hypercapnic exacerbations of COPD.

A. IPAP of 6 cm H2O.

A. BiPAP ventilation

B. EPAP of 6 cm H2O.

B. CPAP therapy

C. CPAP of 6 cm H2O.

C. incentive spirometry

D. auto-PEEP of 6 cm H2O.

D. SVN therapy

16. Dr. Altmann asks a therapist to outline the criteria for using CPAP in the treatment of sleep apnea. The therapist should explain to her that CPAP is the treatment of choice for sleep apnea without significant carbon dioxide retention. However, CPAP should not be used to manage apnea due to . A. central; airflow obstruction B. obstructive; neuromuscular causes C. mixed; airflow obstruction D. drug-induced; neuromuscular causes 17. In addition to CPAP therapy, obstructive sleep apnea may be managed by using all of the following strategies except: A. theophylline. B. tonsillectomy.

20. Mr. King, a patient in the surgical intensive care unit, has a PaO2/FIO2 ratio of 300 mm Hg. The therapist may interpret this finding as: A. normal. B. hypoxemia. C. refractory hypoxemia. D. hypoventilation. 21. Dr. Tomblinson asks a therapist to list the indications for NPPV. The therapist should describe that all of the following conditions could be indications for NPPV except: A. chronic ventilatory failure. B. acute hypercapnic exacerbations of COPD.

C. uvulopalatopharyngoplasty.

C. reduction of respiratory workload in obesity.

D. prosthetic mandibular advancement.

D. acute respiratory failure.

18. BiPAP has an inspiratory positive airway pressure (IPAP) setting which provides , and an expiratory positive airway pressure (EPAP) level which functions as . A. tidal volume; auto-PEEP B. tidal volume; PEEP C. CPAP; auto-PEEP

22. Dr. Tomblinson asks a therapist to list the contraindications for NPPV. The therapist should include all of the following conditions except: A. apnea. B. acute respiratory acidosis. C. inability to handle secretions. D. facial trauma.

D. CPAP; PEEP

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CHAPTER 7 Noninvasive Positive Pressure Ventilation 37

23. Since NPPV is done without a(n) , patients who are unable to handle secretions should not be placed on NPPV because can be a potential problem. A. tidal volume setting; atelectasis B. tidal volume edema

setting;

pulmonary

C. artificial airway; aspiration D. artificial airway; airway obstruction 24. When used in conjunction with NPPV, a nasal mask, oronasal mask, nasal pillows, or a full-face mask is called a(n): A. artificial airway. B. interface. C. noninvasive airway. D. face shield. 25. After setting up the NPPV device and nasal mask for a patient, the therapist notices a minor leak around the mask during the inspiratory phase of NPPV. The therapist should: A. change the nasal mask to an oronasal mask and monitor the patient. B. change the nasal mask to nasal pillows and monitor the patient. C. keep the nasal mask and monitor the patient. D. intubate the patient with an endotracheal tube. 26. After trying on different sizes of nasal mask, the therapist notices that the air leak around the patient’s nasal mask is still significant. The therapist should change the nasal mask to a(n): A. laryngeal mask airway. B. oronasal mask. C. nasal pillows. D. endotracheal tube.

27. Mr. Ellis, a patient on NPPV via a nasal mask, has a moderate air leak through the mouth during the inspiratory phase of NPPV. The therapist should: A. reduce the IPAP level until the leak is minimal. B. increase the IPAP level if feasible. C. reduce the EPAP level until the leak is minimal. D. increase the EPAP level if feasible. 28. A therapist is asked to write up a protocol for the initiation of NPPV. As part of the protocol, the therapist should include this step, “Immediately after setting up the should be done to NPPV device, check for improvement in oxygenation and ventilation. This should be followed by for fine-tuning the pressure settings.” A. SpO2; arterial blood gases B. SpO2; mixed venous blood gases C. arterial blood gases; transcutaneous PO2 D. oxygen content; SpO2 29. Dr. Jetta asks a therapist about the advantages of using a nasal mask instead of an oronasal mask during NPPV. The therapist should outline the advantages as follows: A. comfort, patient compliance B. low cost, patient compliance C. low cost, easy to use D. comfort, light weight 30. The disadvantages of using a nasal mask instead of an oronasal mask during NPPV include: A. difficulty of use, gas leak B. inability to talk, nasal dryness or drainage C. high cost, inability to eat D. gas leak, excessive nasal dryness, or drainage

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38 SECTION 1

Test Questions

31. Ms. Holmes, a patient who is being evaluated for NPPV, asks the therapist to describe the drawbacks of using an oronasal mask. The therapist should explain to her that the potential problems associated with an oronasal mask during NPPV include all of the following except: A. facial injury. B. aspiration.

35. Mr. Roberts, a patient who has been using NPPV via an oronasal mask, complains of skin irritation and breakdown. This problem caused by the NPPV interface may be reduced by using all of the following strategies except by: A. using a chin strap. B. adjusting or trying another headgear.

C. regurgitation.

C. using spacers, foam pads, or topical ointments.

D. asphyxiation.

D. resizing mask or trying another mask.

32. Claustrophobia, patient noncompliance, and use of alarm and monitor are some potential problems associated with use of during NPPV because this device covers the patient’s mouth and nose.

36. Dr. Monty asks a therapist to initiate CPAP therapy for one of her patients. The therapist should set the initial CPAP level and titrate it based on the paat tient’s response.

A. a nasal mask

A. 2 cm H2O

B. nasal pillows

B. 4 cm H2O

C. an oronasal mask

C. 6 cm H2O

D. a full-face mask

D. 8 cm H2O

33. Since nasal pillows can withstand airway cm H2O, it is pressures of up to . commonly used during A. 20; CPAP B. 20; BiPAP C. 60; IPPB D. 60; mechanical ventilation 34. After setting up the NPPV device, a therapist notices a moderate leak around the interface. In order to minimize air leak, the therapist should try all of the following strategies except: A. adjust headgear and use chin strap. B. increase pressure setting. C. use spacers or foam pads. D. try another size or mask.

37. If the BiPAP device does not have a separate CPAP control, a CPAP level of 4 cm H2O may be obtained by setting the: A. IPAP at 4 cm H2O and EPAP at 0 cm H2O. B. IPAP at 8 cm H2O and EPAP at 4 cm H2O. C. IPAP and EPAP at 4 cm H2O. D. IPAP at 0 cm H2O and EPAP at 4 cm H2O. 38. When CPAP is used to manage obstructive sleep apnea, the appropriate level of CPAP is fine-tuned by observing the: A. number of apnea episodes. B. SpO2 readings and number of apnea episodes. C. PCO2 and SpO2 readings. D. PO2 and SpO2 readings.

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CHAPTER 7 Noninvasive Positive Pressure Ventilation 39

39. Mr. Lange, a 65-year-old patient, has been diagnosed with central sleep apnea. His physician orders a CPAP device for use at night. The therapist should set up the device in his home, using all of the following options on the CPAP device except: A. ramp over 30 min. B. pressure relief during exhalation. C. autotitration on each start-up. D. appropriate alarm settings. 40. A therapist received an order from Dr. Samson for the initiation of BiPAP therapy for a patient with COPD. The therapist should set the initial IPAP at cm H2O and EPAP at cm H2O and titrate these settings based on the patient’s response. A. 6; 2 B. 8; 4 C. 10; 2 D. 12; 4 41. In adjusting the time settings on an NPPV device, the IPAP maximum time should than the be set 0.15 to 0.25 sec patient’s actual inspiratory time, and the IPAP maximum time should not be longer than of the respiratory cycle. A. shorter; 30% B. shorter; 50% C. longer; 30% D. longer; 50% 42. After setting the IPAP at 8 cm H2O and the EPAP level at 4 cm H2O, a therapist may increase the IPAP level in cm H2O . increments to provide more

43. After setting the IPAP at 8 cm H2O and the EPAP level at 4 cm H2O, a therapist may increase the EPAP level in . cm H2O increments to A. 1 to 2; provide a larger tidal volume B. 1 to 2; improve oxygenation or relieve upper airway obstruction C. 2 to 3; provide a larger tidal volume D. 2 to 3; improve oxygenation or relieve upper airway obstruction 44. Mr. Devine, a patient who began using NPPV an hour ago, is tolerating NPPV poorly and is breathing out of synchronization with the NPPV device. To solve this problem, the therapist should check . or alter the for A. adequacy of oxygen flow; IPAP level B. adequacy of pressure setting; EPAP level C. presence of air leaks; IPAP maximum time D. presence of air leaks; EPAP maximum time 45. After setting up the NPPV device and adjusting the IPAP and EPAP levels, the patient’s SpO2 reading remains in the 80s. The therapist should set up to go directly into the interface. A. aerosol B. pressure monitor line C. oxygen D. cuff pressure monitor line

A. 1 to 2; ventilatory assistance and larger tidal volume B. 1 to 2; oxygenation C. 3 to 4; ventilatory assistance and larger tidal volume D. 3 to 4; oxygenation

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CHAPTER 8

Initiation of Mechanical Ventilation

1. The following blood gas results were obtained from a 66-year-old patient who had been admitted with left lower lobe pneumonia: pH = 7.33, PaCO2 = 48 mm Hg, PaO2 = 54 mm Hg, FIO2 = 40%. If mechanical ventilation was indicated, which of the following statements describes the need for mechanical ventilation? A. pH is too low. B. PaCO2 is too high. C. PaO2 is too low. D. Mechanical ventilation is not indicated. 2. A patient in the recovery room is receiving 40% oxygen via aerosol face mask. The following data are available: pH = 7.37, HR = 110/min, PaCO2 = 44 mm Hg, f = 8/min, PaO2 = 46 mm Hg, BP = 102/70. To improve the patient’s blood gases, the therapist should: A. continue to monitor the patient. B. increase FIO2 to 60% and monitor the patient. C. obtain pulse oximetry reading and monitor the patient. D. initiate mechanical ventilation.

3. For a postoperative patient without preexisting cardiopulmonary disease, acute ventilatory failure is defined as a: A. sudden decrease of pH to 7.35. B. gradual decrease of pH to 7.35. C. sudden increase of PaCO2 to 60 mm Hg. D. gradual increase of PaCO2 to 60 mm Hg. 4. Patients with impending ventilatory failure typically have marginal but acceptable blood gases in the early stages due to: A. delayed physiologic response. B. compensation by increased minute ventilation. C. elimination of fixed acids. D. decreased metabolic rate. 5. In addition to serial blood gas measurements, which of the following parameter(s) is/are used in the assessment of impending ventilatory failure? A. Tidal volume B. Maximum inspiratory pressure C. Vital capacity D. All of the above

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CHAPTER 8 Initiation of Mechanical Ventilation 41

6. Which of the following breathing patterns is the most common sign of ventilatory failure associated with increased work of breathing and fatigue of respiratory muscles? A. Increased respiratory frequency with an increased tidal volume B. Increased respiratory frequency with a decreased tidal volume C. Decreased respiratory frequency with an increased tidal volume D. Cheyne-Stokes breathing with a variable tidal volume 7. In reviewing the blood gas report of a 70-year-old patient, the therapist notices that the PaO2 is 39 mm Hg. The therapist should interpret the patient’s oxygenation status as: A. normal. B. mild hypoxemia. C. moderate hypoxemia. D. severe hypoxemia. 8. A patient has the following blood gas results: pH 7.37, PaO2 80 mm Hg, PaCO2/ 47 mm Hg, FIO2 50%. What is the calculated PaO2/FIO2 (P/F) ratio? A. 1.6/1 B. 16 mm Hg C. 160 mm Hg D. Insufficient information to calculate answer 9. The oxygenation status of a patient shows a PaO2/FIO2 ratio of 150 mm Hg while breathing spontaneously. This value is consistent with: A. excessive oxygenation.

10. A patient in the ICU has been under respiratory distress since admission. He also develops severe bilateral infiltrates over a 24-hour period. The measured PCWP is 12 mm Hg (normal range 8 to 12 mm Hg). This information suggests that the pulmonary edema is caused by: A. ALI or ARDS. B. congestive heart failure. C. COPD. D. pneumonia. 11. The absolute contraindication to mechanical ventilation is: A. cardiogenic shock. B. smoke inhalation. C. tension pneumothorax. D. near drowning. 12. The physician wants to paralyze and sedate her patient in order to provide total respiratory support. Which of the following modes of ventilation should the therapist select? A. Assist/control B. Inverse ratio ventilation C. Pressure support D. Pressure control ventilation 13. A combination of volume-controlled ventilation and pressure-controlled ven(a combined tilation is called a mode between variables). A. BiPAP; one B. BiPAP; two C. dual mode; one D. dual mode; two

B. acute respiratory distress syndrome. C. acute lung injury. D. normal blood gases.

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42 SECTION 1

Test Questions

14. To maintain a normal PaCO2, ventilator frequencies from and tidal volumes from are recommended as the initial settings for adult patients.

18. Mr. Cohen, a patient with COPD and CHF, is being mechanically ventilated. AutoPEEP of 8 cm H2O is observed. What can be done to reduce the auto-PEEP level?

A. 6 to 8/min; 10 to 15 mL/kg

A. Decrease the tidal volume.

B. 8 to 10/min; 15 to 20 mL/kg

B. Decrease the frequency.

C. 10 to 12/min; 10 to 12 mL/kg

C. Increase the inspiratory flow rate.

D. 15 to 20/min; 8 to 10 mL/kg

D. All of the above.

15. During clinical rounds in the ICU, a therapist notices that Ms. Finley, a patient with COPD, has an auto-PEEP level of 5 cm H2O. In order to determine the factors contributing to auto-PEEP, the therapist should evaluate all of the following except: A. insufficient expiratory time. B. air trapping. C. low tidal volumes. D. insufficient inspiratory flow. 16. The frequency control on a ventilator is . commonly used to regulate the If this value is too high, the frequency can be to make compensation. A. PaO2; decreased B. PaO2; increased C. PaCO2; decreased D. PaCO2; increased 17. After intubation and initiation of mechanical ventilation, the physician asks a therapist to provide an initial tidal volume for a 5-ft female patient. Her body weight is 110 lb (50 kg). Using an ideal range of 10 to 12 mL/kg, the therapist should recommend a tidal volume between:

19. Given the following data, the circuit comand the circuit pression factor is compressible volume during mechanical . ventilation is Expired volume (wye occlusion at 120 mL set tidal volume) = 100 mL Peak inspiratory pressure (wye occlusion at 120 mL set tidal volume) = 50 cm H2O Peak inspiratory pressure (during mechanical ventilation) = 60 cm H2O A. 2 mL/cm H2O; 60 mL B. 2 mL/cm H2O; 120 mL C. 5 mL/cm H2O; 60 mL D. 5 mL/cm H2O; 120 mL 20. The physician would like to initiate pressure support ventilation for a mechanically ventilated patient in the ICU. This mode is used to augment a patient’s A. oxygenation level. B. blood pressure. C. spontaneous tidal volume. D. acid-base balance. 21. The initial pressure support setting requires all of the following except:

A. 400 and 500 mL.

A. spontaneous breathing frequency.

B. 500 and 600 mL.

B. inspiratory flows of ventilator and patient.

C. 550 and 650 mL. D. 650 and 750 mL.

39689_ch08_rev02.indd 42

C. plateau pressure. D. peak inspiratory pressure.

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CHAPTER 8 Initiation of Mechanical Ventilation 43

22. For mechanically ventilated patients with ARDS, postresuscitation complications, or smoke inhalation, an FIO2 of 100% may be used initially. After stabilization, the FIO2 should be kept at or lower to avoid oxygen-induced lung injury. A. 21% B. 50% C. 75% D. 80% 23. For patients who are placed on the mechanical ventilator for noncardiopulmonary complications, such as drug overdose or neuromuscular failure, the initial FIO2 may be set at: A. 21%. B. 40%. C. 60%. D. 80%.

26. As long as the tidal volume and respiratory frequency remain unchanged, an increased flow rate will the I time, the E time, and the I:E ratio. A. decrease; increase; increase B. decrease; increase; decrease C. increase; increase; decrease D. increase; decease; increase 27. Which of the following I:E ratios reflects an I time percent (I time %) of 25%? A. 1:4 B. 1:3 C. 3:1 D. 4:1 28. A constant (square) flow pattern is selected and set at 60 L/min. If the inspiratory time is 0.5 sec, what is the calculated tidal volume? A. 400 mL

24. Positive end-expiratory pressure (PEEP) is indicated in patients with:

B. 500 mL

A. consolidation due to pneumonia.

C. 600 mL

B. refractory hypoxemia due to intrapulmonary shunting.

D. 1,000 mL

C. airflow obstruction due to COPD. D. respiratory depression due to anesthesia. 25. The I:E ratio of a mechanically ventilated patient is about 1.2 to 1. What can be done to change the ratio with a shorter I time and a longer E time? A. Decrease the FIO2. B. Increase the tidal volume. C. Increase the flow rate. D. Increase the FIO2.

29. After setting up a ventilator, the therapist pressure alarm at should set the above the observed peak inspiratory pressure. A. high; 10 to 15 cm H2O B. high; 20 to 25 cm H2O C. low; 10 to 15 cm H2O D. low; 20 to 25 cm H2O 30. Unless the low exhaled volume alarm (low volume alarm) is used as a disconnection warning device, it should be set at about mL than the expired mechanical tidal volume. A. 100; higher B. 100; lower C. 200; higher D. 200; lower

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44 SECTION 1

Test Questions

31. Based on prospective studies of patient outcomes during mechanical ventilation, most hazards and complications related to ventilators are caused by: A. positive pressure. B. equipment malfunction. C. medical professionals. D. All of the above. 32. Which of the following is least likely a potential complication of positive pressure ventilation? A. Hypertension B. Decrease in cardiac output C. Accidental patient disconnection D. Barotrauma 33. A patient has been on the ventilator for about three weeks. The physician is concerned about the potential for barotrauma, and she asks a therapist to outline some pressure criteria for more prudent management of the ventilator. The therapist should recommend all of the following criteria except:

34. Since

positive pressure ventilation the CVP, the pressure gradient between the right atrium and the systemic venous drainage will cause a(n) venous return to the right atrium. A. increases; increased

B. increases; decreased C. decreases; increased D. decreases; decreased 35. High airway pressures are more detrimental to the cardiac output in patients lung compliance than those with with compliance. A. high; low B. low; high C. dynamic; static D. static; dynamic

A. keeping the PIP less than 50 cm H2O. B. keeping the plateau airway pressure less than 35 cm H2O. C. keeping the mean airway pressure less than 30 cm H2O. D. keeping the positive end-expiratory pressure less than 20 cm H2O.

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CHAPTER 9

Monitoring in Mechanical Ventilation

1. While assessing a mechanically ventilated patient, the therapist notes that her patient’s heart rate has increased in the last hour from 96 to 130 beats per minute. The therapist should consider which of the following as the most likely cause(s)? A. Hypoxia B. Respiratory alkalosis C. Side effect of muscle relaxant D. Side effect of morphine sulfate 2. As the therapist is suctioning a patient via the endotracheal tube, the therapist notices that the patient’s heart rate has dropped from 89/min to 55/min. The the patient imtherapist should mediately since this condition is most likely caused by . A. call the physician; congestive heart failure B. call the physician; hypoventilation C. oxygenate; respiratory acidosis D. oxygenate; hypoxia

3. During chart review in the CCU, the therapist notices that Mr. Miner’s systemic blood pressure has been increasing gradually over the past 24 hours. Which of the following is least likely the cause of this condition? A. Anxiety B. Overhydration C. Peripheral vasoconstriction D. Excessive peak inspiratory pressures 4. After initiating mechanical ventilation on a trauma patient who was admitted earlier to the emergency department with flail chest, the therapist notices that his respiratory frequency suddenly increases from 20 to 48 breaths/ min with a marked decrease of breath sounds on the right. Your initial response is to: A. discontinue mechanical ventilation and provide manual bag-to-ET tube ventilation. B. recommend an analgesic and monitor the patient. C. administer bronchodilator aerosol therapy. D. recommend a stat chest radiograph.

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46 SECTION 1

Test Questions

5. The most recent vital signs of a patient show a body temperature of 38.5ºC. This condition would shift the oxyhemoglobin dissociation curve to the and lead to a oxygen saturation level at any PaO2. A. left; higher B. left; lower C. right; higher D. right; lower 6. The therapist was asked to revise the ventilator flow sheet for patient assessment. Under the chest auscultation column, the therapist should make certain that it is done: A. every hour. B. with each patient/ventilator assessment. C. once per shift. D. daily. 7. During chest auscultation of a 68-yearold postoperative patient who has been on mechanical ventilation for two weeks, the therapist hears coarse crackles in both right and left hilar regions. The most appropriate response is to: A. add 5 cm H2O of PEEP. B. recommend a chest radiograph. C. obtain a blood gas. D. suction via the endotracheal tube. 8. While auscultating the lungs of a patient who had been admitted to the hospital with acute asthma exacerbation, the respiratory care practitioner is most likely to hear:

9. The chest radiography of a patient shows scattered white-shaded infiltrates within the dark-shaded lung border. This suggests: A. fluid or secretions in the lung. B. fluid or blood in the pleural space. C. foreign solid objects in the lungs. D. obstruction of the large airways. 10. As the therapist is reviewing a patient’s intake/output record, the therapist notices that the urine output averages 65 mL/hr. The therapist should infer that the patient has: A. normal fluid intake. B. abnormal fluid intake. C. normal urine output. D. abnormal urine output. 11. In reviewing the chart of a patient receiving positive pressure ventilation, the therapist notices that an entry of oliguria was made. This condition is most likely caused by: A. enlargement of the bladder. B. excessive production of antidiuretic hormone (ADH). C. insufficient cardiac output and renal perfusion. D. B and C only. 12. The laboratory report of Mrs. Wilson shows the following electrolyte measurements: Na+ 140 mEq/L, K+ 2 mEq/L, Cl− 103 mEq/L, HCO3− 23 mEq/L. The therapist should interpret the patient’s electrolyte finding as:

A. stridor.

A. hypernatremia.

B. inspiratory crackles.

B. hypokalemia.

C. rhonchi.

C. hypochloremia.

D. wheezing.

D. normal.

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CHAPTER 9 Monitoring in Mechanical Ventilation 47

13. Mr. Autry, a patient in the ICU, has a moderate metabolic acidosis but a normal anion gap. This condition is usually caused by a: A. gain of fixed acid. B. gain of base. C. loss of fixed acid. D. loss of base. 14. Mr. Cavis, a patient who has been undergoing the weaning process, suddenly increases his spontaneous tidal volume and frequency. Assuming his metabolic rate remains constant, the therapist should expect to see which of the following changes on the next set of blood gas results?

17. A 26-year-old 70-kg patient, who is in a diabetic coma, has the following ventilator settings and blood gas results: Mode/ frequency = SIMV 12/min, tidal volume = 850 mL, FIO2 = 40%, pH = 6.82, PaCO2 = 38 mm Hg, PaO2 = 78 mm Hg, HCO3− = 6 mEq/L. Based on the blood gas results the therapist should recommend: A. decreasing the tidal volume. B. decreasing the SIMV frequency. C. administering bicarbonate. D. decreasing the FIO2. 18. One of the indicators for acute respiratory distress syndrome (ARDS) is a P/F (PaO2/FIO2) ratio of:

A. A lower PaCO2

A. ≤200 mm Hg.

B. A lower pH

B. ≤300 mm Hg.

C. A lower PaO2

C. ≤400 mm Hg.

D. All of the above

D. ≤100 mm Hg.

15. In reviewing a patient’s blood gas report, the therapist should look at the value to assess a patient’s ventilatory status and value for the oxygenation status. A. pH; PaCO2 B. pH; PaO2 C. PaCO2; PaO2 D. PaCO2; pH 16. A 36-year-old, 5 ft 2 in., 50-kg female is being mechanically ventilated on a volumecontrolled mode in the postanesthesia care unit. The ventilator settings and arterial blood gases are given below: SIMV frequency 8/min, tidal volume 800 mL, FIO2 40%, pH 7.50, PaCO2 26 mm Hg, PaO2 102 mm Hg. Based on the blood gas results the therapist should:

19. The chest radiograph of a patient in the ICU shows bilateral infiltrates. Other clinical data show a P/F (PaO2/FIO2) ratio of 180 mm Hg and a PCWP of 22 mm Hg. The therapist should further assess the patient for presence of: A. acute lung injury. B. acute respiratory distress syndrome. C. congestive heart failure. D. acute ventilatory failure. 20. The clinical data below are obtained from the records of a mechanically ventilated patient. What is the calculated P(A-a)O2? PB 755 mm Hg, respiratory quotient 0.8, FIO2 100%, body temperature 37°C, PaCO2 40 mm Hg, PaO2 318 mm Hg. A. 397 mm Hg

A. reduce the tidal volume.

B. 340 mm Hg

B. reduce the FIO2.

C. 387 mm Hg

C. increase the frequency.

D. 350 mm Hg

D. initiate PEEP of 5 cm H2O.

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48 SECTION 1

Test Questions

21. Refer to the preceding question. The patient’s intrapulmonary shunt is approximately: A. 14%. B. 16%. C. 18%. D. 20%. 22. Diffusion defects primarily affect a paand one of the tient’s ability to causes is increased . A. ventilate; alveolar-capillary thickness B. ventilate; alveolar surface area C. oxygenate; alveolar-capillary thickness D. oxygenate; alveolar surface area 23. A nurse working in an extended care facility asks a therapist to summarize the use of pulse oximetry. The therapist should provide all of the following information except: A. it is a noninvasive device. B. a pulse oximetry value is expressed in percent oxygen saturation. C. it is a useful method to monitor a patient’s ventilatory status. D. SpO2 of 95% correlates closely with a PaO2 of 70 mm Hg. 24. Integrated pulse CO-oximetry is capable of measuring all of the following except: A. cardia index (SpCI). B. hemoglobin (SpHb). C. carboxyhemoglobin (SpCO), D. oxygen content (SpOC).

25. A patient in the ER has moderate respiratory distress and the SpO2 reading is 96%. Arterial blood gases done at the same time show: pH 7.45, PaCO2 35 mm Hg, PaO2 93 mm Hg, SaO2 82%. In order to find the discrepancy between the SpO2 and SaO2 values, the therapist should evaluate all of the following conditions except presence of: A. methemoglobin. B. dysfunctional hemoglobins. C. carboxyhemoglobin. D. anemia. 26. Clinical application of capnography includes all of the following except: A. ET tube cuff pressure monitoring. B. ET tube placement. C. synchronization of respiratory frequencies between patient and ventilator. D. hypocapnic management of patients with head trauma. 27. Under normal conditions, the PaCO2 value is mm Hg than the PetCO2 value. A. 2; higher B. 2; lower C. 10; higher D. 10; lower 28. Transcutaneous PO2 monitoring has been set up for a premature neonate. As the therapist is managing this device, the therapist should take caution to avoid: A. hyperthermia. B. heat damage to skin. C. hypertension. D. retinopathy.

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CHAPTER 9 Monitoring in Mechanical Ventilation 49

29. Transcutaneous monitoring is capable of providing information on the patient’s: A. oxygenation status. B. ventilatory status. C. acid-base status. D. A and B only. 30. In regard to the use of some transcutaneous oxygen and carbon dioxide monitors, are required every hours.

32. Mr. Vicks, a patient in the neuro ICU, has the following measurements two days following admission to the neuro ICU: systolic blood pressure 90 mm Hg, mean arterial pressure 65 mm Hg, intracranial pressure 18 mm Hg. The calculated cerebral perfusion pressure than normal. If necessary, is this condition may be corrected by increasing the . A. higher: mean arterial pressure

A. blood gas verifications; 4

B. higher; intracranial pressure

B. blood gas verifications; 12

C. lower; mean arterial pressure

C. site changes; 4

D. lower; intracranial pressure

D. site changes; 12 31. Mr. Vicks, a patient in the neuro ICU, has the following measurements upon admission to the ICU: systolic blood pressure 100 mm Hg, mean arterial pressure 65 mm Hg, intracranial pressure 20 mm Hg. Based on these values, the calculated cer, and it ebral perfusion pressure is is indicative of blood flow to the brain. A. 45 mm Hg; adequate B. 45 mm Hg; inadequate C. 80 mm Hg; adequate D. 80 mm Hg; inadequate

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CHAPTER 10

Hemodynamic Monitoring

1. Hemodynamic monitoring is done to gather patient information on all of the following except: A. pulmonary systolic and diastolic pressures. B. systemic systolic and diastolic pressures. C. fluid and electrolyte balance. D. cardiac output and mixed venous oxygen saturation. 2. Mr. Robinson, a patient in the ICU, is having a central venous catheter inserted. for This is done to measure the . evaluation of the A. CVP; right ventricular afterload B. CVP; right ventricular preload C. PAP; left ventricular afterload

4. Which of the following statements accu rately describes hemodynamic physics? A. It is a system open to the atmosphere. B. The pressure exerted by the blood is transmitted to a transducer where it is converted into an electrical signal. C. The pressure exerted by the blood is released into the atmosphere and the gradient is calculated by a transducer. D. All of the above. 5. In hemodynamic monitoring, catheters may be placed directly in all of the following locations except: A. right atrium or vena cava. B. pulmonary artery. C. radial artery. D. pulmonary vein.

D. PAP; left ventricular preload 3. Mr. Jones, a patient with congestive heart failure, is getting a pulmonary artery cath eter put in. This procedure is done to for evaluation of the measure the . patient’s A. PAP; right ventricular afterload B. PCWP; left ventricular preload C. CVP; right ventricular preload D. A and B only 50

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CHAPTER 10 Hemodynamic Monitoring 51

6. As the therapist is monitoring a patient’s hemodynamic status, the therapist notes that the transducer and catheter are clamped to a pole and located about two feet higher than the measuring site. The therapist should adjust the height of the transducer by it. Otherwise, falsely hemodynamic values may result. A. raising; high B. raising; low C. lowering; high D. lowering; low 7. In the United States, hemodynamic pressure readings are commonly measured in: A. cm H2O and kPa. B. mm Hg and cm H2O. C. kPa and mm Hg. D. Pa and kPa. 8. A catheter that rests in the vena cava or right atrium may be used to: A. measure the cardiac output. B. measure the central venous pressure. C. obtain arterial blood samples. D. all of the above. 9. Which of the following statements rega rding arterial lines is not true? A. Arterial lines provide a convenient site for obtaining blood gas samples. B. Arterial lines are simpler and safer than noninvasive monitoring of blood pressure. C. Arterial lines provide a more accurate measurement of systemic blood pressure. D. Arterial lines can be inserted into the dorsalis pedis artery.

10. Refer to Figure 10-1 in the 4th edition of Clinical Application of Mechanical Ventilation. The upstroke (C to A) on the waveform coincides with: A. rapid increase in venous pressure during systole. B. rapid increase in arterial pressure during systole. C. rapid decrease in venous pressure during diastole. D. rapid decrease in arterial pressure during diastole. 11. Refer to Figure 10-1 in the 4th edition of Clinical Application of Mechanical Ventilation. The downslope (A to C) is caused by: A. ventricular relaxation. B. ventricular contraction. C. closure of the pulmonary semilunar valve. D. closure of the aortic semilunar valve. 12. Refer to Figure 10-1 in the 4th edition of Clinical Application of Mechanical Ventilation. Letter (B) marks the point reflecting: A. arterial end-diastolic pressure. B. closure of the semilunar valves during diastole. C. closure of the aortic valve during systole. D. closure of the aortic and pulmonary valves during diastole. 13. During assessment of Mr. Fagan, the therapist obtained these systemic blood pressure readings: systolic 95 mm Hg, diastolic 49 mm Hg. The therapist should report the finding to his physician as: A. systemic hypertension. B. systemic hypotension. C. pulmonary hypotension. D. B and C only.

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52 SECTION 1

Test Questions

14. Which of the following statements is not true regarding mean arterial pressure (MAP)? A. MAP = [Psystolic + (2 × Pdiastolic)]∕3 B. MAP of 60 mm Hg is the minimum pressure needed to maintain adequate tissue perfusion. C. MAP is higher than the systemic systolic pressure. D. Accurate MAP measurement requires insertion of an arterial line. 15. A patient in the ICU has the following blood pressure measurements: systolic blood pressure 100 mm Hg, diastolic blood pressure 65 mm Hg. The calculated pulse . Is the pulse pressure pressure is within normal range? A. 35 mm Hg; within normal range B. 65 mm Hg; within normal range

18. Mr. Zelda, a patient with an admitting di agnosis of severe blood loss, has an initial CVP reading of 14 mm Hg before fluid administration. This reading is . and A. normal; consistent with admitting diagnosis B. normal; inconsistent with admitting diagnosis C. higher than normal; inconsistent with admitting diagnosis D. lower than normal; inconsistent with admitting diagnosis 19. The CVP measurement of Mr. Patel, a patient who is being mechanically vent ilated, has increased from 8 mm Hg to 13 mm Hg in a 24-hour period. In order to determine the cause of this change, the therapist should evaluate all of the fol lowing conditions except:

C. 35 mm Hg; not within normal range

A. peripheral vasodilation.

D. 65 mm Hg; not within normal range

B. right ventricular failure.

16. As the therapist is making rounds in the SICU, the therapist notices that a pa tient’s arterial line tubing is backed up with blood. To identify the cause of this problem, the therapist should assess the presence of: A. air bubbles in tubing.

C. fluid overload. D. systemic hypertension. 20. After successful placement of a catheter in Mrs. Houston’s pulmonary artery, the therapist may proceed to obtain all of the following measurements except: A. mixed venous oxygen content.

B. transducer and catheter placed lower than measurement site.

B. pulmonary capillary wedge pressure.

C. blood clot at catheter tip.

C. cardiac output.

D. depletion of the heparin flush solution.

D. arterial oxygen content.

17. Refer to Figure 10-5 in the 4th edition of Clinical Application of Mechanical Venticorresponds with clo lation. The sure of the tricuspid valve during systole. A. a wave B. c wave C. x wave D. y wave

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CHAPTER 10 Hemodynamic Monitoring 53

21. As the therapist is making rounds in the CCU, Dr. Vicks asks the therapist to take some measurements from a Swan-Ganz catheter. The therapist should the catheter balloon for the pulmonary capillary wedge pressure and the balloon for the pulmonary artery pressure. A. deflate; deflate B. deflate; inflate C. inflate; deflate D. inflate; inflate 22. The slight elevation seen at the dicrotic notch on a hemodynamic waveform rep following resents an increase of the closure of the valve. A. PCWP; aortic B. PCWP; mitral C. PAP; tricuspid D. PAP; semilunar 23. The normal systolic pulmonary artery mm pressure (PAP) ranges from Hg and the diastolic PAP ranges from mm Hg. A. 15 to 25; 6 to 12 B. 25 to 30; 6 to 12 C. 25 to 30; 10 to 20 D. 30 to 35; 10 to 20 24. A patient’s pulmonary artery catheter provides the following data: pulmonary artery systolic pressure 40 mm Hg, mean pulmonary artery pressure 30 mm Hg. The data correlate with a condition called:

25. In reviewing the chart of Mr. Hanley, the therapist notices that his latest sys tolic/diastolic pulmonary artery pressure is 30/15 mm Hg. This reading may be caused by all of the following conditions except: A. positive pressure ventilation with PEEP. B. left ventricular failure. C. decreased cardiac output. D. pulmonary hypoxic vasoconstriction. 26. Ms. Pendleton is being mechanically ven tilated and the therapist is getting ready to measure the hemodynamic values. In order to maintain accuracy and con sistency, the therapist should record her of a mechanical PCWP reading breath. A. at end-inspiration B. at end-expiration C. anytime during the inspiratory phase D. anytime during the expiratory phase 27. The pulmonary capillary wedge pressure (PCWP) of Mr. Miller, a patient with con gestive heart failure, is 20 mm Hg. The therapist should interpret this finding as because the normal PCWP range . is from A. normal; 8 to 18 mm Hg B. normal; 12 to 22 mm Hg C. abnormal; 8 to 12 mm Hg D. abnormal; 20 to 35 mm Hg

A. chronic dehydration. B. pulmonary hypertension. C. normal pulmonary artery pressures. D. pulmonary hypotension.

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54 SECTION 1

Test Questions

28. Mr. Jamison, a patient in CCU, has a pul monary capillary wedge pressure (PCWP) reading of 18 mm Hg while other hemo dynamic values are within normal limits. In the past two days, his PCWP readings have been between 10 to 12 mm Hg. The current PCWP reading may be caused by:

31. The cardiac index (CI) provides a more accurate reflection of the cardiac output in patients with: A. abnormal body size. B. congestive heart failure. C. tachycardia.

A. mitral valve stenosis. B. left-sided heart failure. C. right-sided heart failure. D. A and B only.

D. hypoxia on exertion. 32. Mr. Fellow’s cardiac output is 5 L/min and his body surface area is 2.5 m2. The calculated cardiac index is and it . can be interpreted as

29. During rounds in the CCU, the therapist notices that Ms. Johnson’s PCWP reading has changed from 12 to 17 mm Hg since your last visit. To find the cause of this condition, the therapist should evaluate all of the following conditions except: A. hypervolemia. B. internal blood loss. C. left ventricular failure.

A. 2 L/min/m2; normal B. 2 L/min/m2; lower than normal C. 12.5 L/min/m2; normal D. 12.5 L/min/m2; higher than normal 33. Which of the following statements is not true regarding mixed venous oxygen satu ration (O2 sat)? A. Mixed venous O2 sat is lower than arterial O2 sat.

D. overwedging of catheter balloon. 30. Dr. Kate suspects that the balloon of a Swan-Ganz catheter is not wedging prop erly and asks the therapist to verify its proper function. After performing the PAP diastolic-PCWP gradient test, the therapist obtains these measurements: PAP diastolic pressure 10 mm Hg, PCWP 8 mm Hg. The therapist should tell Dr. Kate that wedging properly the catheter . because A. is; PAP diastolic is 2 mm Hg higher than PCWP B. is; PCWP is higher than 4 mm Hg C. is not; PAP diastolic is only 2 mm Hg higher than PCWP D. is not; PAP diastolic is less than 12 mm Hg

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B. Normal mixed venous O2 sat is higher than 80%. C. Mixed venous O2 sat may be obtained from the pulmonary artery. D. Increased mixed venous O2 sat may be caused by reduced oxygen utilization. 34.

is a less invasive method for hemo dynamic monitoring that uses the arterial pressure waveform, arterial vascular re sistance, and patient data to calculate the stroke volume and cardiac output. A. Echocardiograph B. Pulse contour analysis C. Carbon dioxide elimination D. Pulmonary artery catheter

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CHAPTER 10 Hemodynamic Monitoring 55

35.

is a noninvasive method for hemodynamic monitoring that places a Doppler transducer probe into the esoph agus via the mouth or nose and rests at the midthoracic level. A. Transesophageal echocardiography B. Carbon dioxide elimination

37. Impedance cardiography may be used to measure or calculate all of the following parameters except: A. pulmonary artery and pulmonary artery wedge pressures. B. cardiac output and cardiac index.

C. Echocardiograph

C. stroke volume and stroke volume index.

D. Pulse contour analysis

D. contractility and fluid status.

36. Mr. Allman is undergoing drug therapy for congestive heart failure. Which of the following outpatient procedures would be suitable in evaluating the drug efficacy (e.g., improvement on the cardiac output, contractility, fluid status)? A. Pulmonary artery catheterization B. Echocardiograph C. Electrocardiogram D. Impedance cardiography

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CHAPTER 11

Ventilator Waveform Analysis

For all of the questions in this chapter, please refer to the respective figures in Chapter 11 of the 4th edition of Clinical Application of Mechanical Ventilation. flow wave1. (Figure 11-1) The forms are not used for positive pressure ventilation because the initial flow rate is for most patients. A. constant and descending ramp; too high B. constant and descending ramp; not sufficient

3. (Figure 11-3) The area under a flow-time waveform can be used to estimate the: A. pressure setting. B. tidal volume. C. peak flow. D. mean airway pressure. 4. (Figure 11-4) Under ideal conditions, a reflects a stable linear increase in lung compliance (elastic resistance). A. alveolar pressure (PALV)

C. accelerating ramp and sine; too high

B. airway opening pressure (PAO)

D. accelerating ramp and sine; not sufficient

C. transairway pressure (PTA)

2. (Figure 11-2) In the flow-time and pressuretime waveforms, beginning inspiration is , and points represented by points mark the change from inspiration to expiration. A. a; b B. a; c C. b; c D. b; d

D. peak inspiratory pressure (PIP) 5. (Figure 11-4) A pause in flow delivery at endinspiration causes the pressure to drop to a plateau level and this technique may be used to measure the . Once this pressure is known, may be determined by subtracting this pressure from the peak inspiratory pressure (PIP) at end-inspiration. A. airway opening pressure (PAO); transairway pressure (PTA) B. airway opening pressure (PAO); peak alveolar pressure (PALV) C. peak alveolar pressure (PALV); transairway pressure (PTA)

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D. peak alveolar pressure (PALV); airway opening pressure (PALV)

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CHAPTER 11 Ventilator Waveform Analysis 57

6. (Figure 11-4) Since transairway pressure (PTA) is a gradient between airway opening pressure (PAO) and peak alveolar pressure (Peak PALV), PTA will increase when the PAO is or/and when the PALV is independently.

10. (Figure 11-7) The illustrations show (CPAP, PEEP) is in use because the pressure waveform is above the baseline pressure of 0 cm H2O for the entire respiratory cycles during (mechanical ventilation; spontaneous breathing).

A. increased; increased

A. CPAP; mechanical ventilation

B. increased; decreased

B. CPAP; spontaneous breathing

C. decreased; increased

C. PEEP; mechanical ventilation

D. decreased; decreased

D. PEEP; spontaneous breathing

7. (Figure 11-6) The flow-time and pressuremandatory time waveforms show breaths during mechanical ventilation with an I:E ratio of about .

11. (Figure 11-9) The illustrations show SIMV mode of mechanical ventilation because:

A. assist; 1 to 2

A. spontaneous breaths are present between mechanical breaths.

B. assist; 1 to 3

B. spontaneous breaths are present.

C. control; 1 to 2

C. sensitivity is triggered by spontaneous breathing effort.

D. control; 1 to 3 8. (Figure 11-6) The illustrations show two breaths during mechanical ventilation because of the slight negative deflection on the waveform immediately before each mechanical breath.

D. peak inspiratory flow is constant. 12. (Figure 11-9) The flow-time and pressurespontanetime waveforms show ous breath(s), assisted breath(s), and controlled breath(s).

A. assist; flow-time

A. 1; 1; 3

B. assist; pressure-time

B. 1; 2; 2

C. control; flow-time

C. 2; 2; 1

D. control; pressure-time

D. 3; 1; 1

9. (Figure 11-7) The four breaths in the figbreaths during meure consist of chanical ventilation, and the expiratory time of a breath preceding an assisted breath is . A. assist; shortened B. assist and control; shortened C. assist; prolonged

13. (Figure 11-10) On the flow-time waveform, the peak inspiratory flow is marked . with letter A. a B. b C. c D. d

D. assist and control; prolonged

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58 SECTION 1

Test Questions

14. (Figure 11-10) Since there are no mechanical breaths, the pressure-time waveform shows of cm H2O. A. PEEP; 4 B. PEEP; 5

18. (Figure 11-13) In the second example (right)—flow-limited ventilation—when the flow is changed from constant (dotted line) to descending ramp, the must be in order to deliver the same volume.

C. CPAP; 4

A. inspiratory time; increased

D. CPAP; 5

B. inspiratory time; decreased

15. (Figure 11-11) An increased PIP and PTA with an unchanged PALV is indicative of a condition where the: A. airflow resistance has increased. B. airflow resistance has decreased. C. lung/thorax compliance has increased. D. lung/thorax compliance has decreased. 16. (Figure 11-12) An increased PIP and PALV with an unchanged PTA is indicative of a condition where the: A. airflow resistance has increased. B. airflow resistance has decreased. C. lung/thorax compliance has increased. D. lung/thorax compliance has decreased. 17. (Figure 11-13) In the first example (left)— time-limited ventilation—when the flowtime waveform is changed from constant (dotted line) to descending ramp (solid must be line), the peak in order to deliver the same volume. A. inspiratory flow; increased B. inspiratory flow; decreased C. expiratory flow; increased D. expiratory flow; decreased

C. expiratory time; increased D. expiratory time; decreased 19. (Figure 11-13) The first example (left)— the pressure waveform—shows that with time-limited ventilation, the higher initial peak flow under descending ramp flow than the ones creates a higher created by the constant flow. A. PIP and initial PTA B. PEEP and PALV C. PTA and PALV D. PEEP and PALV 20. (Figure 11-13) In both examples—timelimited and flow-limited ventilation—the flow at end-inspiration is L/min. The pressure measured at this point is the or plateau pressure. A. zero; PIP B. zero; Peak PALV C. 40; PIP D. 40; Peak PALV 21. (Figure 11-14) In the first example (left)— time-limited ventilation—the initial pressure created by the descending ramp flow (solid lines) is than that created by flow-limited ventilation. A. higher B. lower C. same as D. unable to determine from waveforms provided

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CHAPTER 11 Ventilator Waveform Analysis 59

22. (Figure 11-15) In time-limited ventilation, a reduction in peak flow would lead to all of the following changes except:

26. (Figure 11-19) The pressure-time waveform ventilation most likely represents at a pressure level of cm H2O.

A. decrease in inspiratory time.

A. pressure support; 70

B. decrease in PALV.

B. pressure-limited; 70

C. decrease in VT.

C. pressure-controlled; 35

D. decrease in PTA.

D. pressure assist; 35

23. (Figure 11-16) Since flow and inspiratory time determine the delivered tidal volume, a higher end-flow produces a higher while the remains unchanged.

27. (Figure 11-20) Varying flow patterns during pressure-controlled ventilation shows and is . that the patient is A. relaxed; triggering all the breaths

A. PIP; PALV

B. relaxed; relying on all mechanical breaths

B. VT; PALV

C. not relaxed; triggering all the breaths

C. PALV; PIP D. PALV; VT 24. (Figure 11-17) When the peak flow is kept constant at 60 L/min, an increase in inspiratory time from 1 to 2 sec leads to a(n) in volume and a(n) in peak inspiratory pressure. A. increase; increase B. increase; decrease C. decrease; increase D. decrease; decrease 25. During descending ramp flow waveform (DRFW) ventilation, the flow at end. The pressure inspiration is near with no flow is similar to an inspiratory pause. Therefore, the pressure at endinspiration is the same as . A. 0 L/min; peak inspiratory pressure B. 0 L/min; peak alveolar or plateau pressure C. 10 L/min; peak inspiratory pressure D. 10 L/min; peak alveolar or plateau pressure

D. not relaxed; relying on all mechanical breaths 28. (Figure 11-21) The waveforms represent ventilation since the inspiratory time is than the expiratory time. A. pressure support; longer B. pressure support; shorter C. inverse ratio; longer D. inverse ratio; shorter 29. (Figure 11-21) Arrow y shows halation and the likelihood of

ex.

A. complete; air leaks B. complete; air trapping C. incomplete; air leaks D. incomplete; air trapping 30. (Figure 11-22) Among the three sets of flowtime and pressure-time waveforms during set pressure support breaths, the shows that the patient has the highest inspiratory flow and volume demand. A. first (left) B. second (middle) C. third (right) D. unable to determine based on waveforms provided

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60 SECTION 1

Test Questions

31. (Figure 11-23) The pressure waveform shows that the PSV level is about cm H2O, calculated by . A. 10; PIP + PEEP B. 10; PIP – PEEP C. 15; PIP + PEEP D. 15; PIP – PEEP 32. (Figure 11-23) The pressure spike (arrow x) is caused by the: A. mucus plugs in the airway. B. circuit leaks.

36. (Figure 11-26) The first flow wave (A) has a ______ peak flow than the third flow wave (B), while the inspiratory time is same. Therefore, (A) should produce a tidal volume than (B). A. higher; larger B. higher; smaller C. lower; larger D. lower; smaller 37. (Figure 11-27) The dotted line at –2 cm threshold durH2O represents the ing assist mode of mechanical ventilation.

C. insufficient initial flow.

A. pressure support

D. rapid rise in initial flow.

B. negative pressure ventilation

33. (Figure 11-24) The waveform sets “a” and breaths whereas “d” represent sets “b”, “c”, and “e” show breaths. A. pressure-controlled; assisted B. pressure-controlled; volume-controlled C. volume-controlled; pressure-controlled D. volume-controlled; pressure support 34. (Figure 11-24) The waveform set shows a volume-controlled breath initiated by the patient. A. “a” B. “b” C. “c” D. “d” 35. (Figure 11-25) The waveform set shows a volume-controlled breath initiated by the ventilator. A. “a” B. “b”

C. sensitivity D. positive end-expiratory pressure 38. (Figures 11-28 and 11-29) In the pressuretime waveforms, the abnormal waveforms (solid lines) deviate from the normal waveforms (dotted lines) because of: A. reduced work of breathing. B. patient-ventilator dyssynchrony. C. reduced airflow resistance. D. increased lung compliance. 39. (Figures 11-28 and 11-29). The abnormality (dotted line) in the pressure waveforms on the left (a) is caused by inadequate . This is because the abnormality occurs of the inspiratory phase. A. initial peak flow; at the beginning B. initial peak flow; toward the end C. tidal volume; at the beginning D. tidal volume; toward the end

C. “c” D. “d”

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CHAPTER 11 Ventilator Waveform Analysis 61

40. (Figures 11-28 and 11-29). The abnormality (dotted line) in the pressure waveforms on the right (b) is caused by inadequate . This is evident because the abnormality occurs of the inspiratory phase. A. initial peak flow; at the beginning B. initial peak flow; toward the end C. tidal volume; at the beginning D. tidal volume; toward the end 41. (Figure 11-30) In the pressure-time waveform, a rise in pressure during a pause in flow (arrow “a”) may be caused by:

44. (Figure 11-31) Flow waveforms “f” and because “g” illustrate incomplete the expiratory flow fails to reach the zero baseline. This condition may be corrected by increasing the time. A. inspiration; inspiratory B. inspiration; expiratory C. expiration; inspiratory D. expiration; expiratory 45. (Figure 11-31) Pressure waveforms “d” and “e” show that the patient is trying to the breath during pressure support ventilation.

A. auto-PEEP.

A. terminate

B. patient inspiration during pause time.

B. hold

C. patient exhalation during pause time.

C. trigger

D. air leak.

D. stagger

42. (Figure 11-30) In the pressure-time waveform, a drop in pressure during a pause in flow (arrow “b”) may be caused by: A. circuit leak. B. inspiratory effort by patient during pause time. C. expiratory effort by patient during pause time. D. A and B only. 43. (Figure 11-31) Flow-time waveforms “a,” “b,” and “c” represent that the patient’s is than that provided by the pressure support breaths. A. inspiratory flow demand; higher B. inspiratory flow demand; lower C. expiratory flow demand; higher D. expiratory flow demand; lower

46. Refer to the flow waveform in Figure 11-32. In comparison to normal airflow resistance (dotted line), an increased airflow resistexpiratory ance (solid line) causes a flow rate and a ______ expiratory time. A. higher; longer B. higher; shorter C. lower; longer D. lower; shorter 47. Refer to the pressure waveform in Figure 11-32. In comparison to normal airflow resistance (dotted line), an increased airflow resistance (solid line) peak inspiratory prescauses a sure and a ______ expiratory time. A. higher; longer B. higher; shorter C. lower; longer D. lower; shorter

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62 SECTION 1

Test Questions

48. Refer to the flow-time waveform in Figure 11-33. In comparison to normal elastic recoil of the lungs (dotted line), a decreased elastic recoil (solid line) causes a expiratory flow and a ______ expiratory time.

52. (Figure 11-35) The waveform location marked by double-headed arrow shows an inspiratory effort during expiration. This is evident by the drop of below the baseline and a rapid return of the expiratory flow to the baseline.

A. higher; longer

A. “b”; pressure

B. higher; shorter

B. “b”; volume

C. lower; longer

C. “c”; pressure

D. lower; shorter

D. “c”; volume

49. Refer to the pressure-time waveform in Figure 11-33. In comparison to normal elastic recoil of the lungs (dotted line), a decrease in elastic recoil (i.e., higher compliance as in emphysema) (solid line) requires a:

53. (Figure 11-36) In comparison to the first set of normal waveforms, failure of the expired volume to return to baseline (a) and a decrease in peak inspiratory pressure (b) indicate the presence of:

A. higher peak inspiratory pressure.

A. auto-PEEP.

B. lower peak inspiratory pressure.

B. air trapping.

C. higher plateau pressure.

C. gas leak.

D. lower plateau pressure.

D. increased airflow resistance.

50. Refer to the flow-time waveform in Figure 11-34. In comparison to normal lung compliance (dotted line), a decrease in compliance (i.e., stiff lungs) (solid line) expiratory flow and a causes a ______ expiratory time.

54. (Figure 11-37) In the presence of gas leak while PEEP is active, the pressure in the circuit drops to the sensitivity setthe PEEP level (dotted line). ting This condition causes autotriggering of breaths.

A. higher; longer

A. above; mechanical

B. higher; shorter

B. above; spontaneous

C. lower; longer

C. below; mechanical

D. lower; shorter

D. below; spontaneous

51. Refer to the pressure-time waveform in Figure 11-34. In comparison to normal lung compliance (dotted line), a decrease in compliance (solid line) causes a peak inspiratory pressure and a ______ expiratory time.

55. (Figure 11-38) A curve (or loop) created by using volume and pressure provides information related to the patient’s: A. driving pressure. B. peak flow.

A. higher; longer

C. resistance.

B. higher; shorter

D. compliance.

C. lower; longer D. lower; shorter

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CHAPTER 11 Ventilator Waveform Analysis 63

56. (Figure 11-38) In the pressure-volume curve, a linear rise of PALV (straight dotted line) indicates that the patient’s is unchanged. A. lung-thorax compliance B. airway opening pressure C. airway resistance D. airway conductance 57. (Figure 11-39) In the pressure-volume curve, shift of the pressure-volume curve (PVC) to the right (toward the pressure axis) indicates a(n): A. increase of airway resistance. B. increase of lung-thorax compliance. C. decrease of airway resistance. D. decrease of lung-thorax compliance. 58. (Figure 11-40) In the pressure-volume curve, a stable PALV and increases in PTA, PIP, and PAO are indicative of a(n):

61. (Figure 11-42) The point of upper inflecof the alveoli and tion reflects in compliance late in the inspiratory phase. (Note: Compliance change is due to over-stretching.) A. overinflation; increase B. overinflation; decrease C. underinflation; increase D. underinflation; decrease 62. (Figure 11-42) The point of upper inflecthe metion may be corrected by chanical tidal volume until the disappears. A. increasing; auto-PEEP B. increasing; duckbill C. decreasing; auto-PEEP D. decreasing; duckbill 63. (Figure 11-43) In the flow-volume loop, is above the horizontal axis. the

A. increase of airway resistance.

A. inspiratory volume

B. increase of lung-thorax compliance.

B. inspiratory flow

C. decrease of airway resistance.

C. expiratory volume

D. decrease of lung-thorax compliance.

D. expiratory flow

59. (Figure 11-41) The initial point of inflection reflects the change in the from to normal during the inspiratory phase. A. airway resistance; high B. airway resistance; low C. compliance; high D. compliance; low 60. (Figure 11-41) The initial point of inflection may be corrected by adding at or slightly above the reading at the inflection point. A. volume; pressure B. volume; volume C. PEEP; pressure

64. (Figure 11-43) In the flow-volume loop, the pre- and post-bronchodilator response may be assessed by evaluating the: A. inspiratory volume. B. inspiratory flow tracing. C. expiratory volume. D. expiratory flow tracings. 65. (Figure 11-43) In the flow-volume loop, suggests a positive response a(n) to bronchodilator therapy. A. increase in inspiratory flow B. increase in expiratory flow C. decrease in inspiratory flow D. decrease in expiratory flow

D. PEEP; volume

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CHAPTER 12

Management of Mechanical Ventilation

1. A patient’s ventilatory status is best assessed by measuring the patient’s: A. arterial PCO2. B. arterial PO2. C. vital signs. D. tidal volume. 2. The PaCO2 of Ms. Hart, a 40-year-old mechanically ventilated patient with normal cardiopulmonary status, is 60 mm Hg. This value indicates and should be managed by the tidal volume or respiratory frequency. A. hyperventilation; increasing B. hyperventilation; decreasing C. hypoventilation; increasing D. hypoventilation; decreasing 3. Alveolar hyperventilation is usually accompanied by a PaCO2 reading of and this may be managed by the tidal volume or respiratory frequency. A. more than 45 mm Hg; increasing B. more than 45 mm Hg; decreasing C. less than 35 mm Hg; increasing

4. Ventilation may be improved by increasing all of the following ventilator parameters except: A. tidal volume. B. PEEP. C. pressure support. D. frequency. 5. In patients with normal cardiopulmonary is the initial status, increasing the treatment of choice to treat hypoxemia. A. FIO2 B. PEEP C. PSV D. tidal volume 6. In mechanical ventilation, the most common approach to improving minute . ventilation is to increase the However, it should not exceed as auto-PEEP may occur. A. respiratory frequency; 10/min B. respiratory frequency; 20/min C. tidal volume; 600 mL D. tidal volume; 800 mL

D. less than 35 mm Hg; decreasing

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CHAPTER 12

7. The total frequency of a mechanically ventilated patient is 10/min. At this frequency, the blood gas report reveals a PaCO2 of 60 mm Hg. Assuming the tidal volume and deadspace remain constant, calculate the respiratory frequency necessary to achieve a PaCO2 of 40 mm Hg. A. 6/min B. 8/min C. 12/min D. 15/min 8. Airway resistance imposed by the ventilator circuit and endotracheal tube can be minimized or overcome during spontaneous breathing by: A. adding deadspace. B. increasing inspiratory flow. C. using pressure support ventilation. D. all of the above. 9. All of the following statements are true regarding mechanical tidal volume except: A. increasing the tidal volume is the most common approach to improving minute ventilation. B. the tidal volume should be set according to the patient’s body weight. C. increasing the tidal volume should be considered when the respiratory frequency exceeds an ideal breathing pattern. D. insufficient tidal volume increases the risk of atelectasis and hypercapnia.

Management of Mechanical Ventilation 65

10. Permissive hypercapnia is a strategy in value is allowed to go which the above its upper normal limit, and it is used to . A. PaO2; reduce intracranial pressure in patients with head injury B. PaO2; reduce oxygen toxicity C. PaCO2; minimize ventilator-related lung injuries D. PaCO2; compensate for metabolic alkalosis during 11. In the management of permissive hypercapnia, tromethamine (THAM) is preferred because of its ability to the carbon dioxide level while increasing the bicarbonate levels. A. alkalosis; raise B. alkalosis; lower C. acidosis; raise D. acidosis; lower 12. An order has been written for initiating mechanical ventilation at a tidal volume setting of 3 mL/kg. The therapist should contact the physician and explain to her that the tidal volume setting would be too and it may lead to . A. high; barotrauma B. high; alveolar hyperventilation C. low; atelectasis D. low; bronchospasm 13. A patient is being mechanically ventilated at an FIO2 of 100%. As a precautionary measure, the therapist should monitor and limit its use to as lung damage can occur with prolonged exposure. A. 6 to 12 hours B. 12 to 24 hours C. 24 to 48 hours D. one week

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66 SECTION 1

Test Questions

14. The blood gas report of Mr. Orin, a patient on mechanical ventilation, is as follows: pH 7.50, PaCO2 32 mm Hg, PaO2 83 mm Hg. The physician asks a therapist to make appropriate changes to the settings on the ventilator. Which of the following ventilator controls has the least impact in normalizing the blood gas results? A. FIO2 B. Pressure support level C. Respiratory frequency D. Tidal volume 15. The PaO2 value reflects the amount of oxygen , and its clinical application is limited in cases where hypoxia is due to severe . A. bound to hemoglobin; carbon monoxide poisoning

17. A patient is being mechanically ventilated. Among other settings, PEEP of 10 cm H2O and FIO2 of 70% are used. After determining the patient has met the weaning criteria, the therapist should begin the weaning process by decreasing the: A. FIO2 gradually to 40%. B. FIO2 gradually while simultaneously increasing the PEEP. C. PEEP gradually to 3 cm H2O. D. PEEP gradually while simultaneously increasing the FIO2. 18. Inverse ratio ventilation (IRV) is accomplished mainly by: A. decreasing the tidal volume. B. increasing the inspiratory flow rate. C. increasing the inspiratory time.

B. bound to hemoglobin; pulmonary edema

D. decreasing the peak inspiratory pressure.

C. dissolved in the plasma; congestive heart failure

19. In high frequency oscillatory ventilation (HFOV), hypoventilation may be manthe amplitude or by aged by the frequency.

D. dissolved in the plasma; anemia 16. A medical resident asks the therapist to explain the difference between CPAP and PEEP. The therapist should describe that CPAP provides an end-expiratory pressure to patients who: A. are on pressure-controlled mode. B. have spontaneous breathing efforts. C. are on volume-controlled mode. D. have an artificial airway.

A. increasing; increasing B. increasing; decreasing C. decreasing; increasing D. decreasing; decreasing 20. In high frequency oscillatory ventilation (HFOV), the mean airway pressure , and (mPaw) is affected by the the initial mPaw should start at the mPaw obtained during conventional mechanical ventilation. A. power setting; 5 cm H2O above B. power setting; 15 cm H2O above C. frequency; 5 cm H2O above D. frequency; 15 cm H2O above

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CHAPTER 12

21. In patients with severe hypoxia, a recruitment strategy may be used during HFOV by applying an mPaw of cm H2O for sec. A. 10; 10 to 20 B. 20; 20 to 30 C. 30; 30 to 40 D. 40; 40 to 60 22. In high frequency oscillatory ventilation (HFOV), the power setting controls the amplitude of oscillation and thus the: A. frequency. B. tidal volume. C. oxygenation level. D. A and B only. 23. For adult patients, the power setting durand ing HFOV is initially set at rapidly increased to achieve chest wiggle. Chest wiggle is defined as visible vibration from . A. 1; shoulder to belly area B. 1; shoulder to midthigh area C. 4; shoulder to belly area D. 4; shoulder to midthigh area 24. The initial frequency during HFOV is set Hz and may be if usat ing amplitude alone fails to control the PaCO2. A. 5 to 6; increased B. 5 to 6; decreased C. 10 to 15; increased D. 10 to 15; decreased

Management of Mechanical Ventilation 67

25. The suggested weaning process for HFOV is done in the following order: A. FIO2 to 40%, mPaw to 22–24 cm H2O range, SIMV. B. FIO2 to 40%, mPaw to 22–24 cm H2O range, PCV. C. mPaw to 22–24 cm H2O range, FIO2 to 40%, SIMV. D. mPaw to 22–24 cm H2O range, FIO2 to 40%, PCV. 26. Mrs. McFarland, a patient with a history of COPD, has been admitted for elective surgery. Her preoperative blood gases on room air would most likely show: A. pH 7.16, PaCO2 34 mm Hg, PaO2 64 mm Hg. B. pH 7.45, PaCO2 44 mm Hg, PaO2 65 mm Hg. C. pH 7.37, PaCO2 54 mm Hg, PaO2 60 mm Hg. D. pH 7.48, PaCO2 54 mm Hg, PaO2 58 mm Hg. 27. The therapist is reviewing the blood gas results of a 30-year-old, postoperative patient who has been on assist/control vent ilation. The results are as follows: pH 7.51, PaCO2 30 mm Hg, PaO2 102 mm Hg, HCO3− 24 mEq/L, assist/control frequency 12/min, total frequency 18/min, tidal volume 700 ml, FIO2 30%. Based on the information provided, the therapist should make which of the following changes to the ventilator setting? A. Decrease FIO2 to 25%. B. Increase tidal volume to 800 ml. C. Decrease assist/control frequency to 10/min. D. Change to SIMV mode.

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68 SECTION 1

Test Questions

28. Upon entering the ICU, the therapist is alerted by a series of low pressure alarms from a ventilator. The therapist should check the patient and ventilator for all of the following conditions except: A. circuit disconnection. B. airway obstruction. C. endotracheal tube cuff leak. D. loose connections. 29. Upon entering Mr. Pendleton’s room the therapist notices that the high pressure alarm has been triggered since the last patient assessment. It is no longer alarming. The therapist should consider which of the following as the most likely cause? A. Bronchospasm B. Mucus plug C. Tension pneumothorax D. Coughing 30. The most common trigger for apnea alarms is: A. apnea. B. loose humidifier fitting. C. cuff leak. D. circuit disconnection. 31. While monitoring the ventilator, the therapist notices that the pressure gauge goes from 0 cm H2O and then goes up and stays at 8 cm H2O throughout the expiratory phase. Since PEEP is not in use, this observation is called:

32. Among the conditions below, auto-PEEP on the is most likely caused by ventilator setting. A. excessive inspiratory flow B. insufficient tidal volume C. low respiratory frequency D. gas trapping 33. Mr. Johns is being mechanically ventilated with these settings: Mode SIMV, f 12/min, VT 600 mL, FIO2 50%, PEEP 0 cm H2O. Auto-PEEP of 6 cm H2O is observed consistently. The patient is experiencing increased work of breathing. Adjustment of peak flow, tidal volume, and respiratory frequency cannot resolve this problem. The therapist should: A. change mode to assist/control. B. initiate pressure support ventilation. C. initiate bilevel positive pressure ventilation. D. add PEEP of 5 cm H2O. 34. Auto-PEEP may be reduced or eliminated by all of the following methods except: A. increasing the expiratory time. B. reducing the tidal volume. C. reducing the frequency. D. reducing the inspiratory flow. 35. Given: ventilator circuit with a tubing compliance of 3 mL/cm H2O, PIP 50 cm H2O, PEEP 10 cm H2O. The volume “lost” due to these parameters is:

A. asthma.

A. 30 mL.

B. air leak.

B. 120 mL.

C. auto-PEEP.

C. 150 mL.

D. hypercapnia.

D. 180 mL.

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CHAPTER 12

36. When a metered-dose inhaler (MDI) is administered inline to a mechanically ventilated patient with a heat and moisture exchanger (HME), A. the MDI must be placed between the patient and the HME.

Management of Mechanical Ventilation 69

40. The therapist is reviewing the chart of a patient who has been admitted to the ICU for severe malnutrition and dehydration. Which of the following urine output measurements may be used to determine if the patient has a fluid deficit? A. Urinary output <20 mL/hour

B. the MDI must be placed between the ventilator and the HME.

B. Urinary output <400 mL in 24 hour

C. the HME must be removed.

C. Urinary output <160 mL in 8 hour

D. the HME must be replaced with a bacterial filter.

D. All of the above

37. The incidence of ventilator-associated pneumonia may be reduced by employing all of the following procedures except: A. proper hand washing. B. more frequent ventilator circuit change. C. early microbiological exam and use of appropriate antibiotherapy. D. closed suction system. 38. An intubated patient is being treated with a broad-spectrum antibiotic. The physician would like to do a culture and sensitivity sputum test. Since the patient’s cough is not strong enough to expectorate the retained secretions, the therapist to collect the spushould use a tum sample. A. laryngeal mask airway B. esophageal obturator C. suction catheter D. Lukens trap 39. The physician has ordered a sputum sample for determining presence of pulmonary tuberculosis. The therapist should gather the specimen supplies for: A. cytology sputum analysis.

41. The physician asks a therapist to assess her patient for excessive extracellular fluid. Among other signs, the therapist should evaluate all of the following conditions except: A. bounding pulse. B. increased cardiac output. C. pulmonary edema. D. oliguria. 42. The major cation in the extracellular fluid and it plays an compartment is important role in balance. A. sodium; fluid B. potassium; fluid C. calcium; acid-base D. magnesium; acid-base 43. The following electrolytes are collected from a patient with severe sepsis. The patient has been on a mechanical ventilator for two weeks. Which of the following electrolytes is out of its normal range? A. Sodium 138 mEq/L B. Potassium 1.5 mEq/L C. Chloride 105 mEq/L D. Bicarbonate 5 mEq/L

B. culture and sensitivity sputum analysis. C. acid-fast sputum analysis. D. silver stain sputum analysis.

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70 SECTION 1

Test Questions

44. The major cation in the intracellular fluid (ICF) is: A. sodium. B. calcium. C. potassium. D. magnesium. 45. Mr. Warren, a patient with congestive heart failure, shows decreased muscle function, flattened T wave, and depressed ST segment on the electrocardiogram. These are some signs of: A. hypernatremia. B. hyponatremia. C. hyperkalemia. D. hypokalemia. 46. Increased bowel activity, altered neuromuscular conduction, and cardiac arrest are some conditions that may be a result of: A. hyperkalemia. B. hypokalemia. C. hypernatremia. D. hyponatremia. 47. A patient from an extended care facility has an admitting diagnosis of hypoalbuminemia. The patient appears to be undernourished. In caring for this patient, the therapist should be concerned with development of: A. obstructive sleep apnea. B. hyperventilation. C. ketoacidosis. D. pulmonary edema.

48. Mr. Jones, a patient who has been mechanically ventilated for three weeks, is now on a high-calorie diet. Which of the following can be a potential problem associated with overfeeding during mechanical ventilation? A. Decreased work of breathing B. Increased carbon dioxide production C. Decreased oxygen consumption D. Increased fixed acid 49. A diet consisting of low carbohydrate and high fat is more suitable for patients on mechanical ventilation because generates more calories per gram and produces less . A. fat; CO2 B. fat; O2 C. carbohydrate; CO2 D. carbohydrate; O2 50. Dr. Kao asks the therapist to estimate a patient’s resting energy expenditure (REE) using the Harris Benedict equation. The therapist should gather the following set of information: A. height and weight. B. age, height, and weight. C. sex, height, and weight. D. sex, age, height, and weight. 51. The total energy expenditure (TEE) is than the resting energy expenditure (REE), because TEE account for patient factors such as activity, trauma, and infection. A. higher; does B. higher; does not C. lower; does D. lower; does not

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CHAPTER 12

52. Low tidal volume strategy is done to reduce the risk of , and the target volume is reached when . A. atelectasis; peak inspiratory pressure is 35 cm H2O B. atelectasis; plateau pressure is 35 cm H2O C. barotraumas; peak inspiratory pressure is 35 cm H2O

Management of Mechanical Ventilation 71

54. Baby Jones is receiving experimental tracheal gas insufflation (TGI) during mechanical ventilation. TGI is intended to achieve all of the following goals except: A. reduce deadspace ventilation. B. increase CO2 rebreathing. C. lower tidal volume requirement. D. reduce airway pressures.

D. barotraumas; plateau pressure is 35 cm H2O. 53. In order to improve the oxygenation of Mr. Panos, he is being placed in a prone position (PP). Since his oxygen index (OI) is 60 before PP, an OI of following at least one hour of PP is considered a beneficial response to PP. A. greater than 72 B. greater than 60 C. less than 60 D. less than 48

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CHAPTER 13

Pharmacotherapy for Mechanical Ventilation

1. Bronchodilation can be achieved pharmacologically by: A. increasing sympathetic responses. B. decreasing parasympathetic responses. C. enhancing both cholinergic and adrenergic responses. D. A and B. 2. Stimulation of the sympathetic nervous system may result in all of the following except:

4. A physician asks the therapist to administer a sympathomimetic bronchodilator that offers the most beta-2 specificity. From the available drugs below, the therapist should use: A. Xopenex. B. Isuprel. C. atropine sulfate. D. Atrovent.

C. hypertension.

recommended adult dosage of albuterol per aerosol nebulizer treatment is , but the optimal dosage may be higher depending on a patient’s requirement.

D. tachycardia.

A. 0.25%; 0.1 mL

A. bronchodilation. B. increased gastrointestinal activity.

3. Which of the following characteristics describes a pure catecholamine bronchodilator? A. Degraded rapidly by COMT B. Nonspecific receptor binding C. Rapid onset D. All of the above

5. The

B. 0.5%; 0.5 mL C. 5%; 0.5 mL D. 10%; 1 mL 6. Atropine and atropine derivatives promote bronchial relaxation by: A. combining with and blocking adrenergic receptor sites. B. combining with and blocking cholinergic receptor sites. C. stimulating adrenergic receptor sites. D. stimulating cholinergic receptor sites.

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CHAPTER 13 Pharmacotherapy for Mechanical Ventilation 73

7. Mr. Oberton, a COPD patient who is known to be noncompliant with his medication intake schedule, is complaining of psychologic distress. During patient assessment, he states that he has been “seeing things.” Although an unusual occurrence, which of the following anticholinergic agents may cause this side effect? A. Atropine B. Ipratropium bromide C. Glycopyrrolate D. All of the above 8. Dr. Grossman has ordered ipratropium bromide and albuterol sulfate MDI for her patient, Ms. Waller. The therapist MDI inhaler should obtain a(n) before going to instruct Ms. Waller on the use of this inhaler. A. Xopenex and Atrovent B. Combivent

A. Corticosteroids require an onset time of 2 to 24 hours. B. Corticosteroids can be used as a bronchodilator. C. Corticosteroids offer relief by blocking the chemical mediators of inflammation. D. Corticosteroids can be used to manage bronchospasm. 12. Flunisolide is the generic name for: A. Beclovent. B. Vanceril. C. AeroBid. D. A and B only. 13. Which of the following corticosteroid is not suitable for parenteral administration?

C. atropine sulfate

A. Triamcinolone

D. Atrovent and albuterol

B. Cortisone

9. Although classified as a bronchodilator, xanthines offer other benefits to individuals with COPD by: A. reducing inflammation. B. enhancing diaphragmatic contractility. C. heightening carbon dioxide sensitivity. D. All of the above. 10. Mrs. Cartwright, a COPD patient who has been using theophylline for two months, is experiencing nausea, abdominal pain, diarrhea, and nervousness. These signs and may be avoided are related to by keeping the serum level within a therapeutic range of . A. theophylline toxicity; 1 to 4 mcg/mL

39689_ch13_rev02.indd 73

11. Which of the following statements is not true regarding corticosteroid therapy?

C. Prednisolone D. Dexamethasone 14. The physician has ordered a broncodilator MDI for a mechanically ventilated patient. The therapist should administer the medication by using all of the following techniques except: A. activate inspiratory pause. B. use a lower inspiratory flow. C. change tidal volume to 300 mL. D. actuate the MDI with onset of inspiratory flow. 15. Which of the following is not an indication for using a neuromuscular blocking agent? A. Provide patient comfort.

B. inadequate theophylline; 8 to 10 mcg/mL

B. Reduce combativeness.

C. theophylline toxicity; 5 to 15 mcg/mL

C. Relax respiratory muscles.

D. inadequate theophylline; 20 to 30 mcg/mL

D. Decrease intracranial pressures caused by excessive movement.

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74 SECTION 1

Test Questions

16. The neurotransmitter substance released into the synapse at the motor endplate is: A. acetylcholine. B. dopamine. C. adrenaline. D. atropine sulfate. 17. Depolarizing agents cause muscle para lysis by: A. competing with acetylcholine at the receptor sites. B. destroying acetylcholine. C. binding with the receptor site and producing a sustained depolarization. D. increasing the level of acetylcholinesterase. 18. Nondepolarizing agents cause muscle paralysis by: A. competing with acetylcholine at the receptor sites. B. completely destroying acetylcholine. C. binding with the receptor site and producing a sustained depolarization. D. increasing the level of acetylcholinesterase. 19. Succinylcholine (Anectine, Quelicin) is a neuromuscular blocking agent. It induces muscle blockade by . A. depolarizing; binding to the receptor sites and causing sustained depolarization B. nondepolarizing; binding to the receptor sites, and causing sustained depolarization C. depolarizing; competing for the receptor sites, and blocking the action of acetylcholine D. nondepolarizing; competing for the receptor sites, and blocking the action of acetylcholine

20. Mr. Tolly, a patient with reduced hepatic function, is undergoing surgery that requires neuromuscular blockade. Prolonged neuromuscular blockade may be avoided by using , a self-destroying neuromuscular blocker. A. pancuronium bromide B. pipecuronium bromide C. rocuronium D. atracurium 21. Which of the following conditions does not enhance the effects of nondepolarizing agents? A. Low calcium levels in the blood B. Low potassium levels in the blood C. High chloride level in the blood D. High magnesium levels in the blood 22. Malignant hyperthermia is a rare genetic condition that can lead to a sudden surge muscle metabolism. of is the fastest way to detect malignant hyperthermia during use of succinylcholine and volatile anesthetics. A. cardiac; Capnography B. cardiac; Pulse oximetry C. skeletal; Capnography D. skeletal; Pulse oximetry 23. Dantroline sodium (Dantrium) is the preferred treatment for: A. sedative overdose. B. barbiturate overdose. C. malignant hyperthermia. D. postextubation bronchospasm. 24. A peripheral nerve stimulator is used to titrate the appropriate amount of: A. analgesic. B. neuromuscular blocking agent. C. sedative. D. intravenous fluid.

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CHAPTER 13 Pharmacotherapy for Mechanical Ventilation 75

25. With a peripheral nerve stimulator (e.g., Train-of-Four) properly attached to the patient, is/are often adequate to assure patient-ventilator synchrony. A. one muscle twitch in 2 sec B. three muscle twitches in 2 sec C. one muscle twitch in 10 sec D. three muscle twitches in 10 sec 26. A patient who has been given Pavulon about 30 min ago is recovering in the surgical intensive care unit. The physician wants to be notified when reversal of neuromuscular blockade has occurred. The therapist should evaluate the patient by checking all of the following except:

29. Narcotic analgesics produce analgesia by receptors found inbinding to the side and outside the central nervous system. A. mu B. kappa C. sigma D. All of the above 30. A 16-year-old unresponsive male is in the emergency department with narcotic over, such as , should dose. An be used to reverse the potential effects of the narcotic. A. agonist; meperidine B. agonist; nalaxone

A. tongue protrusion for 5 sec or more.

C. antagonist; meperidine

B. vital capacity more than 500 mL.

D. antagonist; nalaxone

C. ability to perform hand grip on command. D. head lift for 5 sec or more. 27. A 30-year-old patient is placed on the mechanical ventilator for head and chest injuries sustained in an automobile crash. Arterial blood gases and hemodynamic monitoring reveal a stable patient, although he is agitated and becoming more difficult to manage. The therapist should recommend use of a: A. benzodiazepine. B. narcotic analgesic. C. barbiturate. D. neuromuscular blocking agent. 28. Diazepam, lorazepam and midazolam are examples of: A. analgesics. B. neuromuscular blocking agents. C. antiseizure agents. D. antianxiety agents.

31. When narcotics are used to manage pain, administration of naloxone should be done respirwith care since it may cause atory depression as well as of pain. A. severe; disappearance B. severe; return C. reversal of; disappearance D. reversal of; return 32. Which of the following is not an adverse effect of narcotic analgesics? A. Respiratory depression B. Muscle paralysis C. Delayed gastric emptying D. Contraction of pupils 33. In caring for patients who are being mechanically ventilated, the therapist may as a sign of pain, since look for the patients are unable to verbalize their discomfort. A. tachycardia B. diaphoresis C. dilated pupils D. All of the above

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76 SECTION 1

Test Questions

34. Barbiturates depress the central nervous system by: A. hyperpolarization of neurons by gamma-aminobutyric acid (GABA).

A. persistent pulmonary hypertension of the newborn.

B. hypopolarization of neurons by gamma-aminobutyric acid (GABA).

B. acute respiratory distress syndrome.

C. hyperpolarization of neurons by catechol-o-methyltransferase (COMT).

C. diagnostic studies in pulmonary hypertension.

D. hypopolarization of neurons by catechol-o-methyltransferase (COMT).

D. all of the above.

35. Depending on the dosage, propofol produces a range of central nervous system to . effects, ranging from A. control of mild pain; control of severe pain

36.

38. Inhaled nitric oxide (iNO) gas is a pulmonary vasodilator and it may be useful in the management of:

39. The effects of inhaled nitric oxide (NO) circulation. In are limited to the the capillaries, free iNO binds to , forming nitrosylhemoglobin, which in turn is oxidized to methemoglobin. A. systemic; hemoglobin

B. memory loss; coma

B. systemic; reduced hemoglobin

C. sedation; deep anesthesia

C. pulmonary; hemoglobin

D. hypotension; hypertension

D. pulmonary; reduced hemoglobin

may be effective in the reversal of agitation and delirium caused paradoxically by sedatives and anxiolytic agents. A. Nitric oxide B. Propofol C. Haloperidol D. Naloxone

37. All of the following statements are true in regard to dexmedetomidine except: A. Dexmedetomidine can be administered nasally. B. Dexmedetomidine has sedative effects.

40. The most recent methemoglobin (MetHb) level of a patient is 30%. The therapist should expect to see the following signs and symptoms at this MetHb level: A. cyanosis of trunk and limbs but asymptomatic. B. central nervous system depression. C. coma, arrhythmia, shock, and convulsion. D. all of the above. 41. In order to deliver the inhaled nitric oxide safely, the delivery system should be able to perform all of the following except:

C. Dexmedetomidine has anagelsic effects.

A. monitoring the iNO level.

D. Dexmedetomidine is used to treat hypotension.

B. monitoring the NO2 level. C. delivering a stable concentration of iNO regardless of the ventilator setting or mode. D. measuring and reporting the amount of iNO used.

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CHAPTER 14

Procedures Related to Mechanical Ventilation

1. Mr. Kingston, a patient in the emergency department, is being readied for the insertion of a chest tube. The patient is likely to have one of the following conditions except:

4. During chest tube placement, the point of the body of the entry is directly rib because arteries, veins and intercostals nerves all lie each rib.

A. hemothorax.

A. over; above

B. tension pneumothorax.

B. over; under

C. Pneumocystis pneumonia.

C. below; above

D. empyema.

D. below; under

2. Ms. Smith, a 30-year-old patient in the medical ICU, has been diagnosed with a 30% tension pneumothorax. The treatment for this condition is:

5. Compared to trocar tube thoracostomy, operative tube thoracostomy requires incision and it carries a a risk of puncturing the lung.

A. oxygen therapy.

A. larger; higher

B. 16 to 20 French sized chest tube.

B. larger; lower

C. three-column pleural drainage setup.

C. smaller; higher

D. No treatment is necessary for tension pneumothorax less than 40%.

D. smaller; lower

3. The common placement site of a chest tube for treatment of tension pneumoalong the midclathorax is at the vicular or midaxillary line. A. second or third intercostal space anteriorly B. fourth to sixth intercostal space anteriorly C. fourth to sixth intercostal space laterally

6. A three-chamber drainage system is preferred over the one-column system because: A. the suction level is not affected by the volume of drainage in the collection chamber. B. it holds more pleural drainage and is more cost-effective. C. the suction level may be adjusted easily by regulating the vacuum control. D. it is operational during transport without a vacuum source.

D. sixth to eighth intercostal space laterally 77

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78 SECTION 1

Test Questions

7. A patient in the ICU is connected to a three-column chest tube drainage system at a suction level of 10 cm H2O. The physician asks a therapist to increase the suction level to 15 cm H2O. The therapist should increase the suction level by:

11. In a three-chamber chest tube drainage system, a large amount of bubbling in the water seal chamber may be indicative of: A. air leak in the drainage system. B. presence of air in the pleural space.

A. increasing the vacuum pressure.

C. excessive vacuum pressure.

B. decreasing the vacuum pressure.

D. A and B only.

C. adding water to the suction chamber. D. removing water from the suction chamber. 8. For adult patients, the water level in of a three-column drainage the system should be initially filled to a level between .

12. Overfilling of water in the suction chamber of a three-chamber drainage systhe suction level to the tem will pleural space, whereas underfilling will the suction level. A. increase; increase B. increase; decrease

A. water seal chamber; 10 to 20 cm H2O

C. decrease; increase

B. water seal chamber; 30 to 40 cm H2O

D. decrease; decrease

C. suction chamber; 10 to 20 cm H2O D. suction chamber; 30 to 40 cm H2O 9. As the therapist is making rounds in the ICU, he notices that the suction chamber of Mr. Jones’ three-chamber chest tube drainage system is bubbling vigorously. The therapist should: A. partially clamp the chest tube. B. decrease the vacuum pressure. C. drain the collection chamber. D. remove water from the suction chamber. 10. As the therapist is assessing a mechanically ventilated patient, she notices that the water level in the middle (water seal) chamber of a three-chamber drainage system fluctuates with the mechanical tidal volume. This observation means that the chest tube and drainage system:

13. Air leaks from the lungs are present when the patient performs a(n) and bubbling is observed in the chamber. A. inspiratory breath hold; collection B. inspiratory breath hold; water seal C. Valsalva maneuver; collection D. Valsalva maneuver; water seal 14. While transporting a patient with a chest tube setup, the drainage system must than the patient’s chest, be kept and the chest tube clamped or occluded. A. higher; must be B. higher; must not be C. lower; must be D. lower; must not be

A. are occluded with clotted blood. B. are receiving too much vacuum pressure. C. have developed a leak. D. are working normally.

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CHAPTER 14 Procedures Related to Mechanical Ventilation 79

15. Fiberoptic bronchoscopy is done for all of the following purposes except: A. evaluation and diagnosis of certain pulmonary problems.

19. The flexible bronchoscopy procedure to collect tissue specimens that involves using a forced-exhalation maneuver is called: A. bronchial brushing.

B. collection of biopsy or cytology samples.

B. transbronchial needle aspiration biopsy.

C. therapeutic treatments.

C. forceps biopsy.

D. all of the above.

D. transbronchial lung biopsy.

16. Dr. Johnson has scheduled to perform a bronchoscopy at 0900 hours. In order to reduce irritation of the mucosal membrane during the procedure, the therapist at . should administer A. 1 to 3 mL of 1% to 4% lidocaine via aerosol; 0730 hours B. 1 to 3 mL of 5% to 10% atropine via aerosol; 0700 hours C. 5 to 10 mL of 1% to 4% lidocaine via aerosol; 0830 hours D. 5 to 10 mL of 5% to 10% atropine via aerosol; 0830 hours 17. To provide pain relief and suppress coughing during bronchoscopy, may be administered to the patient. A. morphine sulfate B. atropine sulfate C. benzodiazepine D. lidocaine 18. As Dr. Satterwhite is performing a bronchoscopy on Mr. Whaley, a mechanically ventilated patient in the ICU, the lowvolume alarm goes off intermittently. The therapist notices that the expired volume is 80 mL less than the set tidal volume. Since this condition has not occurred before the bronchoscopy procedure, the therapist should adjust the ventilator settings by:

20.

is done where the lesion is located beyond the bronchial wall and there is no lesion in the bronchial lumen. A. Transbronchial needle aspiration biopsy B. Bronchial brushing C. Pulmonary lavage with saline D. Open lung biopsy

21. During bronchoscopy, bleeding may be stopped by all of the following techniques except: A. using a vasopressor. B. using heat-induced coagulation. C. wedging the bleeding site with the distal end of the bronchoscope. D. plugging the airway where bleeding occurs. 22. Mr. Manning, a patient undergoing bronchoscopy, suddenly develops cyanosis, diaphoresis, tachypnea, tachycardia, and thready pulse. Based on these signs and symptoms, Mr. Manning should be evaluated for the presence of: A. fluid overload. B. tension pneumothorax. C. mucus plugs. D. internal bleeding.

A. increasing the frequency. B. increasing the tidal volume. C. decreasing the PEEP. D. decreasing the low-volume alarm limit.

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80 SECTION 1

Test Questions

23. Following bronchoscopy, Mr. Allman develops moderate wheezing and mild oxygen desaturation. The therapist should recommend to the physician that an aerosol therapy with should be started.

27. Low PIO2 and relative humidity are two inherited problems during transport of mechanically ventilated patients via: A. pressurized aircraft. B. nonpressurized aircraft.

A. steroid, q2h

C. ground ambulance.

B. steroid, prn

D. water craft.

C. bronchodilator, q2h D. bronchodilator, prn 24. Dr. Bench wants to send her mechanically ventilated patient to radiology for an MRI procedure. Which of the following factors is least essential in ensuring the patient’s safety during the transport? A. Sufficient staffing in the ICU B. Adequate oxygenation and ventilation C. Adequate airway control and cardiopulmonary monitoring D. Stable and acceptable hemodynamic status 25. For interhospital transport, the mode of transportation is mainly based on the: A. insurance coverage. B. size of the patient. C. type of ventilator available. D. distance between hospitals. 26. Prior to transport of a mechanically ven, the road and tilated patient via a traffic condition must be assessed and evaluated carefully. A. ground ambulance B. helicopter C. propeller-driven aircraft

28. For intrahospital transport of mechanically ventilated patients for less than , manual ventilation with a resuscitation bag and oxygen may be sufficient. A. 30 min B. 60 min C. 90 min D. 4 hours 29. Manual ventilation during transport of mechanically ventilated patients often and leads to inadvertent tidal volume and rate. A. hyperventilation; regular B. hyperventilation; irregular C. hypoventilation; regular D. hypoventilation; irregular 30. For ventilators that operate with only the pressure-controlled mode, the must be monitored closely because decreasing compliance or increasing airflow resistance can the delivered tidal volume. A. peak inspiratory pressure; increase B. peak inspiratory pressure; decrease C. expired volume; increase D. expired volume; decrease

D. jet

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31. During transport of a mechanically ventilated patient, monitoring must be done: A. at the beginning of transport. B. toward the end of transport. C. throughout the entire transport. D. No monitoring is necessary because the patient is being mechanically ventilated. 32. During transport of a mechanically ventiis the only alternalated patient, tive in the event of ventilator malfunction. A. endotracheal suctioning B. pulse oximetry check C. return to the originating hospital

33. When a pressurized aircraft is not available, the patient’s oxygenation status should be monitored with a: A. pulse oximeter. B. blood gas sample. C. respirometer. D. carbon dioxide detector. 34. Steel oxygen cylinders should not be used is being done. where A. echocardiography B. computer axial tomography (CAT) C. magnetic resonance imaging (MRI) D. all of the above

D. manual ventilation

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CHAPTER 15

Critical Care Issues in Mechanical Ventilation

1. Lung injuries occur during mechanical ventilation because the lungs in some critically ill patients are in structure and they have compliance and opening pressure requirements. A. homogenous; similar B. homogenous; different C. nonhomogenous; similar D. nonhomogenous; different 2. When nonhomogenous lungs are ventilated by positive pressure, the units are opened and closed intermittently while the normal lung units suffer from .

4. A patient in the ICU has a PaO2/FIO2 of 280 mm Hg and a PCWP of 12 mm Hg. The chest radiograph shows bilateral infiltrates. The data are consistent with: A. ARDS. B. COPD. C. ALI. D. CHF. 5. In the management of ALI and ARDS, the PCWP measurement is used to evaluate or determine the cause of: A. bilateral infiltrates. B. hypoxemia.

A. compliant, atelectasis

C. hypercapnia.

B. compliant, overdistention

D. respiratory acidosis.

C. noncompliant, atelectasis D. noncompliant, overdistention 3. In addition to pulmonary edema, which of the following is one of the clinical features of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)? A. PaO2/FIO2 > 300 mm Hg

6. Which of the following is a cause of indirect lung injury? A. Pneumonia B. Acute pancreatitis C. Pulmonary contusion D. Inhalation of toxins

B. PCWP ≤18 mm Hg and without signs of left atrial hypertension C. Slow onset D. Bronchogram on chest radiograph 82

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CHAPTER 15 Critical Care Issues in Mechanical Ventilation 83

7. The current management strategy for ALI and ARDS is: A. supportive care for oxygenation and ventilation. B. antibiotics.

A. < 40 cm H2O; < 15 cm H2O

C. lung transplant.

B. < 40 cm H2O; < 10 cm H2O

D. hyperbaric oxygenation.

C. < 30 cm H2O; < 10 cm H2O

8. The radiographic signs of pulmonary edema caused by ARDS and congestive heart , and the PCWP failure (CHF) are measurements is typically when pulmonary edema is caused by CHF.

D. < 30 cm H2O; < 15 cm H2O 12. A mechanically ventilated patient is showing incomplete exhalation and developing signs of air trapping. What ventilator setting should the therapist adjust?

A. similar; normal

A. Increase peak inspiratory flow.

B. similar; elevated

B. Increase peak inspiratory pressure.

C. different; normal

C. Increase tidal volume.

D. different; elevated

D. Decrease PEEP.

9. Cardiomegaly, pleural effusion, vascular redistribution, bilateral infiltrates, and elevated PCWP are some signs of: A. ALI. B. ARDS. C. cardiogenic pulmonary edema. D. noncardiogenic pulmonary edema. 10. To protect the lungs from excessive airway pressures, the peak inspiratory pressure , and the plateau should be kept pressure (based on ARDSNet’s recommendation) should be kept . A. < 60 cm H2O; < 40 cm H2O B. < 30 cm H2O; < 20 cm H2O C. < 40 cm H2O; < 20 cm H2O D. < 50 cm H2O; < 30 cm H2O

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11. To protect the lungs from excessive airway pressures, the mean airway pressure and PEEP should be kept and , respectively.

13. Permissive hypercapnia may be done during volumeby lowering the controlled ventilation until the PIP is near the before the procedure. A. peak inspiratory pressure; PEEP B. peak inspiratory pressure; plateau pressure C. tidal volume; PEEP D. tidal volume; plateau pressure 14. A physician wants to initiate permissive hypercapnia on a patient with ARDS and severe hypoxemia. The tidal volume should be in the range of: A. 2 to 4 mL/kg. B. 3 to 5 mL/kg. C. 4 to 7 mL/kg. D. 7 to 9 mL/kg.

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84 SECTION 1

Test Questions

15. The acidosis resulting from permissive hypercapnia may be returned to normal either by renal compensation over time or by neutralizing the acid with: A. carbonic acid. B. bicarbonate. C. tromethamine. D. B or C only. 16. Since PEEP is the end-expiratory pressure (the bottommost pressure on the pressure-time waveform), increasing the PEEP would lead to an instantaneous increase of the: A. peak inspiratory pressure. B. mean airway pressure. C. plateau pressure. D. all of the above. 17. Which of the following is not a recommendation by ARDSNet in the management of ARDS? A. Pressure-controlled ventilation B. Assist/control mode C. PPLAT <30 cm H2O D. SO2 >88% (with FIO2 and PEEP) 18. A student asks the therapist about the purpose of the decremental recruitment maneuver. The therapist would explain that it is done to determine the for patients with . A. peak pressure setting; respiratory acidosis B. peak pressure setting; ARDS C. optimal PEEP; respiratory acidosis D. optimal PEEP; ARDS

19. (The following is step 4 of the decremental recruitment maneuver. See Table 15-4 of the 4th edition of Clinical Application of Mechanical Ventilation.) Immediately after the initial recruitment maneuver, the patient is placed on at a PEEP of cm H2O for a total pressure of 35 cm H2O. A. pressure-controlled ventilation; 20 B. pressure-controlled ventilation; 10 C. volume-controlled ventilation; 20 D. volume-controlled ventilation; 10 20. (The following includes steps 5 and 6 of the entire decremental recruitment maneuver. See Table 15-4 of the 4th edition of Clinical Application of Mechanical Ventilation.) Following the initial recruitment maneuver, the FIO2 is decreased gradually by 5% to 20% until SpO2 stabilizes between , and the PEEP is decreased gradually by cm H2O every 15 to 20 minutes until the SpO2 drops below 90%. A. 88% and 90%; 2 B. 90% and 94%; 2 C. 88% and 90%; 4 D. 90% and 94%; 4 21. (The following is step 8 of the entire decremental recruitment maneuver. See Table 15-4 of the 4th edition of Clinical Application of Mechanical Ventilation.) The final recruitment maneuver is done of by using an FIO2 of 100% and for 40 seconds. A. CPAP; 40 cm H2O B. CPAP; 20 cm H2O C. PEEP; 40 cm H2O D. PEEP; 20 cm H2O

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CHAPTER 15 Critical Care Issues in Mechanical Ventilation 85

22. Indications for prone positioning include patients who require a PEEP of > and FIO2≥ to maintain supine oxygen saturation of ≥90%. A. 10 cm H2O; 60%

A. for 30 minutes q2 hours; every 3 days

B. 10 cm H2O; 100%

B. for 30 minutes q2 hours; when visibly soiled

C. 15 cm H2O; 60%

C. at all times; every 3 days

D. 15 cm H2O; 100%

D. at all times; when visibly soiled

23. Which of the following is not a risk factor for ventilator-associated pneumonia? A. Long duration of mechanical ventilation B. Long-term sedation C. COPD D. Obesity 24. Methicillin-resistant Staphylococcus aureus (MRSA) is the predominant pathogen in ventilator-associated pneumonia following intubation and initiation of mechanical ventilation. A. during the first 48 hours B. from 3 to 7 days C. more than 7 days D. more than 14 days 25. Which of the following is not a parameter in the modified clinical pulmonary infection score (CPIS)? A. Tracheal secretions and presence of microbes B. Electrolytes and arterial blood gases

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26. Strategies for prevention of VAP include elevation of head of bed and changing of the ventilator circuit .

27. An endotracheal tube with a separate dorsal lumen above the cuff is designed to: A. remove subglottic secretions. B. facilitate endotracheal suctioning. C. provide oxygenation. D. irrigate the endotracheal tube. 28. Given: CPP = MAP – ICP. [Cerebral perfusion pressure (CPP), Mean arterial pressure (MAP), Intracranial pressure (ICP).] An increase in intracranial pressure can the cerebral perfusion pressure. In turn, a significant in CPP may lead to hypoxemia and hypoxic ischemic encephalopathy (HIE). A. raise; increase B. raise; decrease C. reduce; increase D. reduce; decrease 29. Which of the following is least likely a sign of mild cerebral oxygen deprivation? A. Slow to perform familiar task B. Slow to make decision

C. Chest X-ray infiltrates and PaO2/FIO2

C. Lack of appetite

D. Body temperature and leukocytes count

D. Diminished alertness

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86 SECTION 1

Test Questions

30. The critical threshold for cerebral perfusion pressure (CPP) is from , and the mortality rate increases when the CPP is than this range. A. 70 to 80 mm Hg; higher B. 70 to 80 mm Hg; lower C. 90 to 100 mm Hg; higher D. 90 to 100 mm Hg; lower 31. Following a successful resuscitation, severe hypotension should be managed by using: A. vasodilators. B. fluid. C. beta agonists. D. oxygen. 32. Given: CPP = MAP – ICP. The CPP may become inadequate when the MAP is too or when the ICP is too . A. high; high B. high; low C. low; high D. low; low 33. To maintain an adequate cerebral perfusion pressure (CPP), the intracranial the pressure (ICP) should be kept clinical threshold of . A. above; 10 mm Hg B. above; 20 mm Hg C. below; 10 mm Hg D. below; 20 mm Hg 34. To maintain an adequate cerebral perfusion pressure (CPP), the systolic blood the clinipressure should be kept cal threshold of .

35. Which of the following is not a cause of traumatic brain injury (TBI)? A. Cerebral edema B. Bomb blasts C. Motor vehicle crashes D. Sports-related injuries 36. In traumatic brain injury, the resulting cerebral edema can lead to significant volume expansion within a rigid skull. In turn, it will cause the intracranial presand the cerebral sure (ICP) to perfusion pressure and cerebral perfusion to . A. increase; increase B. increase; decrease C. decrease; increase D. decrease; decrease 37. A patient has an intracranial pressure (ICP) of 18 mm Hg following a motor vehicle crash. This value is outside the norbut within the mal ICP range of clinical normal of . A. 8 to 12 mm Hg; 20 mm Hg B. 8 to 12 mm Hg; 30 mm Hg C. 10 to 16 mm Hg; 20 mm Hg D. 10 to 16 mm Hg; 30 mm Hg 38. Most traumatic brain injuries occur because the: A. cerebral perfusion is reduced. B. brain makes a sudden impact with the skull. C. skull is fractured. D. fluid is accumulated within the skull.

A. above; 90 mm Hg B. above; 110 mm Hg C. below; 90 mm Hg D. below; 110 mm Hg

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CHAPTER 15 Critical Care Issues in Mechanical Ventilation 87

39. A severe blow to the skull is an example of (acceleration , deceleration) brain injury, and the skull falling on concrete is an example of (acceleration, deceleration ) brain injury. A. acceleration; acceleration B. acceleration; deceleration C. deceleration; acceleration D. deceleration; deceleration 40. Following brain herniation, brain injury can occur when the brain: A. passes through the dural openings. B. accumulates blood and fluid. C. leaks blood and fluid. D. makes contact with the prominent edges of the dural openings. 41. A patient has a diagnosis of severe brain injury. The associated Glasgow coma scale (GCS) would be within the range of:

42. Which of the following is not used to score a patient using the Glasgow coma scale? A. Eye opening B. Motor response C. Vital signs D. Verbal response 43. The physician asks a therapist to manage the ventilator settings for a newly admitted patient suffering from traumatic brain injury and increased intracranial pressure. The therapist should titrate the PaCO2 to a level as low as during the first of mechanical ventilation. A. 18 torr; 24 hours B. 18 torr; 48 hours C. 26 torr; 24 hours D. 26 torr; 48 hours

A. 3 to 8. B. 6 to 10. C. 10 to 12. D. 13 to 14.

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CHAPTER 16

Weaning from Mechanical Ventilation

1. Most patients who are using mechanical ventilation for can have the ventilator discontinued without delay. A. postanesthesia recovery

4. Weaning failure is defined as: A. failure of spontaneous breathing trial (SBT).

B. COPD

B. reintubation of patient within 48 hours following extubation.

C. neuromuscular disease

C. respiratory acidosis and hypotension.

D. traumatic head injury

D. A and B only.

2. Weaning success may be defined as effective spontaneous breathing without any mechanical assistance for a period following extubation. of A. 1 hour B. 8 hours C. 16 hours D. 48 hours 3. Weaning in progress is a category of weanand ing in which the patients are receiving ventilatory support by . A. intubated; noninvasive ventilation (NIV)

5. A therapist is assessing a patient in the intensive care unit who has been taken off the ventilator 1 hour ago. His current vital signs are: HR = 166/min, f = 42/min, BP = 90/52 mm Hg. The patient has diaphoresis and arterial blood gases show mild respiratory acidosis with an arterial saturation of 90%. The therapist should recommend which of the following? A. Continue the weaning process. B. Recommend a sedative. C. Resume mechanical ventilation. D. Begin CPAP.

B. intubated; continuous positive airway pressure (CPAP)

6. Before weaning from mechanical ventilation is considered, the patient should be:

C. extubated; noninvasive ventilation (NIV)

A. sufficiently recovered from ventilatory failure.

D. extubated; continuous positive airway pressure (CPAP)

B. able to assume spontaneous breathing. C. using an FIO2 of 30% or less. D. A and B only.

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CHAPTER 16 Weaning from Mechanical Ventilation 89

7. A therapist is being asked to assess the patient and determine whether he is a good candidate for weaning. His ventilator settings are: SIMV 10/min, FIO2 40%, VT 650 mL. The following information is gathered by the therapist: minute ventilation 8L/min, maximum inspiratory pressure −35 cm H2O, PaO2/FIO2 index 350 mm Hg, PaCO2 48 mm Hg, pH = 7.35. Based on the weaning criteria, the therapist should recommend: A. beginning the weaning process. B. continuing mechanical support and increase the FIO2. C. continuing mechanical support and increase the mechanical frequency. D. replacing mechanical ventilation with CPAP. 8. Mr. Johnson, a patient who is being evaluated for weaning attempt, has the following measurements: vital capacity 12 mL/kg, maximum inspiratory pressure −35 cm H2O in 20 sec, spontaneous frequency 46/min, minute ventilation 8 L/min with satisfactory blood gases. After careful evaluation of the patient and data, which of these measurements does not meet the weaning criteria for an adult patient? A. Vital capacity B. Maximum inspiratory pressure C. Spontaneous frequency D. Minute ventilation 9. Mr. Rasmus, a COPD patient, has been using a T-piece after being taken off mechanical ventilation. For patients with COPD, the therapist should guide the weaning process using the patient’s baseline blood gases or a PaCO2 of mm Hg and a pH near . A. 30 mm Hg; 7.40 B. 50 mm Hg; 7.35 C. 60 mm Hg; 7.30 D. 60 mm Hg; 7.50

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10. A therapist is getting ready to measure the weaning parameters of a patient who has been mechanically ventilated for two weeks. Coaching, patient effort, and cooperation are needed to obtain which of the following weaning parameters? A. Tidal volume and minute ventilation B. PaO2/FIO2 index and vital capacity C. Spontaneous frequency and spontaneous tidal volume D. Vital capacity and maximal inspiratory pressure 11. A patient is being ventilated at an SIMV frequency of 10/min. Over a 2-hour period, the total frequency has increased from 16/min to 24/min. This observation may be an indication of: A. decreased airway resistance. B. increased compliance. C. increased work of breathing. D. all of the above. 12. A therapist is performing weaning parameters on a postsurgical patient. All parameters are within normal limits with the exception of an increased minute volume (15 L). This condition may be caused by: A. excessive carbon dioxide production. B. increase in alveolar deadspace. C. metabolic acidosis. D. all of the above. 13. A breathing pattern that is rapid and shal. The normal rapid low increases shallow breathing index (RSBI) is . A. intrapulmonary shunting; <100 breaths/ min/L B. intrapulmonary shunting; >100 breaths/ min/L C. deadspace ventilation; <100 breaths/ min/L D. deadspace ventilation; >100 breaths/ min/L

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90 SECTION 1

Test Questions

14. A physician asks the therapist to evaluate her patient’s oxygenation weaning criterion. Based on this criterion, the therapist should recommend the weaning attempt to begin when the PaO2 is greater than at an FIO2 of or less.

18. The acceptable P(A-a)O2 for a 60-yearold patient breathing room air should be or less. A. 24 mm Hg B. 34 mm Hg

A. 50 mm Hg; 0.5

C. 44 mm Hg

B. 50 mm Hg; 0.6

D. 54 mm Hg

C. 60 mm Hg; 0.4 D. 60 mm Hg; 0.5 15. A low P/F (PaO2/FIO2) index (e.g., 150 mm Hg) means that the patient has a PaO2 while inspiring a FIO2.

19. In mechanical ventilation, P(A-a)O2 of less than while on 100% oxygen suggests a likelihood of weaning . A. 350 mm Hg; failure B. 450 mm Hg; failure

A. high; high

C. 350 mm Hg; success

B. high; low

D. 450 mm Hg; success

C. low; high D. low; low 16. When P/F (PaO2/FIO2) index is used as one of the predictors for weaning success, the P/F index should be: A. ≥150 mm Hg. B. ≤150 mm Hg. C. ≥60%. D. ≤80%. 17. For a successful weaning outcome, the physiologic shunt (QS/QT) should be less than . In order to calculate the QS/QT, the therapist should obtain the measurements. A. 20%; CcO2, CaO2, and CvO2 B. 20%; PaCO2 and PECO2 C. 30%; CcO2, CvO2, and PaO2 D. 30%; CcO2, CaO2, CvO2, and SaO2

20. Dr. Wentworth asks a therapist to evaluate his patient’s pulmonary reserve for weaning determination. The therapist should assess the patient and measure his: A. vital capacity. B. maximum inspiratory pressure. C. spontaneous tidal volume. D. A and B only. 21. A therapist is assessing Ms. Serbine, a patient with myasthenia gravis. Her best maximal inspiratory pressure (MIP) measurement is –35 cm H2O. Based on this criterion and other information, the therapist should: A. defer weaning until MIP reaches 40 cm H2O. B. defer weaning until MIP reaches 50 cm H2O. C. defer weaning until MIP reaches 60 cm H2O. D. begin the weaning process.

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CHAPTER 16 Weaning from Mechanical Ventilation 91

22. The therapist is performing a static compliance study on a 48-year-old patient who is being evaluated for weaning from mechanical ventilation. The following data are obtained: Corrected tidal volume 700 mL

25. A patient who is being mechanically ventilated has the following data: PaCO2 55 mm Hg, PaO2 65 mm Hg, PECO2 35 mm Hg. What is the patient’s physiologic deadspace percent? A. 22% B. 30%

Peak inspiratory pressure 58 cm H2O

C. 36%

Plateau pressure 45 cm H2O

D. 63%

PEEP 10 cm H2O The calculated static compliance of indicates that the patient meet this weaning criterion. A. 20 mL/cm H2O; does B. 20 mL/cm H2O; does not C. 70 mL/cm H2O; does D. 70 mL/cm H2O; does not 23. Among other weaning criteria, weaning from mechanical ventilation is more likely to be successful when the static compliance is or . A. 10 mL/cm H2O; higher B. 10 mL/cm H2O; lower C. 30 mL/cm H2O; higher D. 30 mL/cm H2O; low 24. A therapist is making rounds in the ICU and the physician asks her to obtain a patient’s physiologic deadspace. The therapist should obtain the patient’s: A. PaCO2 and PECO2. B. PaO2 and PECO2. C. PaCO2 and PECO2. D. CcO2 and CaO2.

26. Mr. Baxter’s respiratory parameters during mechanical ventilation are: minute ventilation 6 L, spontaneous respiratory frequency 20/min. The calculated rapid shallow breathing index (RSBI or f/VT) is about and it indicates weaning . A. 7 breaths/min/L; success B. 67 breaths/min/L; success C. 7 breaths/min/L; failure D. 67 breaths/min/L; failure 27. Which of the following is not true in regard to using the spontaneous breathing trial (SBT) for weaning from mechanical ventilation? A. T-tube, CPAP, or automatic tube compensation may be used during SBT. B. Low-level pressure support may be used during SBT. C. SBT should continue for up to 60 minutes. D. SVT may be done to pediatric patients. 28. Which of the following criteria or thresholds is a contributing factor to SBT failure? A. Spontaneous frequency increase by 20% from baseline B. Systolic blood pressure <100 mm Hg C. An increase in PaCO2 of more than 8 mm Hg from baseline D. f/VT less than 100 breaths/min/L

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92 SECTION 1

Test Questions

29. Synchronized intermittent mandatory ventilation (SIMV) should be used as a modality to: A. provide weaning. B. provide partial ventilatory support. C. augment the minute ventilation. D. all of the above. 30. A patient is on mechanical ventilation and the physician wants to begin the weaning process using pressure support ventilation as part of the weaning strategy. The therapist should titrate the PSV level by gradually increasing the PSV level until the spontaneous tidal volume is or the spontaneous respiratory frequency is . A. 5 to 9 mL/kg; less than 25/min B. 5 to 9 mL/kg; more than 25/min C. 10 to 15 mL/kg; less than 25/min D. 10 to 15 mL/kg; more than 25/min 31. When pressure support ventilation (PSV) is used for weaning, the maximal pressure should be limited to: A. 30 cm H2O. B. 40 cm H2O.

33.

is a mode of ventilation that “guarantees” a stable preset tidal volume by incorporating inspiratory pressure support ventilation with conventional volume-assisted cycles. A. Volume support (VS) B. Volume-assured pressure support (VAPS) C. Mandatory minute ventilation (MMV) D. Airway pressure-release ventilation (APRV)

34. A typical weaning protocol for mechanical ventilation consists of all of the following elements except the: A. detailed cost breakdown. B. patient condition in which weaning may be attempted. C. detailed process of weaning. D. evaluation of weaning outcomes. 35. Ms. Smith, a 50-kg patient being considered for weaning attempt, has the following measurements: pH 7.36, heart rate 100/min, frequency/tidal volume (f/VT) index 145 cycles/L, tidal volume 350 mL. Which of the values above reflects a likelihood of weaning failure for Ms. Smith?

C. 50 cm H2O.

A. pH

D. 60 cm H2O.

B. Heart rate

32. Automatic Tube Compensation (ATC) is a ventilator option that reduces the of the artificial airway. A. length B. diameter C. airflow resistance D. All of the above

C. Frequency/tidal volume (f/VT) index D. Tidal volume 36. The most common cause of weaning failure include all of the following except: A. respiratory muscle fatigue. B. low compliance. C. high airflow resistance. D. duration of spontaneous breathing trial.

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CHAPTER 16 Weaning from Mechanical Ventilation 93

37. All of the following conditions cause a decreased static compliance except: A. bronchospasm. B. atelectasis. C. ARDS. D. obesity.

38. Terminal weaning is defined as withsupport, which results drawal of in the of a person. A. nutritional; vegetative state B. intensive care; vegetative state C. pressure; death D. ventilatory; death

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CHAPTER 17

Neonatal Mechanical Ventilation

1. Indications for intubating a newborn may include all of the following except: A. inadequate bag mask ventilation. B. administration of epinephrine or surfactant. C. initiation of nasal CPCP. D. low heart rate during chest compressions. 2. A neonate has the following signs and readings 1 min after birth: heart rate of 80/min, no respiratory effort, some flexion of extremities, grimace response to stimulation, blue limbs and pink body. The Apgar score is: A. 3. B. 4. C. 5. D. 6. while the 3. Resuscitation should Apgar scoring is being assessed, and scoring should continue every 5 min up to 20 min if the score is less than . A. stop; 5 B. stop; 7 C. continue; 5 D. continue; 7

4. A therapist is asked to intubate a 3,500-gm neonate. The appropriate supplies inlaryngoscope blade clude a size and a size , endotracheal (ET) tube. A. 0; 3; cuffed B. 0; 4; uncuffed C. 1; 3; cuffed D. 1; 4; uncuffed 5. The delivery room physician asks a therapist to intubate a 800-gm neonate. Since the therapist is busy suctioning and providing bag/mask ventilation, the therapist should ask a nurse to obtain a size blade and a size endotracheal tube. A. 00; 2.5 B. 00; 3.0 C. 1; 3.0 D. 1; 4.0 6. If the neonatal endotracheal tube has a vocal cord marking, it should be guided visually until the marking is: A. at the tonsil area. B. about 1 cm above the vocal cords. C. at or slightly below the vocal cords. D. 1 to 2 cm below the vocal cords.

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CHAPTER 17 Neonatal Mechanical Ventilation 95

7. When the vocal cord marking is not available on the ET tube, a useful rule to esti mate the initial depth of intubation (cm marking at the lips) is to: A. add 3 to the infant’s weight in kilograms. B. add 6 to the infant’s weight in kilograms. C. add 5 to the infant’s height in feet. D. add 8 to the infant’s height in feet. 8. Prophylactic use of surfactant is indicated for all of the following neonatal conditions except: A. at risk of RDS.

11. In regards to administration and use of surfactant, A. synthetic surfactant is more effective than natural surfactant. B. surfactants are administered endotracheally. C. therapeutic and rescue dosages are the same. D. A and B only. 12. A full-term neonate has the following umbilical artery blood gases: pH 7.42, PCO2 36 mm Hg, PO2 50 mm Hg, FIO2 60% via oxyhood. Mild cyanosis is noted. The therapist should proceed with:

B. at or less than 26 week gestation.

A. increasing the FIO2 to 70%.

C. PaO2/PAO2 <0.22.

B. intubation and heat aerosol on 60% FIO2.

D. less than 2,000 g birth weight. 9. Therapeutic (rescue) use of surfactant is indicated in neonates with all of the foll owing signs except: A. nasal flaring.

C. intubation and mechanical ventilation. D. nasal continuous positive airway pressure on 60% FIO2.

B. grunting.

13. In regards to nasal continuous positive airway pressure (N-CPAP) therapy,

C. retraction.

A. N-CPAP is provided by a ventilator.

D. apnea.

B. the initial CPAP level should be 2 to 3 cm H2O.

10. Surfactants may be manufactured by all of the following methods except: A. chemical synthesis. B. extraction from bovine (cow) lung tissues. C. extraction from stem cells. D. extraction from porcine (pig) lung tissues.

C. N-CPAP is used to provide ventilation and oxygenation. D. N-CPAP devices do not need supplemental humidification. 14. In pressure-controlled ventilation, a preis used to deliver the tidal volset ume, and the delivered is variable in conditions of changing compliance or airflow resistance. A. volume; volume B. volume; pressure C. pressure; pressure D. pressure; volume

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96 SECTION 1

Test Questions

15. In volume-controlled ventilation, a preset is used to deliver the tidal volume, and the delivered is variable in conditions of changing compliance or airflow resistance. A. volume; volume B. volume; pressure C. pressure; pressure D. pressure; volume 16. A positive response to surfactant replacement would lead to a sudden in lung compliance and of the lungs, unless the pressure is reduced immediately.

19. As a therapist is doing routine ventilator check in the NICU, she notices that the inspired gas temperature at the proximal airway adaptor is 34°C. The therapist should: A. document the temperature in the chart. B. increase the temperature to a range between 34°C and 37°C and document. C. decrease the temperature to a range between 27°C and 30°C and document. D. change the temperature probe. 20. Hazards and complications associated with “rain-out” in the ventilator circuit include all of the following except:

A. increase; overinflation

A. nosocomial infection.

B. increase; atelectasis

B. increased lung compliance.

C. decrease; overinflation

C. aspiration of water into lungs.

D. decrease; atelectasis

D. increased airflow resistance.

17. In volume-controlled ventilation, the initial tidal volume for neonates is typically set at: A. 2 mL/kg. B. 5 mL/kg. C. 12 mL/kg. D. 20 mL/kg. 18. Baby Johnson, a 28-week-gestation neonate, is being ventilated by a mechanical ventilator without a separate frequency control. Which of the following ventilator controls has the least direct influence on the ventilator frequency? A. FIO2 control B. Peak flow C. Inspiratory time D. I:E ratio

21. A neonate has been admitted to the NICU for acute respiratory distress. As a therapist is setting up the ventilator, the other RCP states that the baby is “hard to bag.” Based on this information, the initial peak inspiratory pressure (PIP) on the ventilator should be set from: A. 5 to 10 cm H2O. B. 10 to 20 cm H2O. C. 20 to 40 cm H2O. D. 40 to 60 cm H2O. 22. A therapist receives an order to initiate mechanical ventilation for Baby Nix, a 32-week-gestation neonate transferred to NICU following delivery. Since the therapist has not evaluated the lung compliance, the therapist should initiate mechanical ventilation with an approximate tidal volume range of: A. 3 to 7 mL/kg. B. 10 to 15 mL/kg. C. 16 to 20 mL/kg. D. 25 to 40 mL/kg.

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CHAPTER 17 Neonatal Mechanical Ventilation 97

23. A neonate who is being mechanically ventilated has the following ventilator settings: inspiratory time 0.4 sec, inspiratory flow rate 6 L/min, FIO2 35%, peak inspiratory pressure 15 cm H2O. Calculate the approximate tidal volume delivered by the ventilator. A. 30 mL B. 40 mL C. 50 mL D. 60 mL 24. A medical resident asks the therapist to differentiate the values between a capillary blood sample and an arterial sample. The therapist should explain that the blood gas values obtained from a capillary sample are comparable to that obtained from an arterial sample with the exception of: A. PCO2. B. PO2. C. pH. D. HCO3−. 25. Baby Brown, a neonate in the NICU, has the following blood gas values obtained from the umbilical artery: pH 7.34, PaCO2 44 mm Hg, PaO2 56 mm Hg, FIO2 21%. This blood gas report shows:

27. Newborns with restrictive lung disease, persistent pulmonary hypertension, and air leaks would most likely benefit from what form of high frequency ventilation? A. High frequency positive pressure ventilation B. High frequency jet ventilation C. High frequency oscillatory ventilation D. All of the above 28. While assessing a newborn who is being ventilated by HFJV, a therapist notices that the chest wall is not rising fully and the limbs appear cyanotic. These signs may be caused by all of the following except: A. circuit disconnect. B. pneumothorax. C. decreased lung compliance. D. hypovolemic shock. 29. Dr. Coles wants to initiate high frequency ventilation for a neonate with a ventilator that can assist ventilation during inspiratory and expiratory phases. The therapist should recommend a ventilator that provides: A. high frequency positive pressure ventilation. B. high frequency jet ventilation.

A. respiratory acidosis.

C. high frequency oscillatory ventilation.

B. hypoxemia.

D. any of the above.

C. all values are within normal limits. D. A and B only. 26. The physician has ordered high frequency positive pressure ventilation (HFPPV) for a neonate who remains hypoxic in spite of conventional mechanical ventilation. HFPPV is a mode of ventilation that delivers a frequency range of: A. 40 to 60 cycles/min. B. 60 to 150 cycles/min. C. 120 to 200 cycles/min.

30. During high frequency jet ventilation (HFJV) or high frequency oscillatory ventilation (HFOV), a therapist finds it difficult to assess a patient’s cardiopulmonary status. To safeguard the patient from unexpected deterioration, the therapist should evaluate the patient and rely on the following signs of deterioration except: A. respiratory distress. B. tachypnea. C. hypotension. D. pallor.

D. 240 to 660 cycles/min.

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98 SECTION 1

Test Questions

31. When high frequency oscillatory ventilation (HFOV) is used to support neonates with diffuse alveolar disease (e.g., hyaline membrane disease), the initial mean airway pressure (mPaw) should be maintained at than the mPaw during conventional ventilation.

35. In HFOV, the initial power setting (amplitude of oscillation) for neonatal use increments should be titrated at until is observed. A. 1 cm H2O; toe wiggle B. 1 cm H2O; chest wiggle

A. 3 to 4 cm H2O higher

C. 2 to 4 cm H2O; toe wiggle

B. 3 to 4 cm H2O lower

D. 2 to 4 cm H2O; chest wiggle

C. 6 to 8 cm H2O higher D. 6 to 8 cm H2O lower 32. When high frequency oscillatory ventilation (HFOV) is used to support neonates with nonhomogeneous lung disease (e.g., meconium aspiration syndrome) or air leak, the initial mean airway pressure (mPaw) should be maintained at than the mPaw during conventional ventilation. A. the same or lower B. the same or higher C. 10 cm H2O higher D. 10 cm H2O lower 33. Oxygenation of a neonate during HFOV is mainly affected by the FIO2 and settings. A. bias flow

36. Chest wiggle during neonatal HFOV is defined as observable chest movement down to the: A. fourth rib or nipples. B. sixth rib or 2 inches below nipples. C. eighth rib or umbilicus. D. upper thighs. 37. A higher frequency (Hz) setting in HFOV produces a: A. larger delivered volume. B. lower delivered volume. C. higher bias flow. D. lower bias flow. 38. In HFOV, the initial frequency (Hz) setting for neonatal use should be for neonates <1,000 g and >2,000 g.

B. PEEP

A. 12.5 to 15 Hz; 8 to 10 Hz

C. inspiratory time %

B. 15 to 30 Hz; 10 to 12 Hz

D. mean airway pressure

C. 8 to 10 Hz; 15 to 12.5 Hz

34. When high frequency oscillatory ventilation (HFOV) is used to support neonates, the initial bias flow should be for body weight >2,000 g and <2,000 g.

D. 10 to 12 Hz; 30 to 15 Hz 39. In HFOV, the inspiratory time % for neonatal use should be: A. 15%.

A. 10 L/min; 4 to 8 L/min

B. 25%.

B. 20 L/min; 10 to 15 L/min

C. 33%.

C. 4 to 8 L/min; 10 L/min

D. 50%

D. 10 to 15 L/min; 20 L/min

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CHAPTER 17 Neonatal Mechanical Ventilation 99

40. In HFOV, the initial FIO2 setting for neonatal use should be: A. 21%. B. 40%. C. no higher than 60%. D. 100%. 41. Following stabilization of the neonate, the FIO2 setting on HFOV should be:

44. A therapist receives an order to initiate extracorporeal membrane oxygenation (ECMO) on a neonate who has a gestational age of 30 weeks and weighs 1,800 g. After assessing the patient, the therapist should call and explain to the physician that due to the patient’s gestational age and body weight, the risk of is high. A. heparin-induced intracranial bleed

A. weaned to 21% within 24 hours.

B. barotrauma

B. weaned to 40% within 24 hours.

C. air leak

C. titrated to keep SpO2 between 90% to 95%.

D. hypervolemia

D. titrated to keep SpO2 between 95% to 100%. 42. With the Machine Volume mode in the AVEA ventilator, the clinician sets the: A. peak inspiratory pressure and inspiratory time. B. peak inspiratory pressure and inspiratory flow.

45. Extracorporeal membrane oxygenation (ECMO) therapy should be considered only when the patient has a(n) percent mortality rate using conventional ventilator management strategies. Furthermore, patients who have used conventional mechanical ventilators for or more are not candidates for ECMO. A. 40; 1 week

C. target tidal volume and inspiratory pressure.

B. 40; 2 weeks

D. target tidal volume and inspiratory time.

D. 80; 2 weeks

43. With the Volume Guarantee mode in the Babylog 8000 plus ventilator, the clinician sets the: A. tidal volume and peak inspiratory pressure. B. tidal volume and inspiratory time. C. peak inspiratory pressure and inspiratory time. D. peak inspiratory pressure and inspiratory flow.

C. 80; 1 week

46. The following data are obtained from a neonate who has moderate amount of meconium stain: PAO2 670 mm Hg, FIO2 100%, PaO2 60 mm Hg, duration of PaO2 at or below 60 mm Hg 6 hours. The calculated alveolar-arterial oxygen tension gradient [(A-a)DO2] is , and the patient from extracorporeal membrane oxygenation (ECMO) therapy. A. 60; should benefit B. 610; should benefit C. 60; would not benefit D. 610; would not benefit

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100 SECTION 1

Test Questions

47. In the venoarterial route of ECMO bypass, blood is drawn from the right atrium via the , and the oxygenated blood is returned to the aortic arch via the .

49. Which of the following is not a functional unit of the ECMO system? A. Venous blood drainage reservoir B. Blood pump

A. femoral vein; femoral artery

C. Blood warming device

B. subclavian vein; right common carotid artery

D. Membrane oxygenator

C. internal jugular vein; right common carotid artery D. right atrium; coronary artery 48. The most common circulatory route used route because it for ECMO is the supports the neonate’s function.

50. In the venovenous route, blood is removed from the right atrium via a catheter inand returned serted in the right to the right atrium through a catheter inserted via the . A. internal jugular vein; carotid artery B. internal jugular vein; femoral vein

A. venoarterial; cardiac

C. femoral vein; internal jugular vein

B. venovenous; cardiac

D. external jugular vein; femoral vein

C. arteriovenous; pulmonary D. arterioarterial; pulmonary

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CHAPTER 18

Mechanical Ventilation in Nontraditional Settings

1. Which of the following is not an advantage of providing mechanical ventilation at home? A. Availability of personal care provided by family members B. Improvement of patient’s physical and physiologic functions C. Enhancement of patient’s quality of life D. Reduction of health care cost 2. The health care team for a mechanically ventilated patient should consist of all of the following except:

4. Prior to discharge from the hospital, family members of the mechanically ventilated patient should learn how to: A. perform physical assessment. B. perform endotracheal suctioning. C. change ventilator circuit. D. troubleshoot common ventilator alarms. 5. “Acute ventilatory failure superimposed on chronic ventilatory failure” best describes a mechanically ventilated patient with a history of:

A. nurse.

A. traumatic brain injury.

B. durable medical equipment company.

B. chest trauma.

C. respiratory therapist.

C. COPD.

D. insurance company.

D. neuromuscular disease.

3. The most important element for a successful home mechanical ventilation program is the: A. private room for patient. B. home care team members. C. medical insurance policy. D. equipment and supplies.

6. Which of the following blood gas reports shows acute exacerbation of COPD? A. pH = 7.38, PaCO2 = 46 mm Hg, PaO2 = 75 mm Hg, HCO3− = 26 mEq/L B. pH = 7.36, PaCO2 = 55 mm Hg, PaO2 = 50 mm Hg, HCO3− = 30 mEq/L C. pH = 7.20, PaCO2 = 42 mm Hg, PaO2 = 43 mm Hg, HCO3− = 16 mEq/L D. pH = 7.27, PaCO2 = 74 mm Hg, PaO2 = 43 mm Hg, HCO3− = 33 mEq/L 101

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102 SECTION 1

Test Questions

7. A spontaneously breathing patient has the following respiratory parameters: average VT 200 mL, f 48/min, FIO2 2 L/min oxygen per nasal cannula. This breathing pattern usually leads to a(n): A. increased intrapulmonary shunting. B. decreased intrapulmonary shunting. C. increased deadspace ventilation. D. decreased deadspace ventilation. 8. A significant reduction in lung volume/ capacity is the hallmark of: A. obstructive sleep apnea. B. central sleep apnea. C. obstructive lung disease. D. restrictive lung disease. 9. Mechanical ventilation is indicated for patients with:

11. In selecting potential candidates for a plan of mechanical ventilation at home, the: A. therapist does not have to discuss this plan with the patient. B. patient does not have to consent to this plan. C. patient should be told about the advantages and disadvantages of this plan. D. therapist should go over this plan with the patient during an RT procedure. 12. For patients with frequent apnea or inadequate spontaneous ventilation, the therapist should select the following for mechanical ventilation at home: A. chest cuirass. B. positive pressure ventilator.

A. apnea.

C. diaphragmatic pacing.

B. hypoxemia.

D. negative pressure ventilator.

C. acidosis. D. spinal cord injury. 10. The physician asks a therapist to evaluate her mechanically ventilated patient for possible discharge from hospital to home. Which of the following would be considered high risk by discharging the patient with a home ventilator? A. Desaturation during suctioning B. Hypoxemia

13. Mass casualty is defined as an event that or results in a large number of deaths that a timely response from regional support centers. A. injured; exceeds B. injured; requires C. severely injured; exceeds D. severely injured; requires 14. A mass casualty incident may be caused by:

C. Ventricular arrhythmias

A. man-made events.

D. Triggering of high pressure alarm

B. natural events. C. terrorisms. D. all of the above.

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CHAPTER 18 Mechanical Ventilation in Nontraditional Settings 103

15. Nerve agents are that lead to an accumulation of acetylcholine at the muscarinic and nicotinic receptors throughout the body. A of acetylcholine may quickly induce loss of consciousness, seizures, flaccid paralysis, and apnea. A. acetylcholinesterase agents; sudden surge B. acetylcholinesterase agents; gradual build up C. acetylcholinesterase inhibitors; sudden surge D. acetylcholinesterase; gradual build up 16. The H1N1 flu outbreaks in 2009 showed a much lower mortality rate than the Spanish Flu because of: A. improved knowledge about the flu. B. enhanced isolation technique. C. improved vaccines. D. A and B only. 17. If a 1958/68-like pandemic were to happen today in the U.S., A. mechanical ventilation would be needed for many patients. B. ventilators in the stockpile program should be sufficient. C. mechanical ventilators would not be needed. D. ventilators available in the hospitals should be sufficient. is a simple triage and rapid treat18. ment algorithm for adult admission to the hospital.

19. The START triage and treatment algorithm assesses a patient by using the following three parameters: A. respirations, perfusion, and mental status. B. blood pressure, respiration, and arterial PO2. C. perfusion, heart rate, and blood gases. D. arterial PO2, mean arterial pressure, and mental status. 20. The SALT triage system stands for: A. Save, Assign, Lift to aircraft, Treatment/Transport. B. Save, Assess, Lift to aircraft, Transport. C. Sort, Assign, Leave for hospital, Treatment. D. Sort, Assess, Life-saving interventions, Treatment/Transport. 21. A team of health care providers is providing life-saving intervention (LSI) of the SALT triage system to care for victims of a natural disaster. Which of the following is not done as a part of LSI? A. Open airway B. Control major hemorrhage C. Perform chest compression D. Administer intravenous fluid 22. The physician is using the SOFA score to assess the patient’s health status. Which of the following is not true in regard to SOFA?

A. JumpSTART; before

A. SOFA consists of 6 criteria.

B. START; before

B. SOFA is done prior to admission to a health care facility.

C. SALT; after D. SOFA; after

C. SOFA score is used to predict the outcomes of critically ill patients. D. SOFA stands for Sequential Organ Failure Assessment.

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104 SECTION 1

Test Questions

23. The respiratory parameter of the SOFA score uses for patient assessment and evaluation. A. PaO2/FIO2 B. PaO2 C. P(A-a)O2 D. CaO2 24. A SOFA score of 4 is assigned to the patient when the: A. PaO2/FIO2 is ≤100 mm Hg. B. PaO2 is ≤40 mm Hg. C. P(A-a)O2 is ≥350 mm Hg on FIO2 of 100%. D. CaO2 is ≤15 vol%. 25. A SOFA score of 12 calls for implemenbecause the patient is tation of likely to survive. A. critical care; most B. critical care; least C. palliation care; most D. palliation care; least calls for the 26. A SOFA score from highest priority of critical care because the patient is likely to survive.

be famil28. Respiratory therapists iar with the ventilators stockpiled by the Strategic National Stockpile (SNS) program because the ventilators are . A. should; commonly used by most hospitals B. should; simple portable ventilators C. may not; not commonly used by most hospitals D. may not; not available to the public 29. As of 2012, the stockpile of mechanical ventilators by the Strategic National Stockpile (SNS) program is being replaced with the: A. LTV 1200 and Newport HT50. B. Newport HT50 and Uni-Vent Eagle 754. C. LP-10 and LTV 1200. D. LP-10 and Uni-Vent Eagle 754. 30. Since there may not be enough ventilators for all victims of a mass casualty incidence, exclusion criteria become necessary. The exclusion criteria for ventilator access used by the New York State Department of Health (NYS DOH) clinical conditions are based on and on ethical or quality-of-life issues.

A. 10 to 8; most

A. subjective; rely

B. 10 to 8; least

B. subjective; do not rely

C. 6 to 2; most

C. objective; rely

D. 6 to 2; least

D. objective; do not rely

27. In 2006, the Strategic National Stockpile (SNS) program owned and maintained mechanical ventiapproximately lators. This number is for distribution to states affected by mass casualty.

31. Under the exclusion criteria for ventilator access, end-stage pulmonary failure is defined as: A. FVC <25%.

A. 6,000; adequate

B. FVC <45%.

B. 6,000; inadequate

C. FEV1 <25%.

C. 16,000; adequate

D. FEV1 <45%.

D. 16,000; inadequate

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CHAPTER 18 Mechanical Ventilation in Nontraditional Settings 105

32. Clinical use of hyperbaric oxygen (HBO) may include all of the following conditions except: A. decompression sickness. B. severe carbon monoxide poisoning. C. gas gangrene. D. aerobic infection. 33. Given: At an FIO2 of 21% (PaO2 100 mm Hg), the plasma carries about 0.3 vol% of the oxygen content. At one atomospheric pressure and an FIO2 of 100% (PaO2 = 673 mm Hg), the calculated dissolved oxygen . At three atmospheric is about pressures and an FIO2 of 100%, the calculated dissolved oxygen is about . A. 0.6 vol%; 1.8 vol% B. 1 vol%; 3 vol% C. 2 vol%; 6 vol% D. 3 vol%; 9 vol% 34. Since tissues require a minimum of 6 ml of oxygen per liter of blood flow to maintain at normal metabolism, an FIO2 of atmospheric pressure(s) should meet this demand. A. 100%; one B. 60%; three C. 100%; three D. 60%; ten 35. Decompression sickness occurs when a rapidly. Decompression of diver pressure causes the dissolved gases in blood to form gas bubbles, which can migrate to the . A. ascends to the water surface; joints and tissues B. ascends to the water surface; lungs C. descends into the water at great depth; joints and tissues D. descends into the water at great depth; lungs

39689_ch18_rev02.indd 105

36. In non-diving situations, decompression sickness can occur when a person: A. ascends rapidly from low altitude to high altitude over 18,000 ft. B. ascends rapidly from low altitude to high altitude over 10,000 ft. C. descends rapidly from high altitude to low altitude over 18,000 ft. D. descends rapidly from high altitude to low altitude over 10,000 ft. 37. Treatment for decompression sickness from diving or high-mountain adventure in a hyperbaric chamincludes . ber followed by A. decompression rapidly; recompression rapidly B. decompression rapidly; recompression gradually C. recompression rapidly; decompression rapidly D. recompression rapidly; decompression gradually , the patient may be treated 38. In with 100% inspired oxygen until the carboxyhemoglobin level is less than 5%. A. high-mountain decompression sickness B. mild to moderate carbon monoxide poisoning C. diving decompression sickness D. all of the above 39. In severe carbon monoxide poisoning, to carry oxygen the ability of becomes impaired. Hyperbaric oxygen (HBO) is the treatment of choice because HBO increases the oxygen content by increasing the oxygen . A. hemoglobin; dissolved in plasma B. hemoglobin; delivery C. plasma; combined with hemoglobin D. plasma; delivery

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106 SECTION 1

Test Questions

40. Hyperbaric oxygen (HBO) may be used to treat infections caused by Clostridium perfringens because it is an and its growth is hindered in a(n) environment. A. aerobic; high-pressure B. aerobic; oxygen-rich C. anaerobic; high-pressure D. anaerobic; oxygen-rich 41. When an endotracheal tube is used in the hyperbaric chamber, the cuff may . become overdistended during This condition may be averted by filling the cuff with .

44. The expired tidal volume of a ventilator in a hyperbaric chamber may be moniduring gas comprestored by a sion and decompression. A. mechanical respirometer B. mechanical peak flow meter C. electronic respirometer D. electronic peak flow meter 45. All of the following may be used or performed inside a multiplace hyperbaric chamber with the exception of: A. pulse oximeter. B. electronic blood pressure device.

A. compression; 70% Heliox

C. implanted cardiac pacemaker.

B. compression; water

D. intracranial pressure monitoring.

C. decompression; 70% Heliox D. decompression; water 42. Pressure-controlled ventilation (PCV) is preferred when mechanical ventilation is required in a multiplace hyperbaric chamber because PCV delivers a more stable tidal volume during: A. compression. B. decompression. C. ventilator check. D. compression and decompression. 43. During volume-controlled ventilation, dedecompression results in a livered tidal volume than the set tidal volume. This is due to during decompression. A. larger; gas expansion B. larger; gas contraction C. smaller; gas expansion D. smaller; gas contraction

46. For unacclimatized individuals, recent ascent to an altitude of 8,000 ft above sea level may cause headache and the following symptoms except: A. fatigue. B. insomnia. C. drowsiness. D. gastrointestinal disturbances. 47. Supplemental oxygen, acetazolamide (Diamox), and dexamethasone are some treatments for: A. high-altitude cerebral edema. B. acute pulmonary edema. C. high-altitude pulmonary edema. D. hypoxic brain syndrome. 48. A patient has been diagnosed with highaltitude pulmonary edema. The therapist should recommend the following procedures except: A. descending to lower altitude. B. initiating Heliox therapy. C. using portable hyperbaric chamber. D. administering Nifedipine.

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CHAPTER 18 Mechanical Ventilation in Nontraditional Settings 107

49. Most commercial airplanes travel at a cruising altitude between 25,000 ft and 40,000 ft and the airplane cabin pressure altitude ranges from . Airplanes fuel because of less dense air and lower airflow resistance at this cabin pressure altitude.

53. A mechanically ventilated patient is being transported in a commercial airplane. During ascent, the gas volume . and can lead to A. expands; hyperinflation B. expands; auto-PEEP

A. 0 ft to 1,000 ft; use more

C. contracts; atelectasis

B. 0 ft to 1,000 ft; save

D. contracts; acute lung injury

C. 5,000 ft to 8,000 ft; use more D. 5,000 ft to 8,000 ft; save 50. At a cabin pressure altitude of 8,000 ft, passengers of a commercial airplane may because experience high-altitude the PAO2 is about at this altitude. A. hypoxia; 59 mm Hg B. hypoxia; 100 mm Hg C. pulmonary edema; 59 mm Hg D. pulmonary edema; 100 mm Hg 51. A patient with a baseline SpO2 of 96% is concerned about flying in a commercial airplane. The therapist should assure the patient by informing her that supplemental oxygen would not be needed until the SpO2 reaches: A. 92%. B. 90%. C. 88%. D. 86%. 52. During mechanical ventilation at changing altitude, the measured tidal volume as the barometric and peak flow pressure (from low altitude to high altitude).

54. The therapist is asked to recommend a portable ventilator for a ventilatordependent patient travelling on a commercial airplane. The therapist should ventilator because recommend a it delivers a stable tidal volume, peak inspiratory flow, peak proximal airway pressure, and minute ventilation. A. volume-compensated B. pressure-compensated C. servo-controlled D. portable 55. The therapist is asked to provide information to a ventilator-dependent patient who will be travelling on a commercial airplane. In preparation of the trip, the therapist should ask the patient to do all of the following except: A. locate a destination home care company that provides portable ventilators. B. obtain physician’s written permission to travel with a portable ventilator. C. gather adequate battery packs and supplies for the portable ventilator. D. purchase an extra ticket for a seat adjacent to the traveler.

A. increase; increases B. increase; decreases C. decrease; increases D. decrease; decreases

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108 SECTION 1

Test Questions

56. During airplane with a nonpressure-compensated ventilator, the set tidal volume should be to prevent inadequate tidal volume. A. ascent; increased B. ascent; kept the same C. descent; increased D. descent; kept the same

57. When expired tidal volume monitoring is not available during a flight at changing altitude, the ventilator tidal volume by per 1,000 ft of may be ascent (from low to high altitude). A. increased; 50 mL B. increased; 3% C. decreased; 50 mL D. decreased; 3%

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SECTION 2 Answers to Test Questions

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CHAPTER 1

Principles of Mechanical Ventilation

1. D. hypoventilation; postanesthesia recovery 2. C. reduce temperature of inspired gas. 3. D. radius; 50%

16. A. higher; decreased cardiac output 17. D. 70% 18. C. Pulmonary embolism

4. A. Pulmonary embolism

19. C. Production of carbon dioxide is in excess of elimination.

5. B. deeper and slower

20. B. increasing; decreasing

6. C. postoperative sedation.

21. C. PaO2.

7. A. airway resistance.

22. B. 19

8. B. high; exhalation

23. A. epiglottitis.

9. A. static compliance.

24. C. hypoxia cannot occur with a normal PaO2.

10. B. bronchospasm reduces dynamic and static compliance.

25. D. anemic

11. B. 30 and 40 mL/cm H2O; airways

26. A. oxygenation failure.

12. B. 16 mL/cm H2O.

27. C. moderate hypoxemia.

13. D. 40 and 60 mL/cm H2O; lung parenchyma

28. C. provide oxygenation and minimize work of breathing.

14. D. 18 mL/cm H2O.

29. C. CcO2

15. A. anatomic; one

30. A. eucapnia.

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CHAPTER 2

Effects of Positive Pressure Ventilation

1. D. A and B only. (spontaneous breathing, negative pressure ventilation) 2. B. decreases. 3. C. equal to 4. C. positive pressure breathing. 5. A. increases. 6. A. trachea 7. B. breath sounds. 8. B. check for air leak. 9. D. variable; generally constant 10. D. the dampening effect of the noncompliant lungs results in less pressure transmitted to the thoracic cavity. 11. A. decreasing the respiratory frequency 12. D. increased contractility

16. B. increased; decreased 17. D. decreased; decreased 18. A. Increased pulmonary artery pressure 19. B. increased; decreased 20. A. volume expansion. 21. B. 25% 22. D. decreased; fluid retention 23. D. lower than normal; inadequate 24. D. bicarbonate. 25. D. All of the above. (Decreased GFR, Decreased renal tubular secretion, Increased reabsorption) 26. B. inversely; PEEP 27. C. hepatic

13. A. inspiratory flow rate.

28. C. compression of great vessels in the thorax.

14. B. 15% to 20%; pulmonary to systemic

29. C. excessive concentration of oxygen.

15. D. decreased; decreased

30. D. 10; higher

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Answers to Test Questions

31. C. intestinal.

35. B. pressure

32. C. High fat diet

36. D. All of the above (Oxygenation status, Ventilatory status, Acid/base status)

33. B. 24; head trauma 34. D. A and B only. (Leftward shift of oxyhemoglobin dissociation curve; Increased oxygen affinity for hemoglobin)

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CHAPTER 3

Classification of Mechanical Ventilators

1. D. all of the above (airflow resistance, lung compliance, chest wall compliance).

15. B. tidal volume.

2. B. volume; pressure

17. A. peak inspiratory pressure

3. D. A and B only (a gas source, an electric source).

18. C. volume-controlled and pressurecontrolled ventilation.

4. C. drive mechanism.

19. B. pressure-limited, time-cycled modes.

5. A. control circuit.

20. A. automatic tube compensation.

6. A. pressure

21. C. continuous positive airway pressure

7. D. volume

22. B. high pressure level drops to the low pressure level.

8. B. volume 9. C. control; time-triggered 10. D. patient’s inspiratory effort causing a slight negative pressure change. 11. A. drop in flow gradient in the ventilator circuit. 12. B. pressure-limited. 13. D. pressure-cycled. 14. D. baseline; end-expiration

16. A. peak inspiratory pressure

23. C. Rectangular, Exponential, Sinusoidal, Oscillating 24. B. Ascending ramp, Sinusoidal 25. C. Rectangular, Ascending ramp, Descending ramp, Sinusoidal 26. B. Ascending ramp 27. A. input power 28. B. Control circuit 29. C. output

113

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CHAPTER 4

Operating Modes of Mechanical Ventilation

1. A. transairway pressure.

16. D. IPAP = 8 cm H2O, EPAP = 4 cm H2O.

2. B. below atmospheric pressure.

17. B. IPAP to 8 cm H2O.

3. C. an endotracheal tube must be in place.

18. D. None of the above

4. D. peripheral vasculature is also affected by the negative pressures.

19. C. 5

5. A. maintaining an airtight seal around the chest wall. 6. C. Increase the peak inspiratory pressure. 7. D. The output variable is dependent on the changing characteristics of the patient. 8. C. sensitivity setting.

20. A. acquire a minute volume necessary to normalize the PaCO2. 21. B. reduces the likelihood of breath stacking. 22. C. increasing the mean airway pressure. 23. C. CMV; AC; SIMV. 24. C. mandatory minute ventilation (MMV)

9. B. PEEP; below

25. B. spontaneous tidal volume remains constant.

10. A. positive end-expiratory pressure.

26. A. increase in spontaneous frequency.

11. B. decreased intracranial pressure (ICP). 12. D. ARDS; low

27. D. All of the above (spontaneous tidal volume, spontaneous frequency, arterial blood gas results).

13. B. 10 cm H2O

28. A. spontaneous tidal volume of >10 mL/kg

14. D. continuous positive airway pressure (CPAP).

29. C. 100; 120%

15. C. PaCO2.

30. C. pressure support level and number of mandatory breaths

114

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CHAPTER 4 Operating Modes of Mechanical Ventilation 115

31. C. decreases; increases

41. B. tidal volume; variable flow

32. D. A and B only (volume and flow demand, elastance and airflow resistance characteristics).

42. C. target tidal volume and inspiratory time; flow

33. A. airflow resistance; elastance 34. A. high; overdistension

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43. C. decreases; larger 44. C. barotrauma; peak inspiratory pressure 45. B. mechanical expiration.

35. D. A and B only (inspiratory pressure support ventilation, volume-assisted ventilation)

46. C. high or low pressure level.

36. B. lower than the preset minimal tidal volume.

48. D. increase in cardiac output.

37. C. increase the inspiratory time

49. A. pressure-controlled ventilation

38. A. pressure-regulated volume control in Siemens 300 ventilator.

50. A. airflow resistance imposed by the artificial airway.

39. C. decreasing; increasing

51. D. diaphragm

40. D. PRVC; adult, pediatric, or neonatal

52. C. decreasing; increasing

47. C. biphasic PAP; APRV

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CHAPTER 5

Special Airways for Ventilation

1. C. unconscious; vomiting and aspiration

14. A. closed distal; open distal

2. A. 55; 120

15. B. absent; mask

3. D. A, B, or C (center of her mouth to the angle of the jaw, center of her central incisors to the angle of the jaw, corner of her mouth to the earlobe).

16. D. EGTA; ventilation

4. A. Nasal trauma 5. D. 6; 7 6. D. disposable; esophagus 7. C. leave the cuff inflated because the EOA is in the esophagus. 8. A. prevent gas leak around the patient’s face during ventilation. 9. B. provide ventilation to the lungs. 10. D. 20 to 30 11. A. II, IV, I, III (Inflate and test cuff, Deflate cuff, Lubricate tube with a water-soluble lubricant, Insert tube through opening of a mask) 12. C. The EOA should not be used in children under 16 years old or under 5 ft tall. 13. B. endotracheal intubation with the EOA in place.

17. B. patent; two 18. D. laryngeal opening; is not 19. B. 20; 30 20. D. unconscious; absent 21. B. high; low 22. B. 4; 5 23. D. 60; decrease 24. A. hard; posterior pharynx 25. B. silicone; steam autoclave 26. B. gastric insufflation. 27. D. two; esophagus or trachea 28. C. 100; 15 29. A. esophagus; esophagus 30. D. trachea; trachea 31. D. with or without; opposite the front teeth

116

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CHAPTER 5 Special Airways for Ventilation 117

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32. D. distal and proximal

37. C. right-sided; right upper lobe

33. A. esophagus; 1

38. A. bilateral lung ventilation.

34. D. trachea.

39. B. 35 Fr to 41 Fr.

35. C. cuff leak.

40. B. increase in expired tidal volume.

36. C. left or right lung depending on which lumen is used.

41. C. increase; into the cuff

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CHAPTER 6

Airway Management in Mechanical Ventilation

1. B. 21 days 2. D. Oxygenation 3. C. nasal intubation requires a smaller tube and results in higher airflow resistance. 4. A. leaving the pilot balloon port open. 5. C. seek anesthesia consultation. 6. B. 3, straight 7. A. depth and position of intubation. 8. C. 2 to 10; internal 9. D. epiglottis; lift up anteriorly 10. C. nasal intubation.

17. D. advancing the tube through the vocal cords under direct vision. 18. D. ability to compress the manual resuscitation bag. 19. C. PaO2/FIO2 ratio > 350 mm Hg. 20. B. 20 mg of etomidate and 100 mg of succinylcholine. 21. D. cricoid; close off the esophagus 22. A. 25 cm H2O; ischemia 23. B. over the trachea. 24. B. large syringe and stethoscope. 25. B. minimal leak technique

11. B. 7 to 7.5.

26. B. withdraw catheter and oxygenate the patient with 100% oxygen.

12. B. 30 sec

27. D. suction catheter.

13. B. 21 to 23

28. B. 12

14. D. inflate the cuff and check for bilateral breath sounds.

29. D. –100 mm Hg.

15. A. tongue and epiglottis.

30. B. removes more secretions than an open suction system.

16. C. chest radiograph.

31. A. allow removal of subglottic secretions with a low vacuum pressure.

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CHAPTER 6 Airway Management in Mechanical Ventilation 119

32. B. breathe in; vocal cords 33. C. nonfenestrated tracheostomy tube, the cuff must remain deflated. 34. C. acceptable blood gases on FIO2 of 60%. 35. C. PaO2/FIO2 of 150 mm Hg.

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36. C. leave suction catheter tip extended from ET tube and apply continuous suction during extubation. 37. C. not be reintubated; three 38. B. aerosol therapy with racemic epinephrine.

26/03/13 4:45 PM

CHAPTER 7

Noninvasive Positive Pressure Ventilation

1. C. without an endotracheal or tracheostomy tube. 2. B. one; two 3. A. obstructive sleep apnea. 4. B. 10 sec. 5. A. apnea index. 6. C. 10; abnormal

17. A. theophylline. 18. B. tidal volume; PEEP 19. A. BiPAP ventilation 20. A. normal. 21. A. chronic ventilatory failure. 22. B. acute respiratory acidosis. 23. C. artificial airway; aspiration

7. B. 30%; 4% desaturation for 10 sec or more

24. B. interface.

8. A. increase the IPAP level.

25. C. keep the nasal mask and monitor the patient.

9. C. CPAP or PEEP 10. C. tidal volume; functional residual capacity 11. D. upper airway obstruction. 12. D. pH. 13. D. entire spontaneous breathing cycle; does not

26. B. oronasal mask. 27. A. reduce the IPAP level until the leak is minimal. 28. A. SpO2; arterial blood gases 29. A. comfort, patient compliance 30. D. gas leak, excessive nasal dryness, or drainage

14. B. CPAP imposes more work of breathing on the patient than MV.

31. A. facial injury.

15. C. CPAP of 6 cm H2O.

32. D. a full-face mask

16. B. obstructive; neuromuscular causes

33. A. 20; CPAP

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CHAPTER 7 Noninvasive Positive Pressure Ventilation 121

34. B. increase pressure setting.

41. D. longer; 50%

35. A. using a chin strap.

42. A. 1 to 2; ventilatory assistance and larger tidal volume

36. B. 4 cm H2O 37. C. IPAP and EPAP at 4 cm H2O.

43. B. 1 to 2; improve oxygenation or relieve upper airway obstruction

38. B. SpO2 readings and number of apnea episodes.

44. C. presence of air leaks; IPAP maximum time

39. C. autotitration on each start-up.

45. C. oxygen

40. B. 8; 4

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CHAPTER 8

Initiation of Mechanical Ventilation

1. D. Mechanical ventilation is not indicated.

15. C. low tidal volumes.

2. B. increase FIO2 to 60% and monitor the patient.

16. D. PaCO2; increased

3. C. sudden increase of PaCO2 to 60 mm Hg. 4. B. compensation by increased minute ventilation.

17. B. 500 and 600 mL. 18. D. All of the above (Decrease the tidal vol ume, Decrease the frequency, Increase the inspiratory flow rate). 19. B. 2 mL/cm H2O; 120 mL

5. D. All of the above (Tidal volume, Maxi mum inspiratory pressure, Vital capacity)

20. C. spontaneous tidal volume.

6. B. Increased respiratory frequency with a decreased tidal volume

22. B. 50%

7. D. severe hypoxemia.

23. B. 40%.

8. C. 160 mm Hg

24. B. refractory hypoxemia due to intra pulmonary shunting.

9. B. acute respiratory distress syndrome. 10. A. ALI or ARDS. 11. C. tension pneumothorax. 12. A. Assist/control 13. D. dual mode; two

21. A. spontaneous breathing frequency.

25. C. Increase the flow rate. 26. A. decrease; increase; increase 27. B. 1:3 28. B. 500 mL 29. A. high; 10 to 15 cm H2O

14. C. 10 to 12/min; 10 to 12 mL/kg

122

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CHAPTER 8 Initiation of Mechanical Ventilation 123

30. B. 100; lower 31. D. All of the above (positive pressure, equipment malfunction, medical professionals).

33. D. keeping the positive end-expiratory pressure less than 20 cm H2O. 34. B. increases; decreased 35. A. high; low

32. A. Hypertension

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CHAPTER 9

Monitoring in Mechanical Ventilation

1. A. Hypoxia

16. A. reduce the tidal volume.

2. D. oxygenate; hypoxia

17. C. administering bicarbonate.

3. D. Excessive peak inspiratory pressures

18. A. ≤200 mm Hg.

4. A. discontinue mechanical ventilation and provide manual bag-to-ET tube ventilation.

19. C. congestive heart failure.

5. D. right; lower

21. A. 14%.

6. B. with each patient/ventilator assessment.

22. C. oxygenate; alveolar-capillary thickness

20. B. 340 mm Hg

7. D. suction via the endotracheal tube.

23. C. it is a useful method to monitor a patient’s ventilatory status.

8. D. wheezing.

24. A. cardia index (SpCI).

9. A. fluid or secretions in the lung.

25. D. anemia.

10. C. normal urine output.

26. A. ET tube cuff pressure monitoring.

11. D. B and C only (excessive production of antidiuretic hormone (ADH), insufficient cardiac output and renal perfusion).

27. A. 2; higher 28. B. heat damage to skin.

12. B. hypokalemia.

29. D. A and B only (oxygenation status, ventilatory status).

13. D. loss of base.

30. C. site changes; 4

14. A. A lower PaCO2.

31. B. 45 mm Hg; inadequate

15. C. PaCO2; PaO2

32. C. lower; mean arterial pressure

124

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CHAPTER 10

Hemodynamic Monitoring

1. C. fluid and electrolyte balance.

15. A. 35 mm Hg; within normal range

2. B. CVP; right ventricular preload

16. D. depletion of the heparin flush solution.

3. D. A and B only (PAP, right ventricular afterload; PCWP, left ventricular preload).

17. B. c wave

4. B. The pressure exerted by the blood is transmitted to a transducer where it is converted into an electrical signal. 5. D. pulmonary vein. 6. D. lowering; low 7. B. mm Hg and cm H2O. 8. B. measure the central venous pressure.

18. C. higher than normal; inconsistent with admitting diagnosis 19. A. peripheral vasodilation. 20. D. arterial oxygen content. 21. C. inflate; deflate 22. D. PAP; semilunar 23. A. 15 to 25; 6 to 12 24. B. pulmonary hypertension.

9. B. Arterial lines are simpler and safer than noninvasive monitoring of blood pressure.

25. C. decreased cardiac output.

10. B. rapid increase in arterial pressure during systole.

27. C. abnormal; 8 to 12 mm Hg

11. A. ventricular relaxation.

28. D. A and B only (mitral valve stenosis; left-sided heart failure).

12. B. closure of the semilunar valves during diastole.

29. B. internal blood loss.

13. B. systemic hypotension.

30. A. is; PAP diastolic is 2 mm Hg higher than PCWP.

14. C. MAP is higher than the systemic systolic pressure.

31. A. abnormal body size.

26. B. at end-expiration

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126 SECTION 2

Answers to Test Questions

32. B. 2 L/min/m2; lower than normal.

35. A. Transesophageal echocardiography

33. B. Normal mixed venous O2 sat is higher than 80%.

36. D. Impedance cardiography

34. B. Pulse contour analysis

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37. A. pulmonary artery and pulmonary artery wedge pressures.

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CHAPTER 11

Ventilator Waveform Analysis

1. D. accelerating ramp and sine; not sufficient 2. B. a; c 3. B. tidal volume. 4. A. alveolar pressure (PALV)

18. A. inspiratory time; increased 19. A. PIP and initial PTA 20. B. zero; Peak PALV 21. A. higher 22. A. decrease in inspiratory time.

5. C. peak alveolar pressure (PALV); transairway pressure (PTA)

23. B. VT; PALV

6. B. increased; decreased

24. A. increase; increase

7. A. assist; 1 to 2

25. B. 0 L/min; peak alveolar or plateau pressure

8. B. assist; pressure-time 9. B. assist and control; shortened 10. C. PEEP; mechanical ventilation

26. C. pressure-controlled; 35 27. C. not relaxed; triggering all the breaths 28. C. inverse ratio; longer

11. A. spontaneous breaths are present between mechanical breaths.

29. D. incomplete; air trapping

12. D. 3; 1; 1

30. B. second (middle)

13. B. b.

31. B. 10; PIP – PEEP

14. D. CPAP; 5

32. D. rapid rise in initial flow.

15. A. airflow resistance has increased.

33. C. volume-controlled; pressure-controlled

16. D. lung/thorax compliance has decreased.

34. D. “d”

17. A. inspiratory flow; increased

35. A. “a” 127

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128 SECTION 2

Answers to Test Questions

36. A. higher; larger

51. B. higher; shorter

37. C. sensitivity

52. C. “c”; pressure

38. B. patient-ventilator dyssynchrony.

53. C. gas leak.

39. A. initial peak flow; at the beginning

54. C. below; mechanical

40. D. tidal volume; toward the end

55. D. compliance.

41. C. patient exhalation during pause time.

56. A. lung-thorax compliance

42. D. A and B only (circuit leak; inspiratory effort by patient during pause time).

57. D. decrease of lung-thorax compliance.

43. A. inspiratory flow demand; higher 44. D. expiration; expiratory 45. C. trigger 46. C. lower; longer 47. A. higher; longer 48. C. lower; longer 49. B. lower peak inspiratory pressure.

58. A. increase of airway resistance. 59. D. compliance; low 60. C. PEEP; pressure 61. B. overinflation; decrease 62. D. decreasing; duckbill 63. B. inspiratory flow 64. D. expiratory flow tracings. 65. B. increase in expiratory flow

50. B. higher; shorter

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CHAPTER 12

Management of Mechanical Ventilation

1. A. arterial PCO2.

18. C. increasing the inspiratory time.

2. C. hypoventilation; increasing

19. B. increasing; decreasing

3. D. less than 35 mm Hg; decreasing

20. A. power setting; 5 cm H2O above

4. B. PEEP.

21. D. 40; 40 to 60

5. A. FIO2

22. B. tidal volume.

6. B. respiratory frequency; 20/min

23. D. 4; shoulder to midthigh area

7. D. 15/min

24. B. 5 to 6; decreased

8. C. using pressure support ventilation.

25. B. FIO2 to 40%, mPaw to 22–24 cm H2O range, PCV.

9. A. increasing the tidal volume is the most common approach to improving minute ventilation. 10. C. PaCO2; minimize ventilator-related lung injuries. 11. D. acidosis; lower 12. C. low; atelectasis 13. B. 12 to 24 hours 14. A. FIO2 15. D. dissolved in the plasma; anemia 16. B. have spontaneous breathing efforts. 17. A. FIO2 gradually to 40%.

26. C. pH 7.37, PaCO2 54 mm Hg, PaO2 60 mm Hg. 27. D. Change to SIMV mode. 28. B. airway obstruction. 29. D. Coughing 30. D. circuit disconnection. 31. C. auto-PEEP. 32. D. gas trapping 33. D. add PEEP of 5 cm H2O. 34. D. reducing the inspiratory flow. 35. B. 120 mL. 129

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130 SECTION 2

Answers to Test Questions

36. A. the MDI must be placed between the patient and the HME.

45. D. hypokalemia. 46. A. hyperkalemia.

37. B. more frequent ventilator circuit change.

47. D. pulmonary edema.

38. D. Lukens trap

48. B. Increased carbon dioxide production

39. C. acid-fast sputum analysis.

49. A. fat; CO2

40. D. All of the above (urinary output <20 mL/hour, urinary output <400 mL in 24 hours, urinary output <160 mL in 8 hours)

50. D. sex, age, height, and weight. 51. A. higher; does

41. D. oliguria.

52. D. barotraumas; plateau pressure is 35 cm H2O

42. A. sodium; fluid

53. D. less than 48

43. B. Potassium 1.5 mEq/L

54. B. increase CO2 rebreathing.

44. C. potassium.

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CHAPTER 13

Pharmacotherapy for Mechanical Ventilation

1. D. A and B (increasing sympathetic responses; decreasing parasympathetic responses).

14. C. change tidal volume to 300 mL.

2. B. increased gastrointestinal activity.

16. A. acetylcholine.

3. D. All of the above (Degraded rapidly by COMT; Nonspecific receptor binding; Rapid onset).

17. C. binding with the receptor site and producing a sustained depolarization.

4. A. Xopenex. 5. B. 0.5%; 0.5 mL 6. B. combining with and blocking cholinergic receptor sites. 7. A. Atropine 8. B. Combivent 9. D. All of the above (reducing inflammation; enhancing diaphragmatic contractility; heightening carbon dioxide sensitivity).

15. A. Provide patient comfort.

18. A. competing with acetylcholine at the receptor sites. 19. A. depolarizing; binding to the receptor sites and causing sustained depolarization 20. D. atracurium 21. C. High chloride level in the blood 22. C. skeletal; Capnography 23. C. malignant hyperthermia. 24. B. neuromuscular blocking agent.

10. C. theophylline toxicity; 5 to 15 mcg/mL.

25. B. three muscle twitches in 2 sec

11. B. Corticosteroids can be used as a bronchodilator.

26. B. vital capacity more than 500 mL.

12. C. AeroBid. 13. A. Triamcinolone

27. A. benzodiazepine. 28. D. antianxiety agents. 29. D. All of the above (mu; kappa; sigma)

131

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Answers to Test Questions

30. D. antagonist; nalaxone 31. D. reversal of; return 32. B. Muscle paralysis 33. D. All of the above (tachycardia; diaphoresis; dilated pupils) 34. A. hyperpolarization of neurons by gamma-aminobutyric acid (GABA). 35. C. sedation; deep anesthesia 36. C. Haloperidol

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37. D. Dexmedetomidine is used to treat hypotension. 38. D. all of the above (persistent pulmonary hypertension of the newborn; acute respiratory distress syndrome; diagnostic studies in pulmonary hypertension). 39. C. pulmonary; hemoglobin 40. B. central nervous system depression. 41. D. measuring and reporting the amount of iNO used.

26/03/13 10:03 AM

CHAPTER 14

Procedures Related to Mechanical Ventilation

1. C. Pneumocystis pneumonia. 2. B. 16 to 20 French sized chest tube. 3. A. second or third intercostal space anteriorly

15. D. All of the above (evaluation and diagnosis of certain pulmonary problems; collection of biopsy or cytology samples; therapeutic treatments).

4. B. over; under

16. C. 5 to 10 mL of 1% to 4% lidocaine via aerosol; 0830

5. B. larger; lower

17. A. morphine sulfate

6. A. the suction level is not affected by the volume of drainage in the collection chamber.

18. B. increasing the tidal volume.

7. C. adding water to the suction chamber.

20. A. Transbronchial needle aspiration biopsy

8. C. suction chamber; 10 to 20 cm H2O

19. D. transbronchial lung biopsy.

9. B. decrease the vacuum pressure.

21. D. plugging the airway where bleeding occurs.

10. D. are working normally.

22. B. tension pneumothorax.

11. D. A and B only (air leak in the drainage system; presence of air in the pleural space).

23. D. bronchodilator, prn

12. B. increase; decrease

25. D. distance between hospitals.

13. D. Valsalva maneuver; water seal

26. A. ground ambulance

24. A. Sufficient staffing in the ICU

14. D. lower; must not be

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134 SECTION 2

Answers to Test Questions

27. B. nonpressurized aircraft.

31. C. throughout the entire transport.

28. A. 30 min

32. D. manual ventilation

29. B. hyperventilation; irregular

33. A. pulse oximeter.

30. D. expired volume; decrease

34. C. magnetic resonance imaging (MRI)

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Chapter 15

Critical Care Issues in Mechanical Ventilation

1. D. nonhomogenous; different

17. A. Pressure-controlled ventilation

2. D. noncompliant; overdistention

18. D. optimal PEEP; ARDS

3. B. PCWP ≤18 mm Hg and without signs of left atrial hypertension

19. A. pressure-controlled ventilation; 20

4. C. ALI. 5. A. bilateral infiltrates. 6. B. Acute pancreatitis

20. B. 90% and 94%; 2 21. A. CPAP; 40 cm H2O 22. A. 10 cm H2O; 60% 23. D. Obesity

7. A. supportive care for oxygenation and ventilation.

24. C. more than 7 days

8. B. similar; elevated

25. B. Electrolytes and arterial blood gases

9. C. cardiogenic pulmonary edema.

26. D. at all times; when visibly soiled

10. D. < 50 cm H2O; < 30 cm H2O

27. A. remove subglottic secretions.

11. C. < 30 cm H2O; < 10 cm H2O

28. D. reduce; decrease

12. A. Increase peak inspiratory flow

29. C. Lack of appetite

13. D. tidal volume; plateau pressure

30. B. 70 to 80 mm Hg; lower

14. C. 4 to 7 mL/kg.

31. B. fluid.

15. D. B or C only (bicarbonate; tromethamine).

32. C. low; high

16. D. All of the above (peak inspiratory pressure; mean airway pressure; plateau pressure).

33. D. below; 20 mm Hg 34. A. above; 90 mm Hg 35. A. Cerebral edema 135

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136 SECTION 2

Answers to Test Questions

36. B. increase; decrease 37. A. 8 to 12 mm Hg; 20 mm Hg 38. B. brain makes a sudden impact with the skull. 39. B. acceleration; deceleration

39689_ch15_rev03.indd 136

40. D. makes contact with the prominent edges of the dural openings. 41. A. 3 to 8. 42. C. Vital signs 43. C. 26 torr; 24 hours

02/04/13 11:43 AM

CHAPTER 16

Weaning from Mechanical Ventilation

1. A. postanesthesia recovery

14. C. 60 mm Hg; 0.4

2. D. 48 hours

15. C. low; high

3. C. extubated; noninvasive ventilation (NIV)

16. A. ≥150 mm Hg.

4. D. A and B only (failure of spontaneous breathing trial (SBT), reintubation of patient within 48 hours following extubation).

17. A. 20%; CcO2, CaO2, and CvO2 18. A. 24 mm Hg 19. C. 350 mm Hg; success

5. C. Resume mechanical ventilation.

20. D. A and B only (vital capacity; maximum inspiratory pressure).

6. D. A and B only (sufficiently recovered from ventilatory failure, able to assume spontaneous breathing).

21. D. begin the weaning process.

7. A. beginning the weaning process. 8. C. Spontaneous frequency 9. B. 50 mm Hg; 7.35

22. B. 20 mL/cm H2O; does not 23. C. 30 mL/cm H2O; higher 24. A. PaCO2 and PECO2. 25. C. 36%

10. D. Vital capacity and maximal inspiratory pressure

26. B. 67 breaths/min/L; success

11. C. increased work of breathing.

27. C. SBT should continue for up to 60 minutes.

12. D. all of the above (excessive carbon dioxide production; increase in alveolar deadspace; metabolic acidosis).

28. C. An increase in PaCO2 of more than 8 mm Hg from baseline

13. C. deadspace ventilation; <100 breaths/ min/L

29. B. provide partial ventilatory support.

137

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138 SECTION 2

Answers to Test Questions

30. C. 10 to 15 mL/kg; less than 25/min

35. C. Frequency/tidal volume (f/VT) index

31. B. 40 cm H2O.

36. D. duration of spontaneous breathing trial.

32. C. airflow resistance 33. A. Volume support (VS) 34. A. detailed cost breakdown.

39689_ch16_rev02.indd 138

37. A. bronchospasm. 38. D. ventilatory; death

26/03/13 10:07 AM

CHAPTER 17

Neonatal Mechanical Ventilation

1. C. initiation of nasal CPCP.

17. A. 2 mL/kg.

2. B. 4.

18. A. FIO2 control

3. D. continue; 7

19. B. increase the temperature to a range between 34°C and 37°C and document.

4. D. 1; 4; uncuffed 5. A. 00; 2.5 6. C. at or slightly below the vocal cords. 7. B. add 6 to the infant’s weight in kilograms.

20. B. increased lung compliance. 21. B. 10 to 20 cm H2O. 22. A. 3 to 7 mL/kg. 23. B. 40 mL

8. D. less than 2,000 g birth weight.

24. B. PO2 .

9. D. apnea.

25. C. all values are within normal limits.

10. C. extraction from stem cells.

26. B. 60 to 150 cycles/min.

11. D. A and B only (synthetic surfactant is more effective than natural surfactant; surfactants are administered endotracheally).

27. B. High frequency jet ventilation 28. D. hypovolemic shock. 29. C. high frequency oscillatory ventilation.

12. D. nasal continuous positive airway pressure on 60% FIO2.

30. A. respiratory distress.

13. A. N-CPAP is provided by a ventilator.

31. A. 3 to 4 cm H2O higher

14. D. pressure; volume

32. A. the same or lower

15. B. volume; pressure

33. D. mean airway pressure

16. A. increase; overinflation

34. B. 20 L/min; 10 to 15 L/min 139

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140 SECTION 2

Answers to Test Questions

35. D. 2 to 4 cm H2O; chest wiggle 36. C. eighth rib or umbilicus. 37. B. lower delivered volume. 38. A. 12.5 to 15 Hz; 8 to 10 Hz 39. C. 33%.

43. A. tidal volume and peak inspiratory pressure. 44. A. heparin-induced intracranial bleed 45. D. 80; 2 weeks 46. B. 610; should benefit

40. D. 100%.

47. C. internal jugular vein; right common carotid artery

41. C. titrated to keep SpO2 between 90% to 95%.

48. A. venoarterial; cardiac

42. D. target tidal volume and inspiratory time.

39689_ch17_rev02.indd 140

49. C. Blood warming device 50. B. internal jugular vein; femoral vein

26/03/13 10:08 AM

CHAPTER 18

Mechanical Ventilation in Nontraditional Settings

1. A. Availability of personal care provided by family members 2. D. insurance company.

16. D. A and B only (improved knowledge about the flu; enhanced isolation technique).

3. B. home care team members.

17. A. mechanical ventilation would be needed for many patients.

4. A. perform physical assessment.

18. B. START; before

5. C. COPD.

19. A. respirations, perfusion, and mental status.

6. D. pH = 7. 27, PaCO2 = 74 mm Hg, PaO2 = 43 mm Hg, HCO3− = 33 mEq/L 7. C. increased deadspace ventilation. 8. D. restrictive lung disease.

20. D. Sort, Assess, Life-saving interventions, Treatment/Transport. 21. D. Administer intravenous fluid

9. A. apnea.

22. B. SOFA is done prior to admission to a health care facility.

10. C. Ventricular arrhythmias

23. A. PaO2/FIO2

11. C. patient should be told about the advantages and disadvantages of this plan.

24. A. PaO2/FIO2 is ≤100 mm Hg.

12. B. positive pressure ventilator. 13. C. severely injured; exceeds 14. D. all of the above (man-made events; natural events; terrorisms). 15. C. acetylcholinesterase inhibitors; sudden surge

25. D. palliation care; least 26. A. 10 to 8; most 27. B. 6,000; inadequate 28. C. may not; not commonly used by most hospitals 29. A. LTV 1200 and Newport HT50.

141

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142 SECTION 2

Answers to Test Questions

30. D. objective; do not rely

44. A. mechanical respirometer

31. C. FEV1 <25%.

45. B. electronic blood pressure device.

32. D. aerobic infection.

46. C. drowsiness.

33. C. 2 vol%; 6 vol%

47. A. high-altitude cerebral edema.

34. C. 100%; three

48. B. initiating Heliox therapy.

35. A. ascends to the water surface; joints and tissues

49. D. 5,000 ft to 8,000 ft; save

36. A. ascends rapidly from low altitude to high altitude over 18,000 ft. 37. D. recompression rapidly; decompression gradually

50. A. hypoxia; 59 mm Hg 51. D. 86%. 52. B. increase; decreases 53. A. expands; hyperinflation

38. B. mild to moderate carbon monoxide poisoning

54. B. pressure-compensated

39. A. hemoglobin; dissolved in plasma

55. D. purchase an extra ticket for a seat adjacent to the traveler.

40. D. anaerobic; oxygen-rich 41. D. decompression; water

56. C. descent; increased 57. D. decreased; 3%

42. D. compression and decompression. 43. D. smaller; gas contraction

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26/03/13 10:08 AM

SECTION 3 Answers to Workbook Questions

39689_ch01_rev02.indd 143

26/03/13 4:40 PM

CHAPTER 1

Principles of Mechanical Ventilation

1. D. compensation of acid-base imbalance. 2. B. metabolic acidosis. 3. postoperative; recovering from 4. (1) Apnea; (2) Impending respiratory arrest; (3) Acute exacerbation of COPD; (4) Acute severe asthma; (5) Neuromuscular disease; (6) Flail chest 5. TRUE 6. airflow 7. Airway resistance is primarily affected by the length, size, and patency of the airway, endotracheal tube, and ventilator circuit. 8. A. increased lung compliance. 9. 16-fold 10. C. Chronic asthma

15. decrease 16. deep and slow 17. shallow and fast 18. B. metabolic alkalosis. 19. A. excessive inspiratory flow. 20. D. CST = 20 mL/cm H2O, CDYN = 15 mL/cm H2O 21. higher than; C. The dynamic compliance is lower than the static compliance. 22. low; high 23. Low; high; noncompliant 24. inversely; increased 25. decrease 26. D. acute renal failure.

11. A. Condensation in ventilator circuit

27. D. The patient’s work of breathing is increased.

12. B. Epiglottitis

28. incomplete; decrease

13. C. remove the secretions in the endotracheal tube.

29. increased; obstructive

14. directly; increased

30. lung parenchyma; pneumonia 31. dynamic

144

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CHAPTER 1 Principles of Mechanical Ventilation 145

32. little or no; is not

55. production; removal

33. elastic; elastic

56. D. PaCO2 >45 mm Hg (>50 mm Hg for patients with COPD)

34. present; is 35. peak inspiratory pressure; airflow resistance and compliance 36. similar; decreases; static and dynamic 37. C. peak inspiratory pressure and plateau pressure are both increased. 38. D. static compliance and dynamic compliance are both decreased. 39. C. peak inspiratory pressure is increased while the plateau pressure remains the same. 40. C. dynamic compliance is decreased while the static compliance remains the same. 41. D. decrease in lung compliance. 42. 30 and 40; 40 and 60

57. E. Hypoxemia that responds well to oxygen therapy 58. A. QS/QT > 20% (>30% in critical shunt) 59. C. Gas diffusion rate <75% of predicted normal 60. B. Low barometric pressure as in high altitude 61. A. Metabolic acidosis 62. arterial carbon dioxide tension 63. A. increasing the tidal volume (VT). 64. C. increasing the f. 65. PaCO2 66. increase

44. 140

67. Ventilation/perfusion (V/Q) mismatch occurs when there is an overall uneven distribution of ventilation or perfusion.

45. higher

68. high; perfusion

46. not adequately

69. ventilation; low

47. D. atelectasis.

70. readily

48. sum; anatomic

71. Intrapulmonary shunting means perfusion of poorly ventilated or nonventilated lung units.

43. ventilation; pulmonary blood flow

49. D. arterial and mixed expired gas samples. 50. C. VD/VT = (PaCO2 – PECO2)/PaCO2. 51. normal 52. TRUE 53. Ventilatory failure is the inability of the pulmonary system to maintain adequate removal of carbon dioxide.

72. Refractory hypoxemia refers to the low oxygen level in blood that responds very poorly to oxygen therapy alone. 73. does not; ineffective 74. critical and severe 75. B. Estimated QS∕QT = (CcO2 – CaO2)∕ [3.5 + (CcO2 – CaO2)]

54. hypercapnia; increase

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146 SECTION 3

Answers to Workbook Questions

76. two 77. D. High altitude; fire combustion 78. A. Pulmonary edema; retained secretions

83. Hypoxemia is low oxygen level in blood. Hypoxia is low oxygen level in tissues. 84. TRUE 85. A. hypothermia.

79. C. Emphysema; pulmonary fibrosis

86. C. Chest trauma

80. B. Tachycardia

87. D. Drug overdose

81. hypoxemia; supplemental oxygen

88. B. Hypothermia

82. dissolved in the plasma; does not

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26/03/13 4:40 PM

CHAPTER 2

Effects of Positive Pressure Ventilation

1. decreasing

20. increased; compression

2. lower than

21. pulmonary; systemic; decrease

3. decreased; increased

22. impedes; lower

4. larger

23. lower; lower

5. lower

24. directly; lower

6. A. circuit disconnect.

25. decreased

7. D. Endotracheal tube cuff leak

26. TRUE

8. pressure; volume

27. increase; decrease

9. volume; pressure

28. increase

10. noncompliant; less

29. increase

11. increases; decreases

30. lower

12. C. decrease the tidal volume.

31. lower

13. decrease; reduced

32. less; decreased; hypovolemic; retaining

14. decrease

33. 400 mL; decreased

15. hypotensive

34. oliguria; 400; 160

16. pulsus paradoxus

35. elevation; more than; more than; 10-to-1

17. hypovolemia

36. A. spinal fluid pressure.

18. increase; decrease

37. decrease; higher

19. TRUE

38. C. increase of renal perfusion. 147

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148 SECTION 3

Answers to Workbook Questions

39. higher; higher

53. TRUE

40. PEEP

54. More

41. B. hematocrit >40%.

55. fat-based; more; lower

42. higher; impaired

56. intracranial pressure

43. decreased; decreased

57. alkalosis; reduction

44. 15

46. C. increased bowel sounds.

58. Leftward shift of oxyhemoglobin curve; increased O2 affinity to hemoglobin; reduced O2 release to tissues; cerebral tissue hypoxia; neurologic dysfunction; and hypophosphatemia.

47. TRUE

59. A. secondary anemia.

48. muscle fatigue; excessive CO2 production

60. B. neurologic impairment.

49. TRUE

61. Hypercapnia

50. C. lung compliance is low.

62. stimulation

51. Endocrine diseases (high metabolic rate); electrolyte disorders; drugs; and persistent hypoxemia

63. vasodilation; elevation

52. Undernutrition leads to a reduction of ventilatory efficiency because inadequate nutrition leads to protein catabolism and a loss of muscle performance. Undernutrition also depletes the glycogen storage and protein in the diaphragm. For COPD patients, nutritional deficits lead to muscular dysfunction and peripheral muscle waste.

65. C. Increased cerebral blood flow and intracranial pressure

45. D. increased functional residual capacity.

39689_ch02_rev02.indd 148

64. B. Impaired cerebral metabolism

66. A. Decreased mental and motor functions

26/03/13 11:07 AM

CHAPTER 3

Classification of Mechanical Ventilators

1. operational 2. D. A and B only (similarities and differences).

14. The three types of drive mechanisms are: piston drive, bellows drive, and microprocessor-controlled pneumatic drive.

3. pressure

15. pressure

4. directly

16. compress

5. D. A and B only (compliance and resistance).

17. pneumatic

6. Compliance 7. resistance 8. compressed gas 9. Bird Mark 7; Percussionaire IPV; Monaghan 225/SIMV; and the Percussionaire VDR are some ventilators that utilize pneumatic power.

18. drive mechanism 19. without any further 20. input; output; servo21. Mechanical 22. Pneumatic 23. Coanda Effect

10. Electrically

24. Electronic

11. Examples of electrically powered ventilators include the Carefusion LTV and Puritan Bennett 540.

25. The four control variables on ventilators are pressure, volume, flow, and time.

12. Viasys AVEA, Puritan Bennett 840, and Hamilton C2 are some ventilators that require electrical (for microprocessor control systems) and pneumatic power source. 13. TRUE

26. pressure 27. inside 28. outside 29. positive or negative 30. elastic recoil 149

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150 SECTION 3

Answers to Workbook Questions

31. will not

53. pressure-

32. will; smaller

54. volume-

33. pressure; volume

55. expiratory

34. pressure; higher 35. pressure; flow

56. Positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) are two baseline variables.

36. pressure; higher

57. ventilator; output

37. flow and inspiratory time

58. volume; pressure

38. inspiratory and expiratory; pressure and volume

59. pressure; volume

39. four 40. The four phases of a ventilator-supported breath are: (1) change from expiration to inspiration; (2) inspiration; (3) change from inspiration to expiration; and (4) expiration. 41. start; inspiration 42. Time, pressure, and flow can be used as a trigger variable during mechanical ventilation. 43. time44. pressure45. When the ventilator uses a change in gas flow (i.e., presence of a sufficient gradient) to initiate inspiration, the mechanical breath is flow-triggered. 46. sensitivity 47. higher 48. limit 49. does not end; continues 50. pressure51. volume52. inspiration

39689_ch03_rev02.indd 150

60. allows 61. FALSE 62. pressure; flow 63. inspiration phase 64. volume; tidal volume 65. TRUE 66. pressure; at a specified time interval 67. pressure-support breath 68. increased 69. volume support ventilation (VSV) mode; pressure-regulated volume control (PRVC) mode 70. increasing 71. resistance of the artificial airway; inspiration and expiration 72. two; both 73. removal of CO2 74. expiration 75. Pressure/time, volume/time, and flow/time are three basic output waveforms during mechanical ventilation. 76. rectangular

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CHAPTER 3 Classification of Mechanical Ventilators 151

77. sinusoidal; rotary-

83. high

78. Ascending ramp and sinusoidal are two volume waveforms.

84. A. high pressure alarm.

79. The four flow waveforms include: rectangular (constant), ascending ramp, descending ramp, and sinusoidal. 80. electrical or pneumatic power 81. control circuit; allows 82. Pressure, volume, flow, time, inspiratory and expiratory gas are the five major parameters that output alarms monitor.

39689_ch03_rev02.indd 151

85. low 86. minute volume 87. too long or too short 88. concentration or temperature 89. Oxygen and carbon dioxide analyzers are two common gas analyzers used in mechanical ventilation.

26/03/13 11:09 AM

CHAPTER 4

Operating Modes of Mechanical Ventilation

1. D. positive or negative 2. B. transairway pressure. 3. higher 4. decreasing; below 5. “Iron lung” and chest cuirass (chest shell) are two negative pressure ventilators.

17. intrapulmonary shunting; decreased; auto-PEEP 18. below; breath-triggering effort 19. 60 mm Hg; 50 20. end; exhalation; increases; lowers 21. B. increased cardiac output and renal perfusion.

6. chest cage and abdomen

22. right; less; decreased

7. TRUE

23. FALSE

8. poor patient access; tank shock

24. less

9. home; easy; can

25. 10; 30; 50

10. TRUE

26. increase; venous return from

11. higher

27. reduce; decreased; hypovolemic; retaining

12. Servo control

28. PEEP

13. closed-loop

29. PaCO2

14. patient

30. TRUE

15. 0; refractory hypoxemia; intrapulmonary shunting

31. 8; 4; below

16. continuous positive airway pressure (CPAP)

32. higher 33. TRUE

152

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CHAPTER 4 Operating Modes of Mechanical Ventilation 153

34. ventilation; oxygenation

61. 100

35. cannot

62. 7,500

36. FALSE

63. 200

37. control

64. 4,000

38. mechanical; mechanical

65. D. A and B only (number of mandatory breaths and pressure support level)

39. 16 40. stable; can; below

66. D. all of the above (mandatory frequency, tidal volume, I:E ratio).

41. allows

67. mandatory, pressure support

42. FALSE

68. pressure support

43. control; any

69. assist; flow or volume assist

44. TRUE

70. volume

45. beginning

71. high; overdistention

46. variable

72. tidal volume; volume-assisted cycles

47. at or about; 5

73. minimal tidal volume and pressure support

48. control; any 49. A. decreased work of breathing. 50. minute ventilation; inadequate 51. hypercapnia; inadequate 52. TRUE 53. avert; deadspace ventilation 54. FALSE 55. decreases 56. increases; decreases 57. 10 to 15; 25 58. the preset pressure support level 59. B. end-flow drops to a predetermined level (e.g., 5 L/min). 60. body weight; percent minute ventilation

39689_ch04_rev02.indd 153

74. patient- or time75. lower than 76. pressure-limited; volume-limited 77. longer; constant 78. airflow obstruction 79. Servo 300® 80. flow and inspiratory time 81. peak inspiratory 82. longer 83. time-triggered 84. tidal volume; variable 85. reduced; cannot 86. volume control plus and volume support

26/03/13 11:11 AM

154 SECTION 3

Answers to Workbook Questions

87. target tidal volume and inspiratory time

104. high; low

88. tidal volume

105. C. increase of deadspace ventilation.

89. variable

106. higher; auto-PEEP

90. are

107. TRUE

91. target tidal volume

108. barotrauma

92. pressure support

109. TRUE

93. decreases

110. increase

94. time-; preset

111. pressure control

95. peak inspiratory pressure

112. airflow resistance

96. lower

113. TRUE

97. decreasing; increasing

114. diaphragm

98. two

115. FALSE

99. without

116. decreasing

100. expiration; inspiratory

117. increasing

101. high; low

118. mean airway pressure

102. high or low pressure levels 103. TRUE

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CHAPTER 5

Special Airways for Ventilation

1. ventilation and oxygenation

19. large; inflated

2. TRUE

20. inflated

3. conscious

21. A. prevent gas leak around the patient’s face during ventilation.

4. conscious 5. have; 43 mm; 110 mm 6. one or three; internal channels 7. 55 mm; 120 mm

22. B. provide ventilation to the lungs. 23. esophagus; inflated 24. 20 to 30

9. earlobe

25. B, D, A, C (inflate and test cuff, deflate cuff, lubricate tube with a water-soluble lubricant, insert tube through opening of a mask).

10. angle of the jaw

26. inflated

11. removed immediately because the patient might not need an airway

27. B. should not be used in children under 16 years old or under 5 ft tall.

12. on the patient’s lips or teeth

28. is not

13. cannot

29. with EOA in place

14. C. nasal trauma.

30. closed; open

15. 6; 7

31. TRUE

16. Water-soluble lubricant

32. absent; mask

17. esophagus; disposable

33. ventilation

18. proximal or top; closed

34. esophagus; EOA; EGTA; EGTA

8. center

155

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156 SECTION 3

Answers to Workbook Questions

35. short; mask

56. TRUE

36. laryngeal opening; is not

57. steam autoclave

37. 20

58. esophageal tube; endotracheal tube

38. unconscious; absent

59. esophagus or trachea

39. is; may; lower

60. are two

40. is not

61. 100; 15

41. 20; high; low

62. esophagus; distal; esophagus

42. silicone

63. trachea; proximal; trachea

43. 4; 5

64. with or without

44. 60

65. front teeth

45. Size 1 for neonates and infants up to 5 kg

66. distal and proximal

46. Size 1.5 for infants between 5 and 10 kg

67. esophagus; 1

47. Size 2 for infants and children between 10 and 20 kg

68. esophagus

48. Size 2.5 for children between 20 and 30 kg

69. trachea 70. proximal

49. Size 3 for children over 30 kg and small adults

71. TRUE

50. Size 4 for adults 50 to 70 kg

72. one tracheal and one bronchial; two; two

51. Size 5 for adults 70 to 100 kg

73. left- or right-sided

52. Size 6 for adults over 100 kg

74. left-sided; right-sided

53. without; posterior pharynx; trachea and larynx

75. right-sided

54. anesthetized or awake 55. Regurgitation; laryngeal spasm; bronchospasm; coughing; retching; excessive salivation; and oxygen desaturation are some complications that may occur during removal of LMA.

39689_ch05_rev02.indd 156

76. A. Reduction of deadspace ventilation 77. 68% 78. 35 to 41 Fr 79. direct laryngoscopy; with or without 80. 6 cm

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CHAPTER 5 Special Airways for Ventilation 157

81. as soon as; minimize the incidence of airway trauma 82. both lungs 83. B. increase in expired tidal volume. 84. deflated; advanced

39689_ch05_rev02.indd 157

85. 1 to 2 mL 86. inflated 87. red rubber; PVC 88. (A) largest; (B) Remove; (C) Never; 3-mL; (D) <30 cm H2O; (E) bronchial cuff

26/03/13 11:14 AM

CHAPTER 6

Airway Management in Mechanical Ventilation

1. mouth or nostril

20. B. chest trauma.

2. Tracheotomy; tracheostomy

21. FALSE

3. shorter

22. 1 to 4; 4

4. ET intubation

23. A. soft palate and base of uvula

5. expected duration of needs

24. 1 or 2

6. tracheostomy

25. D. Stylet

7. D. correction of respiratory alkalosis.

26. left

8. C. Epiglottitis

27. straight or curved; 00; 4

9. A. Loss of swallow or gag reflex

28. straight; epiglottis

10. B. Excessive secretions

29. curved; vallecula

11. D. Mechanical ventilation

30. is not; the entire

12. Oral intubation

31. is

13. largest; less; less

32. straight; curved

14. D. allows passage of a larger ET tube.

33. straight

15. B. Easier to insert than oral intubation

34. tongue

16. inflated

35. 2; 10; internal

17. tracheostomy tube; Sterile

36. Since the radiopaque line is impenetrable to X-ray and can be seen on chest radiographs, it is used to confirm the position (depth) of an ET tube following intubation.

18. self-inflating 19. temporary or permanent 158

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CHAPTER 6 Airway Management in Mechanical Ventilation 159

37. inspiratory

64. A. Hyperventilation

38. 10

65. should not be

39. prevent air leak

66. reinflate within 10 seconds

40. water-soluble

67. conditions; aspiration; ventilation and oxygenation

41. If the ET tube is not secured properly, inadvertent extubation or main-stem intubation may occur. 42. FALSE 43. nasal intubation 44. B. 2.5 mm I.D. 45. C. 4.0 mm I.D. 46. E. 6.5 mm I.D. 47. F. 8.0 mm I.D. 48. C. 7. 49. B. prolonged intubation attempt. 50. D. use Magill forceps. 51. lifted anteriorly to the patient 52. after 53. 22 cm 54. Magill forceps

69. severe; <250 mm Hg 70. should not 71. sedation 72. 20; 30 to 60 sec 73. neuromuscular blockade; short 74. 100; 1.5 75. 60 sec; ready for use before 76. Sellick’s; esophagus 77. nondepolarizing; antianxiety; synthetic 78. TRUE 79. Endotracheal; tracheostomy 80. 25 to 35; 25; hypotension; reduced 81. greater

55. 26 cm

82. minimal occlusion volume; inflating; end-inspiration

56. nostril; inspiratory; trachea

83. end-inspiration

57. B. chest radiograph

84. minimal leak technique; inflating; end-inspiration

58. grave; aspiration; vocal cords 59. D. presence of vocal sounds. 60. midaxillary line 61. TRUE 62. main-stem 63. 1.5; above

39689_ch06_rev03.indd 159

68. 8 or less

85. FALSE 86. 3; 2 87. 70 and 150; 100 88. 10 to 15; 5 89. TRUE

02/04/13 11:45 AM

160 SECTION 3

Answers to Workbook Questions

90. remove secretions accumulated above the cuff 91. deflating the cuff 92. has 93. is blocked; open 94. one-way; in only 95. blocks; directs 96. TRUE 97. deflated 98. open 99. removed 100. FALSE 101. D. f/VT 102. less 103. FALSE

39689_ch06_rev03.indd 160

104. 10; 250; –20; 15 105. B. be reintubated; 5 106. B. Hoarseness 107. three 108. A. Loss of coughing reflex 109. C. Vomiting 110. A. Trauma to teeth and soft tissues 111. TRUE 112. vagus 113. high; reduced 114. lips or incisors 115. FALSE 116. harsh or high-pitched sound; partially 117. racemic epinephrine

02/04/13 11:45 AM

CHAPTER 7

Noninvasive Positive Pressure Ventilation

1. artifical airway

19. TRUE

2. does not; patient

20. A. apneas and hypopneas per hour of sleep.

3. one or two 4. IPAP; EPAP 5. IPAP; increased 6. EPAP 7. EPAP 8. PO2, PCO2, SpO2, and PETCO2 may be used as titration endpoints. 9. entire spontaneous breath; does not 10. more 11. does not 12. CPAP 13. obstructive 14. neuromuscular causes 15. 10 16. airflow obstruction 17. apnea index 18. ≥50%; 10; ≥4%

21. D. History of smoking 22. obstructive sleep apnea 23. ventilation; positive end-expiratory pressure 24. Acute respiratory failure and acute hypercapnic exacerbations of COPD are two major indications for bilevel PAP. 25. less than 26. C. Noncardiogenic pulmonary edema 27. D. exacerbations of COPD. 28. aspiration 29. interface 30. Nasal mask, oronasal mask, nasal pillows, and full-face mask are four interfaces used in NPPV. 31. may have a minor leak 32. large 33. oronasal mask

161

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162 SECTION 3

Answers to Workbook Questions

34. mouth

47. 4

35. pulse oximetry; blood gas analysis

48. C. IPAP and EPAP at 4 cm H2O.

36. Comfort and patient compliance are two advantages of using a nasal mask during PPV.

49. A. SpO2 readings and number of apnea episodes.

37. Gas leaks and nasal dryness or drainage are two disadvantages of using a nasal mask during NPPV. 38. An oronasal mask 39. Regurgitation and aspiration; and asphyxiation are two potentially harmful problems with an oronasal mask. 40. Claustrophobia, patient noncompliance, alarm and monitor are three disadvantages of using an oronasal mask during NPPV. 41. nose; CPAP 42. 20; less 43. does not 44. A. status asthmaticus. 45. C. Reducing pressure setting

50. Autotitration 51. 45 min 52. exhalation; exhalation 53. 8; 4 54. 0.15 to 0.25; 50% 55. 1 to 2; ventilatory assistance and larger tidal volume 56. 1 to 2; improve oxygenation or relieve upper airway obstruction 57. air leaks; IPAP maximum time 58. TRUE 59. TRUE 60. 3; relief 61. inhalation; exhalation

46. B. Using chin strap

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CHAPTER 8

Initiation of Mechanical Ventilation

1. A. prevent lung infection

17. C. tension pneumothorax.

2. D. metabolic acid-base imbalance.

18. chest tube; pressure

3. sudden; PaCO2; acidosis

19. D. all of the above (on patient’s request; in cases of medical futility; to reduce or terminate a patient’s pain and suffering).

4. above; acidosis; less 5. PaCO2; gradual and persistent 6. respiratory; hyperventilation 7. Spontaneous VT—Less than 3 mL/ kg. Spontaneous frequency—Greater than 25 to 35/min. Spontaneous minute volume—Greater than 10 L. Vital capacity—Less than 15 mL/kg. Maximal inspiratory pressure, Less than –20 cm H2O.

20. useless 21. Full 22. able; part 23. two; ventilator 24. FALSE

8. 60; 50%; 40

25. eucapneic ventilation

9. 2

26. the patient’s normal value

10. D. P(A-a)O2 = 190 mm Hg, 8% shunt

27. 10 to 12

11. C. PAO2 = (PB – PH2O) × FIO2 – (PaCO2/R)

28. exhalation; auto-PEEP

12. hypoxemia

29. High ventilator or patient frequency, inadequate ventilator inspiratory flow, and air trapping are three conditions that may lead to auto-PEEP.

13. ≤ 300 mm Hg; ≤ 200 mm Hg 14. lower than 15. consistent 16. FALSE

30. PaCO2 31. increased; decreased

163

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164 SECTION 3

Answers to Workbook Questions

32. 10 to 12

59. I time; E time

33. hypoventilation; barotrauma

60. shortens; lengthens

34. lessen; air trapping

61. D. 60 L/min

35. B. ARDS

62. C. I time = 1.25 sec; E time = 3.75 sec

36. C. Emphysema

63. A. 25%

37. A. Pneumonectomy 38. lower

64. The four flow patterns are constant flow, accelerating (ascending), descending ramp, and sine wave.

39. C. 4 mL/cm H2O

65. TRUE

40. C. 120 mL

66. system leak; circuit disconnection

41. B. 580 mL

67. 100 mL; lower; expired

42. spontaneous breathing

68. TRUE

43. TRUE

69. 10 to 15 cm H2O; below

44. B. positive end-expiratory pressure.

70. 10 to 15 cm H2O; above

45. 20 to 25; 8 to 10

71. D. circuit disconnection.

46. 2 to 4

72. inspiration; expiratory; smaller

47. PaO2; 80 and 100 mm Hg; lower

73. D. all of the above (apnea, circuit disconnection, cuff deflation).

48. 50% 49. 40% 50. 5 51. 1:2; 1:4; air trapping 52. expiratory; end; end-expiratory pressure 53. low 54. D. positive end-expiratory pressure. 55. shorter; longer 56. A decreased inspiratory flow rate makes the I time longer and the E time shorter.

74. 15 to 20 sec 75. 10 to 15 breaths/min; over 76. respiratory distress 77. over; below 78. B. Low volume alarm = 600 mL 79. A. Low pressure alarm = 45 cm H2O 80. D. High pressure alarm = 60 cm H2O 81. C. Apnea time delay = 20 sec 82. B. High frequency alarm = 20/min

57. longer; shorter

83. C. High FIO2 alarm = 55%

58. A smaller tidal volume makes the I time shorter and the E time longer.

84. B. Low FIO2 alarm = 45%

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CHAPTER 8 Initiation of Mechanical Ventilation 165

85. C. Barotrauma

92. more; air trapping; weakened

86. B. Physical and psychologic trauma

93. B. pulmonary fibrosis.

87. D. Circuit disconnection

94. increases; decreased

88. A. Nosocomial pneumonia

95. lower; lower

89. FALSE

96. increasing; constricting

90. overdistention

97. high; low

91. PIP—Greater than 50 cm H2O. Plateau pressure—Greater than 35 cm H2O. Mean airway pressure—Greater than 30 cm H2O. PEEP—Greater than 10 cm H2O.

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CHAPTER 9

Monitoring in Mechanical Ventilation

1. 60; 100

20. hypothermia; higher; hypothermic

2. 100/min

21. patient’s core temperature

3. D. hypothermia.

22. phrenic; hypoventilation; paralysis of hemidiaphragms

4. 60/min 5. A. pain and stress. 6. C. carotid artery. 7. hypertension 8. excessive 9. hypotension; hemorrhage 10. hypotension; sepsis 11. inadequate

23. C. consolidation. 24. symmetrical 25. chest auscultation 26. B. Atelectasis 27. D. Airway narrowing 28. A. Pulmonary edema 29. C. Excessive secretions

12. loss of; inadequate

30. D. Right anterior chest between clavicle and nipple (male)

13. FALSE

31. C. Right nipple area (male)

14. 10 to 16

32. E. Left nipple area (male)

15. increased; respiratory distress

33. A. Left midaxillary line about 6 in. below armpit

16. unsuccessful 17. Hyperthermia; right; lower

34. B. Left posterior below scapula next to spine

18. A. infection.

35. B. intubation and extubation.

19. Hypothermia; metabolic 166

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CHAPTER 9 Monitoring in Mechanical Ventilation 167

36. trachea; toward the end

62. alkalosis; decreased; decreasing

37. dark-shaded

63. FALSE

38. white-shaded

64. respiratory muscle fatigue; ventilatory failure

39. white-shaded 40. D. reduction of cardiac output.

65. decreased; decreased; increased; decreased

41. scanty; fluid deficiency

66. moderate

42. A. kidney malfunction.

67. ARDS

43. 50 to 60

68. ≤300 mm Hg

44. FALSE

69. hypoxemia; less than 24 mm Hg

45. 30; 400; 160

70. C. 14%.

46. decreased; increased

71. 75%; hypoxic

47. increase; reduces

72. FALSE. Hypoxemia caused by acute hypoventilation should be treated with oxygen and ventilation because hypoventilation can only be corrected by improving alveolar ventilation.

48. Na+—140 mEq/L; K+—4 mEq/L; Cl−—103 mEq/L; HCO3−—25 mEq/L 49. A. 12 mEq/L, lower than normal 50. metabolic; acidosis; loss 51. normal; hyperchloremia; acidosis; excessive

74. normal or low; poor 75. D. positive end-expiratory pressure.

52. metabolic; acidosis; gain

76. C. Decreased alveolar surface area

53. acidosis; increased; renal failure; alcohol poisoning

77. B. High altitude

54. hyperventilation 55. FALSE 56. alkalosis; hypoventilation 57. 35 to 45 mm Hg 58. 80 to 100 mm Hg 59. 7.35 to 7.45 60. PaCO2 61. acidosis; increased; increasing

39689_ch09_rev02.indd 167

73. low; well

78. C. Pulmonary edema 79. A. Emphysema 80. B. a more invasive measurement. 81. D. measurement of PaO2. 82. FALSE 83. TRUE 84. A. assessment of ventilatory status. 85. C. measuring the SpO2.

26/03/13 11:25 AM

168 SECTION 3

Answers to Workbook Questions

86. A. Venous blood gas sample

108. decrease; should not; does not

87. TRUE

109. PO2; PCO2

88. decreases; underestimates; low

110. on the skin; increase; 44°C

89. low

111. FALSE

90. higher

112. lower; thicker skin in adults

91. D. start aerosol therapy with albuterol and saline. 92. B. cardiac index (SpCI).

113. Skin edema, hypothermia, and capillary perfusion status are three conditions that may affect the accuracy of a PtcO2 electrode.

93. ventilatory

114. below; greater

94. carbon dioxide; a complete respiratory cycle

115. fall

95. TRUE 96. fast response time 97. ease of handling 98. 0% 99. last; end 100. D. oxygenation status. 101. 2; 5 102. B. Increased deadspace ventilation 103. C. Decreased cardiac output 104. A. During CAB graft surgery 105. esophageal intubation 106. decrease 107. This is because a lower volume would further increase the VD/VT ratio.

39689_ch09_rev02.indd 168

116. 4; heating element 117. ventilatory; 44°C 118. higher; increased 119. higher; increased 120. cerebral perfusion pressure 121. brain’s autoregulation mechanism 122. is lost; elevated; vulnerable 123. decreased 124. 70 and 80 125. B. CPP = MAP – ICP 126. raising; lowering 127. 8; 12; less than 128. vasopressor 129. hypotension

26/03/13 11:25 AM

CHAPTER 10

Hemodynamic Monitoring

1. entering

17. A. central venous pressure.

2. right; right; preload

18. closure; aortic; relaxation

3. central venous

19. B. Yes; 80 mm Hg

4. leaving 5. right; right; afterload

20. A mean arterial pressure of 60 mm Hg or higher is needed to maintain adequate tissue perfusion.

6. pulmonary artery or Swan-Ganz

21. product; increase; decrease

7. stop; without

22. B. Pulse pressure = Psystolic – Pdiastolic

8. noncompressible; equally

23. 30 to 40; 30; 40

9. TRUE

24. increase

10. The three catheters for hemodynamic monitoring are arterial, central venous, and pulmonary artery catheters.

25. decrease

11. lower

27. increased; decreased; decreased

12. A. fluid overload.

28. heart

13. 13.3

29. decreased; increased; increased

14. systemic; right; pulmonary

30. D. Dampened pressure signal

15. Four common arteries for placement of an arterial catheter are the radial, brachial, femoral, and dorsalis pedis arteries.

31. A. Measurement lower than actual

26. D. spontaneous tidal volume.

32. E. Measurement higher than actual 33. B. Backup of blood in the tubing

16. radial; ulnar 169

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170 SECTION 3

Answers to Workbook Questions

34. C. Inaccurate reading, signal interference

59. closure

35. superior; right; right

60. increased

36. proximal; pulmonary artery

61. deflated

37. right; systemic

62. the same as

38. right; left

63. 15; 25; 6; 12

39. venous

64. >35; >25

40. subclavian; internal jugular

65. increase; raises

41. D. Right atrial contraction

66. increased; directly

42. A. Closure of the tricuspid valve during systole

67. increased

43. E. Relaxation of right atrium 44. B. Right ventricular contraction 45. C. Relaxation of ventricle 46. TRUE

68. hypovolemia 69. TRUE 70. decreased; lower; lower 71. decreased

48. elevated

72. increase in intrathoracic pressure; decrease in venous return; lower right ventricular output; lower blood volume (pressure) in the pulmonary artery.

49. Elevation

73. inflating; 1.5; deflated

50. 0; 6; 2; 7; higher

74. D. Left atrial contraction

51. smaller; lower

75. B. Closure of the mitral valve during systole

47. elevated; tricuspid; absent

52. decreased; lower 53. A. right ventricular failure. 54. B. vasodilation. 55. C. arterial oxygen saturation. 56. subclavian; jugular; right; right; pulmonary

76. C. Relaxation of left atrium 77. A. Left ventricular contraction 78. E. Relaxation of ventricle 79. increase 80. higher; mitral valve

57. deflated; inflated

81. increased

58. The three components of a typical pulmonary arterial pressure waveform are: systolic phase, diastolic phase, and dicrotic notch.

82. 8; 12; 18

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83. increased

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CHAPTER 10 Hemodynamic Monitoring 171

39689_ch10_rev02.indd 171

84. increased

108. A. Sepsis

85. elevated

109. C. Hypothermia

86. near-normal

110. Pulse contour analysis

87. D. PAP systolic-PCWP gradient.

111. pulse contour analysis

88. lower; diastolic

112. blood flow velocity

89. higher; lower

113. cardiac output

90. higher

114. esophagus; mid-

91. measure

115. rebreathing

92. 4; 8

116. CO2 elimination

93. body size; 2.5 to 3.5

̇CO2. 117. V

94. left; afterload; increased

118. thoracic

95. right; preload; decreased

119. noninvasive; hemodynamic

96. right; afterload; increased

120. FALSE

97. left; preload; increased

121. resistance

98. B. SV = CO∕HR

122. external; high; low

99. The stroke volume may be increased with a higher contractility or preload, or a lower afterload. The stroke volume may be decreased with a lower contractility or preload, or a higher afterload.

123. four; four

̇O2 = QT × C(a-v)O2 100. C. V

126. systole; decreasing

101. pulmonary; hypertension

127. ascending aorta

102. systemic; overload

128. invasive; sporadic

103. 75; 60

129. FALSE

104. B. Decreased cardiac output

130. B. pulmonary artery pressure.

105. D. Increased metabolic rate

131. FALSE

106. A. Severe and prolonged hypoxia

132. A. low cardiac output state.

107. E. Improperly wedged catheter

133. A. intermittent hemodynamic monitoring.

124. outer 125. inner

26/03/13 11:26 AM

CHAPTER 11

Ventilator Waveform Analysis

1. waveforms

14. airflow resistance

2. CMV—Controlled Mandatory Ventilation

15. b and c

FVL—Flow-Volume Loop

16. c

PALV—(Peak) Alveolar Pressure

17. A. Constant peak flow × I Time

PCV—Pressure-Controlled Ventilation

18. inspiratory; b

SIMV— Synchronized Intermittent Mandatory Ventilation

19. volume

TCT—Total Cycle Time

20. less than

VCV—Volume-Controlled Ventilation 3. direct measurements; is not 4. convex

21. plateau pressure; end-inspiration 22. lung compliance

5. lung characteristics

23. PIP; PALV; airflow resistance of the airways; airflow resistance

6. not sufficient

24. PTA

7. decreased

25. time-triggered

8. controlled; cycled

26. does not have

9. expiration; inspiration

27. inspiration; expiration

10. b; c

28. beginning of the next inspiration

11. e; below

29. sensitivity

12. inspiration

30. inspiratory time

13. time-triggered; before 172

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CHAPTER 11 Ventilator Waveform Analysis 173

31. directly; longer; shorter

58. TRUE

32. inversely; shorter; longer

59. inverse ratio pressure-controlled

33. sum

60. delivered tidal volume

34. 8

61. C. peak inspiratory pressure.

35. product

62. inspiratory; inspiratory

36. larger

63. more

37. B. CLT = VT ∕(PALV – PEEP)

64. FALSE

38. a; b

65. tidal volume

39. sensitivity; –2

66. expiratory; airflow resistance

40. expiratory; flow

67. increase; prolong

41. CPAP

68. expiratory; lung compliance

42. PIP; PALV

69. increase; shorten

43. peak PALV or plateau pressure

70. enhances

44. plateau pressure

71. dyssynchrony

45. total compliance

72. expiration; gas trapping

46. PTA

73. high

47. increased

74. low

48. increased

75. –2

49. higher; higher

76. D. metabolic alkalosis.

50. constant and descending

77. initial flow; at the beginning

51. volume delivered; total compliance

78. tidal volume; toward the end

52. decrease

79. initial flow

53. PTA

80. tidal volume

54. D. A and B only (tidal volume and peak inspiratory pressure).

81. exhaling; increases

55. zero; plateau 56. pressure level; frequency; I:E ratio 57. D. all of the above (pressure level, lung compliance, airflow resistance).

39689_ch11_rev02.indd 173

82. inhaling; decreases 83. greater; increased 84. d and e 85. f and g

26/03/13 11:28 AM

174 SECTION 3

Answers to Workbook Questions

86. decreased; prolonged; airflow resistance

99. PTA

87. prolonged; increased

100. CLT

88. decreased; prolonged; compliance

101. pressure

89. decreased

102. D. PIP and PALV

90. increased; shortened; faster

103. B. PALV; PTA, PIP and PAO

91. increased

104. inspiratory

92. inconsistent

105. PEEP; end-expiration

93. less; more

106. decreased

94. increased; increased; exhalation

107. decrease; tidal volume

95. A. gas leak.

108. below

96. expiratory; incomplete; less

109. expiratory flow; inspiratory flow

97. increased 98. circuit leak; drops to the sensitivity setting below the PEEP level

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CHAPTER 12

Management of Mechanical Ventilation

1. ventilation

17. increasing; VT or f

2. increase; one or more

18. increasing

3. improve

19. more; increases

4. oxygenation

20. pressure support ventilation

5. increase; FIO2

21. 10 to 15; increases

6. increase; PEEP

22. reduced; increase

7. reduce; increase

23. tidal volume; decreased

8. acidosis; hypoxemia

24. TRUE

9. hypoventilation

25. body weight; rather narrow

10. 50 to 60; chronic

26. (A) Excessive ventilator tidal volume may increase the likelihood of ventilator-related lung injuries.

11. most recent discharge from 12. A. increase the ventilator frequency. 13. auto-PEEP 14. D. decrease the spontaneous f. 15. The ventilator tidal volume should not be used to regulate the minute ventilation or PaCO2. A larger tidal volume requires a higher peak inspiratory pressure and this increases the likelihood of lung injuries.

(B) Insufficient ventilator tidal volume may induce atelectasis. 27. low 28. infants 29. Patients with extremely high airway resistance or low compliance are more likely to develop ventilator-related lung injuries because of the high peak inspiratory pressure requirement during mechanical ventilation.

16. C. 13/min 175

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176 SECTION 3

Answers to Workbook Questions

30. 4; 7; 10; PaCO2 31. plateau pressure 32. hypoventilation; acidosis 33. A. decreased pulmonary vascular resistance. 34. D. administration of glucocorticoid. 35. A. increase the FIO2. 36. increases; oxygen 37. simple V/Q mismatch 38. B. PAO2 = 178; FIO2 = 32% 39. FALSE 40. PaCO2; greater than 50 mm Hg 41. D. Oxygen therapy and ventilation 42. hypoventilation 43. intrapulmonary shunting; does not

56. 7. The optimal PEEP is 7 cm H2O. The SpO2 shows a continuing upward trend with the increasing PEEP level from 0 to 7 cm H2O. Beyond the optimal PEEP, the next PEEP setting (10 cm H2O) causes the SpO2 to drop from 91% to 89%. 57. FIO2; 40% 58. ARDS; mechanical ventilation 59. noncompliant; collapsed; increasing 60. outside; infant 61. PaCO2 62. higher; lower 63. rise 64. rise 65. power setting 66. 5 67. recruitment; 40; 3 to 5

44. well

68. recruitment; worsen in the first 30 min

45. CPAP; PEEP

69. chest radiograph

46. A. pulmonary hypotension.

70. amplitude of oscillation; tidal volume

47. increasing; decreasing

71. 4; wiggle

48. absolute

72. shoulder; mid-thigh

49. relative; overload

73. 10

50. hemoglobins

74. 5 to 6 Hz

51. 10

75. decreased; 1; 3

52. intrapulmonary shunting

76. higher

53. lung; spontaneous breathing

77. 33%; 1:2

54. mechanical ventilation

78. 50%

55. functional residual capacity; intrapulmonary shunting

79. increasing; decreasing 80. 100%

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CHAPTER 12 Management of Mechanical Ventilation 177

81. FIO2; 40%

103. shortens

82. FIO2; 40%; 22 to 24

104. drops below

83. PCV; 35; 20

105. A. respiratory distress.

84. alkalosis

106. exceeds

85. hyperventilation; acidosis

107. drops below; leakage

86. hyperventilation

108. B. inadequate inspiratory time.

87. FALSE

109. B. bronchodilator.

88. A. partially compensated metabolic acidosis.

110. pressure support ventilation; obstruction; greater than; insufficient

89. be delayed

111. decreasing; increasing

90. should not

112. decreases; increases

91. drops below

113. increases; increased

92. will

114. small

93. C. obstruction of ventilator circuit.

115. expands; is not

94. drops below

116. 120

95. high

117. more; less

96. A. disconnection of ventilator circuit.

118. low

97. Mechanical factors: kinking of circuit, kinking of ET tube, blocked exhalation manifold, water in circuit, herniated ET tube cuff, main stem bronchial intubation, high pressure limit set too low.

119. temporary

98. Patient factors: bronchospasm, coughing, breathing pattern out of synchronization with ventilator, secretions in ET tube, mucus plug.

122. TRUE

99. Tension pneumothorax; atelectasis; ARDS; pneumonia

125. hypoxia; closed inline; preoxygenating

100. exceeds; D. circuit disconnect. 101. FALSE 102. C. excessive inspiratory flow or pressure support.

39689_ch12_rev02.indd 177

120. C. MDI must be placed between the HME and patient. 121. week

123. smaller 124. 50%

126. FALSE 127. humidity 128. should not 129. D. elevation of head of bed to 5° to 10°.

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178 SECTION 3

Answers to Workbook Questions

130. as soon as possible

132. C. Hands

152. Reversal of the signs of ECF in excess indicates that the treatment is successful. These signs include: disappearance of P2 heart sound, reduction in pulse intensity, and clearing of pulmonary edema.

133. A. Manual ventilation bag

153. hypokalemia; decrease; acidosis

134. Gram stain; antibiotics

154. Sodium; 138; 142

135. pulmonary tuberculosis; Pneumocystis jiroveci

155. Potassium; 3; 5

131. B. Oropharynx

136. Culture and sensitivity 137. pathogen 138. D. heart rate. 139. 60%; extracellular; 40; intracellular 140. deficit 141. C. pulmonary edema. 142. decrease; 20 mL/hour 143. renal 144. diminished sensorium

156. 101; 105 157. TRUE 158. 27; abnormal 159. hyponatremia 160. hypernatremia 161. should not. Fluids that have no sodium should not be used to correct fluid deficit, because rapid movement of sodium-free fluid into the brain cells and kidney cells by the action of osmosis may cause edema and shutdown of these organs.

145. The cardiovascular signs of ECF deficit include tachycardia, hypotension, cold extremities, and poor peripheral pulse.

162. uncommon; deficit

146. fluid; ECF

164. hypokalemia

147. Reversal of the signs of ECF deficit indicates fluid replacement therapy is successful. These signs include: decrease in heart rate, increase in blood pressure and urine output.

165. hyperkalemia

148. uncommon; pulmonary edema 149. withhold; diuretic 150. Mannitol; excess 151. increase; poor. Patients with ECF excess typically have an increased urine output as a normal physiologic response to hypervolemia. Therefore, the volume of urine is not a good indicator of treatment success with diuretics.

39689_ch12_rev02.indd 178

163. 3; 5; narrow; intracellular

166. A. renal failure. 167. hypochloremia 168. B. KCl should be undiluted. 169. renal; calcium gluconate 170. C. hypocapnia. 171. decreases; interstitial 172. increased; increased 173. more; less 174. more

26/03/13 11:30 AM

CHAPTER 12 Management of Mechanical Ventilation 179

175. Hypophosphatemia means a serum phosphate level of less than 1 mg/dL. 176. Hypophosphatemia decreases the tissue ATP (adenosine triphosphate) level. In severe form, it may cause the patient to experience confusion, muscle weakness, congestive heart failure, and respiratory failure. 177. adjunctive 178. 10 to 12 179. lower 180. FALSE 181. barotraumas or volutrauma 182. plateau pressure 183. Complications of using low tidal volumes (e.g., 5 to 8 ml/kg) in mechanical ventilation include acute hypercapnia, increased work of breathing, dyspnea, severe acidosis, and atelectasis. 184. face-down 185. D. lower lung compliance. 186. Physiologic goals of prone positioning include: improvement of oxygenation; improvement of respiratory mechanics (e.g., compliance, work of breathing); enhancement of pleural pressure gradient, alveolar inflation, and gas distribution; reduction of inspiratory pressures; reduction of atelectasis and intrapulmonary shunting; facilitation of secretion removal; and reduction of ventilator-related lung injury.

39689_ch12_rev02.indd 179

187. oxygenation parameters; does not 188. increasing 189. B. OI = (mPaw × FIO2)∕PaO2. 190. increased; history of 191. decrease 192. 12 193. 6 194. C. Tension pneumothorax 195. upper 196. continuous or phasic 197. 5 to 20; oxygen or air; distal 198. above 199. continuous 200. continuous 201. last half of the expiratory phase 202. Phasic; 0% 203. TRUE 204. FALSE

26/03/13 11:30 AM

CHAPTER 13

Pharmacotherapy for Mechanical Ventilation

1. Some clinical signs of respiratory distress during mechanical ventilation are: an increase in peak inspiratory pressure, wheezing, hypoxemia, agitation, an increase in spontaneous rate, a decrease in SpO2, and tachycardia. 2. A. increasing the high pressure limit. 3. bronchodilation; bronchoconstriction 4. adrenergic 5. cholinergic 6. sympathomimetic 7. parasympatholytic 8. D. beta-3 (β-3). 9. B. Vasoconstriction, constriction of pupils

13. Examples of catecholamines include: norepinephrine, epinephrine, isoproterenol, and isoetharine. Examples of catecholamine derivatives include: metaproterenol, terbutaline, albuterol, and pirbuterol. 14. rapid; rapid; ineffective 15. Catecholamine derivatives have a more complex chemical structure than catecholamines. The modification in the chemical structure results in more specific beta-2 receptor binding (less cardiac adverse effects) and delayed degradation by COMT and MAO (longer duration of action). 16. B. sleepiness. 17. impede 18. anticholinergic; increase; bradycardia 19. C. bradycardia.

10. D. Decreased gastrointestinal activity

20. not well; fewer

11. A. Positive inotropic effect ( muscular contractility); positive chronotropic effect ( heart rate)

21. FALSE

12. C. Bronchodilation, peripheral vasodilation, decreased gastrointestinal activity

23. improve; heightening; improving

22. asthma and COPD

24. inhibition; antagonist; increase

180

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CHAPTER 13 Pharmacotherapy for Mechanical Ventilation 181

25. FALSE

49. acetylcholine

26. C. constipation.

50. competitive

27. 5 to 15 µg/mL

51. reversible

28. liver; liver

52. Depolarizing

29. liver; reduce; theophylline toxicity; excessive

53. Nondepolarizing

30. increase; higher 31. hormones; adrenal cortex 32. inflammation

55. increased; decreased; increased 56. nondepolarizing

33. B. Pneumocystis pneumonia.

57. potentiate; acetylcholine; acetylcholine; intense

34. no; should not

58. prolonged

35. 2 to 24 hours

59. release; enhances

36. TRUE

60. decreases; diminishes

37. The three general functions of corticosteroids are

61. nondepolarizing; depolarizing

(1) carbohydrate metabolism, (2) immunosuppression, and

62. increase; decrease 63. intensifies; diminishes

(3) reduced inflammation.

64. TRUE

38. Candida; rinsing and gargling

65. A. apnea.

39. prolonged

66. histamine

40. B. a tidal volume of at least 200 mL.

67. Bradycardia, tachycardia, arrhythmias, and circulatory collapse are some adverse effects of neuromuscular blocking agents.

41. A. sedating the patient. 42. increased; reduced; reduced 43. FALSE 44. acetylcholinesterase 45. depolarization; contraction 46. TRUE 47. inhibits; impossible; depolarizing 48. is no; completely

39689_ch13_rev02.indd 181

54. D. Rh factor.

68. genetic; skeletal 69. rapidly 70. capnography; CO2 71. dantrolene sodium (Dantrium) 72. blockade 73. four

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182 SECTION 3

Answers to Workbook Questions

74. decreases 75. one or two; 80% to 90%

97. E. Decrease of ventilatory efficiency and hypoventilation

76. widely; lift; 5

98. B. Formation of deep vein and pulmonary thrombosis

77. –25; 900

99. A. Delay of bowel and gastric function

78. A. having trouble breathing.

100. central nervous

79. central; more

101. The primary CNS effects caused by activation of the mu, kappa, and sigma receptors are sedation, hypnosis, and delirium, respectively.

80. facilitate 81. intravenous; gastrointestinal; slow; intramuscular

102. agonists; antagonists

82. liver

103. agonists

83. cost

104. antagonist

84. B. combativeness.

105. reverse; reverse; severe pain and spontaneous breathing

85. D. withdrawal syndrome of benzodiazepines.

87. A. decrease of mean arterial pressure.

106. Sedation, respiratory depression, and shallow breathing are the major adverse effects of opioid analgesics on the central nervous system.

88. variable; essential

107. TRUE

89. II; V

108. A. direct vasoconstriction.

90. sedation; paralyzed

109. D. combine low-dose opioid analgesic and sedative.

86. depression; opioid analgesics

91. autonomic nervous; inadequate

110. FALSE

92. B. Fast onset/Duration is short initially; multiple doses result in prolonged effect.

111. contraction

93. C. Intermediate onset/Duration is intermediate.

113. A. bradycardia.

94. A. Fast onset/Duration is short but may be prolonged if not carefully dosed.

114. Barbiturates have limited applications in patients on mechanical ventilation because they tend to cause respiratory and cardiovascular depression.

95. D. Breakdown of body tissue and increase of blood clotting

115. C. management of pain.

96. C. Increase of blood pressure and heart rate

39689_ch13_rev02.indd 182

112. physical dependence

116. 8 to 12; 20 117. 4 to 12; long-acting

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CHAPTER 13 Pharmacotherapy for Mechanical Ventilation 183

118. more 119. venodilation; hypotension; inadequate 120. Adverse respiratory effects of barbiturates include: blunted ventilatory response to hypoxia and hypercapnia, reduced tidal volume, and reduced respiratory frequency. 121. increase; decreasing 122. do not; heighten

134. D. all of the above (intravenous route, intramuscular route, oral route). 135. increase; blocking 136. Interference with the normal motor function is the primary adverse effect of blockade of dopamine receptors. 137. QT; tachycardia 138. TRUE 139. without

123. propofol; haloperidol; dexmedetomidine; nitric oxide

140. TRUE

124. intravenous

141. A. control of intracranial pressure.

125. enhancement

142. agonist

126. B. tachycardia.

143. hypotension; bradycardia; arrest

127. Propofol adds to a patient’s total caloric intake because it is formulated in an oil-in-water vehicle. The soybean oil in this vehicle contributes a significant amount of calories from fat.

144. hypotension

128. TRUE 129. no; often 130. does not; advantage 131. gradually 132. Delirium may be caused by medications or other substances (e.g., alcohol, analgesics, anticholinergics) or it may be caused by certain clinical conditions (e.g., fever, head injury, hepatic failure). By withdrawing these drugs or by reversing the clinical causes, haloperidol may not be needed.

145. C. pleural effusion. 146. vasodilation 147. Nitric oxide (NO) may be converted to nitrous oxide (NO2) when exposed to oxygen. NO and NO2 may in turn be converted to nitric acid (HNO3) and nitrous acid (HNO2)—both chemicals that can cause lung inflammation (interstitial pneumonitis). 148. methemoglobin 149. asymptomatic; may 150. 20% and 45% 151. constant; continuous

133. delirium

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CHAPTER 14

Procedures Related to Mechanical Ventilation

1. thoracostomy tube; pleural space

16. TRUE

2. B. pneumonia.

17. does

3. relative

18. hinder

4. during

19. will not

5. late

20. collection

6. sharp

21. D. fluid level in chamber 3 (distal to the patient).

7. Fr 8. 28 to 32 9. children 10. 16 to 20 11. To treat pneumothorax, the chest tube is usually placed at the second or third intercostal space anteriorly along the midclavicular line or midaxillary line.

22. water seal 23. distal; 10 24. suction 25. –10 to –20 26. FALSE 27. A. vacuum level is set too high.

12. To drain pleural fluid, the chest tube is usually placed from the fourth to sixth intercostal space at the midaxillary line.

28. suction

13. over; below

30. A. are working properly.

14. Operative

31. D. A and B only (an air leak in the drainage system, the presence of air in the pleural space).

15. smaller; higher

29. decrease

184

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CHAPTER 14 Procedures Related to Mechanical Ventilation 185

32. increase; decrease

58. TRUE

33. 100 mL

59. Hypoxemia and arrhythmias

34. water seal

60. gag reflex

35. lower

61. sterilized

36. FALSE

62. less than

37. glass

63. diagnostic procedures

38. D. insertion of difficult airway.

64. tertiary medical care or procedures

39. diagnostic 40. B. administration of bronchodilator.

65. D. insufficient nursing and respiratory care staff in the intensive care unit (ICU).

41. channel outlet

66. FALSE

42. Lidocaine; via aerosol

67. E. Gloves (sterile and clean)

43. 5 to 10 mL; 1 to 4%

68. D. Stethoscopes

44. Atropine sulfate

69. B. Intubation supplies (laryngoscope handles and blades, fresh batteries, endotracheal tubes, etc.)

45. morphine sulfate 46. sedation 47. TRUE 48. FALSE 49. pulse oximeter 50. tidal volume; increased 51. saline 52. tissue 53. Transbronchial lung biopsy 54. beyond; is no 55. tissue or loosened cell specimens 56. FALSE 57. C. plugging the airway where bleeding occurs.

39689_ch14_rev02.indd 185

70. A. Oxygen cylinders (full and with wrench) 71. B. distance between hospitals. 72. Boat 73. FALSE 74. ground ambulance 75. Jet 76. nonpressurized 77. TRUE 78. hyperventilation; irregular 79. FALSE 80. TRUE 81. expired volume; tidal volume

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186 SECTION 3

Answers to Workbook Questions

82. rarely

86. manual ventilation

83. is

87. pulse oximeter; FIO2

84. throughout the entire period

88. TRUE

85. after the patient has been stabilized from the transport

89. FALSE

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CHAPTER 15

Critical Care Issues in Mechanical Ventilation

1. nonhomogenous; different

19. similar

2. increases

20. cardiogenic; elevated

3. noncompliant; compliant

21. <50 cm H2O; <35 cm H2O; <30 cm H2O; <10 cm H2O

4. FALSE 5. A. PaO2/FIO2 ≤300 mm Hg regardless of PEEP level.

22. <30 cm H2O 23. High; high

6. ALI

24. lower

7. ARDS

25. increased

8. left-heart dysfunction or failure

26. low

9. can

27. tidal volume; PaCO2

10. Direct

28. 4 to 7 mL/kg

11. direct

29. tidal volume; plateau pressure; plateau pressure

12. Indirect 13. indirect

30. acidosis

14. oxygenation and ventilation

31. D. B and C only (bicarbonate, tromethamine).

15. early

32. Tromethamine; decreasing

16. follow

33. high

17. hypoxemia

34. A. decrease in peak inspiratory pressure.

18. bilateral

35. volume-controlled ventilation; A/C 187

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188 SECTION 3

Answers to Workbook Questions

36. <30 cm H2O; >88% 37. 10 38. optimal PEEP 39. FALSE 40. is; does not 41. pressure-controlled ventilation; 20; 35 42. 90% and 94%; 2 43. immediately before the SpO2 drops below 90%

62. Energy depletion and failure → Depolarization → Excessive glutamate discharge in synaptic cleft → Opening of Ca++ channels → Influx of Ca++ into neurons → (1) Activation of catabolic enzymes and (2) Activation of NO synthase and increased NO production → Cerebral cellular injury 63. direct; indirect 64. mild 65. 70 to 80 mm Hg; decrease 66. FALSE

44. 100%; CPAP; 40

67. D. vasodilators.

45. pulmonary edema

68. absolute; blood replacement

46. FALSE

69. relative; treatment of septicemia

47. face-down; Trendelenberg; lower

70. low; high

48. lower

71. not necessary; stay below

49. >10 cm H2O; ≥60%

72. vasopressors

50. newly acquired; 48

73. 90 mm Hg

51. B. obesity.

74. decrease

52. FALSE

75. TRUE

53. TRUE

76. reduces oxygen consumption and effects of cerebral hypoxia

54. for more than 7 days 55. A. Electrolytes 56. 30 to 45 degrees; at all times; when visibly soiled

77. A. severe hypoxia. 78. TRUE 79. 85 to 90%; low; cannot

57. FALSE

80. increase; decreased

58. removing subglottic secretions

81. 20 mm Hg

59. broad-spectrum; before

82. 70 mm Hg

60. brain

83. primary

61. C. Increase in cerebral perfusion pressure

84. Secondary

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CHAPTER 15 Critical Care Issues in Mechanical Ventilation 189

85. quickly

93. 13 to 14

86. acceleration

94. severe

87. deceleration

95. A. eye opening, motor response, verbal response.

88. pressure wave 89. ICP

96. D. perform and evaluate chest radiography.

90. makes contact with the prominent edges of the dural openings

97. systolic

91. downward

98. 26 torr; 24

92. Unilateral

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CHAPTER 16

Weaning from Mechanical Ventilation

1. 48 2. longer; more

17. PaO2 (without PEEP) >60 mm Hg at FIO2 up to 0.4

3. are

18. PaO2 (with PEEP <8 cm H2O) >100 mm Hg at FIO2 up to 0.4

4. 48

19. SaO2 >90% at FIO2 up to 0.4

5. spontaneous breathing

20. PaO2/FIO2 (P/F) >150 mm Hg

6. B. Fever, infection, sleep deprivation

21. QS/QT <20%

7. C. Arrhythmias, abnormal blood pressures, hypotension

22. P(A-a)O2 <350 mm Hg at FIO2 of 1.0

8. A. Nutritional deficit, pH imbalance 9. D. A and B only (readiness of a patient to begin the weaning trial; likelihood of weaning success).

23. Vital capacity >10 mL/kg 24. Maximum inspiratory pressure >–25 to –30 cm H2O in 20 sec 25. Static compliance 30 mL/cm H2O

10. most

26. VD/VT <60%

11. Spontaneous breathing trial tolerates 20 to 30 min

27. ventilatory

12. PaCO2 <50 mm Hg with normal pH 13. Vital capacity (VC) >10 mL/kg 14. Spontaneous VT >5 mL/kg 15. Spontaneous f <35/min 16. f/VT <100 breaths/min/L

28. 35; 45; compensated; higher 29. An equilibration period of spontaneous breathing is needed to obtain the spontaneous effort based on the patient’s actual ventilatory and oxygenation requirement. 30. vital capacity; require

190

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CHAPTER 16 Weaning from Mechanical Ventilation 191

31. less than; less than

56. 100

32. fast; poor

57. inefficient; larger

33. less; high

58. inefficient; less than

34. increased, acidosis; increased

39. B. 450 mm Hg, 18%

59. To measure the f/VT ratio (rapid shallow breathing index), the patient is taken off the ventilator and allowed to breathe spontaneously for at least 3 min or until reaching a stable breathing pattern. The spontaneous minute volume (VE) and frequency (f) are measured. The average VT (in liters) is calculated by dividing the VE by f. The f/VT ratio is obtained by dividing the f by VT.

40. 2

60. B. 61; successful weaning outcome

41. intrapulmonary shunt

61. 30

42. higher

62. TRUE

43. pulmonary reserve

63. should not

44. Vital capacity and maximum inspiratory pressure are two measurements that require active patient effort. Lack of understanding or poor patient effort may lead to invalid (low) measurements.

64. 20 to 30

35. increased; carbohydrate 36. do not; arterial oxygen content 37. pulmonary perfusion; hypoxemia 38. B. 29%, significant

45. maximal inspiration 46. 10 47. negative; occluded 48. –30 49. low; high; high 50. plateau 51. greater

66. 30 67. 8; 10 68. is not 69. decreased; 1 to 3 70. 5 to 15; 10 to 15; 25 71. 3 to 6; 5 72. 5 73. 30

52. peak airway; plateau pressure

74. PaO2 ≤60 mm Hg on FIO2≥50%

53. Pressure support ventilation

75. SaO2 <90% on FIO2≥50%

54. FALSE 55. A. 25%

39689_ch16_rev03.indd 191

65. TRUE

76. PaCO2 >50 mm Hg or an increase in PaCO2 >8 mm Hg from baseline 77. pH <7.32 or a decrease in pH ≥0.07 from baseline

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192 SECTION 3

Answers to Workbook Questions

78. f/VT >100 breaths/min/L 79. spontaneous f >35/min or increase by ≥50% from baseline 80. heart rate >140 beats/min or increase by ≥20% from baseline 81. Systolic BP (high) >180 mm Hg or increase by ≥20% from baseline 82. Systolic BP (low) <90 mm Hg 83. 40 84. artificial airway 85. pressure support ventilation 86. adjusted automatically by the ventilator

100. Changing blood pressures by 20 mm Hg systolic or 10 mm Hg diastolic; Increasing heart rate by 20/min, or >110/min 101. Decreasing VT to <250 mL; Increasing f to >30/min; Increasing (f/VT) ratio to >100 breaths/min/L; Decreasing MIP to <–20 cm H2O; Decreasing CST to <30 cm H2O/L; Increasing VD/VT to >60% 102. Weaning failure is generally related to: (1) increase of airflow resistance, (2) decrease of compliance, or (3) respiratory muscle fatigue. 103. 8; glottis 104. 1 in.

89. tidal volume

105. displayed prominently. The cut section of an ET tube should be displayed prominently so that others would not presume that an uncut tube had been moved deep into the trachea or bronchus.

90. exhalation; inhalation

106. C. use of pulse oximeter.

91. FALSE

107. Low

92. suggested

108. Clinical conditions that may lead to a decreased static compliance include: atelectasis, adult respiratory distress syndrome (ARDS), tension pneumothorax, obesity, and retained secretions in the lungs.

87. inspiratory 88. SIMV frequency

93. C. PaO2/FIO2 <150 mm Hg. 94. 3 95. 30 96. stopped 97. hyperventilate; decrease; assess the patient and find the cause of hyperventilation 98. A. eucapnic ventilation. 99. Increasing PaCO2 to >50 mm Hg; Decreasing pH to <7.30; Decreasing PaO2 to <60 mm Hg; Decreasing SaO2 or SpO2 to <90%; Decreasing PaO2/FIO2 to <150 mm Hg

39689_ch16_rev03.indd 192

109. Clinical conditions that may lead to a decreased dynamic compliance include: small ET tube, secretions in ET tube, kinking of ET tube, bronchospasm, and airway obstruction. 110. increased 111. low; high 112. TRUE

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CHAPTER 16 Weaning from Mechanical Ventilation 193

113. B. excessive nutritional intake.

39689_ch16_rev03.indd 193

114. Brief spontaneous breathing trials and use of pressure support ventilation may help to improve the functions of the atrophied muscles and the diaphragms.

117. over a period of time. Discussions on a patient’s informed consent should be done over a period of time so that emotion, pain, and other intangible factors would not interfere with an informed and valid decision.

115. withdrawal

118. hopeless

116. death

119. TRUE

02/04/13 11:46 AM

CHAPTER 17

Neonatal Mechanical Ventilation

1. C. premature rupture of amniotic membrane. 2. obstructive lesions 3. B. administration of oxygen. 4. 10; 1 and 5 5. 7; 20 6. 7. The Apgar criteria and (scores) are: heart rate of 110/min (2), irregular and shallow respiratory effort (1), well-flexed muscle tone (2), grimace upon stimulation (1), and pink body but blue extremities (1). 7. 1; 0; 00 8. B. 2.5 9. C. 3.0 10. D. 3.5 11. 20 12. Between intubation attempts, the neonate should be manually ventilated with 100% oxygen until an acceptable SpO2 is obtained. 13. 6

15. lipids 16. phospholipid 17. lower 18. direct instillation; trachea 19. Prophylactic 20. D. all of the above (birth weight less than 1,250 g., gestational age at or less than 26 weeks, PaO2/PAO2 less than 0.22). 21. Therapeutic 22. D. hyperventilation. 23. A. respiratory alkalosis. 24. synthetic; cow; pig 25. respiratory distress syndrome 26. does not; intraventricular hemorrhage 27. FALSE 28. increasing; reducing 29. TRUE 30. 4 to 7 cm H2O; 5 to 10 LPM

14. surfactant deficiency 194

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CHAPTER 17 Neonatal Mechanical Ventilation 195

31. pressure

48. inspiratory; condensation

32. D. all of the above (patient’s compliance, airflow resistance, pressure setting).

49. inside. When the distal temperature probe is placed at the patient connection inside a heated incubator, it senses the incubator temperature (which may be higher than the heated wire temperature limit). This causes premature shutdown of the heated wire function.

33. decreasing; increasing 34. increases. As the patient’s respiratory condition improves, the compliance is increased or the airflow resistance is decreased. This allows the PCV mode to deliver larger tidal volumes at the same pressure setting. 35. increased; decreased. As the patient’s compliance is increased or the airflow resistance is decreased, larger tidal volumes will result from the same pressure setting. The pressure limit should be reduced to avoid excessive volume, pressure, and the incidence of barotrauma. 36. tidal volume 37. rather stable 38. increases 39. decreasing 40. tidal volume 41. unaccounted for 42. low 43. low 44. low 45. drops 46. Water accumulated in the ventilator tubing may cause an increased airflow resistance, a higher risk of contamination, and the potential of accidentally draining the water into the patient’s lungs.

50. A. outside the inlet to the incubator. 51. A. heart rate. 52. A. increasing the pressure limit. 53. D. Correction of metabolic acidosis 54. low 55. lower, higher 56. Initial PIP: 15 to 20 cm H2O (normal compliance); 20 to 30 cm H2O (low compliance) 57. Initial PEEP: 3 to 5 cm H2O (normal compliance); up to 8 cm H2O (low compliance) 58. Initial VT: 4 to 8 mL/kg (normal compliance); 6 to 10 mL/kg (low compliance) 59. Initial frequency: 25 to 40/min (normal compliance); up to 150/min (low compliance especially with air leak) 60. Initial Flow rate: 6 to 8 L/min (normal compliance); 6 to 8 L/min (low compliance) 61. Initial I time: 0.3 to 0.5 sec (normal compliance); Change according to frequency to maintain an I:E ratio of 1:1 (low compliance) 62. Initial I:E ratio: 1:1.5 to 1:2 (normal compliance); at least 1:1 (low compliance).

47. inspiratory

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196 SECTION 3

Answers to Workbook Questions

63. Initial FIO2: Set to keep patient pink using SpO2 or PtcO2 readings (normal or low compliance); use appropriate PEEP (low compliance) 64. C. 50 mL 65. 90 to 95% 66. C. flow, inspiratory time, expiratory time. 67. high; air trapping 68. 5; 3 to 7 69. >50; 35; 45; 7.30; 7.45 70. lower 71. small 72. Since HFV delivers small tidal volumes, ventilation can be achieved at relatively low pressures, greatly reducing the risk of barotrauma.

84. C. in tandem with conventional mechanical ventilation. 85. C. It provides pressure support ventilation. 86. Necrotizing tracheobronchitis is the major hazard of HFJV caused by the impact of high-pressure gas on the wall of the airways. 87. internally 88. Other hazards of HFJV include gas trapping, hyperinflation, obstruction of the airway with secretions, hypotension, and inflammatory injury to the trachea. 89. Auscultation of the breath sounds and heart sounds is difficult due to the constant vibration and noise produced by the jet ventilator. 90. decrease; hypercapnia; hypoxemia 91. decrease; increase

73. conventional mechanical ventilation

92. transillumination

74. RDS

93. 480; 1800; 8; 30

75. 60

94. C. inspiratory and expiratory

76. frequency; tidal volume

95. TRUE

77. conventional; 60; 150

96. mechanical ventilation

78. High frequency positive pressure ventilation is indicated in patients who remain hypoxemic or hypercapnic despite adequate and appropriate conventional ventilation.

97. TRUE

79. decrease

100. prevents; lung injuries

80. directly; increase

101. surfactant

81. pulse of gas

102. not as good as; high

82. 240; 660; 4; 11

103. bradycardia; hypotension

83. A. pulmonary hypotension.

104. oxygenation status

98. greater than 10 99. diffuse; without

105. power setting

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CHAPTER 17 Neonatal Mechanical Ventilation 197

106. 3 to 4

124. A. 588 mm Hg

107. 10 to 15; 20

125. 35; 60; high

108. B. inspiratory time %.

126. B. 33

109. FALSE

127. 35; 50; 7.25; hypotension

110. 8 to 15

128. right; internal; aortic arch; carotid

111. lower

129. Venoarterial ECMO supports the cardiac function of the patient because blood return to the aortic arch is facilitated by the ECMO machine, relieving some of the cardiac workload.

112. 8th 113. pressure-controlled ventilation; volume-controlled ventilation 114. tidal volume; tidal volume; flow 115. D. A and B only (tidal volume, maximal peak inspiratory pressure). 116. expired tidal volume; inspiratory pressure 117. liquids; respiration; low; inflation pressure 118. outside the body 119. 34; 2,000; intracranial 120. two; chronic lung disease 121. TRUE 122. C. Oxygen consumption and cardiac output

130. right; right; right atrium; femoral vein 131. FALSE 132. Pulmonary complications of ECMO include: bleeding (secondary to the high level of heparin required for anticoagulation), intracranial hemorrhage, seizures, pulmonary edema, release of vasoactive substances (secondary to platelet-membrane interaction and pulmonary hemorrhage). 133. Two major cardiovascular complications of ECMO are: hypotension (in hypovolemic patients) and hypertension (in hypervolemic patients). 134. Anemia; leukopenia; thrombocytopenia; consumption

123. 605; 620; severe

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CHAPTER 18

Mechanical Ventilation in Nontraditional Settings

1. D. reduction of stress level of family members. 2. more active 3. psychologic 4. FALSE 5. B. dedication and commitment of home care team members. 6. The need for mechanical ventilation at home may be indicated if the answer is YES to questions 1, 2, and 3, and NO to question 4.

7. D. Airflow obstruction, excessively high compliance, air trapping, acute exacerbation 8. C. Reduction of lung volumes and capacities, deadspace ventilation, muscle fatigue 9. A. Inefficient ventilatory muscle, atelectasis, pneumonia 10. B. Apnea, chronic hypoventilation, atelectasis, pneumonia 11. chronic; compensated

(1) Does the patient have a disease state (e.g., high cervical spine injury, severe respiratory muscle paralysis) which may result in persistent ventilatory failure and an inability to be completely weaned from invasive ventilatory support?

12. acute; chronic

(2) Does the patient exhibit clinical characteristics (e.g., impending ventilatory failure, cerebral hypoxia) that require mechanical ventilation?

14. C. pH = 7.27, PaCO2 = 74 mm Hg, PaO2 = 43 mm Hg, HCO3− = 33 mEq/L

(3) Is the patient clinically stable enough to be managed outside an acute care setting? (4) Are there other noninvasive alternatives besides artificial airway and mechanical ventilation (e.g., diaphragm pacing, pneumobelt) suitable for the patient?

13. Acute exacerbation of COPD occurs when an otherwise stable COPD patient develops acute ventilatory failure as a result of infection, surgery, or other secondary causes.

15. COPD patients are typically more difficult to wean off mechanical ventilation because of airflow obstruction, loss of elastic recoil, air trapping, and presence of other coexisting medical problems. 16. lung volumes; rapid and shallow 17. increased; stable

198

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CHAPTER 18 Mechanical Ventilation in Nontraditional Settings 199

18. higher; low 19. healthy 20. Restrictive lung patients may need mechanical ventilation when they develop hypoventilation, lung infection, pneumonia, atelectasis, and respiratory muscle fatigue. 21. D. mechanical ventilation. 22. FALSE 23. Persistent hypoventilation tends to cause lung infection, atelectasis, and pneumonia. 24. A patient who requires frequent monitoring and laboratory tests or one who is clinically unstable should be ruled out for receiving mechanical ventilation at home. 25. B. patient. 26. advantages and disadvantages 27. The advantages of receiving mechanical ventilation at home include an opportunity for the patient to stay closer to family members and to live in a familiar environment. 28. The disadvantages of leaving the hospital are the feeling of isolation from professional help and the assumption of medical care by oneself and by family members. 29. Decisions made under a hypoxic, confused, or emotional condition will likely lead to inaccurate perceptions and poor transition from the hospital to the home care setting. 30. The desires of the family members must be considered because they are the key persons taking care of the patient and ventilator at home. Successful outcome very much depends upon their commitment and active involvement.

39689_ch18_rev02.indd 199

31. Equipment and professional care are the two major expenses of home ventilator care. 32. lower than 33. physical resources 34. D. positive pressure or negative pressure ventilators 35. A backup ventilator should be available in a home care setting if the patient is totally dependent on mechanical ventilation. 36. chest cuirass 37. raincoat or wrap 38. The pneumobelt is a corsetlike belt (resembling an undergarment) attached to a positive pressure generator. When the positive pressure inflates the belt, it squeezes the abdomen and pushes the diaphragm upward. An alternating sequence of positive pressure and ambient pressure provided to the pneumobelt produces active ventilation. 39. motion 40. augments; phrenic nerves 41. Since a home care ventilator is often maintained by nonmedical personnel, it should be extremely dependable for safety reasons. 42. A home care ventilator should be simple to operate in order to minimize confusion and frustration imposed on the patient and other nonmedical personnel. 43. Ventilators with built-in rechargeable battery packs can be very useful in the event of brief power failure. The patient may also take advantage of this feature to make physician office visits or brief shopping trips. 44. severely injured

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200 SECTION 3

Answers to Workbook Questions

45. natural

70. 6,000

46. man-made

71. brand-specific

47. TRUE

72. FALSE

48. inhibitors; sudden surge

73. would not

49. lower

74. objective; do not rely

50. mechanical ventilation

75. FALSE

51. 60,000

76. Using the exclusion criteria adopted by the NYS DOH, the heart, lungs, liver, kidneys, and nervous system are assessed for organ failure.

52. Triage 53. severely 54. first-responders 55. FALSE 56. before 57. children 58. prehospitalization

77. must 78. Four indications for hyperbaric oxygen (HBO) are: diver decompression, high-altitude decompression sickness, carbon monoxide poisoning, and myonecrosis and gas gangrene of soft tissues due to clostridial infection. 79. 0.3 vol%

59. C. Sort, Assess, Life-saving interventions, Treatment/Transport.

80. 2 vol%

60. TRUE

81. 6 vol%

61. FALSE

82. would

62. FALSE

83. rapidly; joints and tissues

63. during hospitalization

84. B. ascends rapidly from low altitude to high altitude over 18,000 ft.

64. 6 65. The criteria for scoring using the SOFA system are related to oxygenation, blood clotting, liver function, blood pressure, neurologic function, and kidney function.

85. rapidly; gradual 86. 5% 87. dissolved in plasma 88. Anaerobic; anaerobic

66. TRUE

89. water; decompression

67. palliation care

90. compression and decompression

68. 95%

91. tidal volume

69. 10 to 8

92. 6

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CHAPTER 18 Mechanical Ventilation in Nontraditional Settings 201

93. inverse

115. 5,000 ft to 8,000 ft

94. less; more; smaller

116. 8,000 ft; 59 mm Hg

95. increased

117. 10%

96. about the same as

118. 88% to 93%

97. mechanical respirometer

119. increase

98. expired tidal volume

120. expands; increasing

99. are transferred outside

121. pressure-

100. 100%

122. portable

101. manual

123. TRUE

102. TRUE

124. B. purchase an extra ticket for a seat adjacent to the traveler.

103. may 104. 3 105. 564 mm Hg; 59 mm Hg; high-altitude 106. acute mountain sickness 107. vasodilation 108. TRUE 109. noncardiogenic 110. pulmonary edema 111. ascent to high altitude 112. pulmonary edema 113. calcium

125. are not 126. personal traveling companion 127. decrease; increase 128. decreased; hyperinflation 129. increased; inadequate tidal volume 130. ascent; descent 131. hypoxia 132. are not 133. portable 134. are not

114. less; lower

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