Chapter 20: Pharmacology Test Bank

Multiple Choice

1. Which of the following effects is related to activation of -adrenergic receptor sites?

a. Activation of guanyl cyclase b. Skeletal muscle contraction c. Bronchial smooth muscle relaxation d. Release of inflammatory mediators

ANS: C

Activation of -adrenergic receptor sites on airway smooth muscle results in activation of adenyl cyclase, which increases the production of cyclic adenosine monophosphate (cAMP) resulting in bronchial smooth muscle relaxation and skeletal muscle stimulation. -agonists can also inhibit the release of inflammatory mediators through stabilization of the mast cell membrane, which will slow the progression of the inflammatory cascade.

REF: p. 373 a. Tremor b. Tachypnea c. Bradycardia d. Blurred vision

2. Which of the following adverse effects is likely to be experienced by patients who use nonselective 2-adrenergic agonists?

ANS: A

The most common adverse effect observed with the use of selective agents are tremors caused by stimulation of the 2-receptors in skeletal muscle, which is less likely with inhalational therapy than with parenteral or oral therapy. Tachycardia and vasodilatation are observed when -receptors are stimulated on the heart and peripheral vasculature. On initiation and with high-dose treatment, a reduction of serum potassium concentrations can also be seen.

REF: p. 374 a. It is composed of both (R)- and (S)-albuterol. b. The d-isomer is the most active compound. c. A dose of 0.63 mg is equipotent to 1.25 mg of racemic albuterol. d. The d-isomer possesses a longer duration of action.

3. Which of the following statements accurately describes levalbuterol?

ANS: B

Albuterol is composed of both (R)- and (S)-isomers of albuterol. Levalbuterol is the active isomer of albuterol (R-albuterol) and is indicated for the treatment or prevention of bronchospasms in adults and children. In studies of asthma treatment in the pediatric patient, levalbuterol has been compared with both racemic albuterol and placebo. In doses of 0.31 and 0.63 mg, levalbuterol produced an equipotent degree of bronchodilation, as measured by percent change from predose forced expiratory volume at 1 second (FEV1), as did comparable doses of 1.25 and 2.5 mg of racemic albuterol. This same study found that 0.63 mg of levalbuterol was equipotent to 1.25 mg of racemic albuterol, and 1.25 mg of levalbuterol was equipotent to 2.5 mg of racemic albuterol. Therefore, there is no demonstrable difference in terms of safety or effectiveness between levalbuterol and albuterol.

REF: p. 376

4. A patient with status asthmaticus has been admitted to the emergency department. The physician would like to try a 2-agonist that can be administered parenterally. Which of the following drugs should the therapist suggest? a. Terbutaline b. Levalbuterol c. Epinephrine d. Pirbuterol

ANS: A

Terbutaline is the only selective 2-agonist available in parenteral form for the emergency treatment of status asthmaticus in critically ill children.

REF: p. 377

5. The physician asks the therapist to recommend a long-acting -agonist for a patient. Which of the following medications should the therapist recommend? a. Levalbuterol b. Formoterol c. Metaproterenol d. Terbutaline

ANS: B

Formoterol is indicated for long-term, twice daily (morning and evening) administration in the maintenance treatment of asthma and prevention of bronchospasm in adults and children 5 years of age and older. Formoterol is also indicated for the acute prevention of EIB in adults and adolescents 12 years of age and older. Formoterol is available as a single agent in a hard gelatin capsule containing a dry powder blend of 12 µg of formoterol and 25 mg of lactose that is intended for oral inhalation only. Formoterol is also available in a solution for nebulization and in an MDI in combination with budesonide approved for use in patients 12 years of age and older.

REF: p. 378 a. Racemic epinephrine b. Ephedrine c. Norepinephrine d. Fluticasone

6. Which of the following medications is most suited for the treatment of postextubation edema?

ANS: A

Epinephrine is ineffective after oral administration because it is rapidly metabolized, and absorption is rapid following parenteral and inhaled administration. Acting at 2-receptors on bronchial smooth muscle, its effects following nebulized administrations are restricted to the respiratory tract, thus making it useful in the treatment of postintubation and infectious croup.

REF: p. 378

7. Which of the following medications is an effective adjunctive therapy in relieving bronchospasm in patients with acute bronchospasm when combined with albuterol? a. Pirbuterol b. Salmeterol c. Metaproterenol d. Ipratropium bromide

ANS: D

Aerosolized ipratropium is not sufficiently effective to be used as a single agent in the treatment of acute bronchospasms. When administered to children with severe asthma exacerbations, multiple doses of ipratropium and a -agonist reduced the number of hospitalizations and improved overall lung function.

REF: p. 379 a. Inform the nurse that this medication is contraindicated for patients with myasthenia gravis. b. Inform the nurse that the dose is incorrect. c. Inform the nurse that this medication is contraindicated in children. d. Mention nothing because the prescription is correct.

8. While working at the bedside of a small child who has myasthenia gravis, the therapist notices a new medication order prescribing glycopyrrolate for the control of secretions. What should the therapist do at this time?

ANS: A

Contraindications to glycopyrrolate are similar to other anticholinergic medications, including narrow-angle glaucoma, severe ulcerative colitis, tachycardia, paralytic ileus, or myasthenia gravis.

REF: p. 379

9. How long should a patient wait to receive the maximal benefit of inhaled corticosteroids? a. 48 hours b. 5 days c. 1 to 2 weeks d. 1 month

ANS: C

Maximal benefit may not be achieved for 1 to 2 weeks or longer after starting treatment.

REF: p. 380

10. Which of the following responses are considered adverse effects of inhaled corticosteroids?

I. Oropharyngeal candidiasis

II. Dry mouthIII. Wheezing IV. Dysphonia a. I and II only b. II and III only c. II and IV only d. I, III, and IV only

ANS: D

A majority of side effects attributed to corticosteroids are primarily seen with systemic therapy and not inhalational therapy. Following corticosteroid inhalation, local adverse events include oropharyngeal candidiasis, dysphonia, cough, wheezing, and dry throat. The dysphonia appears to be a direct effect of the steroid on the musculature that controls the vocal cords.

REF: p. 381 a. Decrease the dosage b. Use a dry powder inhaler c. Use a holding chamber device d. Brush teeth after each inhalation

11. To reduce the adverse effects of inhaled corticosteroids, what should the therapist recommend?

ANS: C

Proper inhalation technique, such as using a holding chamber device (e.g., spacer) or rinsing the mouth after each inhalation, may help decrease the risk of local adverse events.

REF: p. 381 a. Montelukast b. Omalizumab c. Zafirlukast d. Zileuton

12. Which of the following medications is the only drug that inhibits 5-lipoxygenase?

ANS: D

Zafirlukast and montelukast act by selectively antagonizing leukotriene binding to its cellular receptor, CysLT1, which prevents a cascade that leads to constriction of bronchial smooth muscle. Zileuton acts as a potent and selective inhibitor of leukotriene formation by inhibiting 5-lipoxygenase, the enzyme responsible for converting arachidonic acid to the cysteinyl leukotrienes.

REF: p. 382

13. Which of the following side effects are consistent with chronic administration of theophylline? I. Nausea

II. Vomiting

III. Tachycardia

IV. Central nervous system stimulationa. I and II only b. II and III only c. III and IV only d. I, II, III, and IV

ANS: D

The use of theophylline to treat chronic childhood asthma is problematic due to potentially serious short-term and long-term adverse events. Dose-related acute toxicities include tachycardia, nausea, vomiting, supraventricular tachycardia, central nervous system stimulation, seizures, headache, and electrolyte disturbances. Adverse events seen at therapeutic serum concentrations include insomnia, gastric upset, and hyperactivity.

REF: p. 383 a. Ipratropium bromide b. Magnesium sulfate c. Cromolyn sodium d. Methylprednisolone

14. Which of the following medications works to maintain the integrity of the mast cell?

ANS: C

Although the complete mechanism of action of cromolyn is unknown, it does inhibit mast cell degranulation after exposure to antigens, therefore blocking the release of histamine and leukotrienes. These actions inhibit the early asthmatic response through stabilization of the mast cell membrane. Cromolyn has no intrinsic bronchodilator, antihistaminic, anticholinergic, or vasoconstrictor activity.

REF: p. 384

15. Which of the following effects constitute adverse reactions to dornase alfa (recombinant human deoxyribonuclease I (rhDNase))?

I. Chest pain

II. Pharyngitis

III. Rash

IV. Hypovolemiaa. I and IV only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only

ANS: B

Common adverse events have included voice alteration, pharyngitis, laryngitis, rash, and chest pain. Other less common adverse events include respiratory symptoms, flu syndrome, malaise, hypoxia, and weight loss.

REF: p. 385

16. Which of the following agents should be considered in the rapid-sequence intubation of patients with status asthmaticus? a. Atropine b. Magnesium sulfate c. Halothane d. Ketamine

ANS: D

Ketamine is an anesthetic agent that produces anesthesia, sedation, and amnesia without significant respiratory depression. Because of its bronchodilating effects, ketamine has been used as part of rapid-sequence intubation in pediatric patients with status asthmaticus.

REF: p. 385

17. Which of the following benefits has been associated with the use of inhaled tobramycin?

I. Improvement of FEV1

II. Eradication of Pseudomona aeruginosa

III. Reduction in hospitalization

IV. Reduction in parenteral use of antibioticsa. I and IV only b. I, II, and III only c. I, III, and IV only d. I, II, III, and IV

ANS: D

Use of nebulized tobramycin can improve FEV1 by 7.8% to 12% in CF patients and potentially eradicate P. aeruginosa from the respiratory tract in early colonization and young patients. Several clinical studies have also shown a reduction in hospitalizations for acute exacerbations as have demonstrated benefits of parenteral use of antipseudomonal antibiotics in CF patients with varying degrees of disease severity.

REF: p. 386 a. Immediately after the antibiotic b. No more than 4 hours after administration of the antibiotic c. 15 minutes to 4 hours before each dose d. At the same time as the administration of the antibiotic

18. When should the therapist administer short-acting bronchodilators to improve penetration of inhaled antibiotics?

ANS: C

Short-acting bronchodilators provide a greater reduction in P. aeruginosa density as well as improved FEV1 and sputum drug concentrations when administered between 15 minutes to 4 hours before each dose.

REF: p. 387

19. Nebulized pentamidine should be administered in a negative pressure room and through which of the following nebulizer systems? a. Pari LC Plus b. Nebutech c. Respirgard II d. SPAG

ANS: C

Nebulized pentamidine should be administered in a negative pressure room and through a Respigard II, which routes exhaled breaths through a micro filter to avoid potential adverse events to health care workers in the immediate treatment area.

REF: p. 388 a. rhDNase b. RespiGam c. Omalizumab d. Palivizumab

20. Which of the following medications is a recombinant humanized monoclonal anti-IgE antibody use for the treatment of severe persistent asthma?

ANS: C

Omalizumab is a recombinant humanized monoclonal anti-IgE antibody that binds to the same receptor of the IgE molecule on basophils and mast cells. In turn omalizumab inhibits the release of free IgE from mast cells in response to an allergen exposure and has been shown to decrease the incidence of asthma exacerbations. Subcutaneous omalizumab is recommended as adjunctive therapy in patients 12 years of age and older who have allergies and severe persistent asthma that is inadequately controlled with the combination of high-dose inhaled corticosteroids and long-acting -agonists. There is no indication for the use of omalizumab in the treatment of other allergic conditions, including the relief of acute bronchospasms or status asthmaticus.

REF: p. 389

Chapter 21: Thoracic Organ Transplantation Test Bank

Multiple Choice

1. What typically makes lungs unsuitable for donation?

a. Pulmonary edema b. Platelike atelectasis c. Tracheal tear d. Tracheitis

ANS: A

Lungs are frequently infected and/or atelectatic or injured during prolonged intubation and ventilation, or unsuitable because of pulmonary edema, trauma, or aspiration.

REF: p. 398 a. If arrest is anticipated within the next 24 hours b. If arrest is anticipated within the next 12 hours c. If arrest is anticipated within the next 6 hours d. If arrest is anticipated within the next 1 hour

2. When could kidneys, liver, and lungs be procured for transplantation from a patient with anticipated cardiac arrest?

ANS: D

If circulatory arrest is anticipated within minutes of withdrawal of ventilatory support, organ donation may be possible. In that situation, the organ procurement center is contacted and recovery surgeons are notified and present in a nearby operating room at the time of extubation. If circulatory arrest occurs within 30 to 60 minutes, kidneys, livers, and lungs may be procured for transplantation.

REF: p. 399 a. Cardiomyopathy b. Massive myocardial infarction c. External pacemaker placement d. Primary pulmonary hypertension

3. Which of the following is the most common indication for heart transplantation?

ANS: A

In the 1980s the primary indication for heart transplantation was cardiomyopathy. However, in more recent years the proportion of transplantations for congenital heart defects has been increasing (see Table 21-2 in the textbook). Congenital lesions are the indication in 40% of patients, leading to heart transplantation in children younger than 1 year of age, especially in the United States, but only 25% in older children.

REF: p. 399 a. Cardiomyopathy b. Congenital cardiac lesions c. Valvular problems d. Lethal cardiac dysrhythmias

4. What is the predominant problem leading to heart transplantation in children younger than 1 year of age?

ANS: B

Congenital cardiac lesions are the predominant problem leading to heart transplantation in children younger than 1 year of age, whereas cardiomyopathy predominates in older children.

REF: p. 399 a. Cardiac dysrhythmias b. Sepsis c. Organ rejection d. Graft failure

5. What is the predominant cause of early postoperative mortality associated with heart transplantation?

ANS: D

Early postoperative mortality arises from graft failure and, less commonly, cardiac rhythm disorders.

REF: p. 399

6. Which of the following problems is associated with long-term heart transplant patients? a. Coronary artery disease b. Recurrent pulmonary edema c. Coronary revascularization d. Cardiac dysrhythmias

ANS: A

A troublesome and life-limiting problem in long-term heart transplant survivors, regardless of age, is the development of premature coronary artery disease or coronary vasculopathy, also known as graft atherosclerosis.

REF: p. 400 a. Cardiomyopathy b. Ventricular septal defect c. Cardiac pacemaker abnormalities d. Hypoplastic left ventricle

7. Which of the following cardiac problems is responsible for the vast majority of neonatal cardiac transplants?

ANS: D

Neonatal heart transplantation has been used almost exclusively for hypoplastic left-heart syndrome, which is uniformly fatal if surgical correction or transplantation is not offered. The current experience with either surgical correction or transplantation does not clearly indicate which is more appropriate to optimize survival.

REF: p. 400

8. What are some reasons for the decline in heart–lung transplants among infants?

I. Difficulty in obtaining a donor

II. Avoidance of cardiac rejection

III. Averting premature coronary artery disease

IV. Reducing the length of time on cardiopulmonary bypassa. I and IV only b. II and III only c. I, II, and III only d. II, III, and IV only

ANS: C

With the ability to successfully transplant a single lung or two lungs, the use of heart–lung transplantation for pulmonary disease has decreased. Multiple reasons exist for the decline in heart–lung transplants, including (1) the limited availability of satisfactory coupled heart–lung donations from a single donor (governed in part by the distribution algorithm unique to each country), (2) the practical advantage of using the heart–lung block for three separate donations (one heart and two single lungs), (3) the decreased risk of cardiac rejection if isolated lung transplantation is performed, and (4) the decreased risk of premature coronary artery disease.

REF: p. 400 a. Severe asthma b. Cystic fibrosis c. Acute respiratory distress syndrome d. Tetralogy of Fallot

9. Which of the following chronic lung diseases is the most common indication for bilateral lung transplantation?

ANS: B

Cystic fibrosis is the most common indication for bilateral lung transplantation, almost exclusively above 6 years of age.

REF: p. 400

10. Which of the following conditions is a frequent cause of graft failure occurring within the first 90 days after lung transplantation? a. Organ rejection b. The potency of the antirejection drugs among this population c. Ischemia-reperfusion d. High pulmonary vascular pressures

ANS: C

Deaths within the first 90 days after lung transplantation (early deaths) result most commonly from graft failure due to ischemia–reperfusion injury. Less common are surgical problems such as airway anastomotic dehiscence or massive hemorrhage. Even less common are overwhelming infection, either systemic or pulmonary; multiple organ failure; or acute graft rejection. Late deaths are generally related to infection or bronchiolitis obliterans, usually a manifestation of chronic rejection.

REF: p. 401

11. Which of the following medications are used as antirejection agents?

I. Trimethoprim-sulfamethoxazole

II. Cyclosporine

III. AzathioprineIV. Mycophenolate mofetil a. I and III only b. II and III only c. I, II, and IV only d. II, III, and IV only

ANS: D

Most immunosuppressive regimens for organ transplantations (thoracic and other solid organs) include the combined use of cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and prednisone. Tacrolimus and mycophenolate mofetil are now the most commonly used immunosuppressants and are generally needed for the life of the transplant recipient.

REF: p. 402

12. Which of the following conditions are considered complications of thoracic organ transplantation?

I. Respiratory failure

II. Bronchiolitis obliterans

III. Lung allografts

IV. Infection a. III and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: C

The complications of thoracic organ transplantation can be grouped into the following categories: (1) respiratory failure and related problems, (2) acute rejection, (3) infection, (4) chronic rejection or bronchiolitis obliterans, (5) drug toxicity, and (6) other complications.

REF: p. 402 a. The patient has experienced ischemia–reperfusion injury. b. The patient is developing bronchiolitis obliterans. c. A pneumonia-like infection has occurred. d. Graft failure is present.

13. Twenty-four hours after a pediatric patient has undergone lung transplantation, the therapist notices on the patient’s chest X-ray features consistent with pulmonary edema. How should the therapist interpret this finding?

ANS: A

Reperfusion injury, which occurs in 10% to 20% of lung transplants, mimics the acute respiratory distress syndrome clinically and radiographically. On chest radiography, pulmonary edema, either immediately after transplantation or within the first 72 hours, is usually a sign of ischemic injury or reperfusion injury. Interruption of the pulmonary lymphatics, which are cut during the surgery, also contributes to pleural, alveolar, and interstitial fluid accumulation.

REF: p. 402

14. The therapist notices the following signs in a pediatric patient who recently had a heart transplant:

Decreased cardiac contractility

Congestive heart failure

Tachycardia

Tachypnea

Malaise a. These signs are normal and expected after heart transplantation. b. The patient has become hypovolemic. c. The patient requires cardioversion. d. The patient is in rejection.

How should the therapist interpret these signs?

ANS: D

In the lung transplant patient, tachypnea, bibasilar inspiratory crackles on auscultation, increased interstitial infiltrates on chest radiography, and hypoxemia by pulse oximetry are often associated with acute rejection (see Figure 21-6 in the textbook). For older patients who can perform spirometry, a drop in pulmonary function, either restrictive or obstructive, is often the most sensitive indicator of acute rejection.

REF: p. 403 a. Because the lung is in direct contact with the external environment b. Because the entire cardiac output flows through the lungs multiple times per minute c. Because the pulmonary circulation is more prone to hypertensive episodes than other organs d. Because lung chemotaxis is compromised and fewer neutrophils populate the transplanted lungs

15. Why does the pulmonary infection rate for lung transplantation appear to be higher than with other solid organ transplants?

ANS: A

Although pulmonary infections are common because of the immunosuppression required with any solid organ transplant, the pulmonary infection rate for lung transplantation appears to be high. This may be partially explained by the fact that the lung is the only solid organ that, after transplantation, is regularly in direct contact with the external environment and multiple potential pathogens. Many pulmonary bacterial infections are readily identified but often require bronchoalveolar lavage (BAL) and culture for accurate diagnosis and treatment with antibiotics.

REF: p. 403 a. Serratia marcescens b. Staphylococcus aureus c. Haemophilus influenza d. Burkholderia cepacia

16. Which of the following microorganisms is associated with increased mortality among patients with cystic fibrosis?

ANS: D

The highly antibiotic-resistant Burkholderia cepacia complex organisms have been associated with significant morbidity and mortality in patients with cystic fibrosis. These resistant organisms are found most often in the older patient with advanced lung disease, and this is the patient with cystic fibrosis who most likely needs transplantation. Of concern is the report that Burkholderia species can be particularly lethal to transplant patients with cystic fibrosis who acquire it after transplantation.

REF: p. 404

17. Months after receiving a lung transplant a patient with cystic fibrosis exhibits the following signs and symptoms:

Increasing dyspnea

Increased coughing with sputum production

Colonization with Pseudomonas species a. Bronchiolitis obliterans b. Bronchorrhea c. Acute respiratory distress syndrome d. Pulmonary hypertension

The patient also appears to be in respiratory failure. Which of the following conditions is likely developing?

ANS: A

In the majority of patients, bronchiolitis obliterans is a progressive disease manifested by increasing dyspnea, increased coughing with sputum production, colonization or infection with Pseudomonas species, and eventual respiratory failure and death.

REF: p. 404

18. Which of the following medications is associated with a decreased white blood cell count caused by bone marrow suppression? a. Cyclosporine b. Tacrolimus c. Azathioprine d. Azithromycin

ANS: C

The major complication from both azathioprine and mycophenolate mofetil is a decreased white blood cell count caused by bone marrow suppression; this usually improves with temporary discontinuation of the medicine or a decrease in dose.

REF: p. 404

19. Which of the following forms of interaction tend to occur between the respiratory therapist and a patient who receives a lung transplant?

I. Mechanical ventilation

II. Pulmonary rehabilitation

III. Bronchopulmonary hygieneIV. Hyperbaric oxygenation a. I and III only b. II and III only c. I, II, and III only d. I, II, and IV only

ANS: C

There are multiple areas of interaction between the respiratory therapist (RT) and the transplant patient. Care of the patient who undergoes thoracic transplantation always involves the teamwork of a variety of health care professionals. The child who receives a lung or heart–lung transplant is especially likely to require an RT on the team. Familiarity with the diseases leading to transplantation, as well as the transplantation process, will help the practitioner provide more comprehensive care to the patient as well as improve interaction with the health care team. The RT may already be familiar with the transplant candidate because of his/her role in providing routine care for the primary disease process, particularly for chronic pulmonary diseases such as cystic fibrosis. The RT may become a key contact with the transplant candidate in the initial evaluation process or during pulmonary function testing. After the patient has been accepted to the transplantation list, the RT may be involved in providing an exercise evaluation and rehabilitation program in an effort to optimize the patient's condition while he or she is awaiting transplantation. Immediately after the transplantation procedure, the RT will be involved with the patient in the intensive care unit, primarily providing mechanical ventilatory support and maintenance of the artificial airway. Because of the temporary interruption of ciliary function, the RT may be asked to provide aerosolized bronchodilators, mechanical aids to assist full inflation and cough, and bronchopulmonary hygiene. For most patients, this therapy is not required on a long-term basis. Shortly after the patient is taken off mechanical ventilation, the RT may be involved in additional mucus clearance measures. Exercise and rehabilitation should be resumed as soon as possible after extubation.

REF: p. 405

Chapter 22: Neonatal Complications and Pulmonary Disorders

Test Bank

Multiple Choice

1. What is the incidence of respiratory distress syndrome (RDS) among infants born at less than 28 weeks of gestation? a. 30% to 40% b. 40% to 50% c. 60% to 80% d. >80%

ANS: C

In the United States, respiratory distress syndrome (RDS) has been estimated to occur in 20,000 to 30,000 newborn infants each year and is a complication in about 1% of pregnancies. Its incidence is inversely related to gestational age and birth weight. It occurs in 60% to 80% of infants < 28 wk of gestational age, in 15% to 30% of those between 32 and 36 wk, and rarely in those > 37 wk.

REF: p. 409

2. Which of the following conditions increase the risk for developing RDS?

I. Maternal diabetes

II. Cesarean delivery

III. Multiple births

IV. Premature rupture of membranesa. I only b. II and III only c. I, II, and III only d. II, III, and IV only

ANS: C

The risk for development of RDS increases with maternal diabetes, multiple births, cesarean delivery, precipitous delivery (delivery of infant anywhere unintended), asphyxia, cold stress, and a maternal history of previously affected infants.

REF: p. 409 a. Resolution of the RDS b. An effort to maintain its functional residual capacity (FRC) c. An attempt to overcome increased airway resistance d. Impending death

3. What is the significance of an infant with RDS demonstrating a grunt during each exhalation?

ANS: B

A characteristic grunt during expiration is an attempt to maintain the FRC.

REF: p. 412 a. Persistent pulmonary hypertension of the newborn b. Respiratory distress syndrome c. Bronchopulmonary dysplasia d. Pulmonary interstitial emphysema

4. The therapist is reviewing the chest radiograph of a newborn, preterm infant and observes diffuse, fine, reticulogranular densities, which provide a ground-glass appearance. On the basis of these radiographic findings, which of the following conditions should the therapist suspect is present?

ANS: B

The chest radiograph in RDS typically reveals diffuse, fine, granular (reticulogranular) densities, which present a ground-glass appearance. The heart may be slightly enlarged, and the thymus is nearly always visible.

REF: p. 412 a. The presence of lung maturity b. A gestational age of less than 28 weeks c. The likelihood of RDS d. Laboratory error

5. How should the therapist interpret a lecithin-to-sphingomyelin (L:S) ratio of 2:1?

ANS: A

Lecithin, also known as dipalmitoyl phosphatidylcholine, is the most abundant phospholipid found in surfactant. RDS is unlikely if the L:S ratio is 2.0 or greater.

REF: p. 412 a. The test needs to be redone. b. The unborn infant’s lungs have matured. c. The infant’s lungs are immature. d. The patient has a 50% chance of developing RDS.

6. How should the therapist interpret the lack of supernatant foam appearing during the shake test?

ANS: C

Other tests for lung maturity have been developed; in the foam stability test, amniotic fluid is mixed with different volumes of 95% ethanol. When this mixture is shaken with air, a foam develops that can be seen for several hours at room temperature. If no surfactant is present, the foam will not appear or will appear only briefly, indicating the strong possibility of immature lungs. The shake test is not as specific as a low L:S ratio.

REF: p. 412 a. FiO2 > 40% to 70% and SpO2 < 85% b. FiO2 > 90% and SpO2 < 95% c. Respiratory rate of 40 breaths per minute d. PaO2 50 to 60 mm Hg

7. When should a therapist consider CPAP for a newborn with respiratory distress?

ANS: A

If oxygen saturation cannot be kept > 85% at inspired oxygen concentrations of 40% to 70% or greater, continuous positive airway pressure (CPAP) via nasal prongs or nasopharyngeal tube using a continuous-flow ventilator may be instituted.

REF: p. 415

8. When should a therapist consider intubation and mechanical ventilation for a newborn with respiratory distress?

I. FiO2 > 40% to 70%

II. SpO2 < 85%

III. CPAP of 5-10 cm H2O

IV. pH < 7.20 a. I and II only b. II and III only c. I, II, and III only d. I, II, III, and IV

ANS: D

Classic indications for endotracheal intubation and mechanical ventilation are infants with respiratory failure or persistent apnea. Reasonable measures of respiratory failure are: (1) arterial blood pH < 7.20, (2) arterial blood PaCO2 of 60 mm Hg or higher, and (3) oxygen saturation <85% at oxygen concentrations of 40% to 70% and CPAP of 5 to 10 cm H2O.

REF: p. 415

9. What ventilator settings should a therapist select for a newborn with respiratory distress syndrome?

I. PIP 25-30 cm H2O

II. PEEP 3-6 cm H2O

III. VT 5-6 mL/kg

IV. Frequency 60 breaths per minutea. I and II only b. II only c. I, II, and III only d. I, II, III, and IV

ANS: B

Generally, once the infant is stabilized and in the NICU, a pressure-limited ventilator utilizing a sinusoidal flow pattern is used. Peak inspiratory pressures (PIPs) generally begin at 15 to 25 cm H2O, depending on the size of the infant and the severity of the disease, to establish a tidal volume (VT) between 3 and 5 mL/kg. Positive end-expiratory pressure (PEEP) levels of 3 to 6 cm H2O are used to prevent further alveolar collapse, and rates of 20 to 50 breaths per minute are used to treat hypercapnia. Inspiratory times should be initiated at 0.3 to 0.4 second. If a longer inspiratory time is required before surfactant administration, it should be lowered to 0.3 second after surfactant is administered.

REF: p. 415

10. Which of the following risk factors contribute to the pathogenesis of BPD?

I. Lung immaturity

II. Respiratory failure

III. Oxygen supplementationIV. Positive-pressure ventilation a. I and II only b. IV only c. I, II, III, and IV d. III and IV only

ANS: C

Northway and colleagues proposed four major factors in BPD pathogenesis: (1) lung immaturity, (2) respiratory failure, (3) oxygen supplementation, and (4) positive-pressure mechanical ventilation.

REF: p. 417

11. While reviewing the chest X-ray of a newborn, the therapist observes the following features:

Pulmonary vascular congestion

Prominent perihilar streaking

Fluid in the interlobular fissures

Hyperexpansion

Flat diaphragm a. RDS b. Persistent pulmonary hypertension of the newborn c. Transient tachypnea of the newborn d. Barotrauma

Which of the following conditions does this patient likely have?

ANS: C

The chest radiograph shows pulmonary vascular congestion, prominent perihilar streaking, fluid in the interlobular fissures, hyperexpansion, and a flat diaphragm (see Figure 22-4 in the textbook). Mild cardiomegaly and pleural effusions may also be present.

REF: p. 424

12. Which of the following therapeutic interventions is generally needed to treat transient tachypnea of the newborn (TTN)? a. Endotracheal intubation b. 40% oxygen hood c. Bronchial hygiene therapy d. Bronchodilator therapy

ANS: B

Treatment is largely supportive. The objectives of treatment of TTN are to maintain adequate oxygenation and ventilation. Supplemental oxygen via oxygen hood (usually < 40%) is indicated when signs of respiratory distress are present. CPAP levels of 3 to 5 cm H2O may be needed when higher FiO2 levels are required.

REF: p. 425 a. RSV b. Escherichia coli c. Pseudomona spp. d. Haemophilus influenza

13. In addition to Group B Streptococcus, which of the following microorganisms are responsible for nosocomial pneumonia acquired after delivery?

ANS: B

Bacteria that should be considered when pneumonia is acquired in utero or in the immediate perinatal period include Escherichia coli, Klebsiella spp., Group D Streptococci, Listeria monocytogenes, and pneumococci acquired via transmission from the mother.

REF: p. 425

14. When neonatal pneumonia is suspected, how long does an infant generally receive broadspectrum antibiotics? a. 24 hours b. 48 hours c. 72 hours d. 96 hours

ANS: C

Whenever neonatal pneumonia is suspected, broad-spectrum antibiotics are given for at least 72 hours, or until definitive culture results are obtained. If results prove that infection is present, antibiotics are continued for 14 to 21 days.

REF: p. 428 a. Because these infants can generate strong inspiratory efforts b. Because infants this age have significant cardiac outputs c. Because these infants demonstrate strong peristalsis d. Because these newborns have weak anal sphincter tone

15. Why does meconium staining occur predominantly in infants older than 36 weeks of gestational age?

ANS: C

Meconium passage into the amniotic fluid requires strong peristalsis and anal sphincter tone, which is not common in preterm infants. Meconium aspiration syndrome rarely occurs in infants born at less than 36 weeks of gestation. The longer a pregnancy is allowed to continue past 42 weeks, the greater the chances are of the passage of meconium.

REF: p. 429 a. Ball valve b. Complete c. No obstruction d. Airway inflammation

16. What is the typical type of airway obstruction that occurs with MAS?

ANS: A

If the infant has a large amount of thick meconium within the airways at the time of delivery, complete bronchiole obstruction with subsequent alveolar collapse will result. The more typical picture, however, is that of smaller amounts of meconium within amniotic fluid, causing a ball-valve effect because of partial obstruction of the airways.

REF: p. 429 a. Ground-glass appearance b. Complete whiteout c. Decreased lung volume d. Patchy areas of atelectasis

17. What radiographic features is the therapist likely to see on a typical chest X-ray of an infant with MAS?

ANS: D

The typical chest radiograph shows patchy areas of atelectasis due to obstruction, as well as hyperexpansion from air trapping with flattening of the diaphragm sometimes noted on the radiograph.

REF: p. 431 a. Good muscle tone b. Presence of dark green meconium on the skin c. Heart rate < 100 beats per minute d. Presence of coarse crackles on auscultation

18. The therapist is contemplating the possibility of intubating and suctioning a nonvigorous newborn with MAS. Which of the following clinical parameters confirms the indication for the procedure?

ANS: C

The guidelines are under continuous review and are revised as new evidence-based research becomes available. The current guidelines are as follows: If the baby is not vigorous (defined as depressed respiratory effort, poor muscle tone, and/or heart rate < 100 beats/min), use direct laryngoscopy, intubate, and suction the trachea immediately after delivery. Suction for no longer than 5 seconds. If no meconium is retrieved, do not repeat intubation and suction. If meconium is retrieved and no bradycardia is present, reintubate and suction. If the heart rate is low, administer positive pressure ventilation and consider suctioning again later.

REF: p. 431 a. RDS b. BPD c. PPHN d. GBS pneumonia

19. Eight hours after being born, a baby presents with cyanosis despite administration of adequate ventilation, tachypnea, and retractions. Which of the following conditions should the therapist suspect is affecting this newborn?

ANS: C

PPHN should be suspected in all term infants who have cyanosis that may occur despite adequate ventilation. The recognition of risk factors for PPHN is one of the major diagnostic tools to differentiate babies with PPHN from those with structural heart disease, keeping in mind that idiopathic PPHN can present without signs of acute perinatal distress. Marked lability in oxygenation is frequently part of the clinical history. The infant with PPHN usually presents within the first 12 hours of life with cyanosis, tachypnea, and hypoxia that are refractory to oxygen therapy, as well as signs of respiratory distress, including retractions, grunting, and nasal flaring.

REF: p. 434 a. PPHN b. MAS c. Neonatal pneumonia d. RDS

20. Blood samples are simultaneously obtained from both the right radial artery and the umbilical artery, and the arterial partial pressure of oxygen (PaO2) value from the right radial artery is 20 mm Hg greater than that analyzed from the umbilical artery sample. On the basis of this finding, which of the following conditions does the neonate likely have?

ANS: A

A PaO2 gradient between a preductal (right radial artery) and a postductal (umbilical artery) site of blood sampling >20 mm Hg suggests right-to-left shunting through the ductus arteriosus, as does an oxygenation saturation gradient >5% between preductal and postductal sites on pulse oximetry.

REF: p. 435

21. Which of the following blood gas parameters should the therapist target when managing patients with PPHN?

I. SaO2 > 95%

II. PaCO2 35-45 mm Hg

III. pH 7.35-7.45

IV. PaO2 > 95 mm Hg a. I only b. II and III only c. I, II, and III only d. II, III, and IV only

ANS: C

Adjust ventilators to maintain adequate oxygenation and mild hyperventilation, until stability is achieved for 12 to 24 hours after initially attempting to keep the oxygen saturation above 95%, arterial carbon dioxide tension (PaCO2) at 35 to 45 mm Hg, and pH at 7.35 to 7.45.

REF: p. 436

22. Which of the following medications should the therapist recommend for an infant with apnea of prematurity experiencing episodes of apnea? a. Caffeine b. Benzodiazepines c. Antibiotics d. Doxapram

ANS: A

Caffeine’s proposed mechanisms include stimulation of skeletal and diaphragmatic muscle contraction, increase in the respiratory center’s sensitivity to carbon dioxide, and stimulation of the central respiratory drive. Caffeine appears to be a safer drug, can be given less frequently than aminophylline or theophylline, and is more effective in treating apnea.

REF: p. 438 a. Right-sided pneumothorax b. Severe right lung atelectasis c. Right pleural effusion d. Left-sided atelectasis

23. The therapist is assessing a newborn on the mechanical ventilator. The neonate shows clear signs of respiratory distress, and lung auscultation reveals shifting of the PMI towards the left and breath sounds decreased on the right. What should the therapist suspect this newborn developed?

ANS: A

Neonates with spontaneous pneumothorax are usually asymptomatic or have mild signs of tachypnea with an oxygen requirement. Occasionally, severe respiratory distress (grunting, nasal flaring, and intercostal retractions) may occur. In the ventilated neonate, pneumothorax may lead to a rapid clinical deterioration, resulting in cyanosis, hypotension, hypoxemia, hypercapnia, and respiratory acidosis. In unilateral pneumothorax, the cardiac apex can be shifted away from the affected side and breath sounds decreased over that side.

REF: p. 439

24. While reviewing the chest X-ray of a newborn, the therapist observes the following features: continuous diaphragm sign and linear bands of air paralleling the left side of the heart and the descending aorta with extension superiorly along the great vessels into the neck. Which of the following conditions does this patient likely have? a. Pneumothorax b. Cardiac tamponade c. Pneumomediastinum d. Pneumopericardium

ANS: C

Typical radiological signs of pneumomediastinum include the continuous diaphragm sign (interposition of air between the pericardium and the diaphragm, which becomes visible in the central mediastinal part) and linear bands of mediastinal air paralleling the left side of the heart and the descending aorta (pleura appears as a fine opaque line) with extension superiorly along the great vessels into the neck.

REF: p. 440 a. Intubation and mechanical ventilation b. Mask CPAP c. Needle aspiration d. Confirm air leak with a chest X-ray and place a chest tube afterwards

25. A newborn suspected of having a pneumothorax is rapidly deteriorating. What should the therapist suggest at this time?

ANS: C

Needle aspiration: In a rapidly deteriorating clinical situation, thoracentesis or pericardiocentesis may confirm the diagnosis and be therapeutic in pneumothorax and pneumopericardium, respectively.

REF: p. 441 a. Suggest removal of the chest tube in 24 hours b. Clamp the tube and obtain a CXR c. Keep the chest tube until bubbling stops d. Remove the chest tube and obtain a follow-up CXR

26. A neonate diagnosed with a pneumothorax was treated with a chest tube. After 36 hours, the therapist noticed that bubbling is present in the chest tube system. What should the therapist do at this time?

ANS: C

Suction should be maintained until fluctuation of air in the tube and active bubbling have ceased. At this time the tube should be clamped and removed within 24 hours if there has been no reaccumulation of air in the pleural cavity.

REF: p. 442