|When coming upon an accident victim outside the hospital setting who appears unconscious, what should a practitioner immediately do?||Look for any obvious head or neck injuries.|
|You enter a man’s room and find him collapsed on the floor in a prone position. He is totally unresponsive, and there is no breathing. To properly institute procedures to secure his airway, what must you do first?||Employ the log-roll technique to obtain a proper position.|
|What is the most common cause of airway obstruction in unconscious patients? A) Foreign body lodged in the upper airway B) Oral or nasal secretions blocking the pharynx C) Tongue falling back into the pharynx D) Severe spasm of the laryngeal muscula||C) Tongue falling back into the pharynx|
|A patient with suspected spinal trauma is admitted to the emergency department and
||Apply the jaw thrust maneuver.|
|Should the initial attempt to ventilate fail, which of the following actions would you suggest?||Reposition the victim’s head and repeat the effort.|
|What is the primary indication for tracheal suctioning? A) Presence of pneumonia B) Presence of atelectasis C) Ineffective coughing D) Retention of secretions||D) Retention of secretions|
|What is the most common complication of suctioning? A) Hypoxemia B) Hypotension C) Arrhythmias D) Infection||A) Hypoxemia|
|Complications of tracheal suctioning include all of the following
|How often should patients be suctioned? A) At least once every 2 to 3 hours. B) Whenever they are moved or ambulated. C) When secretions are seen or heard in airways. D) Whenever the charge nurse requests it.||C) When secretions are seen or heard in airways.|
|What is the normal range of negative pressure to use when suctioning an adult patient? A) –100 to –120 mm Hg B) –80 to –100 mm Hg C) –60 to –80 mm Hg D) –20 to –30 mm Hg||A) –100 to –120 mm Hg|
|You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case? A) 6 Fr B) 8 Fr C) 10 Fr D) 14 Fr||C) 10 Fr|
|You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case? A) 10 Fr B) 12 Fr C) 14 Fr D) 16 Fr||C) 14 Fr|
|To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following?||Preoxygenate the patient with 100% oxygen.|
|To maintain positive end-expiratory pressure (PEEP) and high FIO2 when suctioning a mechanically ventilated patient, what would you recommend?||Use a closed-system
|Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning?||I. Limit the amount of negative pressure used. II. Hyperinflate the patient before and after the procedure. III. Suction for as short a period of time as possible.|
|Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem?||The patient has
|What general condition requires airway management?||I. Airway compromise II. Respiratory failure III. Need to protect the airway|
|Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management?||I. Hypotension II. Bradycardia III. Cardiac arrhythmias IV. Laryngospasm|
|What is the standard size for endotracheal or tracheostomy tube adapters? A) 22 mm external diameter B) 15 mm external diameter C) 15 mm internal diameter D) 22 mm internal diameter||B) 15 mm external diameter|
|What is the purpose of the additional side port (
||Ensure gas flow if the main port is blocked.|
|What is the primary purpose of a cuff on an artificial tracheal airway?||Seal off and protect the lower airway.|
|Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement?||I. Length markings on the curved body of the tube. II.
|What is the purpose of a tracheostomy tube obturator?||Minimize trauma to the tracheal mucosal during insertion.|
||C) 8 mm|
|What is the purpose of an endotracheal tube stylet? A) Helps ascertain proper tube position. B) Adds rigidity and shape to ease insertion. C) Minimizes mucosal trauma during insertion. D) Protects the airway against aspiration.||B) Adds rigidity and shape to ease insertion.|
|What should be the maximum time devoted to any intubation attempt? A) 30 seconds B) 60 seconds C) 90 seconds D) 2 minutes||A) 30 seconds|
|Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned about how far above the carina? A) 1 to 3 cm B) 4 to 5 cm C) 7 to 9 cm D) 4 to 6 inches||B) 4 to 5 cm|
|After an intubation attempt, an expired
||B) Placement of the endotracheal tube in the esophagus.|
|To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend?||Nasal spray of 0.25% racemic epinephrine/2% lidocaine|
|What is the primary indication for tracheostomy?||B) When a patient has a long-term need for an artificial airway.|
|Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube?||I. Patient’s tolerance of the endotracheal tube. II. Relative risks of continued intubation versus tracheostomy III. Patient’s severity of illness and overall condition. IV.
|Expectorants||increase fluid in resp tract and stimulate cough|
|SSKI||potassium iodine-expectorant for asthma and bronchitis (no longer used)|
|Bronchorrhea||condition associated with excess thin watery pulmonary secretions, most often with head injury, drug of choice- glycopyrrolate (Robinal), hazard is mucus plugging|
|Mucomyst||n-acetylcysteine, mucolytic, breaks down disulfide bonds|
|Mucus molecule||mucopolysaccaride chain, strands of amino acids and amino sugars connected by disulfide bonds|
|Mucolytics drugs||dornase alfa (Pulmozyme), n-acetylcysteine (Mucomyst), sodium bicarb|
|Dornase Alfa||aka Pulmozyme, mucolytic, lyces bacteria and cellular debri DNA, most often used with CF & bronchiectisis, never mix with other drugs, need special jet neb|
|Sodium Bicarb||mucolytic, alters PH to disrupt amino acid chain|
|mucolytic indicators||thick inspissated secretions, aerosol – able to cooperate & deep breath, trach or endotrach by direct instillation|
|Bland aerosol||aerosols that do not have a direct effect on mucus molecule and usually no side effects. Normal saline (.9%NaCl), hypo (.45%NaCl) and hypertonic saline (5%NaCl), and sterile distilled water|
|Secretion patients||CF, bronchiectisis and chronic bronchitis|
|increased secretion indicators||tactile fremitise (you can feel it), rhonchi (low pitch rumble), caused by ineffective cough and muscle fatigue|
|Mucolytics||agents that disrupt musus molecule so that secretions can be removed (coughed or suction), cause mucolysis (breaking apart)|
|Sterile distilled water||most common solution in LVN for humidification of airway, also used as a dilute in SVN|
|Sputum induction||used when pt has dry non-productive cough, hypertonic saline (5% to 10%) not to exceed 1500 mg/day|
|Hypotonic||osmotic pressure is less than body fluid, most common is .45% NaCl (1/2 NS), used in LVN when pt cannot tolerate distilled water and as dilute in SVN for pt with severe salt restriction|
|Hypertonic||osmotic pressure is greater than body fluid, used for sputum production, most common 5-10% NaCl (hygroscopic droplets attract humidity and grow larger)|
|NS||normal Saline, osmotic pressure is same as body fluid (0.9% NaCl), most common bronchodilator dilute, unlikely to cause bronchospasm, but can increase sodium|
|Bland aerosol indicators||pt who require humidity of resp tract, intubated or trach. As thinning agent prior to postural drainage and chest percussion, sputum induction. (continuous jet, Babington or USN)|
|n-acetylysteine||aka Mucomyst, indicated for pt with excessive purulent thick or inspissated secretions, breaks disulfide bond, also used in acetaminophen (Tylenol) overdose, 10-20 % solution, bad smell, max 72 hrs|
|zafirlukast||aka Accolade, anti-asthmatic, selective and competitive antagonist of leukotriene receptors, hazard is renal failure, can’t be taken with food, so poor pt compliance|
|budesonide||aka Pulmacort, aerosol corticosteroid (only SVN steroid) needs a specific jet neb|
|fluticasone||aka Flovent, aerosol corticosteroid,|
|flunisolide||aka Aerobid, aerosol corticosteroid|
|triamcinolone||aka Azmacort, aerosol corticosteroid intermediate duration 5-10 days ramp up|
|SVN steroid||budesonide aka Pulmacort|
|Asthma attack anatomy||mast cell exposed to allergen (antigen-antibody), mast cell degranulates releasing histamines (edema, mucus, constriction), cytokines (recruiters-cause late stage) and leukotrines (inflammatory mediator)|
|Bronchial asthma||most common chronic lung disease, 4% of population and increasing, symptoms, dyspnea, diffuse wheezing, airway obstruction from bronchospasm, edema and mucus.|
|Asthma mucus||thickened & viscid (sticky) with eosinophils|
|a-adrenergic drugs & mucosal edema||indications-difficulty breathing, tachypnea, tachycardia, wheezing. aerosol a-adrenergics give rapid response, with decreased side effects, severe or life threatening cases give in IV or instilled, racemic epi is most common drug|
|Mucosal edema||accumulation of fluid in the mucosal membrane, caused by infection, trauma, disease, or conditions like anaphylaxis or allergic reaction (most often treated with alpha racemic epi|
|Asthma attack progression||coughing, exp wheezes, I:E wheezes, insp wheeze (air trapping), vent failure (intibate)|
|Anti-asthmatic drug classes||mast cell stabilizers & leukotriene blockers|
|Corticosteroid side effects||long term oral- cushing syndrome, immunosuppressant & diabetes’s, aerosols- throat irritation, horsiness, coughing, dry mouth, fungals-candidiasis (do not use w/bronchiectisis, pneumonia)|
|Corticosteroid indicators||aerosolized should always be considered if long term use is ordered, pt who are unresponsive to B2 bronchodilators, IV or IM with status asthmaticus|
|Corticosteroids||anti-inflammatory, steroids produced by the adrenal cortex|
|Aerosol steroid advantage||decreased systemic side effects, no addiction, no cushings|
|Aerosol steroid disadvantage||increased expense, not for status asthmaticus, increased risk of superinfection, horseness, cough, requires pt effort and coordination|
|Severe asthma protocol||1st line-O2, B2 bronchodilator, steroid-(prednisone IV), 2nd line – anticholenergic-Atrovent, 3rd line- epinephrine-IM or aerosol. if all fails then intibate and mech vent|
|Asthma attach management||1-B2 agonist, 2-steroids/anti-inflammatory, 3-increase 1 and 2|
|leukotrine blockers||competitive antagonist for leukotrines receptors, Accolade aka zafirlukast, Singular aka montelukast, Zyflo aka zileutin|
|Mast cell stabilizers||prophylactic-prevent extrinsic asthma by stabilizing mast cell wall so it will not burst, Intal aka cromolyn sodium and Tilade aka nedocromil sodium|
Respiratory Therapy Clinical Practice Test Questions:
1. A 60 kg patient, 52 y/o man is admitted to the
ABG: 7.49/ CO2 30, Pa02 59, HR 120, RR 26. What should the RT reccomend?
a. increase the ps level to 15 cmh20
b. institute 5 cm h20 PEEP
c. increase fi02 to 75%
d. initiate SIMV with the following settings : RR 10, VT 600, Fi02 60%
Refractory hypoxemia typically is from atelectasis, pneumonia or pulmonary edema so just increasing fi02 or PS will not help (also you dont want to go over 60%). It is not a ventilation issue so mechanical ventilation is not indicated. Initiating PEEP will combat atelectasis and fix your problems. (PS is related to ventilation and PEEP to oxygenation so thats why you increase peep over PS)
2. A 70 kg patient is recieving mech. vent. The RT notes the patient’s sp02 drops from 97 to 86%. The right lung is expanding more than the left, with clear bs on the right but diminished ones on the left. the patient’s ETT is 29 at the lip. What should the RT do at this time?
a. withdraw the tube to 24cm
b. reccomend a stat chest xray
c. advance the tube 2 cm
d. obtain an abt
because the ETT should be 2-6 cm above the carina which is 21-25 at the lip typically. His tube is in too far (right mainstem intubation) so you just withdraw the tube a little.
3. the ability of the patient to follow instructions would be indicated by which of the following?
a. orientation to person
b. performance of tasks when asked
c. ability to feed himself
d. awareness of time
4. Advantages of a low pressure, high volume ETT cuff include
a. easier insertion into the airway
b. less occlusion to tracheal blood flow
c. improved distribution of alveolar air.
because this type of cuff contains residual air when deflated it requires less air to be inflated and less pressure is exerted on the tracheal wall.
5. Failure to hyperoxygenate a patient on a ventilator before ET suctioning may result in:
(there are two answers to this question): B and D (hypoxemia and bradycardia)
suctioning can decrease the 02 to patient and cause cardiac arrythmias
6. The following data have been collected for a patient receiving mechanical ventilation with a volume ventilator: SIMV, VT 750, set rate 4, spont. rate 12, 35% 7.29/50/72/26. Based on this data what should the RT reccomend?
a. increase the VT to 850
b. increase fi02 to 40%
c. increase set rate to 8
d. change to assist/control mode with RR of 15
This patient has a high CO2. both increasing the VT and increasing the rate would help lower the CO2, however increasing the rate is more correct because with such a low set rate, we can assume the patient has been weaning. If the patient’s CO2 begins to rise during weaning you change what caused the problem (the rate in this situation)
8. If not cleaned properly, which one of the following devices is most likely to contaminate a patient’s airway with bacteria?
a. bubble humidifier
b. heated wick humidifier
d. heated jet nebulizer
Bacteria grow better in warm moist environments. However the jet nebulizer would more likely grow bacteria because they produce particles that are about the same size of bacteria and so if there were bacteria the neb would aerosolize the bacteria very easily and infect the patient. humidified particles are much smaller, so bacteria would have a hard time getting to the patient.
9. It is important to monitor airway pressure in a patient receiving mechanical ventilation because it best reflects:
a. lung compliance
Lung compliance is determined by VT/PIP , so monitoring the PIP (airway pressure) can give you pertinent info on the compliance of the lungs.
10. The most reliable method of determining whether the lungs of a patient receiving mechanical ventilation are getting stiffer and harder to ventilate is by measuring the
a. static lung compliance
b. dynamic lung compliance
c. spontaneous VT
Static lung compliance measures the stiffness/stretchiness of the lungs when there is no air movement (measured during a breath hold). The dynamic lung compliance is measured during airflow and can be impacted by airway resistance (such as secretions) and the PIP can increase due to the Raw, so it is not an accurate representation of the lungs themselves. spontaneous VT and pa02 are indicators of lung compliance.
11. A patient arrives in the ER after being pulled from a burning house. the RT should reccomend obtaining. which of the following measurements to best determine the severity of the patient’s smoke inhalation?
HbCO will tell you the severity of smoke inhalation and help evaluate the patient for CO poisioning from smoke.
12. A patient is receiving ventilation with a volume cycled ventilator and the low pressure alarm suddenly sounds. The corrective action would be to
a. suction the patient
b. begin manual resuscitation
c. increase the flow
d. determine whether the patient is disconnected from the vent
low pressure alarm indicates a big leak (aka being disconnected from the vent)
13. The physician has ordered 40% 02 to be administered to an active 3 y/o. Which of the following delivery decices would you reccomend?
A. 02 tent
B air entrainment mask
C simple 02 mask
d. 02 hood
an active 3 y/o kid tolerates a tent much better than any kind of mask, and is too big for the 02 hood.
14. The physician orders a 35% aerosol mask to be set up fro a patient who requires an inspiratory flow of 42 L/min. What is the minimum flow rate to which the flowmeter must be set to meet this patient’s demands?
The air to
Add ratio together and multiply by
so 5+1=6. the only one that would equal 42 is 8
15. A premature infant is receiving 02 via a 50% 02 hood and has a pa02 of 43 torr and a paC02 of 40 torr. The RT should recommend which of the following?
A. Increase 02 to 70%
B. Intubate and institute mechanical ventilation
C. Initiate CPAP of 4cm H20 and 50% 02
D. Increase the 02 to 100%
You do not want to go over 60% Fi02, and since he is already on 50% and there is not an option to increase to 60% placing the patient on CPAP is the best choice. mechanical ventilation is not neccesary because the patient’s CO2 is within normal limits
16. to most effectively increase a patient’s alveolar minute ventilation while the patient is using a ventilator in the control mode, you would reccomend increasing which of the following
a. sigh rate
b. inspiratory flow
D. ventilator rate
alveolar minute ventilation shows the volume actually reaching the alveoli per minute. to increase this, increase VT. You cannot just increase the rate because you will still be delivering the same amount of VT. (even though minute ventilation would increase since it is VT x RR)
17. Tracheal secretions tend to dry out in an intubated patient when inspired air has which of the following charachteristics?
a. an absolute humidity of 24 mg/L of gas
b. a water vapor pressure of 47 mmhg
c. 50 mg of particulate water per liter of gas
d. a relative humidity of 100% at 25 degrees C
when air that is not fully saturated at body temperature is deliverd to an intubated patient patient’s secretions get thicker due to lack of inspired water. It must contain an absolute hubidity of 44 mg/L of gas (which is the same as water vapor pressure of 47 mmhg- so B wouldnt dry out secretions) D would dry out secretions because it is saturated at room temperature (25 C) not body temperature (37 C)
18. When a patient is
a. increase VT
b. increase fi02
c. decrease mechanical
d. decrease RR
Decreasing RR will decrease the minute ventilation and increase the CO2. if you increase VT that will blow off more
19. Which of the following ABG’s show renal compensated respiratory acidosis? (no sp02 included)
CO2 up = PH down
Bicarb up = PH up
20. You suspect a patient may have a pulmonary embolism. which of the following would be the most appropriate recommendation for diagnosis of this condition?
b. v/q lung scan
c. coagulation studies
d. shunt study
this is the best test to find a pulmonary embolism