TMC Practice Exam

1. Which of the following procedures would be most helpful in preventing atelectasis in a cooperative postoperative patient?

2. The primary purpose of oxygen administration in the management of heart failure is to:

3. You attach a patient in ICU to the pulse oximeter module on a multichannel bedside monitor. The best way to verify that you are getting a good reading would be to:

4. Which of the following respiratory signs noted on inspection of an adult patient would be considered ABNORMAL?

5. A 23 y/o firefighter is admitted with suspected smoke inhalation. You place him on a non-rebreathing mask. What is the most appropriate method of monitoring his oxygenation?

6. You measure the blood pressure of an adult patient as 88/53 mm Hg. Which of the following chart entries would you use in describing this finding?

7. Which of the following findings would you expect to observe on the AP chest radiograph of a patient suffering from advanced stages of pulmonary emphysema?

8. Which of the following pulmonary function findings are common to patients with chronic bronchitis and also found in those with emphysema?

9. A physician orders 2.5 mL ipratropium bromide (Atrovent) 0.2% TID for a COPD patient with recurrent bronchospasm. Which of the following methods would you use to deliver this drug?

10. While reviewing the flow sheet of a patient receiving artificial ventilatory support, you note a progressive rise in heart rate over the last two hours. Which of the following actions would you recommend to help identify the cause of this problem?

11. A patient in ICU develops a supraventricular tachycardia at a rate of 165/min. Which of the following effects would this have on cardiac function?

12. During an intermittent positive-pressure breathing (IPPB) treatment, the inspiratory time can be extended by:

13. The nurse calls you over to examine the arterial blood gas results of a 50-kg (110 lb) patient who is receiving volume control A/C ventilation. Currently the patient has a VT of 400 mL, rate of 10/min, and 35% O2. Her blood gas results are as follows: pH 7.30, PaCO2 48 torr, HCO3 23 mEq/L, BE -2 mEq/L, PaO2 73 torr, SaO2 94%. Based on these values, which of the following changes is

14. A 150 lb female patient is receiving volume controlled SIMV with a volume of 600 mL, a mandatory rate of 12/min with 5 cm H2O pressure support. You note that her total rate of breathing is 45/min, and that she is using her scalene muscles during most spontaneous breaths. Which of the following is the most appropriate action at this time?

15. A patient with P/F ratio of 400 has:

16. In discussing the goals of IPPB therapy with a postoperative patient, which of the following explanations would be most appropriate?

17. The chest X-ray of a patient admitted to ICU exhibits a large area of consolidation in the left lung. Which of the following is a potential cause of this finding?

18. Within one second after initiating a forced vital capacity (FVC) maneuver, a patient with normal lungs should be able exhale what percent of the FVC?

19. When treating a patient with active tuberculosis, you note large amounts of bloody secretions. You should notify the:

20. During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far?

21. In assessing a new adult admission to ICU, you note a spontaneous respiratory rate of 38/minute. The most likely cause of this observation is:

22. A home care patient with COPD has persistent dyspnea and exhibits signs of increased work of breathing even at rest, but little or no wheezing. The patient currently is receiving no medication. Which of the following drugs would you recommend for this patient?

23. Which of the following would be the most likely cause of stridor in a child?

24. Which of the following would represent an abnormal V/Q scan suggesting pulmonary embolism?

25. Which of the following describes the ventilatory pattern that is best suited for maximum aerosol deposition in the small airways?

26. The ICU nurse calls you to assess a patient that became agitated and complains of difficulty breathing. The patient presents with decreased right chest excursion, absent breath sounds in the right upper lobe and slight tracheal deviation to the left. Which of the following procedures would you recommend be done FIRST?

27. A sleep study report should include which of the following information about blood oxygen levels?

28. After intubation, a trauma patient exhibits asymmetrical movement of the chest during manual inflation via a bag-valve resuscitator. Your partner reports diminished breath sounds on the left. No crepitus is noted. These findings are most indicative of which of the following?

29. Auscultation of an 18 year old female patient’s chest reveals diffuse wheezing and an irregular heart rate. Chart review indicates a history of frequent nighttime awakenings with dyspnea and cough. Which of the following aerosolized drugs would be most appropriate to administer?

30. An alert patient with emphysema and an elevated CO2 level is given 50% O2 by an air-entrainment mask. One hour later the nurse calls you to evaluate the patient. He is now very lethargic. Which of the following is the most likely cause of this?

31. During auscultation of a patient’s chest, you hear intermittent “bubbling” sounds at the lung bases. Which of the following chart entries best describe this finding?

32. A patient is receiving ventilatory support after thoracic surgery. You measure the patient’s maximum inspiratory pressure (MIP/NIF) as -33 cm H2O. Based on this value, the patient has:

33. Which of the following ECG leads should be placed in the left midaxillary line?

34. On inspection of a patient’s ECG strip, you note no identifiable P waves; rapid irregular undulations of the isoelectric line; and an irregular ventricular rhythm. In addition, the precordial cardiac rate is greater than the peripheral pulse rate. The most likely problem is:

35. If tolerated, a specified postural drainage position should be maintained for at least:

36. During postural drainage therapy, a patient’s heart rate remains stable at 92/min and the SpO2 is 97%. However, after you pre-oxygenate the patient and begin nasotracheal suctioning, the patient’s heart rate suddenly drops to 40/min. The most likely reason for this is:

37. Your review of a patient’s chart notes an admission diagnosis of fluid depletion/ dehydration. Which of the following findings would be most likely on bedside assessment of the patient?

38. You obtain an expired carbon monoxide (CO) reading of 18 ppm on a COPD patient participating in a pulmonary rehabilitation program. Based on this finding, you can conclude that the patient:

39. Which of the following conditions will cause a DECREASE in the FIO2 delivered to a patient receiving oxygen at 4 L/min via a nasal cannula?

40. A bubble humidifier is connected to a flowmeter set and running at 5 L/min. When you obstruct the outlet of the small-bore delivery tubing, the pressure pop-off does NOT sound. Which of the following is the most likely cause of this observation?

41. Which of the following VD/VT ratios is inconsistent with the ability of a patient to maintain adequate CO2 removal at a tolerable level of ventilation?

42. You are reviewing the chest X-ray of a 32 year-old female receiving ventilatory support via an oral endotracheal (ET) tube. To assure proper placement of the tube, you would look for its tip to be positioned

43. Which of the following thoracic ultrasound findings is consistent with the presence of a pneumothorax?

44. Which of the following can best help minimize the risk of nosocomial infection/VAP associated with mechanical ventilation?

45. When suctioning an adult patient using a DISS wall-mounted regulator system with collection bottle, you would initially set the vacuum pressure at:

46. A physician has ordered ribavirin (Virazole) to be administered by aerosol to an immunocompromised infant with severe bronchiolitis. Which of the following aerosol devices would you recommend in this situation?

47. A patient with asthma is in acute respiratory distress and presents to the emergency department with markedly diminished breath sounds. Following bronchodilator therapy, auscultation of the chest reveals rhonchi and wheezing. This change suggests which of the following?

48. A postop patient receiving incentive spirometry treatments complains of dizziness and tingling in the extremities following therapy. Which of the following is the most likely cause of these symptoms?

49. In which of the following clinical situations would a patient benefit most from deep breathing exercises?

50. On reviewing the blood gas report on a patient, you note a PaCO2 of 25 torr, a base excess (BE) of –10 mEq/L, and a pH of 7.35. You would characterize this acid-based abnormality as:

51. Which of the following is associated with the administration of aerosolized epinephrine?

52. Upon exam of an acutely dyspneic and hypotensive patient, you note the following – all on the left side of the chest: reduced chest expansion, hyperresonance to percussion, absent of breath sounds and tactile fremitus, and a tracheal shift to the right. These findings suggest:

53. In obtaining a medication history from a patient admitted for an acute exacerbation of asthma, which of the following information would you consider least important?

54. When inspecting a chest radiograph, you note that the heart is shifted to the patient’s right. Which of the following is the most likely cause of this finding?

55. Which of the following patients is the best candidate for high-frequency oscillation ventilation (HFOV)?

56. An orally intubated patient is paralyzed and receiving volume control ventilation. The high-pressure alarm on the ventilator keeps sounding and the patient has markedly decreased breath sounds. Your first action should be to:

57. A 5-foot, 4-inch-tall 110-lb. woman with normal lungs has a tidal volume of 480 mL and is breathing at a rate of 14 breaths/min. What is her approximate alveolar ventilation?

58. Bronchial breath sounds heard over the periphery indicate

59. While assessing the airway of an intubated patient receiving positive pressure ventilation, you notice a large air leak throughout inspiration with a measured cuff pressure measured of 15 cm H2O. You should:

60. Prior to intubation in an emergency, injection of air into the pilot line fails to inflate the cuff. You should

61. You run a control solution through a blood gas analyzer as part of daily quality control. The measured high PO2 value is 9 torr outside of the acceptable range. Prior runs were all in range. You should:

62. A patient has acute respiratory acidosis. You would expect the base excess (BE) to range between:

63. What percent decrease in FEV1 needs to occur to conclude that a methacholine challenge is positive for airway hyperreactivity?

64. The doctor is concerned that his ARDS patient on pressure control ventilation has high plateau pressures (> 30 cm H2O) and that this may be causing further lung injury. Which of the following modes of ventilation would you consider as an alternative?

65. A patient receiving pressure controlled SIMV develops progressive atelectasis in the lower lobes and now requires 70% O2 to keep his SaO2 above 80-85%. Comparison chest X-rays indicate a generalized decrease in lung volume. What would you recommend to help correct the problem?

66. To prevent hypoxemia during suctioning an intubated patient receiving invasive ventilatory support, you should do which of the following?

67. You are trying to wean an alert intubated patient off full ventilatory support using an “on ventilator” CPAP protocol with 40% O2. Early in the initial effort his respiratory rate increases from 24 to 30/min and you start to observe some use of his accessory muscles of respiration. Which of the following would be your first action?

68. A premature 1850 g newborn infant is receiving 40% oxygen in an oxyhood. A chest X-ray shows a ground-glass appearance bilaterally, with air bronchograms. An arterial blood gas reveals the following: pH 7.36, PaCO2 44 torr, PaO2 45 torr, HCO3 24 mEq/L, BE 0 mEq/L. Which of the following actions is appropriate at this time?

69. Within one second after initiating a forced vital capacity (FVC) maneuver, a patient with normal lungs should be able exhale what percent of the FVC?

70. If a patient’s chest X-ray shows infiltrates in the posterior segments of the lower lobes, postural drainage should be performed in which of the following positions?

71. You are about to suction an infant who has a 3.0 mm (ID) endotracheal tube in place. What is the MAXIMUM size catheter you would use in this case?

72. During auscultation, you hear a creaking or grating sound which increases in intensity with deep breathing, but is not affected by coughing. Which of the following conditions best ‘fits’ this finding?

73. Which of the following patient instructions for using a dry powder inhaler (DPI) is correct?

74. A patient is asked to inhale as deeply as possible and blow out all his air as hard as they can until empty. What test is being performed?

75. You cannot maintain satisfactory oxygenation on an ARDS patient receiving 100% O2 and being ventilated with pressure control ventilation at a plateau pressure of 40 cm H2O and 15 cm H2O PEEP. Which of the following modes of ventilation would you recommend at this time?

76. Prior to giving an aerosol treatment, you find a note in the chart that states your patient had pink frothy secretions on admission to the ED. This is most indicative of:

77. In order to provide long-term positive pressure ventilation, a cuffed artificial airway is needed to:

78. Which of the following information in a patient’s medical history would be LEAST important to consider in evaluating the patient’s pulmonary condition?

79. A 15-year-old with cystic fibrosis is receiving pressure control SIMV with pressure support due to a severe bilateral pneumonia. The pulmonologist asks you to administer aerosolized dornase alfa (Pulmozyme, DNase) in-line with the ventilator. Which of these devices would you select to administer this therapy?

80. You are asked to assess a 34-year-old homeless man admitted through the ER with an abrupt onset of chills and fever. He has bilateral rhonchi with a productive cough. His SpO2 is 88% on room air. What should you recommend?

81. A doctor orders aerosol therapy for a patient receiving mechanical ventilation who is being provided humidification with a heat and moisture exchanger (HME). To assure effective therapy you must:

82. While assisting a physician with a transthoracic ultrasound exam, you observe gliding or shimmering of the pleural layer during breathing. This observation

83. Over a 3-hour period, the plateau pressure of a patient receiving volume controlled ventilation has remained stable, but her peak pressure has been steadily increasing. Which of the following is the best explanation for this observation?

84. On inspection of an ECG rhythm strip from an adult patient, you note the following: rate of 150; regular rhythm; normal P waves, P-R intervals, and QRS complexes. The most likely problem is:

85. Which of the following would tend to decrease a patient’s energy expenditure?

86. Despite an intensive regimen of positive airway pressure and airway clearance therapy, a postoperative patient continues to exhibit clinical manifestations of atelectasis due to large airway obstruction. The best treatment approach in this case would be:

87. After withdrawal from inhaled nitric oxide (NO) therapy, an infant suddenly becomes hemodynamically unstable. You should:

88. A patient you are caring for is scheduled for a positron emission tomography (PET) chest scan. The most likely purpose of this test is to:

89. For which of the following patients would you recommend extra precautions if undergoing a cardiopulmonary exercise test?

90. A doctor wants your recommendation on how to monitor the cardiopulmonary status of a patient undergoing a bronchoscopy procedure during moderate sedation. You should recommend the following:

91. The purpose of the pilot balloon on an endotracheal or tracheostomy tube is to:

92. You are assisting a nurse in ICU measure a patient’s central venous pressure (CVP) with a strain-gauge pressure transducer. You note that the pressure transducer is positioned well above the middle of the patient’s lateral chest wall. What effect if any would this have on the CVP measurement?

93. After bronchodilator therapy, you record the following PFT data on a 67-year-old male COPD patient who reports dyspnea on exertion: FEV1/FVC = 64%; FEV1 = 66% predicted. You would characterize the stage of the patient’s COPD as:

94. A doctor orders a metered dose inhaler (MDI) bronchodilator for a patient receiving mechanical ventilation via a dual-limb breathing circuit. To maximize aerosol deposition, you would:

95. Which of the following are acceptable changes in patient status during a spontaneous breathing trial for weaning from mechanical ventilation?

96. Under which of the following circumstances you should select an active heated water humidifier during mechanical ventilation instead of a heat and moisture exchanger (HME)?

97. Maximum inspiratory pressure (MIP; NIF) measurement provides information about which of the following?

98. While assessing a patient’s radial pulse, you note that the pulse feels full and bounding. Which of the following conditions would be the most probable cause of this finding?

99. What size suction catheter would you select to suction a patient with a 9.0 mm ID tracheostomy tube?

100. A doctor institutes volume control ventilation for an 80 kg ARDS patient. Which of the following is the maximum pressure you would aim to achieve in this patient?

101. On inspection of a 12-lead ECG, you note the absence of P waves and a variable R-R interval (> 0.12 sec). Which of the following is the most likely problem?

102. In individuals with disorders characterized by an increase in airway resistance, such as emphysema, which of the following breathing patterns results in the minimum work?

103. When administering aerosolized albuterol (Proventil) you should be on guard for which of the following adverse effects?

104. The intracranial pressure (ICP) of a patient with closed head trauma receiving volume control A/C ventilation has risen from 18 mm Hg to 26 mm Hg despite aggressive treatment with osmotic diuresis, CSF fluid drainage, sedation and neuromuscular blockade. Which of the following short-term ventilatory strategies would you recommend to help manage this patient?

105. In reviewing the chart of a 65-year-old patient diagnosed with COPD and chronic hypoxemia, you would expect to see which of the following findings?

106. In inspecting an elderly female patient, you note that her spine has an abnormal anterposterior (AP) curvature. Which of the following terms would you use in charting this observation?

107. You are instructing an 8-year-old boy with asthma on the use of an albuterol MDI. What can be done to increase the deposition of the bronchodilator?

108. If a patient complains of difficulty in starting the IPPB treatment, which control should be adjusted?

109. Which of the following findings would you expect to observe on the AP chest radiograph of a patient suffering from advanced stages of pulmonary emphysema?

110. Which of the following medications you would recommend to help quiet an ICU patient who is breathing asynchronously on a ventilator?

111. In observing a patient, you note that her breathing is extremely deep and fast. Which of the following terms would you use in charting this observation?

112. Which of the following arterial blood gas results would most likely be reported for a patient who is having a mild asthma attack?

113. Postural drainage would best be indicated for a patient with:

114. A patient who is receiving an aerosol treatment with acetylcysteine (Mucomyst) and hypertonic saline via a SVN suddenly becomes dyspneic. The most likely cause of this problem is:

115. The maximum amount of air that can be exhaled from the maximum inspiratory level is defined as which of the following?

116. A patient is receiving pressure control SIMV with an FIO2 of 0.35, a set rate of 18, and a pressure limit of 25 cm H2O. Results of an arterial blood gas analysis are as follows: pH 7.45, PaCO2 34 mm Hg, HCO3 23 mEq/L, SpO2 83%. On the basis of these results, the most appropriate action would be to:

117. The primary aim in treating cardiogenic pulmonary edema is to:

118. A physician orders 20% acetylcysteine (Mucomyst) 4 mL QID via SVN for a COPD patient with an abnormally large volume of viscid secretions. Based on your preliminary bedside assessment you determine that the patient has an inadequate cough. Which of the following would you recommend?

119. In assessing a patient in the acute phase of ARDS, you would expect to find:

120. Gross observation of a patient’s sputum specimen reveals purulent green sputum that has separated into layers and has a foul odor. Which of the following is most likely causing the patient to produce this type of sputum?

121. A patient has a vital capacity of 3200 ml, a functional residual capacity of 4500 ml and expiratory reserve volume of 1200 ml. What is her residual volume (RV)?

122. In which of the following conditions would a ventilation scan be normal but a perfusion scan reveal areas of absent blood flow?

123. Which of the following are prerequisites for successful application of noninvasive positive pressure ventilation (NPPV) in the management of chronic neuromuscular disease?

124. An AP X-ray of a 3-year-old child with wheezing and stridor shows an area of prominent subglottic edema, but the lateral neck X-ray appears normal. What is the most likely problem?

125. To increase a patient’s maximum expiratory ow when using a cough assist or mechanical in-exsufflation (MI-E) device, you would:

126. A recently intubated 55 kg female patient receiving volume controlled ventilation has no breath sounds over the left side of her chest. Her SpO2 on 40% O2 has quickly dropped from 96% to 82%. At the same time, the peak inspiratory pressure on the ventilator has increased from 35 cm H2O to 55 cm H2O. You note a tube length marking of 25 cm at the teeth. What action should you take?

127. You notice that a disposable nebulizer is delivering large water droplets down the large bore tube. To correct this problem, you should

128. Which of the following conditions is an absolute contraindication against IPPB therapy?

129. Simple spirometry CANNOT be used to measure the

130. Which of the following approaches can be used to obtain a medication history from a patient with a depressed level of consciousness or who is severely agitated?

131. Which of the following analyzers would you select if your objective were to continuously measure changes in the FIO2 in a ventilator circuit with the fastest possible response time?

132. The wife of a comatose patient asks you to cancel a previously approved DNR order. You should

133. Which of the following is true regarding synchronous intermittent mandatory ventilation (SIMV)?

134. Which of the following is a key therapeutic objective in the management of a patient who has closed head trauma and is receiving ventilatory support?

135. What is the most common arrhythmia seen with pulmonary disease?

136. Which of the following statements is TRUE regarding capillary blood gas sampling?

137. You hear bronchial breath sound over the patient’s right middle lobe. What condition is probably present?

138. A physician requests your advice in managing a 49 year-old obese male patient with confirmed obstructive sleep apnea. Which of the following would you recommend?

139. The Apgar score for a normal newborn infant ranges between

140. The development of paradoxical pulse in a patient following trauma or cardiothoracic surgery, especially in connection with increasing venous pressure and heart rate, suggests:

141. You recommend against inserting a supraglottic airway (e.g., LMA, Combitube, King LT) in a patient:

142. You instruct a patient to take a deep breath and then exhale as quickly as possible. You then observe the recording of the fastest air movement. Which of the following is being measured?

143. During the administration of an aerosol treatment, the patient’s respiratory rate drops from 15 breaths/min to 6 breaths/min. Identify this breathing pattern.

144. While checking a ventilator with a heated humidifier but unheated circuit, you note that there is very little condensation in the tubing and that water does not have to be drained. The most likely explanation is that the:

145. To validate the readings provided by a transcutaneous blood gas monitor, you should:

146. A 56-year-old male is brought to the emergency room by ambulance complaining of tightness in his chest with radiating left shoulder pain. You should recommend:

147. Sputum induction is performed on a trach patient to gather a sample for microbiological identification. The sample is collected using a Lukens trap. When applying suction after entering the airway, the mucus should

148. A doctor orders a changeover to CPAP for a patient receiving bi-level positive airway pressure (BiPAP) via a device with separate IPAP and EPAP controls. To effect this change you would:

149. You observe the following on the bedside capnograph display of a patient receiving ventilatory support. What is your interpretation of this display data?

150. Upon reviewing the patient’s chart, results of a chest x-ray indicate: “Complete opacification of the left chest with a shift of the trachea and mediastinum to the left.” These findings are consistent with which of the following?

151. An asthmatic patient is struggling to initiate inspiration on an ICU ventilator operating in the assist-control mode. Which of the following ventilator settings would you first check to determine the cause of this problem?

152. Which of the following conditions is most associated with the likelihood of a difficult airway?

153. To avoid thermal injury when using a transcutaneous blood gas monitor to track an infant’s PO2, you should:

154. A 45-year-old patient with asthma is prescribed 0.3 mL of albuterol (Proventil) in 3 mL normal saline via small volume nebulizer. Before initiating therapy, you note from chart review that the patient is severely hypertensive and has been experiencing episodes of superventricular tachycardia. You should do which of the following?

155. A patient is receiving IPPB therapy via pressure-cycled ventilator with a mouthpiece. You observe that the patient is exhaling, but after triggering on the ventilator fails to cycle off. Which of the following should be done to correct this problem?

156. An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend?

157. A 59-year-old postoperative man who weighs 77 kg (169 lb) is receiving volume control A/C ventilation at a rate of 14/min with a tidal volume of 650 mL and an FIO2 of 0.4. Results of the arterial blood gas analysis are as follows: pH 7.51, PaCO2 30 torr, HCO3 23 mEq/L, BE -1, PaO2 117 torr, SaO2 99%.

158. A patient with paradoxical chest wall movement most likely has:

159. A home care patient with chronic bronchitis who lives alone is having difficulty clearing secretions via simple coughing. Which of the following should you recommend?

160. You would recommend against using noninvasive positive pressure ventilation (NPPV) for a patient with: