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During VC-CMV, a change in ____ or rate is needed to correct for respiratory alkalosis or acidosis.
1. inspiratory time
2. FIO2
3. pressure limit
4. Vt

VT

During mechanical ventilation of a CHF patient, the PaCO2 = 28 mm Hg and the f = 16/min. If the desired PaCO2 is 40, then the f must be changed to ____.
1. 7/min
2. 11/min
3. 18/min
4. 14/min

11/min

During mechanical ventilation of a head injury patient, the PaCO2 = 48 mm Hg and the f = 12/min. If the desired PaCO2 is 30, then the f must be changed to ____.
1. 19/min
2. 28/min
3. 10/min
4. 8/min

19/min

During PC-CMV, a change in ____ or rate is needed to correct for respiratory alkalosis or acidosis.
1. Vt
2. inspiratory time
3. Either A or B
4. pressure limit

Either A or B (Vt or inspiratory time)

Common causes of respiratory alkalosis include the following except ____.
1. mechanical ventilation
2. hypoxia
3. medications (salicylate, xanthines, analeptics)
4. opiates for pain management

opiates for pain management

Head injury that results in a high minute ventilation and hyperventilation is sometimes difficult to control, regardless of the mode selected. Some patients with brain injury have a tendency to breath with a high tidal volume and rate, which is due to a central nervous system lesion and cannot be corrected.
1. True
2. False

True

Common causes of metabolic alkalosis include all of the following except ____.
1. loss of gastric fluid and stomach acids (vomiting, nasogastric suctioning)
2. acid loss in the urine (diuretic administration)
3. mechanical ventilation
4. acid shift into the cells (potassium deficiency)

mechanical ventilation

In the presence of fever, burns, multiple trauma, sepsis, hyperthyroidism, muscle tremors or seizures, agitation, and multiple surgical procedures, it is not unusual for metabolism to be high. In these situations the elevated ____ is due to the increased metabolic rate.
1. FIO2
2. mean airway pressure
3. VCO2
4. PIP

VC02

Hyperventilation may be needed for brief periods when acute neurological deterioration is present and ICP is elevated. Mild hyperventilation (PaCO2 30 - 35 mm Hg) may be used for longer periods in situations where increased ICP is refractory to standard treatment.
1. False
2. True

True

A deliberate limitation of ventilatory support to avoid lung overdistention and injury is termed ____.
1. protective hyperresonance
2. permissive hypoxemia
3. permissive hypercapnea
4. permissive hypocapnea

permissive hypercapnea

The time spent suctioning is brief and must not exceed 15 seconds. Suction is applied intermittently rather than continuously, and the catheter is rotated as it is withdrawn.1. False
2. True

True

The intent of saline lavage is to loosen secretions; however, saline does not thin secretions, and instilling saline may increase the risk of dislodging bacteria from the endotracheal tube, causing them to enter the patient's airway and potentially leading to nosocomial pneumonia.
1. False
2. True

True

During mechanical ventilation of a patient with COPD, the PaO2 = 58 mm Hg and the FIO2 = 0.50. If the desired PCO2 is 65, then the FIO2 must be changed to ____.
1. 0.56
2. 0.44
3. 0.65
4. 0.74

0.44

During mechanical ventilation of a patient with CHF, the PaO2 = 38 mm Hg and the FIO2 = 0.60. If the desired PCO2 is 60, then the FIO2 must be changed to ____.
1. 0.74
2. 0.95
3. 0.64
4. 0.38

0.38

During mechanical ventilation of a patient with CHF, the PaO2= 48 mm Hg, the FIO2 = 0.60, and the PEEP is 5 cm H2O. If the desired PCO2 is 60, then the FIO2 must be changed to ____.
1. 0.66
2. 1.00
3. 0.85
4. 0.75

0.66

It is important to try and keep FIO2 below 0.4 to 0.5 to prevent the complications of O2 toxicity, while keeping the partial pressure of O2 in the arteries (PaO2) between 60 and 90 mm Hg and the CaO2 near normal (20 mL/dL).
1. False
2. True

True

Factors that increase Paw during PPV include all of the following except ____.
1. increased f
2. increased FIO2
3. increased total PEEP
4. increased PIP

increased FIO2

Atelectasis is the partial or complete collapse of previously expanded areas of the lung, producing a shrunken, airless state. It may be caused by all of the following except ____.
1. alveolar hyperinflation
2. blockage of air passages
3. shallow breathing with increased FIO2
4. surfactant deficiency

alveolar hyperinflation

The positive pressure employed with CPAP or PEEP is commonly applied to the airway with all of the following devices except ____.
1. esophageal obturator
2. a tight fitting mask
3. endotracheal tube
4. nasal prongs

esophageal obturator

A(n) ____ is a device that provides a constant pressure throughout expiration regardless of the rate of gas flow or ventilation (i.e., flow independent).
1. isothermal resistor
2. threshold resistor
3. electrical resistor
4. flow resistor

threshold resistor

The level of PEEP set must be balanced against producing profound cardiopulmonary side effects such as decreased venous return, decreased cardiac output, decreased blood pressure, increased shunting, increased VD/Vt barotrauma, and volutrauma.
1. True
2. False

True

The use of PEEP allows for the reduction of FIO2 because PEEP improves oxygenation and helps to avoid the complications associated with a high FIO2 in certain disorders. Specific clinical disorders that may benefit from the use of PEEP include all of the following except ____.
1. bilateral diffuse pneumonia
2. cardiogenic pulmonary edema
3. ALI or ARDS
4. carbon monoxide poisoning

carbon monoxide poisoning

Patients' clinical conditions that indicate that PEEP or CPAP therapy be started as soon as possible include all of the following conditions except ____.
1. pathological conditions with FIO2 values ³0.5
2. pathological conditions with high compliance
3. pathological conditions that damage pulmonary cells (types I and II)
4. high peak pressures (>35 cm H2O)

pathological conditions with high compliance

A clinician is asked to reduce the PEEP that the patient has been receiving from 10 to 5 cm H2O, using an older-generation ventilator. After the adjustment is made, the ventilator begins initiating inspiration spontaneously (auto-cycling). Which of the following best explains this malfunction?
1. The sensitivity control needed to be reset after PEEP was adjusted.
2. The peak flow control is probably not adjusted properly.
3. The respiratory rate should have been reset after PEEP was adjusted.
4. The pressure limit was not reset after PEEP was adjusted.

The sensitivity control needed to be reset after PEEP was adjusted.

A patient is receiving 10 cm H2O PEEP with an FIO2 of 0.40. The patient is hypoxemic and the clinician decides to increase the PEEP to 15 cm H2O and maintain the FIO2. The subsequent cardiac output measurement shows a change from 4.5 to 2.7 L/min. The most appropriate action is to ____.
1. apply PEEP at 20 cm H2O and maintain the FIO2 at 0.40
2. discontinue PEEP, set the FIO2 at 1.0, and obtain an ABG sample in 30 minutes
3. apply PEEP at 10 cm H2O and increase the FIO2 to 0.50
4. apply PEEP at 5 cm H2O and maintain the FIO2 at 0.40

apply PEEP at 10 cm H2O and increase the FIO2 to 0.50

If cardiac output is low, O2 transport may be enhanced by all of the following methods except ____.
1. slightly reducing the PEEP level
2. using beta-blocking agents
3. using volume loading (administration of fluids)
4. using inotropic agents

using beta-blocking agents

Despite risk, it is still important to use PEEP, since it can prevent alveolar collapse during exhalation and reopening even when a low Vt setting is used. It is now theorized that it is important to use the pressure-volume loop to set PEEP ____.
1. at the peak inspiration point detected during inflation of the lung
2. at the lower inflection point detected during inflation of the lung
3. at the upper inflection point detected during inflation of the lung
4. above the upper inflection point detected during deflation of the lung

above the upper inflection point detected during deflation of the lung

In primary ARDS (direct), lungs are mostly consolidated. In secondary ARDS (indirect), alveolar collapse is predominant. A lung recruitment maneuver is less likely to improve oxygenation and compliance of the lung in secondary ARDS.
1. True
2. False

False

Several types of recruitment maneuvers are currently being used in the clinical setting. These include a sustained high pressure in the CPAP mode, PCV with a single high PEEP level imposed, PCV with progressive increases in PEEP level, and sigh maneuvers.
1. True
2. False

True

The ARDS Network trial and other studies provide strong evidence in support of using VT of 6 mL/kg and a Pplateau <30 cm H2O when ventilating patients with ARDS. The differences in survival are significant when these settings are used compared with using a VT of 12 mL/kg.
1. True
2. False

True

Relaxation of smooth airway muscle in the presence of reversible airflow obstruction is a general indication for the use of:
1. Antiinfective agents
2. Steroids
3. Adrenergic bronchodilators
4. Mucolytics

Adrenergic bronchodilators

Ipratropium agents may be indicated to treat:
1. Nonallergic rhinitis
2. The common cold
3. Allergic rhinitis
4. All of the above

Nonallergic rhinitis
The common cold
Allergic rhinitis
***All of the above***

The most common side effect of anticholinergic bronchodilators is:
1. Increased heart rate
2. Wheezing
3. Delirium
4. Dry mouth

Dry mouth

Possible side effects of aerosolized Atrovent include which of the following?
I. Flulike symptoms
II. Pharyngitis
III. Cardiac arrest
IV. Dry mouth
V. Dyspnea

1. I, II, IV, and V only
2. I, II, and III only
3. I, II, III, IV, and V
4. I, II, and IV only

I, II, IV, and V only

Disease states that could benefit from the use of adrenergic bronchodilators include which of the following?
I. Asthma
II. Bronchitis
III. Emphysema
IV. Bronchiectasis
V. Pleural effusion

I, II, III, and IV only

Racemic epinephrine comes in what percent solution?
1. 1.25%
2. 2.25%
3. 5.
4. 0.05%

2.25%

The keyhole theory indicates that the larger the side-chain attachment to a catechol base, the:
1. Shorter the duration of action
2. More easily it is metabolized
3. More easily it is broken down by COMT
4. Greater the b2 specificity

Greater the b2 specificity

Albuterol is available in which of the following forms?
I. Syrup
II. Nebulizer solution
III. Metered dose inhaler (MDI)
IV. Oral tablets
V. Dry powder inhaler (DPI) capsules
1. I, II, and V only
2. I, II, III, IV, and V
3. II and III only
4. III, IV, and V only

I, II, III, IV, and V

Inhalation is the preferred route of administering catecholamines for which of the following reasons?
I. Rapid onset of action
II. Smaller dosage used
III. Reduced side effects
IV. Drug is delivered to target organ
V. Safe and painless route
1. I, III, and V only
2. I, II, III, IV, and V
3. III and IV only
4. I and II only

I, II, III, IV, and V

You receive an order to administer 5 ml of albuterol by small volume nebulizer (SVN). You would:
1. Give 0.5 ml of medication because that is probably what the doctor meant to write
2. Confirm the order on the chart and administer as directed
3. Call the physician to confirm the medication dose
4. Have your supervisor administer the treatment

Call the physician to confirm the medication dose

A patient with glottic edema is in mild distress. Which of the following medications would be of benefit in this situation?
1. Ipratropium bromide
2. Albuterol
3. Racemic epinephrine
4. Theophylline

Racemic epinephrine

Ipratropium bromide can be delivered by which of the following methods?
I. Tablet
II. Nebulizer
III. Injection
IV. MDI
V. Nasal spray
1. II only
2. I, III, and IV only
3. II, IV, and V only
4. I, II, and IV only

II, IV, and V only

Sedation is frequently required for mechanically ventilated patients for agitation and sleep deprivation, which can result from all of factors below except ____.

1. pain
2. adverse drug effects
3. flail chest and paradoxical breathing
4. extreme anxiety and delirium

flail chest and paradoxical breathing

Sedation may be required for mechanically ventilated patients who are being treated with non-conventional modes of ventilation including all of the following except ____.

1. inverse I:E ventilation
2. high-frequency ventilation
3. permissive hypercapnia
4. pressure support ventilation for weaning

pressure support ventilation for weaning

Benzodiazepines have been the drugs of choice for the treatment of anxiety in critical care.

1. False
2. True

True

Drugs that produce anxiolytic, hypnotic, muscle relaxation, anticonvulsant, and anterograde amnesic effects are ____.

1. benzodiazepines
2. opioids
3. NMBAs
4. neuroleptics

benzodiazepines

Propofol (Diprivan) is an intravenous, general anesthetic agent that possesses sedative, amnesic, and hypnotic properties at low doses, although it has no analgesic properties.

1. True
2. False

True

An appropriate depolarizing agent for use during intubation is ____.

1. Pavulon
2. Fentanyl
3. Vecuronium
4. Succinylcholine

Succinylcholine

NMBAs should not be used with sedatives for patients on mechanical ventilation.

1. False
2. True

False

A fresh postoperative patient displaying ventilator dysynchrony should first be treated with ____.

1. NMBAs
2. analgesics
3. sedatives
4. neuroleptics

analgesics

The most potent analgesic agent is ____.

1. Demerol HCl
2. Fentanyl
3. morphine sulfate
4. Dilaudid

Fentanyl

Nondepolarizing agents resemble acetylcholine in their chemical structure. These drugs induce paralysis by binding to acetylcholine receptors and causing prolonged depolarization of the motor end plate.

1. False
2. True

False

Regardless of the NMBA used, it is important to understand that these drugs do not possess sedative or analgesic properties and must, therefore, be used in conjunction with adequate amounts of sedatives and analgesics to ensure patient comfort.

1. True
2. False

True

NMBAs are commonly used in mechanically ventilated patients when ____.

1. cardiac arrhythmias are present
2. the patient is in severe pain
3. patient anxiety results from ICU psychosis
4. patient-ventilator dysynchrony cannot be corrected

patient-ventilator dysynchrony cannot be corrected

A patient exhibits delirium characterized by disorganized thinking and unnecessary motor activity after being on a ventilator in the ICU for 4 days. The drug type appropriate to treat this condition is a(n) ____.

1. neuroleptic
2. sedative
3. analgesic
4. NMBA

neuroleptic

Fentanyl exerts significant effects on the cardiovascular system but does not cause histamine release like morphine.

1. True
2. False

False

Fentanyl citrate (Sublimaze) is a synthetic opioid that is approximately 100 to 150 times more potent than morphine.

1. False
2. True

True

Morphine is a potent opioid analgesic agent that is the preferred agent for analgesic intermittent therapy for mechanically ventilated patients because of ____.

1. its ability to alter the control of breathing
2. its effects on the central nervous system
3. its benign cardiac effects
4. its longer duration of action

its longer duration of action

Although the primary pharmacological action of opioids is to relieve pain, these drugs can also provide significant secondary sedative and anxiolytic effects, which are mediated through two types of opioid receptors: µ and ê receptors.

1. True
2. False

True

Reversal of opioid side effects can be accomplished with the opioid antagonist ____.

1. acetylcholine
2. propofol (Diprivan)
3. naloxone hydrochloride (Narcan)
4. the butyrophenone haloperidol

naloxone hydrochloride (Narcan)

Observing the patient's skeletal muscle movements and respiratory effort can provide an easy method to determine if the patient is paralyzed with NMBAs; however, more sophisticated electronic monitoring is typically required to determine the depth of paralysis.

1. True
2. False

True

____ is a rare but potentially fatal disorder that is characterized by sustained skeletal muscle depolarization.

1. Hypertension
2. Malignant neoplasm
3. Malignant hyperthermia
4. Hypotensive neuralgia

Malignant hyperthermia

Vecuronium bromide (Norcuron) is an intermediate duration nondepolarizing aminosteroid NMBA that does not possess the vagolytic properties of pancuronium.

1. False
2. True

True

It has been known for several decades that PPV decreases cardiac output. This phenomenon can be understood in part by comparing intrapleural (intrathoracic) pressure changes that occur during normal spontaneous negative pressure breathing and intrapleural (intrathoracic) pressure changes that occur during positive pressure ventilation.

1. False
2. True

True

PEEP with assist/control decreases cardiac output less than when PEEP is used with IMV/SIMV or CPAP alone.

1. True
2. False

True

During spontaneous breathing, the fall in intrapleural (intrathoracic) pressure that draws air into the lungs during inspiration also draws blood into the major thoracic vessels and heart. This phenomenon increases ____.

1. right ventricular afterload
2. right ventricular preload
3. systemic vascular resistance
4. P capillary resistance

right ventricular preload

During inspiration with high Vt or when high levels of PEEP are used, the pulmonary capillaries that interlace the alveoli are stretched and narrowed. As a result PEEP ____.

1. increases right ventricular afterload
2. decreases right ventricular afterload
3. decreases left ventricular afterload
4. increases right ventricular preload

decreases right ventricular afterload

Left ventricular output may also be decreased when high Vts are used during PPV, because the heart is compressed between the expanding lungs. This is known as ____.

1. cardiac hypertrophy
2. cardiomyopathy
3. cardiac tamponade
4. pneumomediastinum

cardiac tamponade

In addition to reduced venous return and alteration in ventricular function, lower cardiac output may be due to myocardial dysfunction associated with ____ and the resultant myocardial ischemia.

1. reduced renal blood flow
2. reduced portal blood flow
3. reduced carotid blood flow
4. reduced coronary blood flow

reduced coronary blood flow

Systemic hypotension commonly occurs in hemodynamically normal individuals receiving positive pressure ventilation.

1. False
2. True

False

It is unusual to see a reduction in cardiac output in normovolemic patients when low levels of PEEP are used (i.e., 5 to 10 cm H2O of PEEP).

1. True
2. False

True

Patients with very stiff lungs, such as those with ARDS or pulmonary fibrosis, receiving positive pressure ventilation are ____.

1. more likely to experience hemodynamic changes with high pressures
2. less likely to transmit alveolar pressure to the intrapleural space
3. more likely to have higher intrapleural pressures
4. less likely to have decreased lung compliance

less likely to transmit alveolar pressure to the intrapleural space

Maintaining the lowest possible mean airway pressure helps to minimize the reductions in cardiac output that can occur during mechanical ventilation.

1. False
2. True

True

Positive pressure ventilation and PEEP can be beneficial for patients with left ventricular dysfunction and elevated filling pressures for all of the following reasons except ____.

1. reductions in venous return decrease the preload to the heart and thus improve length-tension relationships and improve the stroke volume
2. PEEP decreases the transmural coronary artery pressure, changing myocardial perfusion
3. PEEP may improve cardiac function by raising the PaO2 and improving myocardial oxygenation and performance
4. PPV raises the intrathoracic pressure, decreases the transmural LV systolic pressure and, thus, the afterload to the left heart

PEEP decreases the transmural coronary artery pressure, changing myocardial perfusion

With normal I:E ratios, the majority of pulmonary perfusion and gas exchange occurs during ____.

1. expiratory time
2. coughing maneuvers
3. ventricular systole
4. inspiratory time

expiratory time

Inflation hold is now used almost exclusively to measure plateau pressure in order to calculate static compliance, not to improve the distribution of alveolar gas.

1. True
2. False

True

Increased amounts of PIP may be needed to ventilate patients with elevated Raw, but this increased pressure will not all reach the alveoli. This is true in all of the following conditions except ____.

1. mucus plugging
2. mucosal edema
3. bronchospasm
4. lobar pneumonia

lobar pneumonia

The most serious management complications associated with PPV include all of the following except ____.

1. alterations in cardiac function
2. respiratory alkalosis
3. interference with gas exchange
4. increased risk of lung injury from over-distension

respiratory alkalosis

When severe, uncontrollable increased intracranial pressure is present, patients may be mechanically hyperventilated to reduce intracranial pressure by ____.

1. lowering PaCO2 to 25 to 30 mm Hg
2. raising PaCO2 to 45 to 50 mm Hg
3. lowering PaCO2 to 15 to 20 mm Hg
4. lowering PaCO2 to 10 to 13 mm Hg

lowering PaCO2 to 25 to 30 mm Hg

It has been known for nearly half a century that pressurized breathing can induce reductions in renal function and urine output. These effects include ____.

1. renal responses to increased FIO2 administration
2. renal responses to diuretic administration
3. renal responses to increased IV fluid administration
4. renal responses to hemodynamic changes resulting from high intrathoracic pressures

renal responses to hemodynamic changes resulting from high intrathoracic pressures

Although urinary output stays fairly constant over a wide range of arterial pressures, it becomes severely reduced as the glomerular capillary pressure decreases below 75 mm Hg.

1. False
2. True

True

In the seriously ill mechanically ventilated patient, administering positive pressure increases all of the following except ____.

1. renal blood flow
2. weight gain
3. water and sodium retention
4. pulmonary edema

renal blood flow

PPV increases splanchnic resistance, decreases splanchnic venous outflow, and may contribute to gastric mucosal ischemia. This last change is one of the factors leading to increased incidence of ____, which are frequently seen in critically ill patients.

1. liver metastases
2. tracheal malacia
3. portal blood flow increases
4. gastrointestinal bleeding and gastric ulcers

gastrointestinal bleeding and gastric ulcers

Barotrauma implies trauma associated with pressure. Examples of barotraumas resulting from mechanical ventilation include all of the following except ____.

1. subcutaneous emphysema
2. subcutaneous edema
3. pneumomediastinum
4. pneumothorax

subcutaneous edema

Prolonged alveolar over-distention from mechanical ventilation leads to the release of inflammatory mediators from the lungs that can cause failure of other organs of the body. This response has been termed ____.

1. biotrauma
2. barotrauma
3. volutrauma
4. atelectrauma

biotrauma

More recent evidence demonstrates that the repeated opening and closing of lung units generates shear stress, with direct tissue injury at the alveolar and pulmonary capillary level as well as the loss of surfactant from these unstable lung units. This injury is now termed ____.

1. volutrauma
2. atelectrauma
3. biotrauma
4. barotrauma

atelectrauma 100%

The term ____, in general, is used when referring to lung injury occurring in humans that has been identified as a consequence of mechanical ventilation.

1. VALI
2. ARDS
3. VILI
4. VAPS

VALI

A condition that can be accelerated by mechanical ventilation is ____. It can be detected by a hyperresonant percussion note and absence of breath sounds on the affected side of the thorax.

1. ejectate injury
2. pneumoperitoneum
3. pneumococcal pneumonia
4. pneumothorax

pneumothorax

____ occurs when an alveolus that is normally expanded is adjacent to one that is collapsed (atelectasis) and unstable. As airway pressure increases during inspiration, the normal alveolus inflates, but the collapsed unit does not.

1. Absorption injury
2. Volutrauma
3. Emphysema
4. Shear stress

Shear stress

Chemical mediators produced in the lung during ventilator mismanagement can leak into the blood vessels. The pulmonary circulation then carries these stimulating substances to other areas of the body and sets up an inflammatory reaction in other organs such as the kidneys, gut, and liver.

1. True
2. False

True

Mechanical ventilation is not benign and may cause lung injury. Treating patients with lung-protective strategies includes all of the following except ____.

1. low FIO2
2. low Vt
3. permissive hypercapnea
4. therapeutic PEEP

low FIO2

It is generally considered important in mechanical ventilation of patients with ALI and/or ARDS to open alveoli with a recruitment maneuver and keep them open with an appropriate level of PEEP.

1. False
2. True

True

The positive effects of PEEP in ALI and ARDS include all of the following except ____.

1. improved oxygenation
2. improvement of the V/Q relationships of the lungs
3. decreased CVP and right ventricle preload
4. FRC is increased when collapsed alveoli open up

decreased CVP and right ventricle preload

Ventilator-associated pneumonia (VAP) refers specifically to a pneumonia acquired by a patient receiving mechanical ventilation 48 hours after intubation.

1. True
2. False

True

Strategies for reducing the risk for colonization and VAP include all of the following except ____.

1. saline instillation into the ET tube during suctioning.
2. semirecumbent positioning of patient
3. handwashing and use of accepted infection control procedures and practices and use of closed suction catheters and sterile suction technique
4. continuous aspiration of subglottic secretions

saline instillation into the ET tube during suctioning.

The easiest way to detect air trapping or auto-PEEP is to evaluate ____.

1. the manometer PIP
2. the volume-time curve on the ventilator graphic
3. the flow-time curve on the ventilator graphic
4. the pressure-time curve on the ventilator graphic

the flow-time curve on the ventilator graphic

Management of patient-ventilator asynchrony begins with several specific steps. The initial step is to ____.

1. analyze the FIO2
2. check low pressure alarm setting
3. disconnect the patient from the ventilator and perform manual ventilation
4. decrease the peak flow setting

disconnect the patient from the ventilator and perform manual ventilation

As opposed to a ventilator-related problem, patient-related problems include all of the following except ____.

1. pneumothorax
2. increased patient circuit rainout
3. artificial airway problems
4. bronchospasm

increased patient circuit rainout

Rupture of the innominate artery can occur and is most often noticed with ____.

1. pulmonary artery lines
2. heated wire patient circuits
3. endotracheal tubes
4. tracheostomy tubes

tracheostomy tubes

Causes of airway problems that can lead to sudden distress include all of the following except ____.

1. cuff inflated to 24 mm Hg
2. endotracheal tube kinking
3. migration of the endotracheal tube above the vocal cords
4. migration of the endotracheal tube into the right mainstem bronchus

cuff inflated to 24 mm Hg

The sudden onset of dyspnea can be visually recognized by the physical signs of distress, which include all of the following except ____.

1. diaphoresis
2. nasal flaring
3. tachypnea
4. no accessory muscle use noted

no accessory muscle use noted

If a tension pneumothorax is strongly suspected and death is imminent, the appropriate next step is to ____.

1. confirm the finding with a chest radiograph
2. insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line
3. obtain a 7 Fr trocar and establish a pleural drainage tube
4. use a Heimlich chest drainage valve with chest tube placement

insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line

Wheezing associated with increased Raw from airway reactivity, such as occurs with asthma, is treated with all of the following except ____.

1. inhaled bronchodilators
2. parenteral corticosteroids
3. peak flows above 2 L/sec
4. increased expiratory time

peak flows above 2 L/sec

Abdominal distention during mechanical ventilation can be caused by ____.

1. excessive nasogastric suction
2. pneumothorax
3. pneumomediastinum
4. pneumoperitoneum

pneumoperitoneum

The occurrence of low pressure, low volume, and low VE alarms indicates that ____ is causing the problem.

1. pneumothorax
2. a leak
3. bronchospasm
4. pulmonary embolism

a leak

Leaks rarely result from a patient disconnection in the modern ICU.

1. False
2. True

False

During ventilation with VC-CMV, pleural leaks can sometimes be compensated for by increasing the ____.

1. Vt setting
2. peak flow
3. pressure limit
4. number of chest tubes

VT setting

Auto-PEEP may interfere with the ventilator's ability to detect patient efforts. This is corrected by decreasing the sensitivity setting.

1. True
2. False

False

During volume ventilation, a concave appearance on the inspiratory pressure curve indicates active inspiration with inadequate flow.

1. True
2. False

True

Asynchronous breathing may occur when patients with COPD are ventilated with PSV. These patients are known to have an active short inspiration. If the patient begins to actively exhale during the inspiratory phase of PSV, this can be corrected by ____.

1. switching to a ventilator with adjustable pressure-cycling characteristics
2. switching to a ventilator with adjustable flow-cycling characteristics
3. switching to PRVC
4. switching to VC-CMV

switching to a ventilator with adjustable flow-cycling characteristics

Conditions leading to high pressure alarms can be divided into all of the following categories except ____.

1. airway problems
2. leaks associated with the ventilator or patient circuit
3. changes in lung characteristics or patient-related conditions
4. obstructive problems related to the ventilator or patient circuit

leaks associated with the ventilator or patient circuit

The ventilator alarms that are most likely to occur include all of the following except ____.

1. low exhaled volume alarm
2. ventilator inoperative alarm
3. low ET cuff volume alarm
4. low pressure alarm

low ET cuff volume alarm

Although invasive ventilation is effective and often necessary to support alveolar ventilation, it has many associated risks that often result in increased mortality, morbidity, and financial cost.

1. True
2. False

True

NPPV is considered a life-saving application that offers a number of benefits over IPPV. Least significant among these is the avoidance of intubation.

1. False
2. True

False

Endotracheal intubation is associated with all of the following complications except ____.

1. choanal atresia
2. nosocomial pneumonia
3. airway trauma and increased risk of aspiration
4. patient discomfort requiring the use of sedatives

choanal atresia

The physiological goal of NPPV in acute respiratory failure is to improve gas exchange by ____.

1. decreasing the effect of conducting airway secretions
2. increasing alveolar ventilation and resting the respiratory muscles
3. decreasing FRC
4. increasing right ventricular preload

increasing alveolar ventilation and resting the respiratory muscles

When compared with patients with COPD receiving only conventional medical therapy (such as bronchodilators, antiinflammatory agents, oxygen, and antibiotics), patients with COPD receiving NPPV have shown significant improvement in vital signs, pH and blood gas values, respiratory rate, and breathlessness within the first hour of application.

1. True
2. False

True

A number of studies have found that NPPV is currently considered a standard of care to treat ____ in selected patients.

1. hypoxemic respiratory failure/ARDS
2. COPD exacerbations
3. asthma exacerbations
4. community-acquired pneumonia

COPD exacerbations

When NPPV was compared with CPAP in the treatment of CPE, patients treated with NPPV had more rapid improvements in PaCO2 and pH, but mortality rates and intubation rates were not significantly different.

1. True
2. False

True

NPPV can be useful in chronic cases as supportive therapy for all the following clinical disorders except ____.

1. nocturnal desaturation and poor sleep quality
2. metabolic disorders leading to acidosis
3. chronic hypoventilation
4. respiratory muscle fatigue

metabolic disorders leading to acidosis

Disorders associated with nocturnal hypoventilation that generally benefit from NPPV include all of the following except ____.

1. pulmonary fibrosis
2. obesity hypoventilation syndrome
3. central sleep apnea
4. obstructive sleep apnea combined with COPD or CHF

pulmonary fibrosis

Symptoms of chronic hypoventilation that may be indications for NPPV include all of the following except ____.

1. daytime anxiety
2. fatigue and morning headache
3. daytime hypersomnolence
4. dyspnea

daytime anxiety

Symptoms and selection criteria for NPPV in acute respiratory failure include all of the following except ____.

1. respiratory rate >24 breaths/min
2. purse-lipped breathing
3. paradoxical breathing
4. accessory muscle use

purse-lipped breathing

NPPV can be used after extubation in patients who exhibit fatigue. NPPV in this setting reduces work of breathing and maintains adequate gas exchange as effectively as invasive ventilation.

1. False
2. True

True

Physiological criteria for commitment to NPPV include all of the following except ____.

1. pH <7.35
2. SaO2 <92%
3. PaO2/FIO2 <200
4. PaCO2 >45 mm Hg

SaO2 <92%

Mask discomfort is the most frequently occurring complication of NPPV. The most common problem is ____.

1. mask strap pressure leads to increased ICP
2. air leaks around the mask often result in eye irritation
3. pressure sores may occur over the forehead
4. nasal masks are not well tolerated

air leaks around the mask often result in eye irritation

All of the following factors will increase ventilatory demand (workload) except:

1. increased compliance
2. severe hypoxemia
3. bronchospasm
4. pulmonary infection

increased compliance

Ventilatory capacity is determined by all of the following except:

1. trigger level
2. muscle endurance
3. central nervous system (CNS) drive
4. muscle strength

trigger level

All of the following factors can reduce a patient's ventilatory drive except:

1. respiratory alkalosis
2. depressant drugs
3. decreased metabolism
4. metabolic acidosis

metabolic acidosis

When is ventilator dependence likely to occur?
I. when ventilatory capacity exceeds demand
II. when arterial hypoxemia is present
III. when the patient is malnourished
IV. when the cardiovascular system is unstable


1. II and IV
2. II, III, and IV
3. I, II, and III
4. III and IV

II, III, and IV

All of the following indicate that an adult patient is ready to be weaned from ventilatory support except:

1. MIP = -33 cm H2O
2. VD/VT = 0.55
3. PAO2 - PaO2 = 430 on 10O2
4. PO2 = 76 mm Hg on 4O2

PAO2 - PaO2 = 430 on 100% O2

Which of the following five adult patients receiving ventilatory support is the best candidate for weaning?
Maximum voluntary
Patient
VC
VE
ventilation (MVV)
MIP
VD/VT
Qs/QT

1.5
4.6
9.9
-33

Which of the following patients exhibits an acceptable ventilatory demand?
VE
PaCO2

8
36

A patient has an adequate ventilatory reserve if which of the following is TRUE?

ability to double the resting minute ventilation

You measure the spontaneous rate of breathing and VT on four patients receiving ventilator support. For which one is successful weaning most likely?
Breathing frequency
VT

29
350

A patient receiving ventilator support has a spontaneous rate of breathing of 26/min and an average VT of 300 ml. What is this patient's rapid-shallow breathing index?

1. 12
2. 87
3. 66
4. 105

87

Which of the following signs observed on a mechanically ventilated patient indicate that successful weaning is unlikely?
I. palpable scalene muscle use during inspiration
II. palpable abdominal tensing during expiration
III. presence of an irregular breathing pattern
IV. patient unable to alter breathing pattern on command


1. III and IV
2. I, II, III, and IV
3. I, II, and III
4. II and IV

I, II, III, and IV

Which of the following is false about the P0.1 measure?

1. Chronic obstructive pulmonary disease (COPD) patients with a P0.1 greater than 6 cm H2O are difficult to wean.
2. P0.1 is the airway pressure measured 100 ms after occlusion.
3. P0.1 is an effort-dependent measure of respiratory drive.
4. P0.1 correlates well with central respiratory drive.

P0.1 is an effort-dependent measure of respiratory drive.

Successful weaning is less likely when a patient's work of breathing exceeds what level?

1. 16 J/min
2. 8 J/min
3. 4 J/min
4. 12 J/min

16 J/min

Above what pressure-time index (PTI) will most patients be unable to sustain spontaneous breathing?

1. 0.05
2. 0.10
3. 0.15
4. 0.03

0.15

Which of the following electrolyte imbalances can hinder weaning from ventilatory support?
I. hypophosphatemia
II. hypomagnesemia
III. hypokalemia


1. II and III
2. I and II
3. I, II, and III
4. I and III

II and III

Which of the following cardiovascular signs would indicate that a patient's cardiovascular status is unstable and that weaning should NOT begin at this time?

1. heart rate of 108/min
2. cardiac index of 2.5 L/min/m2
3. systolic blood pressure of 80 mm Hg
4. hemoglobin content of 10 g/dl

systolic blood pressure of 80 mm Hg

Of the following adult patients receiving ventilatory support, which has a stable enough cardiovascular profile to consider weaning?
Heart rate
Systolic blood pressure (mm Hg) Hemoglobin (g/dl)
Clinical status

92
90
8
no arrhythmias

Which of the following must you verify when considering weaning an obtunded patient?
I. adequate gag reflex
II. no depressant drugs
III. adequate cough


1. II and III
2. I and III
3. I and II
4. I, II, and III

I, II, and III

Common approaches used to wean patients from ventilatory support include which of the following?
I. T-tube alternating with mechanical ventilation
II. pressure-supported ventilation (PSV)
III. intermittent mandatory ventilation


1. I and II
2. I, II, and III
3. I and III
4. II and III

I, II, and III

Which method of weaning may be useful to minimize auto-PEEP?

1. synchronized intermittent mandatory ventilation
2. T-piece
3. intermittent mandatory ventilation
4. continuous positive airway pressure (CPAP)

continuous positive airway pressure (CPAP)

An alert patient receiving intermittent mandatory ventilation at a rate of 8/min and VT of 600 ml has stable vital signs and satisfactory blood gases on an FIO2 of 0.45. What would you do to initiate weaning for this patient?

1. Decrease the mandatory rate to 5 to 6/min.
2. Lengthen the automatic sigh interval.
3. Increase FIO2 to 60%.
4. Decrease the VT to 500 ml.

Decrease the mandatory rate to 5 to 6/min.

A physician is using a pressure support protocol to wean a patient off ventilatory support. The patient is now at a 5 cm H2O pressure level and has a spontaneous respiratory rate of 21/min. Other cardiovascular and respiratory signs indicate that the patient remains stable. Which of the following actions would you recommend at this point?

1. Switch the patient to intermittent mandatory ventilation at a rate of 2/min.
2. Switch the patient to 5 cm H2O continuous positive airway pressure (CPAP) through the endotracheal tube.
3. Decrease the pressure support level to 3 cm H2O.
4. Extubate the patient and provide supplemental O2.

Extubate the patient and provide supplemental O2.

An alert patient receiving ventilatory support through a demand flow intermittent mandatory ventilation system exhibits clinical signs of an increased work of breathing whenever you try to decrease the mandatory rate below 6/min. In order to aid in weaning this patient, which of the following would you recommend?

1. Apply a low level of pressure support.
2. Decrease the mandatory VT.
3. Increase the mandatory VT.
4. Apply a high level of inspiratory pressure.

Apply a low level of pressure support.

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