Exam Review Ch 2 Gather Clinical Info

On assessment of an acutely ill patient, you note all the following in the region of the left lower lobe: decreased expansion, a dull percussion note, and the absent of breath sounds/tactile fremitus. You also observe a shift in the trachea toward the left, more prominent during inspiration. These findings suggest:
1. left-sided obstruction/atelectasis
2. left-sided pneumothorax
3. left-sided consolidation
4. left-sided pleural effusion
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On assessment of an acutely ill patient, you note all the following in the region of the left lower lobe: decreased expansion, a dull percussion note, and the absent of breath sounds/tactile fremitus. You also observe a shift in the trachea toward the left, more prominent during inspiration. These findings suggest:
1. left-sided obstruction/atelectasis
2. left-sided pneumothorax
3. left-sided consolidation
4. left-sided pleural effusion
1. left-sided obstruction/atelectasis
A unilateral decrease in lung expansion, combined with a dull percussion note and the absent of breath sounds & tactile fremitus signifies either local lobar obstruction with atelectasis or a pleural effusion on the affected side. In general, the trachea shifts away from large effusions but toward areas of atelectasis.
A small child is admitted to the Emergency Department with fever, difficulty swallowing, drooling, and stridor. An AP X-ray of the neck area is negative, but a lateral neck film indicates supraglottic swelling. Which of the following is the most likely diagnosis?
1.asthma
2.croup
3.foreign body obstruction
4.epiglottitis
4.epiglottitis
Based on the clinical signs and symptoms and the radiographs, the most likely diagnosis is epiglottitis. In this condition, the AP X-ray may appear normal, but the lateral neck film often reveals a prominent shadow caused by the swollen epiglottis, called the "Thumb sign."
When inspecting the X-ray of an out-patient with nephrotic syndrome, you note a homogeneous area of increased density that obscures the left costophrenic angle. Which of the following is the most likely problem?
1.pleural effusion
2.bacterial pneumonia
3.pulmonary edema
4.atelectasis
1.pleural effusion
Pleural effusion is commonly associated with cardiac failure, but can also occur with certain infections, metastasis, renal disease (especially nephrotic syndrome) and collagen vascular disorders. On X-ray, pleural effusion appears as homogeneous areas of increased density that are position- dependent. If the patient is upright, fluid will accumulates in and 'blunt' or obscure the costophrenic angles. If the patient is placed in a decubitus position, the effusion will 'layer out' laterally.
A 67-year-old patient with COPD complains that she becomes breathless after brushing her hair and must sit down to catch her breath. This complaint is most closely related to which of the following?
1.Increased work of breathing
2.cardiac tamponade
3.increased pulmonary reserve
4.orthopnea
1.Increased work of breathing
A patient who cannot perform simple activities of daily living without experiencing dyspnea is showing classic signs of increased work of breathing. In fact, on the American Thoracic Society Breathlessness Scale, breathlessness occurring when involved in activities of daily living such as dressing rates as the severest form of dyspnea.
When using a numeric rating scale (NRS) to quantify a patient's pain intensity, the patient reports a level of 5 on the 10-point scale. You note that his last rating was a level of 2. Based on this rating and the reported change, you should:
1.Immediately report the findings to the patient's physician
2.Record your findings in the respiratory care progress notes
3.Repeat the assessment to see if the results are reproducible
4.Advise the patient to try and relax and focus on the positive
1..Immediately report the findings to the patient's physician
In general, whenever a patient reports a pain severity greater than 4 units or a change in pain score greater than 2 units on a 10-point numeric rating scale, you should be immediately report the findings to the patient's physician.
What type of sputum would be most common in a patient with an advanced bacterial infection of the respiratory tract?
1.purulent sputum
2.mucoid sputum
3.bloody sputum
4.frothy sputum
1.purulent sputum
Most advanced bacterial infections cause purulent secretions. Mucoid secretions increase first. These secretions soon become infiltrated with fragmented bacteria, leukocytes, and tissue cells damaged by the inflammatory process. Cell disruption releases large amounts DNA and RNA. DNA gives secretions their purulent trait, yellow to greenish color, and high viscosity. This is in contrast to the colorless, clear or frothy, mucoid type seen in early infections.
A patient with inspiratory stridor most likely has which of the following conditions?
1.Bronchospasm: Yes; Laryngeal edema: Yes; Secretions in large airways: Yes
2.Bronchospasm: No; Laryngeal edema: Yes; Secretions in large airways: No
3.Bronchospasm: Yes; Laryngeal edema: No; Secretions in large airways: Yes
4.Bronchospasm: No; Laryngeal edema: No; Secretions in large airways: Yes
2.Bronchospasm: No; Laryngeal edema: Yes; Secretions in large airways: No
A patient with inspiratory stridor most likely has either laryngeal edema or a tumor or mass affecting the glottic area. If the patient is a child, foreign body obstruction is also a possibility. Secretions in the large airways typically manifest as rhonchi on auscultation and fremitus on palpation.
You note on inspection of an AP chest radiograph that the right hemidiaphragm is elevated above normal. Which of the following is the most likely cause of this abnormality?
1.right pleural effusion
2.right tension pneumothorax
3.right phrenic nerve paralysis
4.right lower lobe pneumonia
3.right phrenic nerve paralysis
An elevated hemidiaphragm indicates phrenic nerve paralysis on the affected side or hepatomegaly (right side only). Pleural effusions blunt the costophrenic angles, whereas hyperinflation tends to flatten the hemidiaphragms, as does tension pneumothorax (on affected side).
A small child is admitted to the Emergency Department with fever, difficulty swallowing, drooling, and stridor. An AP X-ray of the neck area is negative, but a lateral neck film indicates supraglottic swelling. Which of the following is the most likely diagnosis?
1.asthma
2.croup
3.foreign body obstruction
4.epiglottitis
4. epiglottitis
Based on the clinical signs and symptoms and the radiographs, the most likely diagnosis is epiglottitis. In this condition, the AP X-ray may appear normal, but the lateral neck film often reveals a prominent shadow caused by the swollen epiglottis, called the "Thumb sign."
In which of the following conditions are fine, late inspiratory crackles (rales) most likely to be heard on auscultation?
1.pulmonary edema
2.croup
3.pleural effusion
4.asthma
1.pulmonary edema
Fine, late inspiratory crackles are thought to occur when collapsed bronchioles and/or alveoli 'pop' open toward the end of inspiration. Patients with disorders that reduce lung volume--such as atelectasis, pneumonia, pulmonary edema and fibrosis--are most likely to have late inspiratory crackles. Asthma is better associated with wheezing and croup with stridor. A pleural effusion normally decreases breath sound, but does by itself not cause crackles.
When interviewing a patient, which of the following might be relevant to the patient's pulmonary status? 1.Occupational history: Yes; Medical history: Yes; Smoking history: Yes; Family history: No 2.Occupational history: No; Medical history: Yes; Smoking history: No; Family history: Yes 3.Occupational history: Yes; Medical history: No; Smoking history: Yes; Family history: No 4.Occupational history: Yes; Medical history: Yes; Smoking history: Yes; Family history: Yes4.Occupational history: Yes; Medical history: Yes; Smoking history: Yes; Family history: Yes In addition to a patient's chief complaint, a variety of history relating to the patient's occupation, family, smoking and past medical conditions, should be gathered to help in your assessment.Inspection of a PA chest radiograph reveals a CT ratio of 60%. Based on this finding, the most likely problem is: 1.pneumothorax 2.pleural effusion 3.cardiomegaly 4.atelectasis3. Normally, the heart width is less than 50% of the width of the thoracic cage. Cardiomegaly exits when the cardiac-to-thoracic width ratio (CT ratio) exceeds 50% on a PA chest radiograph. Pneumothorax, pleural effusion, atelectasis all can affect the position of the heart, but not its size.On assessment of an acutely ill patient, you note all the following in the region of the left lower lobe: decreased expansion, a dull percussion note, and the absent of breath sounds/tactile fremitus. You also observe a shift in the trachea toward the left, more prominent during inspiration. These findings suggest: 1.left-sided obstruction/atelectasis 2.left-sided pneumothorax 3.left-sided consolidation 4.left-sided pleural effusion1.left-sided obstruction/atelectasis A unilateral decrease in lung expansion, combined with a dull percussion note and the absent of breath sounds & tactile fremitus signifies either local lobar obstruction with atelectasis or a pleural effusion on the affected side. In general, the trachea shifts away from large effusions but toward areas of atelectasis.Which of the following patients most likely has a health literacy limitation? 1.One who cannot describe how to take medications: Yes; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: Yes 2.One who cannot describe how to take medications: No; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: No 3.One who cannot describe how to take medications: Yes; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: No 4.One who cannot describe how to take medications: No; One who cannot correctly fill out a form: No; One who asks a lot of care-related questions: Yes3.One who cannot describe how to take medications: Yes; One who cannot correctly fill out a form: Yes; One who asks a lot of care-related questions: No You should suspect health literacy problems when a patient offers excuses when asked to read, e.g. left their eyeglasses at home; does not reorient materials provided so as to be unreadable, e.g., up-side down; identifies medications by their appearance (e.g., color or shape) rather than by name; fails to correctly take medications or cannot describe how to take them; or has difficulty correctly filling out forms.A comprehensive environmental history needs to include information on: 1.the jobs of all household members 2.home/apartment temperature settings 3.commuting distance to/from work 4.approximate hours per day spent on feet1. In addition to work-related exposures, a comprehensive environmental history should include information on present and previous home locations, jobs of household members, home insulating and heating/cooling system, home cleaning agents, pesticide exposure, water supply, recent renovation/remodeling, air pollution (indoor and outdoor), hazardous wastes/spill exposure, and hobbies (e.g., painting, sculpting, ceramics, welding, woodworking, automobiles, gardening, etc.)Which of the following is relevant information regarding a patient's occupational exposure history? 1.cleaning agents used at home 2.patient's residential water supply 3.protective equipment worn on job 4.patient's hobbies/avocational pursuits3.protective equipment worn on job Work-related practices relevant to a patient's occupational exposure history include the type of worksite ventilation, use of personal protective equipment (e.g., respirators, gloves, and coveralls), and on-the-job personal habits such as smoking and/or eating in work area or washing one's hands with solvents. Information regarding cleaning agents used at home, the patient's residential water supply, and a patient's hobbies/avocational pursuits are relevant to the environmental exposure history, but are not occupational or work-related.When inspecting a chest radiograph, you note that the heart is shifted to the patient's left. Which of the following is the most likely cause of this finding? 1.left sided atelectasis/lung collapse 2.left sided pleural effusion 3.left sided tension pneumothorax 4.right sided pneumonectomy1. The heart and mediastinum are pulled toward areas of decreased lung volume (e.g., atelectasis, fibrosis, surgical resection) and pushed away from space occupying lesions (e.g., pneumothorax, pleural effusion, large mass lesions). A shift of the heart position to the right would therefore be caused either decreased right-sided lung volume or a space occupying lesion on the left. Of the options listed, only left sided atelectasis/lung collapse would shift the heart's position to the left.A patient with paradoxical chest wall movement most likely has: 1.atopic asthma 2.chronic bronchitis 3.flail chest 4.tension pneumothorax3. Paradoxical chest wall movement is a common sign of flail chest. Flail chest occurs when 3 or more adjoining ribs are fractured in two or more places. This section of the chest wall becomes unstable and is 'sucked in' during inspiration and bulges out during expiration. Flail chest is usually the result of trauma.In which of the following conditions are fine, late inspiratory crackles (rales) most likely to be heard on auscultation? 1.atelectasis 2.croup 3.pleural effusion 4.asthma1 Fine, late inspiratory crackles are thought to occur when collapsed bronchioles and/or alveoli 'pop' open toward the end of inspiration. Patients with disorders that reduce lung volume—such as atelectasis, pneumonia, pulmonary edema and fibrosis—are most likely to have late inspiratory crackles. Asthma is better associated with wheezing and croup with stridor. A pleural effusion normally decreases breath sound, but does by itself not cause crackles.In reviewing the chest x-ray report for a 62-year-old homeless person, you note the following: cavitation, infiltrates, and calcified nodules. These findings are most consistent with which of the following at diagnoses? 1.acute asthma 2.pulmonary edema 3.pulmonary emphysema 4.post-primary tuberculosis4. The x-ray of a patient with post-primary (reactivation) TB usually reveals cavity formation, noncalcified round infiltrates and homogeneously calcified nodules (tuberculomas), usually 5-20 mm in size.Which one of the following measures could be used to evaluate changes in symptoms occurring among participants in a pulmonary rehabilitation program? 1.changes in sputum production 2.changes in O2 consumption 3.changes in blood pressure 4.changes in O2 saturation1 Measures useful in evaluating changes in symptoms occurring among participants in a pulmonary rehabilitation program include: dyspnea score comparisons (Borg scale); frequency of cough, sputum production or wheezing; weight loss or gain; and standardized psychological tests. Though potentially useful as measures of improvement, O2 consumption, O2 saturation and vital signs are not patient symptoms.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? 1.hypovolemia 2.hypertension 3.cardiovascular shock 4.low cardiac output2.hypertension A 'bounding' pulse is characterized by forceful pulsations that quickly disappear, indicating a high systolic pressure without a rise in diastolic pressure (increased pulse pressure). A bounding pulse is normal during exercise or as a result of a 'fight or flight' release of epinephrine. A bounding pulse also can signal an abnormal condition, most commonly hypertension due to atherosclerosis or disorders causing increased stroke volume. Hypovolemia, shock, and low cardiac output usually result in decreased systolic and pulse pressures.When checking for proper adult placement of an endotracheal or tracheostomy tube on chest X-ray, the distal tip of the tube should be positioned where? 1.1 to 3 cm above the carina 2.1 to 3 cm below the larynx 3.4 to 6 cm above the carina 4.23 cm from the base of the tongue3. 3 An AP chest X-ray is the most common method used to confirm proper placement of an endotracheal or tracheostomy tube. Ideally, the tube tip should be positioned about 4 to 6 cm above the carina. This normally corresponds to a location between thoracic vertebrae T2 and T4, or about the same level as the superior border of the aortic knob.A patient with an acute upper airway obstruction would have which of the following physical signs? 1.inspiratory crackles 2.unilateral lung expansion 3.dullness to percussion 4.inspiratory stridor4. Signs of acute upper airway obstruction include marked respiratory distress, altered voice, dysphagia, stridor, decreased breath sounds, and tachycardia. Conscious patients also may exhibit the 'hand-to-the-throat' choking sign. If the obstruction is complete and not resolved by treatment, asphyxiation will progress to cyanosis, bradycardia, hypotension, and cardiovascular collapse.Rapid, deep ventilation is most likely to be observed in a patient with which of the following conditions? 1.anxiety 2.CNS depression 3.hypothermia 4.hyperoxemia1. Fear, anxiety and pain all are strong stimuli that can cause a stress response and increase ventilatory drive. Hypoxemia also can increase ventilatory drive. CNS depression and hypothermia would tend to decrease ventilatory drive Hypoxemia also can increase ventilatory drive.A patient's respirations are characterized by a gradual increase and then a gradual decrease in the depth of breathing, followed by a period of apnea. This pattern is known as which of the following? 1.Biot's breathing 2.Cheyne-Stokes breathing 3.Kussmaul's breathing 4.apneustic breathing2. Cheyne-Stokes breathing is characterized by a gradual increase and then a gradual decrease in tidal volume, followed by periods of apnea. This pattern is associated with brain injuries, especially to the respiratory centers in the brainstem (pons and medulla). It also is observed in some patients with chronic heart failure.On examination of a normal patient's neck, the midline of the trachea should be directly below the center of the: 1.suprasternal notch 2.midclavicular line 3.midaxillary line 4.anterior axillary line1. Normally, the trachea is located centrally in the neck of a forward facing patient. The midline of the neck can be located by palpation of the suprasternal notch at the base of the anterior neck. The midline of the trachea should be directly below the center of the suprasternal notchHypoxia can occur without cyanosis in patients with what disorder? 1.hypothermia 2.hyperthermia 3.polycythemia 4.anemia4 Central cyanosis generally occurs when hemoglobin (Hb) levels are at or above normal and the arterial oxygen saturation falls below 80%, corresponding to a Pao2 of about 45-50 torr. Patients with anemia have low Hb levels. Sand thus can be severely hypoxic before cyanosis ever appears.All of the following findings are associated with potential difficulty orally intubating a patient EXCEPT: 1.macroglossia 2.soft palate not visible 3.deviated septum 4.short/thick neck3 A short/thick neck, poor range of neck motion, macroglossia (enlarged tongue), and Mallampati Class 4 assessment of pharyngeal anatomy (soft palate, uvula and tonsils not visible; only hard palate visible) are all associated with the potential for difficult oral intubation. A deviated septum would only be a potential problem for nasal intubationUpon palpating a patient's pulse, you note 85 unevenly spaced beats, with a marked decreased in pulse strength during inspiration. Which of the following describes the patient's pulse? 1.thready pulse 2.bounding pulse 3.pulsus alternans 4.pulsus paradoxus4 A decrease in pulse strength or blood pressure during inspiration is termed pulsus paradoxus. It is often seen in patients during severe episodes of airway obstruction (e.g., status asthmaticus) and also in patients with constrictive pericarditis or cardiac tamponade.A 25-year-old comatose woman is seen in the emergency room. You observe that her respiratory rate is 24/min. and her tidal volume is consistently large. No periods of apnea have been observed. Which of the following breathing patterns would be most consistent with these observations? 1.Kussmaul's breathing 2.Cheyne-Stokes breathing 3.Biot's breathing 4.eupnea1 Kussmaul's breathing is characterized by consistently large tidal volumes and an increase respiratory rate with no periods of apnea. It is most commonly observed in diabetic ketoacidosis (as respiratory compensation for metabolic acidosis).In patients with COPD, pedal edema is a sign of: 1.impaired pulmonary diffusion 2.hypercapnia (impaired CO2 removal) 3.right ventricular hypertrophy 4.systemic hypertension3 Many patients with COPD are chronically hypoxemic. Chronic hypoxemia causes pulmonary vasoconstriction, which forces the right ventricle to work harder than normal. Over time, this increase in workload may result in right ventricular hypertrophy and poor venous blood flow return to the heart. When the venous return to the right side of the heart is reduced, the peripheral blood vessels engorge, resulting in an accumulation of fluid in the tissues of the ankles, referred to as pedal edema.A premature infant receiving positive pressure ventilation exhibits acute respiratory distress, asymmetrical chest motion and hypotension. Which of the following procedures would you initially recommend? 1.chest transillumination 2.arterial blood gas 3.A-P chest radiograph 4.capillary heal stick1 Transillumination can quickly detect the presence of a pneumothorax in small infants. You should recommend transillumination for any high-risk infant (especially those receiving positive pressure ventilation) with clinical signs of unilateral pneumothorax, i.e., retractions, tachypnea, cyanosis, hypotension, and asymmetrical chest motion. When transillumination results are positive in infants with these signs (the affected side "lights up"), immediate chest tube insertion is indicated. On the other hand, if transillumination is negative but the infant still exhibits these signs, you should recommend an immediately chest X-ray.Ideally, where should the tip of a properly positioned pulmonary artery catheter appear on an AP chest X-ray? 1.in the lower lobe, posteriorly 2.in the superior vena cava or right atrium 3.in the lower lobe, anteriorly 4.in the upper lobe, posteriorly1 A pulmonary artery catheter is used for hemodynamic monitoring and administering fluids and medications. Accurate wedge pressure measurement requires the catheter tip be visualized in the lower lobe, ideally posteriorly. Improper placement can result is false readings, e.g., pressure in the alveoli instead of the pulmonary veins/left atrium. The correct answer is: in the lower lobe, posteriorlyOn palpating the neck region of a patient on a mechanical ventilator, you note a crackling sound and sensation. What is the most likely cause of this observation? 1.upper bronchial obstruction 2.subcutaneous emphysema 3.pneumonia of the upper lobes 4.atelectasis of the upper lobes2 When air leaks from the lung into subcutaneous tissues, fine beads of air produce a crackling sound and sensation when palpated. Leakage of air from the lungs into subcutaneous tissues is referred to as subcutaneous emphysema. The crackling sensation produced on palpation is called crepitus.You ask a patient what day of the week it is and which hospital he is in. Which of the following are you trying to assess? 1.verbal skills 2.emotional status 3.desire to cooperate 4.sensorium4 To quickly assess patients for their level of consciousness, or "sensorium," we ask them the time of day, where they are, and who they are. Alert patients are well oriented to time, place, and person, or "oriented x 3." The most common reasons for a patient not being oriented are neurologic injury, sedation, or severe hypoxemia or hypercapnia. In general, only alert patients can fully cooperate and participate in their own care.Which of the following medications administered in a therapeutic range would be most likely to interfere with a patient's ability to cooperate? 1.ampicillin 2.furosemide (Lasix) 3.theophylline (Aminophylline) 4.phenobarbital4 The only drug listed that would affect the mental status of a patient in its therapeutic range is phenobarbital, a powerful sedative-hypnotic.A patient with a fever and severe cough is producing small amounts of yellow-white sputum with blood streaks. Which of the following disorders is most likely? 1.bronchiectasis 2.bacterial pneumonia 3.bronchial asthma 4.bronchogenic carcinoma2 Certain respiratory disorders produce easily recognizable sputum samples. Pseudomonas infections typically produce thick, green sputum with a musty smell. Sputum sample from a patient with bronchiectasis tends to be foul-smelling and settles out into 3 distinct layers. Blood-streak sputum is common in pneumococcal pneumonia, and frothy, pink, watery secretions are seen in pulmonary edema.How would you characterize the degree of dyspnea of a patient who walks slower than people of the same age because of breathlessness? 1.slight 2.moderate 3.severe 4.very severe2 You can assess a patient's exercise tolerance via interview using the American Thoracic Society Breathlessness Scale. By inquiring as to when breathlessness is first noticed by the patient, you can assign a rating to the symptom, with a descriptive term for each level. In this case, a patient who walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at own pace on level ground would be characterized as having moderate dyspnea.While palpating a patient's chest, you notice that the vibrations on inhalation and exhalation clear when the patient effectively coughs. This indicates that: 1.the patient has emphysema 2.there is an occluded airway 3.secretions were present in the airways 4.the patient has pneumonia3 Palpable vibrations (fremitus) that clear with a cough usually indicates secretions in the airway. The correct answer is: secretions were present in the airwaysTo verify that a patient or her family can properly set-up and operate a pulse oximeter for overnight trend recording, you would: 1.provide simple step-by-step written instructions for the patient and patient's family 2.demonstrate proper set-up and operation of the sensor and oximeter on the patient 3.require a return demonstration to verify proper use of the equipment 4.provide a phone number where the patient can immediately get needed help3 Although all these factors are essential in planning and conducting overnight oximetry in the home setting, the only way to assure that a patient or her family can set-up and operate a pulse oximeter is to require a return demonstration, i.e., have the patient or family actually go through the steps needed to properly operate the device.When checking for proper adult placement of an endotracheal or tracheostomy tube on chest X-ray, the distal tip of the tube should be positioned where? 1.4 to 6 cm above the carina 2.1 to 3 cm above the carina 3.1 to 3 cm below the larynx 4.23 cm from the base of the tongue1 Proper placement of endotracheal tracheostomy tubes should be checked by chest X-ray. The tube tip should be 4-6 cm above the carina. This position minimizes the chance tube movement down into the mainstem bronchi or up into the larynx.A patient has a lower than normal mixed venous O2 content. All of the following could cause this condition EXCEPT: 1.cardiogenic shock 2.hyperthermia 3.cyanide poisoning 4.hypovolemia3 A lower than normal mixed venous O2 content (CVO2) indicates impaired tissue oxygenation. A low CVO2 can be due to reduced oxygen delivery (decreased Hb, PO2, or cardiac output), or increased oxygen demand. Cardiogenic shock and hypovolemia both decrease cardiac output, while hyperthermia increases oxygen demand. In cyanide poisoning, the CVO2 can be higher than normal, even though tissue hypoxia may be present.Before administration of a prescribed bronchodilator, an asthmatic patient with moderate wheezing has a FEV1 of 3.7 L. Thirty minutes after aerosol administration of the drug, the patient's FEV1 is 4.1 L. Based on this information you would: 1.wait another 30 minutes and repeat the test 2.recommend increasing the bronchodilator dosage 3.recommend discontinuing bronchodilator therapy 4.recommend decreasing the bronchodilator dosage2 In this patient's case, the change in FEV1 is less than 10% [(4.1 - 3.7)/4.1 = 9.7%], indicates a lack of significant improvement in airway caliber. In order to relieve the patient's symptoms, you should recommend increasing the dose of the prescribed bronchodilator.After performing comprehensive pulmonary function testing on a patient, you note the following results: Test % Predicted FEV1 50% RV1 50% TLC1 35% DLCO 60% Which of the following interpretations is most consistent with these findings? 1.The patient has pulmonary fibrosis 2.The patient has pulmonary emphysema 3.The patient has chronic bronchitis 4.The patient is not exerting maximum effort2 The low FEV1% and higher than normal TLC and RV confirm an obstructive disorder with hyperinflation (emphysema, chronic bronchitis, acute asthma, etc.). Among these obstructive disorders, only patients with emphysema exhibit a low DLCO, due to the destruction of the alveolar-capillary membrane.After three minutes of peak activity during an oxygen titration test, a patient's SpO2 drops from 90% to 87%. Which of the following actions is indicated? 1.continue the test for another three minutes at the same liter flow 2.increment the O2 flow by 1 liter per minute and continue the test 3.immediately terminate the test and assess the patient's vital signs 4.increment the O2 flow by 1 liter per minute and terminate the test2 During an oxygen titration test, you have the patient maintain their peak activity level for at least 3 minutes, then measure the SaO2. If the patient's saturation at the peak activity level is 3 88%, the patient does not need any additional oxygen and the test can be terminated. If on the other hand, the patient's SaO2 drops by 2% or more or if the SaO2 < 88% (PaO2 ≤ 55 torr), increment their O2 flow by 1 L/min (up to 6 L/min). After stabilization on the new O2 flow for 3 minutes, re-assess the SaO2 while the patient continues to exercise. Repeat this procedure until the SaO2 is at least 88% or the PaO2 is above 55 torr. Note that for safety purposes, the AARC recommends a target SaO2 of 93%.While assisting in a treadmill exercise capacity test, the patient complains to you that she is developing severe shortness of breath and some chest pain. Which of the following actions would you recommend at this time? 1.increase the O2 flow rate 2.decrease the treadmill speed 3.decrease the treadmill incline 4.terminated the procedure at once4 Any exercise test should be terminated if the patient exhibits an abnormal or hazardous response occurs. Abnormal or hazardous responses include wide swings in blood pressure; development of severe angina, dyspnea or a serious arrhythmia; or the patient becoming dizzy, confused or cyanotic.A patient receiving mechanical ventilation with 8 cm H2O PEEP has a balloon-tipped pulmonary artery catheter in place. To obtain an accurate measurement of her pulmonary artery wedge pressure (PAWP) you would: 1.level the transducer to 2nd intercostal space/midaxillary line 2.remove the patient from the ventilator and PEEP 3.make the PAWP measurement at end-expiration 4.turn the PEEP to '0'3 For accurate central venous and pulmonary artery pressure measurements, you need to level the transducer at the patient's plebostatic axis, i.e., the intersection of 4th intercostal space with midaxillary line. To minimize the effect of changes in intrathoracic pressure during breathing on PAWP, you should make your measurements at end-expiration. Do NOT remove patients from PEEP/CPAP or decrease the PEEP level to measure PAWP.A patient in shock exhibits the following cardiovascular measures: a DECREASE in pulmonary artery pressure, an INCREASE in systemic vascular resistance, and a DECREASE in cardiac output. Given these data, the most likely type of shock is: 1.anaphylactic shock 2.neurogenic shock 3.hyperdynamic septic shock 4.hypovolemic shock4 In combination, a DECREASE in pulmonary artery pressure, an INCREASE in systemic vascular resistance, and a DECREASE in cardiac output are all consistent with hypovolemic shock. These findings are also consistent with hypodynamic septic shock.A patient has a body surface area (BSA) of 2.0 m2 and a cardiac output (CO) of 3.0 L/min. What conclusions can you draw regarding the patient's cardiac index? 1.the patient's cardiac index is below normal 2.the patient's cardiac index is normal 3.the patient's cardiac index is above normal 4.insufficient data to compute the cardiac index1 Cardiac index (CI) = CO/BSA. In this case CI = 3.0/2.0 = 1.5 L/min/m2. Because a normal range for cardiac index is 2.5-4.0 L/min/m2, this patient's cardiac index is below normal.The normal range for the pulmonary artery wedge pressure (PAWP) as measured via the distal port of a pulmonary artery (Swan-Ganz) catheter is: 1.20 - 30 mm Hg 2.6 - 12 mm Hg 3.10 - 20 mm Hg 4.2 - 6 mm Hg2 The pulmonary artery wedge pressure (PAWP; also PCWP) normally ranges between 6-12 mm Hg. Increases in PAWP can indicate 1) LV failure/cardiogenic shock; 2) hypervolemia; 3) cardiac tamponade/constrictive pericarditis; 4) mitral stenosis; 5) positive pressure ventilation/PEEP; and 6) pneumothorax. PAWP normally falls during spontaneous inspiration. Abnormal decreases in PAWP indicate either noncardiogenic shock or hypovolemia.Five minutes after elevating the pressure to 20 cm H2O during a CPAP titration study, a patient still exhibits obstructive respiratory events and some periods of central sleep apnea. What should be the next step in conducting this study? 1.Stop the study and recommend alternative therapy for the sleep disorder 2.Increase the CPAP pressure to 22 cm H2O for 5 minutes and continuing observing 3.Begin titrating with BiPAP up to a maximum IPAP-EPAP = 10 cm H2O 4.Maintain 20 cm H2O CPAP for an additional 10 minutes and continuing observing3 During a CPAP titration study, you generally increase the CPAP level until the obstructive events are abolished or controlled, or until you reach a maximum CPAP level of 20 cm H2O. If there are continued obstructive respiratory events at high levels of CPAP (> 15 cm H2O) or the patient exhibits periods of central sleep apnea, you should consider a trial of BiPAP, starting at EPAP = 4 and IPAP = 8, with a recommended maximum IPAP-EPAP differential of 10 cm H2O and a maximum IPAP of 30 H2O.At what level should the diaphragm be to verify a good inspiration on an AP chest radiograph? 1.6-7th posterior ribs 2.8-9th posterior ribs 3.10-11th posterior ribs 4.12th posterior rib2 A good inspiration is needed to properly visualize lung structures, especially at the bases. On an AP film inspiration is adequate if diaphragm is at the level of the 8-9th posterior ribs or 6th anterior rib on the right.Which of the following tests would you recommend to help a physician assess the effectiveness of steroid treatment for a patient with asthma? 1.Carbon monoxide diffusing capacity (DLCO) 2.Methacholine challenge test (PC20) 3.Exhaled nitric oxide test (FENO) 4.Treadmill exercise challenge test3 Analysis of the exhaled fraction of nitric oxide (FENO) is used in both the diagnosis and management of asthma. In asymptomatic patients on inhaled steroids, low levels indicate effective treatment and good compliance with therapy. High level may indicate inadequate steroid dose, poor treatment compliance, or poor inhaler technique.