Wong's Nursing Care Of Infants And Children 10th Edition By Marilyn Hockenberry, David Wilson TEST B

Chapter 1: Fetal Lung Development Test Bank MULTIPLE CHOICE 1. Which of the following phases of human lung development is characterized by the formation

of a capillary network around airway passages? a. Pseudoglandular b. Saccular c. Alveolar d. Canalicular ANS: D

The canalicular phase follows the pseudoglandular phase, lasting from approximately 17 weeks to 26 weeks of gestation. This phase is so named because of the appearance of vascular channels, or capillaries, which begin to grow by forming a capillary network around the air passages. During the pseudoglandular stage, which begins at day 52 and extends to week 16 of gestation, the airway system subdivides extensively and the conducting airway system develops, ending with the terminal bronchioles. The saccular stage of development, which takes place from weeks 29 to 36 of gestation, is characterized by the development of sacs that later become alveoli. During the saccular phase, a tremendous increase in the potential gasexchanging surface area occurs. The distinction between the saccular stage and the alveolar stage is arbitrary. The alveolar stage stretches from 39 weeks of gestation to term. This stage is represented by the establishment of alveoli.

REF: pp. 3-5 2. Regarding postnatal lung growth, by approximately what age do most of the alveoli that will

be present in the lungs for life develop? a. 6 months b. 1 year c. 1.5 years d. 2 years ANS: C

Most of the postnatal formation of alveoli in the infant occurs over the first 1.5 years of life.

At 2 years of age, the number of alveoli varies substantially among individuals. After 2 years of age, males have more alveoli than do females. After alveolar multiplication ends, the alveoli continue to increase in size until thoracic growth is completed.

REF: p. 6 3. The respiratory therapist is evaluating a newborn with mild respiratory distress due to tracheal

stenosis. During which period of lung development did this problem develop? a. Embryonal b. Saccular c. Canalicular d. Alveolar ANS: A

The initial structures of the pulmonary tree develop during the embryonal stage. Errors in development during this time may result in laryngeal, tracheal, or esophageal atresia or stenosis. Pulmonary hypoplasia, an incomplete development of the lungs characterized by an abnormally low number and/or size of bronchopulmonary segments and/or alveoli, can develop during the pseudoglandular phase. If the fetus is born during the canalicular phase (i.e., prematurely), severe respiratory distress can be expected because the inadequately developed airways, along with insufficient and immature surfactant production by alveolar type II cells, gives rise to the constellation of problems known as infant respiratory distress syndrome.

REF: p. 6 4. Which of the following mechanisms is (are) responsible for the possible association between

oligohydramnios and lung hypoplasia?

I. Abnormal carbohydrate metabolism II. Mechanical restriction of the chest wall III. Interference with fetal breathing IV. Failure to produce fetal lung liquid a. I and III only b. II and III only c. I, II, and IV only d. II, III, and IV only ANS: D

Oligohydramnios, a reduced quantity of amniotic fluid present for an extended period of time, with or without renal anomalies, is associated with lung hypoplasia. The mechanisms by which amniotic fluid volume influences lung growth remain unclear. Possible explanations for reduced quantity of amniotic fluid include mechanical restriction of the chest wall, interference with fetal breathing, or failure to produce fetal lung liquid. These clinical and experimental observations possibly point to a common denominator, lung stretch, as being a major growth stimulant.

REF: pp. 6-7 5. What is the purpose of the substance secreted by the type II pneumocyte? a. To increase the gas exchange surface area b. To reduce surface tension c. To maintain lung elasticity d. To preserve the volume of the amniotic fluid ANS: B

The primary role of mammalian surfactant is to lower the surface tension within the alveolus, specifically at the air–liquid interface. This allows the delicate structure of the alveolus to expand when filled with air. Without surfactant, the alveolus remains collapsed because of the high surface tension of the moist alveolar surface. Surfactant is composed predominantly of an intricate blend of phospholipids, neutral lipids, and proteins.

REF: p. 8

6. Which of the following tests of the amniotic fluid have been shown to be sensitive indicators

of lung maturity? a. Levels of prednisone b. Levels of epidermal growth factor c. Levels of prostaglandins d. Levels of phosphatidylglycerol and phosphatidylcholine ANS: D

Of clinical relevance during late gestation, analysis of amniotic fluid for the concentration of phosphatidylglycerol and phosphatidylcholine has been shown to be a sensitive indicator of the state of fetal lung maturity.

REF: p. 8

Chapter 2: Fetal Gas Exchange and Circulation Test Bank MULTIPLE CHOICE 1. Which of the following embryonic germ layers gives formation to the respiratory system? a. Endoderm b. Mesoderm c. Ectoderm d. Periderm ANS: A

The respiratory system—pharynx, lungs, and epithelial lining of the trachea and lungs— originates in the endoderm. Refer to Box 2-1 in the textbook to see the list of various tissue systems found in the three embryonic layers.

REF: p. 13 2. What is the function of Wharton’s jelly inside the umbilical cord? a. To help provide nutrition to the fetus b. To prevent the vessels inside the cord from kinking c. To help protect the fetus d. To regulate the temperature between the fetus and the mother ANS: B

Wharton's jelly, a gelatinous substance inside the umbilical cord, helps protect the vessels of the fetus and may prevent the cord from kinking.

REF: p. 13 3. Which of the following organs is considered to be the first to form? a. Heart b. Brain c. Lungs d. Kidneys ANS: A

The heart is considered to be the first complete organ formed. By 8 weeks of gestation, the normal fetal heart is fully functional, complete with all chambers, valves, and major vessels.

REF: p. 14 4. A pregnant woman is coming for an early prenatal evaluation and wants to know if she can

listen to the baby’s heartbeat. How early can the fetal heartbeat be detected? a. Day 8 b. Day 22 c. Day 45 d. Day 60 ANS: B

By day 22 cardiac contractions are detectable and bidirectional tidal blood flow begins.

REF: p. 14 5. Which of the following anatomic structures is a (are) fetal shunt(s)?

I. Foramen ovale II. Sinus venosus III. Ductus venosus IV. Ductus arteriosus a. III only b. I, III, and IV only c. I, II, and IV only d. II, III, and IV only ANS: B

Figure 2-6 in the textbook illustrates fetal circulation and the three shunts present in the fetus that close soon after birth. They include (1) the foramen ovale, the opening between the right atrium and the left atrium, which enables oxygenated blood to flow to the left side of the fetal heart; (2) the ductus venosus, which appears continuous with the umbilical vein and shunts 30% to 50% of oxygen-rich blood around the liver; and (3) the ductus arteriosus, which allows most of the pulmonary arterial blood flow to bypass the nonfunctioning fetal lungs and enter the aorta.

REF: p. 17 6. Which of the following events causes cessation of right-to-left shunt through the foramen

ovale? a. Increased levels of PO2 in the blood of the neonate b. Decreased levels of PCO2 in the blood of the newborn c. Increased systemic vascular resistance d. Removal of the placenta, causing lowered blood volume returning to the right side of the fetal heart ANS: C

Once the cord is clamped and the PVR decreases, pressures in the right side of the heart decrease and pressures in the left side increase. Because the foramen ovale flap allows blood to flow only from right to left, it closes when the pressures in the left atrium become greater than those in the right atrium. Closing the foramen ovale further facilitates the increase of blood flow to the lungs during the transitional period and is necessary to maintain normal extrauterine circulation.

REF: p. 18 7. How long after birth should it take for the ductus arteriosus to close completely? a. 24 hours b. 48 hours c. 96 hours d. 1 week ANS: C

Because the pressure in the aorta also increases and becomes greater than the pressure in the pulmonary artery, the amount of shunting through the ductus arteriosus decreases. The functional closure of the ductus arteriosus occurs as a result of being exposed to an increased PO2, a decrease in PVR leading to the reduction in blood pressure within the ductal lumen, a decrease in the local production of prostaglandins, and a reduction in the number of prostaglandin receptors within the tissue of the ductus arteriosus. Normally, constriction of the ductus arteriosus starts to occur at birth, and 20% of the ductus closes within 24 hours, with 80% closed in 48 hours, and 100% by 96 hours after birth.

REF: p. 18

Chapter 3: Antenatal Assessment and High Risk Delivery Test Bank MULTIPLE CHOICE 1. A pregnant woman has been diagnosed with pregestational diabetes. Which of the following

risk factors should the therapist be aware at the time of delivery? a. Unexplained abruption placenta b. Oligohydramnios c. Microcephaly d. Fetal malformations ANS: C

Adverse fetal outcomes include unexplained fetal death in the third trimester of pregnancy and major fetal structural malformations. Close surveillance of the maternal metabolism and close fetal biophysical evaluation have significantly decreased the risk of fetal death as well as the necessity of delivering a fetus prematurely because of abnormal test results. The rate of fetal structural malformations in infants born to pregestational diabetic women can be as high as 10% to 15% compared with a rate of 1% to 2% for infants of otherwise normal women. The most frequently encountered defects include malformations of the cardiovascular system, including both the heart and great vessels, and the central nervous system, including the brain and spinal cord. No amount of maternal metabolic surveillance or fetal biophysical assessment after the period of fetal organogenesis will decrease this risk. Therefore, it is recommended strongly that women with diabetes mellitus receive counseling and treatment with the goal of achieving optimal glycemic control before they become pregnant.

REF: p. 22 2. The respiratory therapist is attending a term labor of a woman diagnosed with gestational

diabetes. The baby is very large for gestational age. What other metabolic disturbances should be considered?

I. Hyperglycemia II. Hypocalcemia III. Hyperkalemia IV. Hypoglycemia a. II and IV only b. I, II, and III only c. I and III only d. II, III, and IV only ANS: D

Poor blood sugar control in these women is associated with an increased risk of macrosomia (birth weight greater than 4000 g), traumatic vaginal delivery, preterm delivery, and a small risk of fetal death in some women. After delivery, the infants are at increased risk for metabolic disturbances in the neonatal period; these include hypoglycemia, hypocalcemia, hyperkalemia, hyperbilirubinemia, and idiopathic respiratory distress syndrome.

REF: p. 22

3. Which of the following microorganisms often affect pregnancy outcome? a. Group B Streptococcus b. Haemophilus influenzae c. Mycobacterium tuberculosis d. Hepatitis C virus ANS: A

A number of infectious agents can affect pregnancy outcome. Among the most important in the United States are group B Streptococcus (GBS), herpes simplex virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV). As many as 10% to 40% of pregnant women are colonized with GBS. Their infants are at risk for death or severe morbidity if they are born prematurely or after prolonged rupture of the fetal membranes.

REF: p. 23 4. What is generally accepted as a safe limit for alcohol consumption during pregnancy to avoid

the development of fetal alcohol syndrome? a. One to two 8-ounce drinks per day are considered acceptable. b. Four to five 8-ounce drinks per week are considered safe. c. Three to four 12-ounce drinks per week are considered reasonable. d. No safe range of alcohol consumption is deemed safe during pregnancy.

ANS: D

Alcohol is a potent teratogen, an agent or factor that causes malformation in the fetus. Fetal alcohol syndrome, associated with maternal use of alcohol in pregnancy, is characterized by mental retardation and prenatal and postnatal growth restriction, as well as by brain, cardiac, spinal, and craniofacial anomalies. It is usually seen among children of women who consume four to six alcoholic drinks daily throughout pregnancy. However, no safe range of alcohol consumption during pregnancy exists.

REF: p. 24 5. What is the average birth weight difference between infants born of mothers who smoke and

those born of nonsmoking mothers? a. Infants born of mothers who smoke tend to be about 200 g lighter than infants born of mothers who do not smoke. b. Infants born of mothers who smoke are generally about 400 g lighter than infants born of nonsmoking mothers. c. Infants born of mothers who smoke are predisposed to weigh approximately 600 g less than infants born of mothers who do not smoke. d. Infants of mothers who smoke are likely to be born about 800 g lighter than those born of mothers who do not smoke.

ANS: A

The mean birth weight of infants of women who smoke during pregnancy is about 200 g less than that of infants of nonsmokers.

REF: p. 24 6. A woman with a long history of smoking is now in the last part of the third trimester of her

pregnancy. She is at high risk for which of the following conditions?

I. Premature rupture of membranes II. Placental abruption III. Placenta previa IV. Sudden infant death syndrome a. II and IV only b. I, II, and III only c. I and III only d. I, II, III, and IV ANS: D

Smoking is associated with a higher incidence of preterm premature rupture of membranes (rupture of the membranes before the onset of labor—before 37 weeks of gestation), placental abruption (separation of the placenta before birth of the newborn), and placenta previa (the placenta partially or completely covers the cervix), and risk of infant death from sudden infant death syndrome, (the unexplained death of an infant under 1 year of age).

REF: p. 24 7. Which of the following conditions are associated with preeclampsia?

I. Multiparity II. Proteinuria III. Generalized edema IV. Hypertension a. II and III b. I, II, and III c. I, III, and IV d. II, III, and IV ANS: D

Preeclampsia is a pregnancy-specific multisystem disorder traditionally diagnosed as the onset or exacerbation of hypertension, proteinuria, and edema in the second half of pregnancy. It complicates approximately 5% to 8% of pregnancies.

REF: p. 24 8. What is the main potential problem associated with the premature rupture of membranes? a. Fetal dehydration b. Fetal infection c. Maternal hypotension d. Maternal renal failure ANS: B

In utero, the fetus is contained in the sterile fluid-filled amniotic sac. If the membranes that compose the external lining of the amniotic sac rupture before term (before 37 weeks of gestation) or before the onset of normal labor at term, the fetal environment is no longer sterile, increasing the risk of fetal infection.

REF: p. 25

9. Which of the following conditions is responsible for up to 40% of the preterm births in the

United States? a. Cervical insufficiency b. Premature rupture of the fetal membranes c. Obstetrical intervention mandated by fetal jeopardy d. Hormonal treatment during pregnancy ANS: B

The causes of premature rupture of the fetal membranes are generally not known but are responsible for 35 percent to 40 percent of preterm births in the United States. Preterm rupture of the fetal membranes can be seen as being responsible for all of the problems faced by most prematurely born infants.

REF: p. 25 10. How should the therapist interpret an amniotic fluid index of 5 cm? a. Polyhydramnios b. Multihydramnios c. Oligohydramnios d. Anhydramnios ANS: C

The amniotic fluid index (AFI) is calculated by measuring the largest vertical pockets of fluid in each of the four uterine quadrants at the time of ultrasound examination.

Oligohydramnios, too little amniotic fluid or an AFI below 5 cm, is usually associated with congenital anomalies (especially renal agenesis or urinary tract obstruction), fetal growth restriction or demise, postterm pregnancy, ruptured membranes, uteroplacental insufficiency, and use of prostaglandin synthase inhibitors.

REF: p. 25 11. Once preterm labor is diagnosed, which of the following medications should be considered as

tocolytic? a. Magnesium sulfate b. Sodium bicarbonate c. Calcium carbonate d. Epinephrine ANS: A

Once preterm labor is diagnosed, prompt measures should be taken to try to stop labor and prevent an early delivery. Intravenous hydration is commonly the first approach used.

However, it does not seem to be of clinical significance in a well-hydrated patient. Excessive hydration should be avoided because it might exacerbate the risk of pulmonary edema that is usually associated with use of tocolytics. The most commonly used tocolytics are magnesium sulfate, beta-mimetic agents, and indomethacin (a prostaglandin inhibitor). Less commonly used are nifedipine (calcium channel blocker), nitroglycerin (nitric oxide donor drug), atosiban (oxytocin antagonist), and combination therapy.

REF: p. 27

12. A pregnant woman at 30 weeks of gestation with premature rupture of membranes has been

admitted to the hospital with preterm labor. The physician has ordered betamethasone. When does the maximal benefit of antenatal corticosteroid occur to reduce RDS? a. After 12 hours b. After 24 hours c. After 48 hours d. After 1 week ANS: C

All women between 24 and 34 weeks of gestation with preterm labor and intact membranes are candidates for antenatal corticosteroid therapy. Patients with preterm labor and ruptured membranes benefit from corticosteroid therapy between 24 and 32 weeks of gestation.

Betamethasone and dexamethasone are most commonly used for antenatal corticosteroid therapy. Maximal benefit occurs 48 hours after initiation of therapy and lasts for 7 days.

REF: p. 27 13. Which of the following conditions is a significant problem in postterm pregnancy? a. Infection b. Fetal anencephaly c. Meconium aspiration d. Obesity ANS: C

Meconium aspiration is a significant problem. Meconium passage in utero is common after 42 weeks of gestation. It is frequently associated with fetal hypoxia. Meconium becomes more concentrated in the amniotic fluid when associated with oligohydramnios. Aspiration of meconium may lead to obstruction of the respiratory passages and interference with surfactant function.

REF: p. 28 14. A woman 41-weeks pregnant is at high risk for complication in the postpartum period. Which

of the following agents will be more appropriate to induce labor? a. Magnesium sulfate b. Aspirin c. Terbutaline d. Oxytocin ANS: D

Labor induction can be achieved with various medications when the cervix is favorable for induction. Intravenous infusion of oxytocin, a hormone secreted from the posterior pituitary that stimulates uterine contractions and milk letdown, is most commonly used.

REF: p. 29 15. What is the most common invasive procedure to assess the fetal condition? a. Amniocentesis b. Scalp fetal pH c. Stress test d. Needle ultrasound

ANS: A

The most commonly performed invasive procedure to assess fetal condition is amniocentesis.

In this procedure, under sterile conditions a needle is inserted through the skin and uterine wall to obtain a sample of fluid from the amniotic sac (see Figure 3-3 in the textbook).

Depending on the reason for performing the procedure, the concentration of many substances in the fluid can be measured. For example, as the fetal lung matures, pulmonary surfactant is secreted from the fetal lung into the amniotic fluid, where its concentration can be measured.

Fetal cells isolated from amniotic fluid can be used to assess for fetal chromosomal abnormalities (e.g., trisomy 21), fetal enzyme deficiencies (e.g., Tay-Sachs), and certain discrete genetic mutations (e.g., sickle cell disease).

REF: p. 29 16. The respiratory therapist is called to assist in the labor of a pregnant woman whose NST

reported two accelerations in fetal heart rate, each of at least 15 beats per minute and lasting at least 15 seconds, associated with maternal perception of fetal movement over a period of 20 minutes. What is the best course of action? a. A C-section should be scheduled as soon as possible. b. No action is required because this reactive NST is associated with normal uteroplacental function. c. A CST should be performed before fetal stress is confirmed. d. Oxytocin should be to be administered to prevent more fetal stress.

ANS: B

A reactive NST requires at least two accelerations in fetal heart rate, each of at least 15 beats per minute and lasting at least 15 seconds, associated with maternal perception of fetal movement over a period of 20 minutes. A reactive NST is highly correlated with normal uteroplacental function.

REF: p. 30 17. A fetus is undergoing a contraction stress test. Uterine contractions are stimulated by the

intravenous infusion of oxytocin into the mother. The fetal PO2 drops below 12 mm Hg and causes the fetal heart rate to slow. Which of the following conditions is likely indicated by this occurrence? a. Placenta abruption b. Oligohydramnios c. Uteroplacental insufficiency d. Nuchal cords ANS: C

During a contraction stress test FHR levels are monitored continuously while uterine contractions are stimulated by intravenous infusion into the mother of a dilute solution of oxytocin. In a normal pregnancy, fetal Po2 (partial pressure of oxygen) decreases with each uterine contraction and then rapidly returns to normal. A fetal Po2 drop below 12 mm Hg, resulting in slowing of the FHR, indicates uteroplacental insufficiency. This slowing of the FHR in response to uterine contractions is called a late deceleration.

REF: p. 30 18. How should the therapist interpret a fetal biophysical profile score of 7?

a. b. c. d.

The fetus requires careful evaluation and possibly immediate delivery.

The fetus requires another biophysical profile in 24 hours.

The fetus appears to be normal.

The data are inconclusive and the profile needs to be redone immediately.

ANS: C

The fetal biophysical profile (BPP) assesses placental function and fetal well-being. The BPP has been likened to the Apgar score. Five determinants of fetal status are assessed and a score of 0 to 2 given. Four are assessed by ultrasonography: fetal breathing, fetal tone, fetal gross body movement, and amniotic fluid volume. The fifth determinant is the nonstress test. A BPP score of 8 to 10 is considered normal and reassuring; a score of 6 is equivocal and is generally repeated within 24 hours; BPP scores of 0 to 4 are clearly abnormal and are associated with poor perinatal outcomes and require careful evaluation and usually immediate delivery.

REF: p. 30 19. Which of the following maternal complications is associated with cesarean section? a. Intraoperative bladder or bowel injuries b. Endomyometriosis c. Failure to progress in labor d. Placenta previa ANS: A

Although cesarean delivery might be the least traumatic for the fetus, for the mother it is associated with an increased risk of significant blood loss, anesthesia complications, intraoperative bladder or bowel injuries, postoperative wound infection, endomyometritis, and thromboembolic events. The syndrome of transient tachypnea of the newborn (wet lung or type II respiratory distress syndrome) includes the clinical features of cyanosis, grunting, and tachypnea during the first hours of life. It is more commonly seen in infants delivered by cesarean section. Placenta previa occurs when the placenta covers the cervical os. Cesarean delivery is usually required.

REF: p. 32 20. In lieu of obtaining a scalp blood gas sample, what can the therapist do to conduct intrapartum

assessment of the fetus? a. Fetal scalp stimulation b. Umbilical cord blood sampling c. Placental blood sampling d. Biophysical profile ANS: A

On many obstetric services, when persistent severe variable or late decelerations of the FHR are diagnosed, fetal scalp blood is obtained via transvaginal fetal scalp puncture, allowing blood gas measurements to be obtained. Scalp blood pH greater than 7.25 is considered reassuring; values of 7.15 or less signal high risk of fetal acidemia. Many clinicians believe that scalp blood gas assessment in the face of an abnormal FHR pattern more precisely defines the fetus at risk and can thus prevent unnecessary forceps and cesarean deliveries. An alternative to scalp blood gas assessment is fetal scalp stimulation. Using the underlying rationale of the NST, transvaginal stimulation of the fetal scalp to induce fetal movement causes the fetal heart rate to accelerate and reassures the clinician that the fetus is not hypoxemic or acidemic.

REF: p. 32 21. A therapist is called to the labor and delivery room to assist in the resuscitation of a term

newborn. If necessary, what FiO2 should be used to start positive pressure ventilation? a. 100% and wean as needed b. 21% and make changes utilizing preductal oximetry c. 50% and wean for SpO2 > 88% d. Any FiO2 as long as peak pressures do not exceed 20 cm H2O ANS: B

One of the biggest changes to accepted resuscitation standards for newborns in NRP 2011 (6th ed) is the need for compressed air and pulse oximetry for all newborns requiring resuscitation.

If ventilation is necessary, term infant ventilation is started with room air (21%) via positive pressure device, and changes in oxygen concentration are made utilizing clinical assessment and preductal pulse oximetry.

REF: pp. 34-35 22. A therapist treating a newborn with hypoxemia due to hypothermia should also be aware of

which of the following conditions? a. Hypercarbia b. Hypoglycemia c. Hypocalcemia d. Left-to-right shunt ANS: B

Thermal management is critically important to a successful extrauterine transition. Efforts should be made to reduce heat loss as much as possible. There is a marked increase in glucose and oxygen consumption when a newborn infant is cold stressed. In an infant with a difficult transition, cold stress may precipitate the development of persistent pulmonary hypertension, a clinical situation where pulmonary vascular resistance remains high, fetal shunts remain open, and blood flow to the newborn lung is minimal.

REF: p. 35 23. A therapist is resuscitating a term newborn. What should be the rate of ventilation? a. 20 to 30 breaths per minute b. 30 to 40 breaths per minute c. 40 to 60 breaths per minute d. 60 to 100 breaths per minute

ANS: C

The rate of ventilation recommended is 40 to 60 breaths per minute and is determined by how frequently the bag is squeezed in the case of the self-inflating and flow-inflating bags.

REF: p. 35 24. A therapist is resuscitating a term newborn. The heart rate falls to 55 beats per minute. What is

the best course of action? a. Intubate and provide positive airway pressure b. Administer IV or ET epinephrine c. Apply bag-mask ventilation d. Continue compressions until heart rate is greater than 60 ANS: B

Medications should be prepared for administration if the heart rate remains below 60 beats per minute. Placing an umbilical catheter for administration is ideal for epinephrine administration. However, the first dose of epinephrine may be given via the ET tube if the placement of the umbilical line delays prompt administration of the medication. Doses of epinephrine will vary based on the route of administration.

REF: p. 35

Chapter 4: Exam and Assessment of the Neonatal and Pediatric Patient Test Bank MULTIPLE CHOICE 1. What measures can the therapist take to prevent heat loss and cold stress before performing

resuscitation on a preterm neonate?

I. Dry the infant’s skin.

II. Wrap the infant in pre-warmed blankets.

III. Remove wet linens from around the infant.

IV. Measure the neonate’s body temperature. a. IV only b. I and II only c. I, II, and III only d. I, II, and IV only ANS: C

Preventing heat loss is critical when caring for a newborn because cold stress increases oxygen consumption and impedes effective resuscitation. If possible, deliver the infant in a warm, draft-free area. Heat loss can be greatly reduced by rapidly drying the infant's skin, immediately removing wet linens, and wrapping the infant in pre-warmed blankets.

REF: p. 41 2. What should the therapist do to avert injury and atelectasis, and to avoid interfering with the

infant's ability to establish adequate ventilation, while stabilizing a preterm neonate before resuscitation?

I. Use a bulb syringe.

II. Avoid excessive suctioning of clear fluid from the nasopharynx.

III. Use a suction catheter clearing the mouth first and then the nose.

IV. Suction using direct laryngoscopy. a. IV only b. I and II only c. I, II, and III only d. I, II, and IV only ANS: C

To avert injury and atelectasis, and to avoid interfering with the infant's ability to establish adequate ventilation, avoid excessive suctioning of clear fluid from the nasopharynx.

REF: p. 41 3. As the head of a neonate contaminated with meconium emerges at birth, the heart rate monitor

indicates 120 beats/minute, and the physician notices that the infant has good muscle tone and a strong respiratory effort. What should the physician do at this time to provide airway care? a. Intubate the infant immediately. b. Perform pharyngeal and tracheal suctioning immediately. c. Perform tracheal suctioning only at this time.

d. Only routine monitoring of respiratory vital signs is needed at this time.

ANS: D

Attempts to suction meconium from the pharynx or trachea before birth, during birth, or postpartum increase the likelihood of severe aspiration pneumonia. Some obstetricians perform oral and nasal suctioning on meconium-stained infants after delivery of the head but before delivery of the shoulders. However, a large, multicenter, randomized trial showed no benefit from this practice. Therefore, current recommendations for infants with meconium are that (1) no intrapartum suctioning should occur; (2) infants who are vigorous at birth (strong respiratory effort, a heart rate of greater than 100 beats/min, good muscle tone) should not receive tracheal suctioning; and (3) infants who are not vigorous (no or poor respiratory effort, a heart rate of less than 100 beats/min, poor muscle tone) may receive direct laryngotracheal suctioning.

REF: p. 42 4. A newborn does not appear to respond to the extrauterine environment. Cry is weak and the

respiratory effort is not strong. Which of the following methods should the therapist use to stimulate the newborn? a. Hold the newborn upside down. b. Rub over the sternal area. c. Suction the nasopharynx. d. Gently rub the back.

ANS: D

If the newborn does not respond to the extrauterine environment with a strong cry, good respiratory effort, and the movement of all extremities, the infant requires stimulation.

Flicking the bottoms of the feet, gently rubbing the back, and drying with a towel are all acceptable methods of stimulation. Slapping, shaking, spanking, and holding the newborn upside down are contraindicated and potentially dangerous to the infant.

REF: p. 42 5. The therapist has completed a 1-minute Apgar score. The following evaluations were

obtained: (1) the infant is pale; (2) the heart rate is 90 beats/minute; (3) the respiratory effort is irregular; (4) some muscle tone is noted; and (5) no response to nasal suctioning is found.

On the basis of these findings, what Apgar score should be assigned to this neonate? a. 1 b. 2 c. 3 d. 5 ANS: C

The Apgar scoring system is depicted on Table 4-1.

The infant evaluated in this question earned 1 point each for the heart rate, respiratory effort, and muscle tone. Scores for color and reflex irritability were both 0. The total Apgar score is therefore 3. Apgar scores are generally used to ascertain the need for resuscitation and are obtained at 1 minute and 5 minutes after birth. A score below 7 indicates the need for resuscitative efforts.

REF: p. 42 6. Which of the following parameters of the Apgar score provides the most important prognostic

value? a. Heart rate b. Respiratory rate c. Skin color d. Muscle tone ANS: A

The most important of the signs is heart rate, which indicates life or death. Failure of the heart rate to respond to resuscitation is an ominous prognostic sign. Heart rate appears to be least affected by developmental maturity but may still be inadequate because of developmental difficulties in establishing cardiorespiratory function at birth.

REF: p. 43 7. Which of the following factors are taken into consideration when assessing the gestational age

of a neonate?

I. Previous maternal pregnancies II. Prenatal ultrasound evaluations III. Postnatal findings based on physical and neurologic examinations IV. Gestational duration based on the last menstrual cycle a. I and III only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: D

Ideally, gestational age assessment is performed before the neonate is 12 hours old to allow the greatest reliability for infants less than 26 weeks of gestational age. Evaluating gestational age requires consideration of several factors. The three main factors are as follows: • Gestational duration based on the last menstrual cycle • Prenatal ultrasound evaluation • Postnatal findings based on physical and neurologic examinations REF: p. 43 8. The gestational age of a newborn has been evaluated to be 34 weeks. The newborn’s birth

weight is greater than the 90th percentile. How should the therapist classify this infant? a. Small for gestational age b. Average for gestational age c. Large for gestational age

d. Very large for gestational age ANS: C

Once gestational age is determined, weight, length, and head circumference are plotted on a standard newborn grid. Any infant whose birth weight is less than the 10th percentile for gestational age is classified as small for gestational age. Similarly, an infant whose birth weight is more than the 90th percentile is large for gestational age. When using intrauterine growth curves, considering specific charts that are race and gender specific may be necessary.

Along with prematurity, abnormal gestational age and size for gestational age are associated with many neonatal disease processes.

REF: p. 43 9. An infant arrives in the newborn nursery with an axillary body temperature of 95.6° F. Which

of the following events may be responsible for this infant’s temperature? a. The neonate was in an infant warmer in the delivery room. b. The infant was swaddled in numerous blankets. c. The delivery room temperature was low. d. The newborn has protracted diarrhea.

ANS: C

Normal values for temperature are 97.6° F ± 1° F axillary and 99.6° F ± 1° F rectally; however, temperature on arrival in the nursery may be lower if the delivery room was cold or may be higher if the radiant warmer was operating at a higher temperature because of incorrect probe position or warmer malfunction.

REF: p. 43 10. A physical examination is being performed on a newborn, and the therapist notices that the

infant’s arms do not move symmetrically. Which of the following situations could account for this problem? a. An injury to the infant’s brachial plexus may have occurred during birth. b. The infant may have been born breach. c. The baby was born via cesarean section. d. The infant experienced nuchal cords during birth.

ANS: A

Observing the infant’s overall appearance is an important aspect of the physical examination.

Ideally, examine the infant lying quietly and unclothed in a neutral thermal environment.

Body position and symmetry, both at rest and during muscular activity, provide valuable information regarding possible birth trauma. For example, an infant who does not move the arms symmetrically could have a broken clavicle or an injury to the brachial plexus.

REF: p. 43 11. The therapist notices that an infant presents with irregular areas of dusky skin alternating with

areas of pale skin. On the basis of this observation, which of the following conditions should the therapist anticipate this patient having? a. Polycythemia b. Hypotension c. Situs inversus with dextrocardia

d. Renal insufficiency ANS: B

Observing skin and color often provides diagnostic clues. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia.

REF: p. 44 12. Which of the following neonatal skin presentations at birth is associated with a high

hematocrit value or polycythemia and neonatal hyperviscosity syndrome? a. Mottling b. Lanugo c. Reddish blue appearance d. Vernix ANS: C

A ruddy, reddish blue appearance is frequently associated with a high hematocrit value, or polycythemia (hematocrit > 65%), and neonatal hyperviscosity syndrome. The yellow color associated with mild to moderate jaundice is common among newborns after the first day of life. Jaundice on the first day of life, however, is always an indication for an immediate evaluation. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin.

An extremely pale or mottled infant suggests hypotension or anemia. The presence of lanugo, the fine hair that covers premature infants mostly over the shoulders, back, forehead, and cheeks, indicates an even younger gestational age than one presenting with vernix. Often a grayish white cheese-like substance, called vernix caseosa, is present in the skin folds of a term infant. However, vernix is even more abundant on a preterm infant and suggests an earlier gestational age.

REF: p. 44 13. Why are chest retractions more prominent among neonates than among older children and

adults? a. Because neonates generate a greater subatmospheric intrapleural pressure b. Because newborns have relatively thin and weak musculature and a less rigid thorax c. Because neonates have a much higher respiratory rate d. Because airway resistance through the smaller caliber airways is higher ANS: B

Chest wall retractions are more prominent and easily observed among neonates than in an older children or adults. The newborn musculature is relatively thin and weak, and the thoracic cage is less rigid. The flexible chest wall and thoracic cage of the newborn exhibit noticeable retractions as lung compliance worsens.

REF: p. 46 14. Why is it difficult to localize auscultation findings of the thorax of a newborn? a. Because the neonate’s chest is small and sounds are difficult to differentiate b. Because the newborn infant is frequently crying c. Because the neonate’s tidal volume is so small

d. Because the newborn’s pulmonary compliance is low ANS: A

Auscultation of the newborn can sometimes be difficult. The newborn’s chest wall is small, and sounds easily transmit from one lung region to another. Abdominal sounds may even transmit to the lungs, although bowel sounds heard from the chest in place of absent breath sounds may indicate a diaphragmatic hernia. Localizing auscultation findings in a preterm infant is frequently difficult or impossible with single-head stethoscopes. Auscultation with a double-head stethoscope has proved useful in some situations.

REF: p. 48 15. While performing a physical examination on a newborn infant, the therapist notices that the

point of maximal cardiac impulse is to the left of the sternal border. Which of the following conditions can cause this situation? a. Atelectasis of the right lung b. Bilateral pulmonary consolidation c. Right-sided pneumothorax d. Left main stem bronchus intubation ANS: C

The point of maximal cardiac impulse (PMI) is the position on the chest wall at which the cardiac impulse can be maximally seen. The PMI is usually seen in newborns because of the relatively thin and flexible chest wall. Typically, the PMI is relatively close to the sternal border because of the predominance of the right ventricle in the fetal period. A mediastinal shift due to a pneumothorax will move the PMI away from the affected side of the chest.

REF: p. 48 16. Which of the following statements refers to the diagnostic procedure called transillumination? a. Place a light source between the surface of the bed and the patient’s back, and

orient the patient in a supine position. b. Direct a light source toward the ipsilateral surface of the patient’s thorax. c. Position a beam of light against a patient’s chest wall in a well-lit room. d. Insert a fiberoptic light source down a patient’s endotracheal tube and beyond the

tube’s distal tip.

ANS: B

With suspected pneumothorax, perform transillumination of the chest wall, using a highenergy flashlight or fiberoptic device in a darkened room. Direct the light source on the chest wall of the suspected (ipsilateral) side. A large pneumothorax will reveal an excessively pink and illuminated, usually irregular, area of light, or “glowing” area, through the chest wall when compared with the contralateral side.

REF: p. 48 17. A neonate is found to have a bounding pulse. Which of the following conditions may

contribute to this finding? a. Low cardiac output b. Coarctation of the aorta c. Left-to-right shunt

d. Patent foramen ovale ANS: A

Weak pulses suggest low cardiac output states such as shock and hypoplastic left-sided heart syndrome. Bounding pulses are seen in infants with patent ductus arteriosus and left-to-right shunt. The bounding characteristic of the pulse results from rapid runoff of the blood into the low-resistance pulmonary circulation. This lowers the systolic blood pressure and produces a wider pulse pressure. Brachial and femoral pulses should be equal in intensity and felt simultaneously. A delayed or weak femoral pulse can indicate coarctation of the aorta.

REF: p. 48 18. What condition would be responsible for the therapist observing a pulse oximeter indicating

decreased perfusion while central blood pressure remains normal? a. Volume depletion with compensatory peripheral vasoconstriction b. Hypoplastic left-sided heart syndrome c. Hypervolemia with compensatory peripheral vasodilation d. Hypoplastic right-sided heart syndrome ANS: A

A pulse oximeter will display a low pulse rate and perfusion signal as peripheral pulses and perfusion decrease. The cause of this poor perfusion status must be determined. However, if the pulse oximeter suggests decreased perfusion while central blood pressure remains normal, the cause may be volume depletion with compensatory peripheral vasoconstriction.

REF: p. 49 19. For the purpose of assessing right-to-left shunting, as in the case of persistent pulmonary

hypertension, which of the following sites would render postductal blood?

I. Right arm II. Left arm III. Right leg IV. Left leg a. I only b. II only c. I, III, and IV only d. II, III, and IV only ANS: D

In addition, placing pulse oximeters on preductal and postductal sites allows for assessing right-to-left ductal level shunting, as seen with persistent pulmonary hypertension of the newborn. In this case the right arm, or preductal site, will have a higher saturation, while the postductal site, or left arm and lower extremities, will have a lower saturation due to venous admixture occurring postductally.

REF: p. 49 20. The therapist is evaluating a newborn with an abdominal defect consisting of protrusion of the

membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord. Which of the following conditions is consistent with this description?

a. b. c. d.

Enterocolitis Ascites Congenital diaphragmatic hernia Omphalocele

ANS: D

Successful abdominal examination requires a calm and quiet infant. Observe the contour of the abdomen and determine whether it is scaphoid (sunken anterior wall), flat, or distended.

Distention is a significant finding characterized by tightly drawn skin through which engorged subcutaneous vessels can easily be seen. More noticeable abnormalities of the abdomen include prune belly syndrome, which is a congenital lack of abdominal musculature; omphalocele, a protrusion of the membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord; and gastroschisis, a defect in the abdominal wall lateral to the midline with protrusion of the intestines.

REF: p. 49 21. After the umbilical cord has been cut in the delivery room during the delivery of an infant

who is large for gestational age, the therapist notices that the umbilical cord is large and fat.

Which of the following maternal conditions is likely present? a. Congestive heart failure b. Renal insufficiency c. Diabetes mellitus d. Hypertension ANS: C

The umbilical cord of an infant who is large for gestational age and born to a diabetic mother is frequently large and fat.

REF: p. 49 22. The therapist notices that a preterm newborn has a grunting cry. Which of the following

conditions is most consistent with this description? a. Hypothyroidism b. Neurologic injury c. Respiratory distress syndrome d. Laryngeal edema ANS: A

A loud and vigorous cry is usually a sign of a healthy infant. A moaning, weak, or faint cry suggests illness. Frequently, an infant with respiratory distress syndrome strains with a grunting cry. An infant with a piercing, high-pitched cry often has a neurologic injury, drug withdrawal, or increased intracranial pressure. Hoarse crying can be associated with laryngeal edema, as in recently extubated infants. However, a hoarse cry may also be heard with congenital hypothyroidism, cretinism, or hypocalcemia with laryngospasm.

REF: p. 51 23. Which of the following pieces of information represent components of patient history for a

new pediatric patient?

I. Chief complaint II. History of present illness III. Past medical history IV. Occupational history a. I and II only b. III and IV only c. I, II, and III only d. I, II, III, and IV ANS: C

The history for a new patient can be divided into the chief complaint, or primary concern, history of the present illness (HPI), past medical history (PMH), review of symptoms (ROS), family history (FH), and social and environmental histories. The history for a follow-up or for an established patient can be modified to include an interim health history and a review of key components of the PMH, ROS, and social and environmental histories. An occupational history is inappropriate for a pediatric patient.

REF: p. 52 24. Which of the following components compose the history of present illness section of a

patient’s medical history? a. Immunizations b. Symptoms exhibited by parents c. Aggravating or alleviating factors d. Symptoms resulting in hospitalizations ANS: C

Components of the history of present illness include the following: Duration Intensity or severity Improvement or deterioration Triggers Aggravating or alleviating factors Medications (past and current) Chronicity Seasonality REF: p. 53 25. Which of the following components compose the past medical history section of the patient’s

medical history?

I. Birth weight II. Previous mechanical ventilation III. Recurrence of symptoms based on season IV. Emergency department visits a. II only b. II and IV only c. I, II, and IV only d. I, II, III, and IV

ANS: C

Components of past medical history include the following: History of prematurity Birth weight Need for and duration of oxygen therapy, assisted ventilation, or both in the neonatal period Previous emergency room visits, hospitalizations, or both for respiratory disturbances (including intensive care unit admissions and any need for assisted ventilation) Previous surgeries Immunization history REF: p. 53 26. Which of the following components of a patient’s medical history is intended to determine the

presence of symptoms not identified in the history of present illness and may be related or contribute to the child’s underlying condition? a. Chief complaint b. Past medical history c. Review of systems d. History of present illness ANS: C

The review of symptoms (ROS) attempts to identify symptoms that were not identified in the HPI and that may be related or contribute to the child's underlying respiratory condition. A systematic review of symptoms related to atopic diseases, gastroesophageal reflux, immunodeficiency, as well as thoracic cage, neurologic, and neuromuscular disorders, may suggest previously unidentified contributions to the presenting pulmonary complaint.

REF: p. 53 27. A child who demonstrates head bobbing, nasal flaring, and grunting is exhibiting signs of

____________________. a. respiratory distress b. hypoxemia c. hypercapnia d. acidemia ANS: A

Head bobbing, nasal flaring, and grunting are common signs of respiratory distress in infants and young children and are compensatory mechanisms to decrease the work of breathing.

Head bobbing occurs when the sternocleidomastoids (neck muscles that serve to flex and rotate the head), in an attempt to overcome decreased lung compliance, increased airway resistance, or both, contract during inspiration, pulling the head down and the clavicles and rib cage up (see Figure 4-9 in the textbook). This results in the head bobbing forward in synchrony with each inspiration. Nasal flaring and grunting can be present in the pediatric patient as well. The presence of one or more of these signs typically indicates significant airway obstruction and/or lung disease.

REF: p. 55 28. Which of the following pulmonary diseases are not chest wall deformities but are

characterized by an increased anteroposterior diameter?

a. b. c. d.

Pectus excavatum Interstitial pulmonary disease Pneumonia Cystic fibrosis

ANS: D

Inspection of the chest wall may reveal increased anteroposterior diameter, abnormal shape, muscular weakness, or obesity. Chest wall inspection should include anterior, posterior, and lateral examination. Chronic obstructive lung diseases such as severe asthma, advanced CF, and severe bronchopulmonary dysplasia may be associated with increased anteroposterior diameter of the chest due to increased air trapping. The chest wall may be abnormally shaped such as in pectus carinatum ("pigeon breast"), pectus excavatum ("sunken chest"), kyphosis ("hunchback" appearance), and scoliosis (abnormal "sideways" spinal curvature).

REF: p. 55 29. During a physical examination of a child’s chest, the therapist perceives increased tactile

fremitus over the patient’s right lower lobe. Which of the following conditions may cause this physical sign? a. Pulmonary consolidation b. Pneumothorax c. Mucous plug d. Aspirated foreign object ANS: A

Palpation of the chest wall and neck may be helpful in the physical examination of a child with respiratory disease. In infants and young children, palpation of the chest during quiet breathing may elicit rhonchal or bronchial fremitus, which are vibrations of the chest resulting from movement of air through airways partially obstructed by mucus. In an older child, palpation of the chest during normal speech may elicit tactile fremitus, vibrations of the chest produced by the spoken voice. Tactile fremitus may be increased over areas of the chest wall corresponding to underlying pulmonary consolidation.

REF: p. 56 30. While percussing the thorax of a child during a physical examination, the therapist hears a dull

percussion note over the child’s right lung. Which of the following conditions may cause this physical finding?

I. Atelectasis II. Pneumothorax III. Pleural effusion IV. Consolidation a. I and II only b. I, III, and IV only c. II, III, and IV only d. I, II, III, and IV ANS: B

Chest percussion is performed by tapping the finger of one hand with a finger of the other hand over corresponding areas of the patient’s chest, usually while the patient is sitting upright. A relatively high-pitched percussion note, or hyperresonance, suggests focal or generalized air trapping or pneumothorax. A relatively dull percussion note indicates atelectasis, consolidation, or pleural effusion.

REF: p. 56 31. After placing a stethoscope over a small child’s trachea, the therapist hears expiratory stridor.

Which of the following conditions is consistent with this finding? a. Laryngotracheobronchitis b. Adenotonsillar hypertrophy c. Asthma episode d. Tracheomalacia ANS: D

Stridor is a high-pitched, monophonic, audible noise that may occur during inspiration or expiration, or may be biphasic. Inspiratory stridor suggests extrathoracic airway obstruction, such as occurs in laryngomalacia, subglottic stenosis, and croup. Expiratory stridor suggests intrathoracic central airway obstruction, such as occurs in mass or vascular compression of the trachea, tracheomalacia, and bronchomalacia. Biphasic stridor typically indicates a more severe degree of laryngeal or central airway obstruction and may be associated with signs of respiratory distress.

REF: p. 57 32. While auscultating a young child’s thorax, the therapist hears bilateral fine crackles.

Which of the following conditions can produce these adventitious sounds? a. Pulmonary edema b. Bronchitis c. Croup d. Asthma ANS: A

Crackles can be further described as inspiratory, expiratory, fine, and coarse. Fine crackles are less loud crackles with high-frequency components and short duration; they are usually associated with distal small airway and/or alveolar diseases such as pneumonia or pulmonary edema. Coarse crackles are louder crackles with lower frequency and longer duration; they are usually associated with medium and/or large airway disease such as bronchitis.

REF: p. 57 33. Which of the following white blood cell counts constitutes the condition leukopenia? a. Less than or equal to 3500/mm3 b. 5000 to 10,000/mm3 c. 10,000 to 20,000/mm3 d. Greater than or equal to 25,000/mm3 ANS: A

The white blood cell (WBC) count of the newborn is usually significantly higher than pediatric or adult values. Leukopenia, WBCs less than 3500/mm3, and leukocytosis, WBCs greater than 25,000/mm3, suggest infection. WBCs greater than 25,000/mm3, however, are not unusual in the immediate newborn period.

REF: p. 58

Chapter 5: Pulmonary Function Testing and Bedside Pulmonary Mechanics Test Bank MULTIPLE CHOICE 1. Which of the following major forces opposes inspiration? a. Inspiratory flow b. Surface tension c. Airway resistance d. Respiratory rate ANS: C

The combination of lung compliance (C) and airway resistance (Raw) is the major force opposing inspiration, whereas elastic recoil is the force responsible for passive normal exhalation.

REF: p. 66 2. Pulmonary function testing has been ordered in an infant. Which of the following represents a

real risk to this infant? a. The infant may require sedation for up to 3 hours. b. If the infant cries, it will make the test invalid or open to misinterpretation. c. The gases used for the PFT may be toxic for the infant. d. The inability to feed the child 24 hours prior to the test ANS: B

In infant testing, the subject may need to be lightly sedated in the laboratory for 2 to 3 hours to complete a full set of studies. Sedation carries some risk, and testing should not be viewed as routine. The NPO guidelines from the hospital sedation policy may allow infants who are younger than 6 months to receive formula and solids for up to 6 hours, breast milk for up to 4 hours, and clear liquids for up to 2 hours before sedation. Children who are 6 months or older may receive solids and liquids for up to 6 hours and clear liquids for up to 2 hours before sedation.

REF: p. 66 3. Why must caution be exercised when using a face mask while performing pulmonary function

testing on neonates? a. To prevent trigeminal nerve stimulation b. To avoid necrosis of the facial skin c. To prevent vagal reflexes d. To prevent gastric insufflations ANS: A

A face mask is required when testing neonates and infants. Caution must be exercised because using a face mask can cause trigeminal nerve stimulation and induce vagal reflexes that may alter the pattern of heart or respiratory rhythm.

REF: pp. 66-67

4. The respiratory therapist places a face mask on an infant to measure FRC. What should the

therapist do to minimize the presence of air leaks and improve accuracy of the test? a. Place a nose clip on the infant. b. Minimize the amount of helium used during the test. c. Minimize oxygen concentration and increase nitrogen concentration. d. Apply petroleum jelly on the edges of the mask before applying the mask to the face.

ANS: D

Applying petroleum jelly to the edges of a disposable mask is helpful for ensuring an airtight seal with no leaks on the infant's face.

REF: p. 68 5. How is airway resistance calculated? a. By dividing the airway occlusion pressure by the expiratory flow b. By dividing the transpulmonary pressure by the expiratory flow c. By multiplying the expiratory flow by the pressure gradient responsible for

initiating inspiration d. By multiplying the expiratory occlusion pressure by the transpulmonary pressure

gradient ANS: A

Airway resistance (Raw) reflects the nonelastic airway and tissue influences resisting gas flow. Raw is calculated from the ratio of airway occlusion pressure to expiratory flow. Raw is described in centimeters of water per liter per second (cm H2O/L/s).

REF: p. 68 6. Which of the following factors is the most important determinant of high airway resistance

and air trapping in small infants? a. The small tidal volume b. Small diameter of the airways c. Excessive amount of mucus production d. The length of the airways ANS: B

Raw is dependent on the radius, length, and number of airways and varies with volume, flow, and respiratory frequency. The small diameters of an infant's tracheobronchial tree result in high resistance to gas flow.

REF: p. 68 7. On the partial expiratory flow–volume loop shown here, identify the point depicting the

“maximal expiratory flow at FRC.”

a. b. c. d.

A B C D

ANS: C

A relatively noninvasive technique to generate a partial expiratory flow volume (PEFV) curve in infants allows the measurement of expiratory flows during a forced maneuver in infants and small children. A rapid thoracic compression or "hug" is delivered to the sleeping infant's chest and abdomen with an inflatable jacket to produce a forced expiration. A pneumotachometer with a sealed face mask measures exhaled gas flow. The flow at the endexpiratory point of a normal resting tidal breath (FRC) is measured on the PEFV curve. This flow value, the maximal expiratory flow at FRC, is reported as liters per second.

REF: p. 68 8. A pre- and postbronchodilator, partial expiratory pressure–volume maneuver was performed

on a 9-month-old boy. The child’s prebronchodilator maxFRC was 67 mL/second and the postbronchodilator maxFRC was 94 mL/second. How should the therapist interpret these data? a. The data are erroneous. b. The data are inconclusive. c. The patient will not clinically improve with bronchodilator administration. d. The patient has demonstrated clinically significant improvement with bronchodilator administration.

ANS: D

PEFV studies are frequently performed before and after aerosolized bronchodilator therapy.

An increase in maximal expiratory flow at FRC by at least 20% demonstrates a positive response to bronchodilator therapy. The maxFRC values presented in the question (pre-maxFRC, 67 mL/s; and post-maxFRC, 94 mL/s) indicate a 40% improvement.

REF: p. 68 9. According to the ATS-ERS acceptability criteria for an FVC maneuver performed on a 9-year-

old child, what is considered a satisfactory exhalation time? a. 1 second

b. 2 seconds c. 3 seconds d. 6 seconds ANS: C

Satisfactory exhalation duration is 6 seconds (3 second for children <10 years old) or a plateau in the volume–time curve.

REF: p. 70 10. A child has been diagnosed with vocal cord dysfunction. Which of the following flow–volume

loops demonstrates this condition? a. Figure 5-9C b. Figure 5-9A c. Figure 5-9B d. Figure 5-8B ANS: A

Flow limitation on the inspiratory portion of the loop is characteristic of an extrathoracic obstruction (Figure 5-9B). This is common in children with vocal cord dysfunction (VCD).

REF: p. 70 11. The respiratory therapist is looking at a flow–volume curve that displays a concave shape on

the expiratory tracing. What is this change most consistent with? a. Neuromuscular disease b. Abnormal chest wall configuration c. Interstitial fibrosis d. Asthma ANS: D

The most common chronic diseases in children—asthma, cystic fibrosis, and bronchopulmonary dysplasia—are obstructive. Obstructive diseases produce a concave shape or scoop to the flow–volume curve.

REF: p. 74 12. A reduction in the DLCO may indicate the presence of which of the following conditions?

I. Pulmonary fibrosis II. Pulmonary edema III. Hematologic disorders IV. Bronchiolitis obliterans a. I and II only b. I and III only c. I, II, and III only d. I, II, III, and IV ANS: D

Indications for testing in the pediatric population that may produce a reduced DLCO include pulmonary fibrosis (primary disease or secondary to radiation treatment or chemotherapy), immunologic disorders (scleroderma, systemic lupus erythematosus), bronchiolitis obliterans, pulmonary edema, and hematologic disorders.

REF: p. 74 13. The therapist is reviewing a flow–volume loop obtained from a pediatric patient and observes

decreased volume and normal flows. On the basis of this observation, how should the therapist interpret this finding? a. Obstructive pattern b. Restrictive pattern c. Fixed airway obstruction d. Variable extrathoracic obstruction ANS: B

The restrictive pattern is typically characterized by preserved flows with a reduction in the volume.

REF: p. 74 14. Which of the following pulmonary function values characterize an obstructive lung defect?

I. The forced vital capacity (FVC) may remain normal.

II. The forced expiratory volume in 1 second (FEV1) is decreased.

III. The ratio of residual volume to total lung capacity (RV/TLC) may be normal.

IV. The FEV1 is decreased. a. II and IV only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only ANS: C

On the basis of spirometry, an obstructive lung disorder is characterized as follows: • FVC normal or decreased • FEV1 decreased • FEV1/FVC decreased • TLC normal or increased • RV increased • RV/TLC increased Table 5-2 in the textbook compares obstructive and restrictive lung diseases in terms of these spirometric measurements.

REF: p. 74 15. On the basis of the bronchial provocation data presented in the following table, identify the

PD20 (provocative dose that produces a 20% fall in FEV1).

a. b. c. d.

0.025 mg/mL 0.25 mg/mL 2.5 mg/mL 10 mg/mL

ANS: D

Methacholine and mannitol are two very common inhalation challenge agents that have welldescribed protocols. In methacholine testing, a test is considered positive if the FEV1 falls more than 20% from baseline. The concentration of the challenge drug is used as a marker of the degree of bronchial reactivity and is called the PD20, the provocative dose that produces a 20% fall in FEV1. For example, a patient with highly reactive asthma may have a fall in FEV1 of 20% with a methacholine concentration of 0.25 mg/mL. A patient with mild asthma may experience a 20% fall in the FEV1 at 10 mg/mL. In mannitol testing a 15% decline in FEV1 is considered a positive response. The patient presented in this question experienced clinically significant bronchial provocation at a methacholine dose of 10 mg/mL because the FEV1 dropped 24% from baseline at that point.

REF: p. 78 16. On the basis of the data presented below, calculate the time constant.

• Tidal volume (VT), 600 mL • Respiratory rate (RR), 12 breaths/minute • Lung compliance (C), 0.2 L/cm H2O • Airway resistance (Raw), 2.5 cm H2O/L/second • Peak inspiratory pressure (PIP), 30 cm H2O • Inspiratory time (TI), 2 seconds • Expiratory time (TE), 1 second a. 4.5 seconds b. 3.0 seconds c. 0.5 second d. 0.1 second ANS: C

Respiratory time constants, tau (), are the mathematical product of compliance and resistance expressed as seconds because all the units of pressure and volume measurement cancel out except time. A time constant is an interval over which a given change occurs, as a percentage of total change. Three time constants are required to reach 95% of inflation or exhalation. TI, or inflation time, and TE should be at least three times the respiratory time constants for optimal inspiration or expiration to occur.

REF: p. 82 17. How should the therapist interpret the following pressure–volume loop obtained from a

mechanically ventilated infant?

a. b. c. d.

A leak has developed in the ventilator–patient system.

The patient’s lungs are being overinflated.

The patient is displaying trigger dyssynchrony.

The patient’s lungs are exhibiting increased compliance.

ANS: B

The pressure–volume loop demonstrates overdistention. Note the "penguin" or "bird's beak" appearance in the shape of the loops. These loops demonstrate idealized slopes (dashed lines) for change in compliance for the entire breath (C) and change in compliance in the last 20% of inspiratory pressure (C20). The C20/C ratio identifies lung overdistention.

REF: p. 83 18. What is the clinical purpose for measuring the maximal inspiratory pressure (MIP)? a. To assess lung function before and after bronchodilator administration b. To help patients with asthma management at home c. To evaluate the strength of respiratory muscles d. To assist in performing bronchial hygiene techniques ANS: C

MIP is an important measure to help differentiate weakness from other causes of restrictive lung disease. It can be an important differentiating point for children and young adults with various neuromuscular diseases. These patients usually have a combination of scoliosis and muscle weakness, both of which might contribute to reduced lung volumes. Measuring MIP helps in determining how much reduction might be caused by weakness. Because many neuromuscular diseases are progressive, MIP helps to document this progression. MIP may also indicate the patient's physical ability to take a deep breath and is often measured when weaning a patient from mechanical ventilation is being considered.

REF: p. 84

Chapter 6: Radiographic Assessment Test Bank MULTIPLE CHOICE 1. What type of X-ray view is obtained when the radiographic plate is placed behind the patient’s

back with the x, and the side up may better define ____________________. a. Anteroposterior view b. Posteroanterior view c. Lateral view d. Frontal view ANS: A

Feedback: When the radiograph is performed at the patient bedside with mobile radiographic equipment, the image receptor is placed behind the patient's back and the X-ray tube is placed in front of the patient's chest. This obtains a frontal view in the anteroposterior (AP) projection, with the beam passing from anterior to posterior.

REF: p. 89 2. The lateral decubitus view is a frontal radiographic projection whereby the side down can be

evaluated for presence of ____________________. a. Atelectasis; a pneumothorax b. A pleural effusion; a pneumothorax c. Consolidation; atelectasis d. A pleural effusion; consolidation ANS: B

The lateral decubitus position is a frontal projection performed with the patient lying on either the right side (right lateral decubitus) or on the left side (left lateral decubitus). The down side can be evaluated for presence of fluid, such as a mobile pleural effusion, and the up side will demonstrate free air, such as in the case of a pneumothorax (air in the pleural cavity). Dechray tube in front of the patient’s chest?

REF: p. 89 3. The respiratory therapist is evaluating a child with suspected foreign body aspiration. The

radiographer gently adds pressure to the abdomen during expiration to take the chest radiograph. If an obstruction is confirmed, what changes should the RT expect to see? a. The size of the affected lung will decrease. b. The size of both lungs will decrease. c. The size of the affected lung will remain the same or the lung will be hyperexpanded. d. The size of the unaffected lung will increase.

ANS: C

Forced expiratory images are used in assessing the presence of a pneumothorax and to evaluate for foreign body aspiration in small children. When assessing foreign body aspiration in very young patients, the radiographer may gently add pressure to the abdomen during expiration. If an obstruction is present, the affected lung will not decrease in size but remain normal to hyper-expanded.

REF: p. 89 4. Which of the following radiographic views would be the best suited for evaluating fractured

ribs in a pediatric patient? a. Lateral decubitus at full inspiration b. Posteroanterior view at full expiration c. Anteroposterior view d. Oblique view ANS: D

Oblique views are usually rotated 45 degrees from the frontal position. They are typically used in the evaluation for rib fractures and to better evaluate the entire heart borders.

REF: p. 89 5. How will well-expanded, air-filled lungs appear on a chest radiograph? a. Light colored b. Gray c. Black d. White ANS: C

The normal structures that are visualized on a chest radiograph are distinguishable because of differences in the absorption of the X-ray beam by the organs and tissues within the thoracic cavity. Bone and metallic orthopedic hardware appear bright white because of greater X-ray absorption and less exposure of the image receptor. In contrast, air has little beam absorption, and therefore well-expanded lungs appear relatively black. Soft tissue organs and fluid usually appear as shades of gray in between the white bones and black lungs.

REF: p. 90 6. A respiratory therapist is evaluating a chest radiograph of a patient taken 2 days after being

admitted for significant respiratory distress right middle lobe pneumonia. Although the therapist notices a dramatic clinical improvement of the patient, the chest X-ray appears to be more radiopaque than the one on admission. What could explain this situation? a. The therapist is mistakenly looking at a different patient’s film. b. Incorrect exposure of the image receptor may have happened. c. Although the patient looks better, the pneumonia is probably worse. d. This is a normal phenomenon.

ANS: B

Incorrect exposure of the image receptor may alter the normal gray scale. Digital radiographic images are automatically rescaled to allow proper image contrast and brightness, and the image can be manipulated by the clinician after it is processed.

REF: p. 90 7. A therapist is viewing a chest X-ray of a pediatric patient who recently emerged from general

anesthesia after upper abdominal surgery. The right hemidiaphragm is elevated, and atelectasis is seen as a long, thick horizontal line within the right lower lobe. Which of the following terms describes this type of atelectasis? a. Discoid b. Lobar atelectasis c. Silhouette sign d. Plate ANS: D

When an X-ray beam passes through the chest, the densities of all the structures it encounters are summated. Thus a flat object such as platelike atelectasis (collapse of all or part of the lung) may add little to the opacity of the chest in one projection but may appear opaque when viewed on edge in another projection.

REF: p. 90 8. A pediatric patient with pneumonia has an infiltrate in the lower half of the right lung. The

right heart border is obliterated. In which lobe(s) of the right lung is the infiltrate located? a. Right upper lobe b. Right middle lobe c. Right lower lobe d. Right middle and lower lobes ANS: B

Differences in tissue density allow the viewer to discriminate between different structures.

The heart, which is composed of soft tissue of muscle density, is clearly demarcated by a distinct edge from the adjacent air-filled lung. However, if the lung becomes denser from loss of air, as in atelectasis, or if the alveoli become filled with pus, as in pneumonia, the sharp edge between the heart and the lung is no longer apparent. The sign caused when two normal structures lose their distinct edge and blend imperceptibly is widely known as the silhouette sign. If the right heart border is visible next to the infiltrate, the pneumonia is located in the right lower lobe. If the right heart border is obliterated, the infiltrate must be located in the right middle lobe, which resides immediately next to and in the same plane as the right side of the heart. Because the right lower lobe does not lie in the same plane as the right heart border, the two structures remain distinct on a chest radiograph.

REF: p. 90 9. Which of the following structures on a chest radiograph projects to the left, causes a

prominent bulge of the superior mediastinum, and creates a mild indentation on the trachea? a. Left hemidiaphragm b. Apex of the heart c. Aortic arch d. Hilum ANS: C

In normal anatomy the aortic arch is on the left and causes a prominent bulge of the superior mediastinum and a mild indentation on the trachea.

REF: p. 90 10. A therapist is examining an AP chest radiograph of a neonate and notices a structure

projecting away from the mediastinum toward the right upper lung. This structure looks like a sail with a sharp inferior margin and lateral margins with wavy contours. Which of the following structures is the therapist observing? a. Thymus b. Right heart border c. Aortic notch d. Lymph node in the hilar region on the right ANS: A

The mediastinum is composed of the heart, aorta, main pulmonary artery and proximal branches, origins of the great vessels from the aorta, the superior vena cava, and thymus.

Thymic tissue is usually prominent in the neonate and becomes less apparent with age because of regression of the thymus and growth of surrounding structures. Because it is an anterior mediastinal structure, the thymus in the small child fills the anterior clear space normally seen on the lateral projection of a teenager or adult. On the AP or PA projection it may only cause widening of the superior mediastinum. When the thymus projects away from the mediastinum, typically into the right upper lung, it appears as a "sail" with a sharp inferior margin. The lateral margins often have a characteristic wavy contour (see Figure 6-4 in the textbook).

Unlike a pathologic mass such as lymphoma, the normal thymus does not exert mass effect on the trachea.

REF: pp. 90-91 11. While viewing the chest X-ray of an 18-month-old boy, a therapist notices that the trachea is

truncated and that the right lung is collapsed. Which of the following situations or conditions may have caused this situation? a. An elevated right hemidiaphragm b. A mucous plug in the right mainstem bronchus c. A mass compressing the trachea d. A right-sided pneumothorax ANS: B

Truncation of the right mainstem bronchus is often the sign of a mucous plug when the right lung is collapsed. Although the right hemidiaphragm is usually slightly higher than the left because of the underlying liver, the position of the diaphragm may indicate hemidiaphragm paralysis or abdominal pathology.

REF: p. 92 12. A therapist is viewing a frontal chest radiograph of a neonate who has just been

endotracheally intubated. The tip of the endotracheal tube is located between the inferior clavicular border and the carina. What should the therapist do at this time? a. Perform routine respiratory assessment in the morning and care for an intubated patient at this time. b. Withdraw the endotracheal tube a few millimeters. c. Advance the endotracheal tube a few millimeters. d. Remove the endotracheal tube and reinsert it because it is in the esophagus.

ANS: A

The frontal chest radiograph can readily be used to assess the proper placement of the ET tube, which should be positioned in the midtracheal region between the inferior clavicular border and the carina. If the tip is located above the clavicular border, the ET tube is too shallow.

REF: p. 92 13. While viewing an anteroposterior view of a chest radiograph of a 24-month-old intubated

child, a therapist notices that the endotracheal tube has now migrated right above the inferior clavicular border. What could explain this new location of the endotracheal tube? a. Flexion of the head b. Extension of the head c. Rotation of the head to the right d. Rotation of the head to the left ANS: A

The position of the head, especially in a neonate, may result in a significant change in position of the endotracheal tube tip: the tip will advance toward the carina when the head is flexed.

REF: p. 92 14. Which of the following radiographic views provides the best perspective for ascertaining the

position of an endotracheal tube in the patient’s esophagus? a. Anteroposterior view b. Left lateral decubitus c. Lateral view d. Oblique view ANS: C

If a chest radiograph is obtained for suspected esophageal intubation, the stomach, small bowel, and esophagus will be distended with air while the lungs will be underinflated.

Although usually not necessary, a lateral projection would demonstrate the endotracheal tube in the more posterior esophagus. The lateral projection may be more useful for showing adequate tracheal positioning and length in long-term placement of a tracheostomy tube.

REF: p. 92 15. A therapist is viewing frontal and lateral neck X-rays of a 12-month-old child and notices

what is described as the “steeple” or “church steeple” sign: subglottic narrowing below the vocal cords, and an overdistended hypopharynx. Which of the following conditions does this child likely have? a. Laryngotracheobronchitis b. Tracheomalacia c. Adenoidal enlargement d. Epiglottitis ANS: A

Croup (laryngotracheobronchitis) is the most common cause of upper airway obstruction in children, with a peak incidence in infants and children 6 months to 5 years of age. Most cases are virally induced (parainfluenza) and cause inspiratory stridor with a barking cough. Frontal and lateral neck radiographs may show the characteristic subglottic narrowing below the vocal cords with loss of the normal "shouldering" of the airway and resultant "church steeple" appearance. The hypopharynx usually appears overdistended.

REF: p. 93 16. While viewing a lateral view of a neck radiograph of an 18-month-old child, a therapist

notices that the epiglottis is enlarged, the aryepiglottic folds are thickened, and the hypopharynx is overdistended. Which of the following conditions does this child likely have? a. Bronchopulmonary dysplasia b. Esophageal fistula c. Croup d. Epiglottitis ANS: D

Whereas croup usually improves within a few days of supportive therapy, epiglottitis is a lifethreatening disease causing acute inspiratory stridor, fever, and dysphasia (speech impairment). The usual pathogen is Haemophilus influenzae, type B with the risk of infection now greatly reduced by routine immunization programs. The diagnosis should be made by physical examination or by direct visualization through a scope. If a lateral radiograph of the neck is obtained, the epiglottis is enlarged (referred to as the thumb sign) and the aryepiglottic folds are thickened with overdistention of the hypopharynx. The radiograph is performed upright in the position most comfortable for the patient to breathe. Because safety of the child is of primary concern, the radiograph should be performed portably in the emergency department, where intubation can be performed quickly if necessary.

REF: p. 93 17. A mother has just given birth to a 42-week infant who is small for his gestational age. A chest

radiograph of this neonate reveals coarse, patchy opacities secondary to atelectasis from bronchial obstruction alternating with areas of hyperinflation. Which of the following clinical disorders does this infant likely have? a. Acute respiratory distress syndrome b. Pulmonary interstitial emphysema c. Meconium aspiration syndrome d. Transient tachypnea of the newborn ANS: C

Although meconium staining of amniotic fluid occurs in 12% of deliveries, only 2% of these newborns develop meconium aspiration syndrome. Predisposing factors are postmaturity, intrauterine stress, and small size for gestational age. The aspirated meconium is produced by the bowel plugs’ bronchi and causes a chemical pneumonitis. The chest radiograph is characterized by coarse, patchy opacities secondary to atelectasis from bronchial obstruction alternating with areas of hyperinflation.

REF: pp. 95-96

18. A therapist is viewing frontal chest X-ray of a 12-year-old child and notices mediastinal shift

towards the right hemithorax along with elevated hemidiaphragm and vascular crowding.

Which of the following conditions does this child likely have? a. Atelectasis b. Pneumonia c. Pleural effusion d. ARDS ANS: A

Segments, lobes, and entire lungs may be collapsed, or atelectatic. This loss of volume may shift fissures toward the area of atelectasis, cause mediastinal shift toward the affected side, and elevate the ipsilateral diaphragm. Crowding of the pulmonary vascular and interstitial markings in the affected region will occur. The other lung or adjacent lobes may become more lucent secondary to hyperexpansion.

REF: pp. 96-97 19. Which of the following are criteria to order a chest radiograph in a pediatric patient who does

not have chest symptoms?

I. Fever II. Oxygen saturation < 95% III. White blood cell count > 20,000/mm3 IV. Creatinine > 2 mg/dL a. II and III only b. I and IV only c. I, II, and III only d. III only ANS: C

Chest radiographs may also be appropriate for evaluation in a pediatric patient who does not have chest symptoms but does have a fever, oxygen saturation < 95%, and a white blood count >20,000/mm.

REF: p. 98

Chapter 7: Bronchoscopy Test Bank MULTIPLE CHOICE 1. Which of the following clinical signs receives the highest diagnostic yield in the neonatal

population for flexible bronchoscopy? a. Wheezing b. Stridor c. Discoid atelectasis on chest X-ray d. Increased airway secretions ANS: B

Of all indications for diagnostic pediatric flexible bronchoscopy, stridor receives the highest diagnostic yield of the procedure, identifying specific lesions in more than 80% of patients.

REF: p. 103 2. Why is rigid bronchoscopy preferred over flexible bronchoscopy for the removal of a foreign

body from the tracheobronchial tree of a pediatric patient? a. It is the only way to deliver large foreign bodies through the subglottic area. b. It enables better ventilation of the patient while under general anesthesia. c. A lower fraction of inspired oxygen is required with rigid bronchoscopy, reducing the risk of oxygen toxicity. d. Less anesthesia is needed when rigid bronchoscopy is performed.

ANS: B

Although some authors believe that the flexible bronchoscope can be used for the therapeutic purpose of foreign body removal, rigid bronchoscopy is a better and safer approach in children. It allows better ventilation of the patient under general anesthesia and facilitates safer delivery of large foreign bodies through the subglottic area and the larynx compared with the flexible bronchoscope.

REF: p. 104 3. A hospitalized patient with cystic fibrosis has developed massive hemoptysis. What is the

utility of flexible fiberoptic bronchoscopy in this situation? a. It is useful for removing blood clots. b. Flexible bronchoscopy can be effectively used to insert balloon catheters to tamponade the bleeding portion of the lung. c. The flexible bronchoscope can be effectively inserted to enable the deposition of blood-clotting medications into the lungs. d. Flexible bronchoscopy is usually inadequate in this type of situation.

ANS: D

Bronchoscopy can be useful for therapeutic purposes: it can facilitate removal of blood clots and placement of single-lumen or double-lumen endotracheal tubes and balloon catheters to tamponade (i.e., to exert direct pressure on) a bleeding site in the airway. In situations with massive hemoptysis or brisk bleeding, however, the flexible bronchoscope is usually inadequate because of its limited visualization and suction capabilities compared with the rigid bronchoscope.

REF: p. 104 4. The therapist selects a 3.0-mm–diameter insertion tube to be used for flexible bronchoscopy

on a neonate who requires surfactant therapy. What should the therapist do with this insertion tube at this time? a. Prepare the insertion tube for attachment to the flexible bronchoscope. b. Replace the 3.0-mm insertion tube with one that is 4.0 mm in diameter. c. Substitute the 3.0-mm–diameter insertion tube with a 2.0-mm–diameter insertion tube. d. Recommend that the physician perform rigid bronchoscopy.

ANS: A

The insertion tube is the flexible portion of the bronchoscope that is inserted into the patient's airways. These tubes have the same working length of 55 cm, but they vary in outer diameter from less than 2.0 mm to 6.3 mm. The instruments most often used in pediatric patients are 2.2-mm–diameter scopes for neonates, 2.8- to 3.7-mm scopes for older children, and 4.7- to 4.9-mm scopes for adolescents.

REF: p. 105 5. Which of the following features characterize insertion tubes of bronchoscopes described as

“spaghetti scopes”?

I. They lack cables necessary to direct the distal tip, causing it to flex and distend.

II. They are less than 2 mm in diameter.

III. They are used for patients who are not intubated.

IV. Their use is limited to visualization of an airway via insertion down an endotracheal tube. a. I only b. I and II only c. I, II, and III only d. I, II, and IV only ANS: D

The insertion tubes of the thinnest bronchoscopes, those less than 2.0 mm in diameter, contain only light and image bundles. They are nondirectable because they lack the cables necessary to direct the distal section of the scope. Appropriately, they have been nicknamed “spaghetti scopes,” and their use is limited to visualization of an airway via insertion down an endotracheal tube.

REF: p. 106 6. Which of the following features are consistent with a large flexible bronchoscope compared

with a smaller one? a. Has a suction channel

b. Provides recording of the procedure c. Is more rigid d. Produces less heat ANS: A

Larger, flexible bronchoscopes have two control cables aligned 180 degrees from each other that connect a hinged bending section at the distal tip of the tube to a control lever at the head of the scope. These cables allow the operator to flex and extend the distal tip of the bronchoscope in order to direct the passage of the scope through the airways. The 2.2-mm scopes have this directable capability, but they lack the third major component of the insertion tube, a suction channel. The larger scopes contain suction channels, varying in diameter from 1.2 mm in the 2.8- to 3.7-mm scopes to 3.2 mm in the 4.5-mm scopes. These suction channels allow for the suction of airway secretions, the instillation of lavage fluids or medications into the airway, and the passage of brushes and biopsy forceps for obtaining airway cytology and pathology specimens. The channel, direction cables, and fiberoptic bundles are enmeshed in a woven metal sheath and then enclosed in a nonlatex flexible plastic membrane.

REF: p. 106 7. What percent lidocaine spray is used for neonatal flexible bronchoscopy? a. Less than 1% lidocaine b. 1% to 2% lidocaine c. 3% to 4% lidocaine d. 5% to 6% lidocaine ANS: B

Equipment, such as 1% to 2% lidocaine spray, 2% lidocaine jelly, syringes containing aliquots of 1% to 2% lidocaine, a Lukens trap, 10-mL normal saline aliquots for lavage, and clean gauzes, may be placed on top of the cart for easy access.

REF: p. 107 8. Which of the following drug class combinations is often used to induce conscious sedation in

a neonate undergoing flexible bronchoscopy? a. Benzodiazepine and opioid narcotic b. Cephalosporin and opioid narcotic c. Mucolytic and bronchodilator d. Atropine and epinephrine ANS: A

During the procedure, nearly all pediatric patients require some type of sedation. The most common approach is conscious sedation. Intravenous drugs are preferable to intramuscular medications because of their quicker onset, shorter duration, and titratable dosage for optimal effects. Although various sedative agents are available, the combination of a benzodiazepine (e.g., midazolam) and a narcotic (e.g., fentanyl or morphine) is widely accepted. In addition to sedative effects, the narcotic provides analgesic and antitussive effects, and the benzodiazepine offers anxiolytic effects and antegrade amnesia. The most common side effect of this combination is respiratory depression. On occasion, benzodiazepines can induce cardiovascular depression, and narcotics can elicit muscular rigidity and impaired liver and kidney functions. Fortunately, if these complications occur, specific reversal agents, naloxone (0.01 mg/kg per dose) and flumazenil (0.2 mg/kg per dose), can be given to restore the patient’s respiratory status. These antagonists, along with atropine and epinephrine for adverse cardiac events, should be immediately available.

REF: p. 107 9. Because one of the major risks of flexible bronchoscopy is aspiration of gastric contents,

infants under 6 months should not take anything by mouth how many hours before the procedure? a. 1-2 hours b. 3-4 hours c. 4-6 hours d. 8-12 hours ANS: B

One of the major risks of flexible bronchoscopy is aspiration of gastric contents. Infants under 6 months should not take anything by mouth before the procedure for 3 to 4 hours, older infants and toddlers for 4 to 6 hours, and older children for 8 hours, to ensure an empty stomach.

REF: p. 107 10. During a bronchoscopy procedure on a pediatric patient, the therapist notices that a patient’s

SpO2 (oxygen saturation as determined by pulse oximetry) is 90%. What should the therapist do at this time? a. Continue monitoring the patient as the procedure progresses. b. Provide supplemental oxygen to the patient until the SpO2 is 95%. c. If the patient’s SpO2 falls to 88%, administer oxygen to achieve an SpO2 of 90%. d. Stop the bronchoscopy procedure until the patient’s SpO2 returns to its preprocedure level.

ANS: B

Ideally, oxygen saturation should be maintained above 95% at all times, with supplemental oxygen delivered to the patient if necessary.

REF: p. 109 11. When using normal saline for bronchoalveolar lavage, what is the maximum amount of

normal saline per kg that should be used? a. 1 mL/kg per aliquot b. 1 mL/kg total

c. 2 ml/kg per lung d. 2 mL/kg total ANS: A

If bronchoalveolar lavage is performed, the bronchoscopist wedges the bronchoscope in the selected segmental or subsegmental bronchi and normal saline is instilled in three to five aliquots of up to 1 mL/kg per aliquot.

REF: p. 109 12. Which of the following medications is administered to the patient’s nasal mucosa for the

purpose of reducing the risk of epistaxis during a bronchoscopy procedure? a. Lidocaine b. Hypertonic saline c. Phenylephrine d. Racemic epinephrine ANS: C

The most common route for nonintubated pediatric patients is the transnasal approach. The flexible bronchoscope is lubricated with lidocaine jelly, or another sterile water–based lubricant, and then inserted through a nostril into the nasopharyngeal area. A topical decongestant (e.g., phenylephrine) may be administered to the nasal mucosa first to facilitate passage of the scope past edematous tissue and to reduce the risk of bleeding.

REF: p. 109 13. A flexible bronchoscopy has been ordered in a child undergoing mechanical ventilation for

acute respiratory distress syndrome. After several events of desaturation and therapeutic recruitment maneuvers, the physician wants to rule out mucus plugging. What should the therapist suggest to avoid alveolar derecruitment in this patient? a. Take the patient off and bag throughout the procedure. b. Increase PEEP on the ventilator until the procedure is completed. c. Use a PEEP-Keep TM adaptor. d. Increase tidal volume to sustain lung recruitment during the procedure.

ANS: C

A PEEP-KeepTM is used when performing flexible bronchoscopy in a patient through an endotracheal tube or LMA. REF: p. 110 14. Which of the following are considered common risk factors for children who undergo

bronchoscopy? a. Weight less than 10 kg b. Upper airway pathology c. Lower airway pathology d. Preprocedure hypercapnia ANS: A

Patient risk factors for adverse events include upper airway pathology, preprocedure hypoxemia, and weight less than 10 kg.

REF: p. 110 15. Which of the following complications of flexible bronchoscopy are considered most

common?

I. Transient cough II. Hypoxemia III. Respiratory depression IV. Bronchospasm a. I and II only b. III and IV only c. I, II, and IV only d. I, II, III, and IV ANS: D

The most common complications include transient cough, respiratory depression, hypoxemia, hypercapnia, and bronchospasm during the procedure. Cough is almost universally seen during and after the procedure, but it is usually self-limited and resolves within 24 hours.

Respiratory depression is usually associated with oversedation and sometimes requires reversal agents. Any bronchospasm is relieved promptly in most patients by bronchodilator aerosol treatments.

REF: p. 110 16. A pediatric patient is brought to the bronchoscopy suite for a follow-up assessment of

laryngomalacia. Last time the child developed a mild laryngospasm during the procedure.

How should this complication be prevented? a. Intravenous infusion of lidocaine b. Application of topical epinephrine to the vocal cords c. Application of topical lidocaine to the vocal cords d. Prophylactic insertion of an endotracheal tube ANS: C

A less common but potentially more serious complication is laryngospasm. This problem can be avoided by application of topical lidocaine to the vocal cords. If laryngospasm occurs, the bronchoscope must be withdrawn immediately and airway resuscitation initiated.

REF: p. 110 17. Which of the following organisms is often responsible for cross-contamination between

bronchoscopies? a. Staphylococcus b. Mycoplasma c. Pseudomonas d. Klebsiella ANS: C

The organisms most often responsible for cross-contamination between bronchoscopies are Mycobacterium and Pseudomonas.

REF: p. 110

18. The therapist has been asked to clean the bronchoscope after a procedure. Which of the

following chemicals should be used as a high-level disinfectant? a. Vinegar b. Soapy water c. 5% chlorhexidine d. 2% alkaline glutaraldehyde ANS: C

High-level disinfection is a cleaning method that inactivates all viruses, fungi, and vegetative microorganisms, but not necessarily all bacterial spores. The most common agent used is 2% alkaline glutaraldehyde. Immersion in glutaraldehyde for 20 minutes can destroy virtually all pathogens surviving on a well-cleaned bronchoscope.

REF: p. 111 19. The pulmonologist has called the RT department requesting equipment for a bronchoscopy in

the next 30 minutes. Which of the following methods will allow the therapist to have the scope disinfected and ready to use in that time frame? a. Peracetic acid submersion b. Alcohol submersion c. Ethylene oxide d. 2% alkaline glutaraldehyde ANS: A

Two highly effective methods against all types of microorganisms are ethylene oxide gas sterilization and peracetic acid submersion. Ethylene oxide is noncorrosive and able to penetrate all portions of the bronchoscope without requiring high pressures. However, a venting cap must be placed to equalize the pressure between the interior and the exterior of the bronchoscope. The major disadvantage of ethylene oxide sterilization is that it is time consuming, taking at least 12 to 16 hours to complete the process. An alternative method is the STERIS system (refer to Figure 7-3 in the textbook), an automated, microprocessorcontrolled device using a sterilant concentrate, peracetic acid, as the active biocidal agent.

This chemical sterilization process requires only 25 minutes. Once the disinfection or sterilization process is completed, the bronchoscope is rinsed with tap water and may be wiped with alcohol before storage in a dry, clean cabinet.

REF: p. 111 20. Which of the following features are considered advantages of the rigid bronchoscope over the

flexible bronchoscope?

I. Improved anatomic definition II. Ability to provide better ventilation III. Large internal diameter IV. Ability to introduce larger instruments a. I and II only b. III and IV only c. I, III, and IV only d. I, II, III, and IV

ANS: D

The rigid bronchoscope has some advantages over flexible bronchoscopy, including its relatively large internal diameter, improved anatomic definition, the ability to provide ventilation during the procedure, and the ability to use larger instruments.

REF: p. 111

Chapter 8: Invasive Blood Gas Analysis and Monitoring Test Bank MULTIPLE CHOICE 1. A respiratory therapist has been ordered to obtain a blood gas sample from a nonintubated

premature baby. After selecting the best site to obtain the sample, what should the RT suggest to ameliorate the pain associated with the procedure? a. Administer a small dose of fentanyl b. Inject lidocaine at the injection site c. Give a pacifier dipped in 24% sucrose d. Administer a lidocaine drip ANS: C

For infants more than 4 months of age and for children, anesthetic cream or a lidocaine injection may be used to control the pain felt during a blood gas procedure. For nonintubated infants and premature newborns, a pacifier dipped in 24% sucrose is effective in helping to ameliorate the effects of pain.

REF: p. 115 2. Which of the following arteries is considered the optimal puncture site for obtaining arterial

blood samples from neonatal and pediatric patients?

a. b. c. d.

Radial artery Axillary artery Ulnar artery Popliteal artery

ANS: A

The preferred site in both neonatal and pediatric populations is the radial artery. The radial artery provides good access as well as collateral circulation to the hand by the ulnar artery. No nerves or veins are directly adjacent to the radial artery, and the patient’s wrist is easier to manipulate than other body parts. The bone and firm ligaments of the wrist make it easy to palpate, stabilize, and compress the radial artery.

REF: pp. 115-116 3. If a blood gas sample is not obtained from an arterial stick in a premature baby without central

access, which of the following sites should be considered because this blood vessel is larger than the radial artery at this age? a. Dorsalis pedis b. Temporal c. Posterior tibial d. Femoral ANS: B

The dorsalis pedis or posterior tibial artery is considered if the radial artery shows signs of poor collateral circulation. In addition, the temporal artery provides an alternative site for the premature or newborn infant. Access is generally good because two branches are close to the scalp. In most premature and neonatal patients, the temporal artery branches are larger than the radial artery.

REF: p. 116 4. In addition to the dorsalis pedis, which of the following arteries is involved when the modified

Allen’s test is performed using a foot as the potential arterial puncture site? a. Axillary artery b. Femoral artery c. Posterior tibial artery d. Dorsalis pedis ANS: C

The modified Allen’s test can also be used to verify collateral circulation when using one of the arteries of the foot as a puncture site, by elevating the foot and compressing the dorsalis pedis and posterior tibial arteries. Collateral circulation is confirmed by releasing pressure from the artery that will not be punctured and assessing the nail beds and sole of the foot for return of blood flow.

REF: p. 116 5. The neonatal intensive care unit (NICU) respiratory therapy supervisor is observing a

therapist obtain an arterial blood sample from an infant’s radial artery and notices that the therapist has the bevel of the needle pointed upward, entering the patient’s skin at a 45-degree angle and in a direction against the arterial flow. What should the supervisor do at this time? a. Continue to observe the procedure. b. Inform the therapist to turn the bevel downward. c. Tell the therapist to penetrate the infant’s skin at about a 60-degree angle. d. Advise the therapist to insert the needle in the same direction as the blood flows.

ANS: A

Insert the needle of the syringe or butterfly catheter into the artery at a 35- to 45-degree angle with the bevel up and advance it gently. Enter the artery from the direction opposite, or against, the blood flow. A flash in the hub of the syringe or butterfly catheter verifies that the needle penetrated the artery and is located in the lumen. In the small pediatric patient it is quite easy to pass through the artery with the needle. If a good pulse is palpated and no blood return occurs after the needle is inserted, pull the needle back incrementally and continue to watch for a flash of blood. If resistance is met when inserting the needle, slowly withdraw it immediately and change direction because it has most likely touched the bone.

REF: p. 117 6. In addition to applying direct pressure to the puncture site immediately after the arterial

puncture procedure, what can the therapist do to minimize the risk of hematoma formation in a patient who requires frequent radial arterial punctures? a. Have the patient maintain the arm in an elevated position for a couple of hours after the radial puncture. b. Have the patient shake the arm periodically throughout the day. c. Alternate arms used for arterial puncture and use other sites as well. d. Apply a bandage to the puncture site.

ANS: C

Scarring, laceration of the artery, and hematoma formation are more likely to occur with repeated puncture of an artery. Alternating puncture sites decreases this risk.

REF: p. 118 7. Which of the following factors would adversely affect the correlation between arterial

puncture measurements and those from a capillary sample? a. Hypotension b. Hyperventilation c. Hypoxemia d. Hyperthermia ANS: A

The accuracy of capillary blood gas value measurements is severely compromised by the presence of hypotension, hypothermia, hypovolemia, and lack of perfusion.

REF: p. 118 8. A 12-hour-old infant is experiencing respiratory distress, and the neonatologist orders a heel

stick to assess the infant’s oxygenation status. What action should the therapist take at this time? a. Perform the heel stick as ordered. b. Instead of using the newborn’s heel, the therapist should use a finger as the site. c. Inform the physician that this procedure is inappropriate at this time. d. Explain to the doctor that an arterial puncture procedure is appropriate.

ANS: C

A capillary puncture is contraindicated in neonates less than 24 hours old. A newborn has a low systemic output, and vasoconstriction tends to be maximal during this stage secondary to a decrease in environmental temperature and an increase in circulating catecholamines.

Capillary blood sampling is not recommended in a patient with decreased peripheral blood flow, especially in the case of hypotension.

REF: p. 120 9. With an umbilical artery catheter (UAC) in the “low position,” which of the following blood

vessels should be avoided? a. Celiac artery b. Superior mesenteric artery c. Renal artery d. Descending aorta ANS: C

The low position is usually at the third to fourth lumbar (L3 to L4) space, between the renal artery and aortic intersection and above the takeoff of the inferior mesenteric artery. The UAC is placed to avoid the large tributaries supplied by these vessels in an effort to minimize trauma and hemodynamic disturbances of vital organs.

REF: p. 120 10. On the basis of the position of the three-way stopcock shown here, identify which of the

following activities related to arterial line blood sampling is occurring.

a. b. c. d.

The therapist is aspirating blood diluted with infusion fluid.

The therapist is withdrawing blood from the arterial line.

The therapist is keeping the stopcock in its normal operational position.

The therapist is infusing fluid back into the system after having removed a blood sample.

ANS: C

What is depicted by the position of the three-way stopcock is the system’s normal operating position with the flush, or infusion, solution going to the patient while the sample port is closed.

REF: p. 122 11. A 3-kg neonate has lost 30% of his circulating blood volume. Approximately how much fluid

should be infused to compensate for this loss? a. 30 mL b. 60 mL c. 90 mL d. 120 mL ANS: C

The circulating blood volume in neonates and children is approximately 85 to 90 mL/kg and 70 to 75 ml/kg, respectively. Because the circulating blood volume in neonates and children is small, recording and limiting the volume of blood withdrawn from these patients and/or infused is important.

REF: p. 122 12. A patient has a systolic blood pressure of 100 mm Hg and a diastolic pressure of 75 mm Hg.

What is this patient’s mean arterial pressure? a. 25 mm Hg b. 58 mm Hg c. 83 mm Hg d. 175 mm Hg ANS: C

Monitoring arterial pressure waveforms helps to determine the patency of an arterial line and the quality of the pulse pressure and to calculate the mean arterial pressure (MAP). The arterial line monitor calculates MAP internally. However, the formula to obtain an indirect measurement of MAP with a sphygmomanometer is as follows: MAP = [(2 X diastolic) = systolic]/3 REF: p. 123 13. Which of the following factors influence the central venous pressure (CVP) measurement?

I. Bicuspid valve function II. Right ventricular pressure III. Intravascular volume IV. Systemic venous return a. I and III only b. II and III only c. II and IV only d. II, III, and IV only ANS: D

The placement of a central venous catheter provides for the measurement of the right atrial pressure, which represents the filling pressure of the right atrium. Systemic venous return, intravascular volume, tricuspid valve performance, myocardial function, and right ventricular pressure all affect the right atrial pressure.

REF: p. 124 14. How would tricuspid stenosis be expected to influence a patient’s CVP value? a. Elevate it above normal b. Cause it to fall below normal c. Produce fluctuations in the CVP value d. Have no effect in the CVP value ANS: A

Increased CVP values may result from: • Hypervolemia, as with sudden fluid shifts or volume overload

• Interference with the ability of the right ventricle to pump blood, such as in tricuspid valve regurgitation or tricuspid stenosis, right ventricular failure or infarction, increased pulmonary vascular resistance, or cardiac tamponade • Increased systemic vasoconstriction • Left ventricular failure REF: p. 124 15. On the basis of the following waveform, in which of the following anatomic locations is the

distal tip of the pulmonary artery catheter located?

a. b. c. d.

Right atrium Right ventricle Pulmonary artery Wedged position

ANS: D

The pressure waveform presented represents the characteristic tracing obtained when the balloon on the pulmonary artery catheter is inflated and the catheter is allowed to float into the wedged position.

REF: p. 125 16. On the basis of the following waveform, in which of the following anatomic locations is the

distal tip of the pulmonary artery catheter located?

a. b. c. d.

Right atrium Right ventricle Pulmonary artery Wedged position

ANS: C

The pressure waveform presented represents the characteristic tracing obtained when the distal tip of the pulmonary artery catheter is residing in the pulmonary artery.

REF: pp. 125-126 17. On the basis of the following waveform, in which of the following anatomic locations is the

distal tip of the pulmonary artery catheter located?

a. b. c. d.

Right atrium Right ventricle Pulmonary artery Wedged position

ANS: B

The pressure waveform presented illustrates the characteristic tracing obtained when the pulmonary artery catheter is located in the right ventricle. Notice the high right ventricular systolic pressure (30 mm Hg) and the low right ventricular diastolic pressure (below 5 mm Hg).

REF: p. 126 18. Which of the following pulmonary artery catheter waveforms represents the catheter’s normal

location?

a. Right atrium

b. Right ventricle c. Pulmonary artery d. Wedged position ANS: C

This pressure waveform reflects the presence of the distal tip of the pulmonary artery catheter in the pulmonary artery, where this catheter should normally reside. After the pulmonary artery catheter has been placed in the proper position, the catheter’s monitor should show the catheter positioned to produce a pulmonary artery pressure waveform, except for times when pulmonary capillary wedge pressure readings are obtained.

REF: pp. 125-126 19. Which of the following is one of the most common arrhythmias observed as a complication

from the insertion of a pulmonary artery catheter? a. Premature ventricular contraction b. S3 gallop c. Atrial fibrillation d. Paroxysmal atrial contraction ANS: A

At insertion, complications include bleeding, pneumothorax, tricuspid or pulmonic valve damage, right atrium or right ventricle perforation, and arrhythmias resulting from the catheter traversing the right ventricle. The most frequently observed arrhythmias are premature ventricular contractions and ventricular tachycardia.

REF: p. 126 20. Calculate a patient’s total arterial oxygen content given the following data:

•Arterial oxygen tension (PaO2), 100 mm Hg •Arterial carbon dioxide tension (PacO2), 45 mm Hg •Arterial oxygen saturation (SaO2), 97.5% •Hemoglobin concentration ([Hb]), 15 g/dL •Cardiac output, 4.5 L/minute •Stroke volume, 55 mL/beat a. 19.9 vol% b. 18.7 vol% c. 16.6 vol% d. 14.9 vol% ANS: A

The formula for calculating the total arterial oxygen content (CaO2) is as follows: O2 delivery = O2 content = (Hb X 1.34 X SaO2) + (PaO2 X 0.003) REF: pp. 129-130 21. Which of the following conditions can cause methemoglobinemia? a. Anemia b. Inhalation of nitric oxide (NO) c. Use of dobutamine d. High fraction of inspired oxygen

ANS: B

Methemoglobin forms when hemoglobin is oxidized to the ferric state. It causes the oxyhemoglobin dissociation curve to shift to the left, resulting in a decrease in hemoglobin's ability to combine with oxygen. Nitrate-containing molecules in medications and therapeutic gases may cause methemoglobinemia.

REF: p. 131

Chapter 9: Noninvasive Monitoring in Neonatal and Pediatric Care Test Bank MULTIPLE CHOICE 1. What clinical parameter is critically important to monitor when mechanical ventilation is

administered? a. Blood pressure b. Heart rate c. Temperature d. Respiratory rate ANS: A

In mechanically ventilated children, increasing intrathoracic pressure (by increasing positive end expiratory pressure, for example) can reduce venous return, resulting in decreased BP. REF: p. 136 2. How is the percentage of functional hemoglobin that is saturated with oxygen determined via

pulse oximetry? a. The percentage of red light that lands on the photodiode represents the SpO2 (oxygen saturation as determined by pulse oximetry). b. The percentage of infrared light that reaches the photodetector reflects the SpO2. c. The ratio of the red and infrared light that reaches the photodiode signifies the SpO2. d. The sum of the amount of red and infrared absorbed by the tissue determines the SpO2.

ANS: C

A pulse oximeter sensor has two light-emitting diodes (LEDs) that function as light sources and a photodiode that measures the amount of light from the LEDs (see Figure 9-1 in the textbook). One LED emits red light, and the other diode emits infrared light. The sensor is placed over a translucent part of the body (finger, toe, earlobe, etc.). As the light from the diodes passes through the blood and tissue, some of the light from both the red and the infrared diodes is absorbed by oxyhemoglobin. The photodiode then measures the amount of light that passes through the body without being absorbed. Because oxyhemoglobin (hemoglobin bound with oxygen) and deoxyhemoglobin (hemoglobin not bound with oxygen) absorb significantly different amounts of light, the proportion of oxyhemoglobin (expressed as a percentage) is determined (see Figure 9-2 in the textbook).

REF: p. 137 3. The therapist has applied a bandage-type pulse oximetry probe too tightly to an infant’s finger.

What problem can be expected to occur in this situation? a. The SpO2 will read erroneously low. b. The SpO2 will read erroneously high. c. The monitor will display a message indicating inadequate pulse. d. The monitor will display fluctuating SpO2 values between being erroneously low and high.

ANS: C

Correct application of the sensor is crucial to the quality of readings from the pulse oximeter.

The sensors should be placed firmly to avoid falling off or motion artifact, but care should be taken to avoid overtightening and compromising local circulation.

REF: p. 137 4. The therapist has been asked to measure preductal oxygen saturation. Where could the

therapist place the pulse oximeter probe? a. Right thumb b. Left thumb c. Forehead d. Left earlobe ANS: C

Sensor placement on right arm or head will reflect preductal values while the left arm and the lower parts of the body will reflect postductal oxygen saturation values.

REF: p. 138 5. As the therapist applies a pulse oximeter finger probe to a neonate who is receiving

supplemental oxygen, she notices that the SpO2 reading is 100%. What should the therapist do in this situation? a. The therapist should continue monitoring the patient because the reading is accurate. b. The therapist should obtain an arterial blood sample to confirm P2 level. c. The therapist should switch to using a capnometer. d. The therapist should reduce the fraction of inspired oxygen.

ANS: B

The sensitivity of pulse oximetry to detect the presence and degree of hyperoxia may be limited in the neonatal patient. If the oximeter is reading an SpO2 of 100%, the arterial oxygen tension (PaO2) could be between 90 and 250 mm Hg. However, many neonatal intensive care units will target an SpO2 below a certain threshold in order to reduce the risk of retinopathy of prematurity in premature babies.

REF: p. 139 6. A therapist is monitoring a child on the mechanical ventilator who is hemodynamically stable.

The PetCO2 is 48 mm Hg. If accurate, what should be the PaCO2? a. 43-48 mm Hg b. 45-48 mm Hg c. 50-53 mm Hg d. Exactly the same as PetCO2 ANS: C

PetCO2 can be used as a surrogate for the arterial partial pressure of CO2 (PaCO2) within physiologic limits. Normally, PetCO2 is 2-5 mmHg below PaCO2. The reason for this is the proportion dead-space ventilation.

REF: p. 140

7. What is volumetric capnography able to determine?

I. Airway dead space II. Alveolar tidal volume III. Shunt fraction IV. Alveolar minute volume a. II, III, and IV only b. I only c. I, II, and IV only d. I, II, III, and IV ANS: C

The concentration of CO2 is plotted against exhaled tidal volume to determine relevant ventilation data such as airway dead space, alveolar tidal volume, and extrapolation of CO2 elimination and alveolar minute ventilation.

REF: p. 142 8. Why do transcutaneous oxygen tension (PO2) and carbon dioxide tension (PCO2) values differ

from PaO2 and PaCO2 measurements? a. Because of the lag time between the cardiac output and the time the blood reaches the transcutaneous electrode site b. Because the skin is much more permeable to oxygen than carbon dioxide c. Because oxygen is consumed and carbon dioxide is produced in transit from the left ventricle to the electrode site d. Because metabolism in the tissue consumes oxygen and produces carbon dioxide at the site of the electrode ANS: D

Transcutaneous measurements of PO2 and PCO2 require a heating element, built into the sensor, which elevates the temperature in the underlying tissue. Increasing the skin's temperature increases capillary blood flow to the tissues, making it more permeable to gas diffusion. The tissue under which the sensor is placed will continue to consume oxygen and produce carbon dioxide (according to their metabolic demands). Consequently, measured values obtained with a transcutaneous monitor will differ from arterial values. Generally, the PO2 is slightly lower than in the arteries, and the PCO2 is slightly higher.

REF: p. 142 9. While attending to a neonatal patient in the neonatal intensive care unit (NICU), the therapist

notices that a transcutaneous electrode is affixed to the upper chest of the neonate. What should the therapist do at this time? a. The therapist should only continue monitoring the patient since the transcutaneous electrode is properly placed. b. The therapist should reposition the electrode on the neonate’s abdomen. c. The therapist needs to move the transcutaneous electrode to the infant’s right shoulder. d. The therapist should relocate the electrode on the sternum as close as possible to the heart.

ANS: A

The site should be a highly vascular area such as the earlobe, upper chest, abdomen, thighs, or the lower back if the patient is supine; bony areas and those with limited perfusion, such as over the spine, should be avoided.

REF: p. 142 10. The therapist is assessing a mechanically ventilated infant and observes that the

transcutaneous electrode temperature is set between 41° C and 44° C. What action does the therapist need to take at this time? a. The temperature range set is appropriate; therefore, no action is necessary. b. The therapist should increase the temperature range to 47° C to 48° C. c. The temperature of the transcutaneous electrode needs to be reduced to 36° C to 38° C. d. The electrode needs to be repositioned and maintained at the same temperature.

ANS: A

Selecting a sensor temperature is important to proper operation. The temperature range is usually 41° to 44° C. Heating of the sensor requires that the site be changed on a routine basis to prevent thermal injuries. The frequency of site changes ranges from 4 to 12 hours (depending upon the device and sensor temperature) but can be reduced if necessary.

REF: p. 142 11. Which of the following is the main physiologic factor responsible for deriving accurate

transcutaneous data? a. Heart rate b. Minute ventilation c. Peripheral perfusion d. Ventilation-perfusion ratios ANS: C

Changes in perfusion can adversely affect the accuracy of transcutaneous measurements. The skin reacts to cold, shock, and certain drugs by contracting the superficial blood vessels, opening larger, deeper arterioles to achieve a shunting effect. Capillary blood flow is reduced on exposure to cold temperatures in order to reduce the loss of body heat. Shock and certain medications can also divert blood from capillaries to the central circulation. In all cases of reduced capillary perfusion, the capillary blood that is measured using a transcutaneous monitor may reflect measurements associated with venous blood, with a considerably lower PO2 and higher PCO2 (compared to values obtained with good capillary perfusion). If a patient has poor skin integrity, transcutaneous monitoring may also be contraindicated.

REF: p. 143 12. Which of the following features or characteristics apply to mainstream capnography?

I. The mainstream capnograph contains narrow tubing that can become occluded with mucus.

II. Mainstream capnography generally employs infrared spectrometers.

III. The mainstream capnograph does not add much weight to the breathing circuit.

IV. The mainstream capnograph is placed at the proximal end of the endotracheal tube. a. I and II only b. II and IV only

c. I, II, and III only d. I, III, and IV only ANS: B

Gases from an exhaled breath can reach the sample chamber in one of two ways. Mainstream capnographs are used in ventilated patients, with placement at the proximal end of an endotracheal tube (see Figure 9-5 in the textbook). This method employs infrared spectrometers. Sidestream capnograph analyzers continuously aspirate a sample of gas through a small tube to the analyzer.

REF: p. 139 13. Where on the following normal capnogram is the end-tidal carbon dioxide (PetCO2)

represented?

a. b. c. d.

A B C D

ANS: D

The normal capnogram can be divided into four phases (see Figure 9-6 in the textbook): Phase A-B: The inspiratory phase, during which the sensor detects no carbon dioxide Phase B-C: The initial expiratory phase, during which carbon dioxide rapidly increases as the alveoli begin to empty Phase C-D: The completion of expiration as the alveoli empty (alveolar plateau) and show a slight increase in carbon dioxide Phase D-E: The beginning of inspiration as the waveform returns to zero REF: p. 141 14.

While working in the NICU with a mechanically ventilated newborn who is being monitored for PetCO2, the therapist observes the following capnogram:

What interpretation should the therapist make of this capnogram? a. This capnogram is normal. b. The patient is receiving about 10 cm H2O positive end-expiratory pressure. c. The patient is rebreathing his own exhaled gas. d. The neonate is being hyperventilated.

ANS: C

Rebreathing is characterized by an elevation in the A-B phase of the capnogram, with a corresponding increase in ETCO2. It indicates the rebreathing of previously exhaled carbon dioxide. Rebreathing can be caused by allowing an insufficient expiratory time or by inadequate inspiratory flow (see Figure 9-7 in the textbook).

REF: p. 141 15. The following capnogram was obtained from a newborn infant receiving mechanical

ventilation.

How should the therapist evaluate this capnogram? a. Airway obstruction b. Hypoventilation c. Hyperventilation d. Increased dead space ventilation ANS: A

Obstruction of the expiratory flow of gas will be noted as a change in the slope of the B-C phase of the capnogram. The B-C phase may diminish without a plateau. Obstruction can be caused by a foreign body in the upper airway, increased secretions in the airways, the patient having bronchospasms, or partial obstruction of the ventilator circuit (see Figure 9-8 in the textbook).

REF: p. 141 16. An infant demonstrates the following capnogram while being mechanically ventilated.

How should the therapist interpret this capnogram?

a. The patient has received a paralytic agent. b. A paralytic agent is indicated for this patient because of the spontaneous breathing

efforts represented by the downward deflections. c. The patient may have developed a pneumothorax. d. A leak has developed in the patient-ventilator system.

ANS: C

A stair-stepping of the D-E phase of the capnogram, caused by unequal and incomplete emptying of the lungs, along with a failure to return to baseline, may suggest a pneumothorax (see Figure 9-10 in the textbook).

REF: p. 142 17. What is the purpose of indirect calorimetry? a. To measure heat produced and lost from the body b. To calculate energy expenditure by measuring VO2 and VCO2 c. To calculate resting energy expenditure d. To measure gas exchange ANS: B

Direct calorimetry extrapolates energy expenditure by measuring heat produced and lost from the body while indirect calorimetry combines measurements of VO2 and VCO2 into an equation to calculate energy expenditure. Most energy expenditure reports will contain results for VO2, VCO2, REE, and respiratory quotient (which is VCO2/VO2 and can be used to determine substrate utilization).

REF: p. 144 18. Which of the following conditions will preclude the use of indirect calorimetry?

I. Cuffed endotracheal tubes II. Circuit leaks III. FiO2 40% IV. HFOV a. I, II, and III only b. II and III only c. II and IV only d. I, III, and IV only ANS: C

Conditions that preclude the use of indirect calorimetry include: uncuffed endotracheal tubes, cuff or ventilator circuit leaks >10-15%, FiO2 >50%, need for high-frequency ventilation or extracorporeal membrane oxygenation, and active chest tube leakage.

REF: p. 145

Chapter 10: Oxygen Administration Test Bank MULTIPLE CHOICE 1. In which of the following conditions is the oxygen-carrying capacity reduced despite the

presence of a normal arterial oxygen tension? a. Carbon monoxide poisoning b. Polycythemia c. Heart failure d. Cyanide poisoning ANS: B

In conditions such as anemia or carbon monoxide poisoning, the oxygen-carrying capacity of the blood is reduced despite the presence of normal arterial oxygen tension (PaO2).

REF: p. 149 2. What is the minimum level of oxygen tension in a child that requires oxygen administration? a. PaO2 of 80 mm Hg b. PaO2 of 60 mm Hg c. SpO2 of 92% d. SpO2 of 95% ANS: B

In the child, a PaO2 less than 80 mm Hg and a SpO2 less than 95% usually indicate hypoxemia. However, general practice is to only treat SpO2 < 90% or a PaO2 < 60 mm Hg. REF: p. 149 3. Where does the fetal oxyhemoglobin dissociation curve reside in comparison with the normal

adult oxyhemoglobin dissociation curve? a. The two curves have the same position and coincide with each other. b. The adult oxyhemoglobin dissociation curve lies to the left of the fetal curve. c. The fetal oxyhemoglobin dissociation curve lies to the left of the adult curve. d. The fetal oxyhemoglobin dissociation curve lies to the right of the adult curve.

ANS: C

Because fetal hemoglobin has a much greater affinity for oxygen, the oxygen dissociation curve is shifted to the left, allowing a higher saturation for any given PaO2.

REF: p. 149 4. The therapist has evaluated a neonate’s oxygenation status to be as follows: PaO2, 40 mm Hg,

and SpO2 (oxygen saturation as determined by pulse oximetry), 80%. What should the therapist do at this time? a. Continue monitoring the oxygen level of the neonate. b. An FiO2 of 1.0 needs to be administered. c. An FiO2 sufficient to raise the SpO2 to 90% needs to be given. d. An FiO2 sufficient to elevate the PaO2 to 80 mm Hg should be provided.

ANS: C

The normal immediate postnatal PaO2 of 50-60 mm Hg corresponds closely with a SpO2 of 85-90%. For this reason, it is generally agreed that a PaO2 less than 50 mm Hg and a SpO2 less than 88% in the newborn indicate hypoxemia and necessitate initiation of oxygen therapy.

The PaO2 and the SpO2 are the principal clinical indicators used to begin, monitor, adjust, and terminate oxygen administration.

REF: p. 149 5. Which of the following disorders can develop in neonates as a result of receiving

concentrations of oxygen that produce a high PaO2? a. Atelectasis b. Hyperoxia c. Retinopathy of prematurity d. Bronchopulmonary dysplasia ANS: C

The role of oxygen in the development of retinopathy of prematurity (ROP) is controversial. It is believed to cause constriction of retinal and cerebral vessels in neonates and infants, which can lead to ischemia, varying degrees of retinal scarring, and retinal detachment. Formerly referred to as retrolental fibroplasia, ROP may resolve spontaneously or result in permanent visual impairment, including blindness. Current practice supports oxygen therapy targeting SpO2 levels at 88% to 95% and maintaining a PaO2 value of 50 to 80 mm Hg in infants weighing less than 1500 g.

REF: p. 149 6. Which of the following problems occurs as a result of absorption atelectasis? a. Pulmonary vasodilation b. Increased intrapulmonary shunting c. Decreased alveolar pressure d. Increased partial pressure of nitrogen in the blood ANS: B

High concentrations of oxygen have been linked to atelectasis, pulmonary vasodilation, and pulmonary fibrosis. In the face of high oxygen levels, the alveolar oxygen tension (PAO2) may increase and the alveolar nitrogen decrease, resulting in absorption atelectasis. As the nitrogen is replaced by oxygen, the blood rapidly absorbs the oxygen, gas volume decreases, and atelectasis develops. High FiO2 levels may also result in pulmonary vasodilation. As the pulmonary vasculature dilates and alveolar volumes decrease, areas of ventilation–perfusion mismatch occur with increased intrapulmonary shunting and worsening of arterial oxygen delivery.

REF: p. 150 7. Which of the following oxygen-delivery devices would be most suitable for an infant being

treated for choanal atresia? a. Nasal cannula b. Nasal catheter c. Oxygen hood d. Oxygen mask

ANS: C

When compared with an oxygen hood, the nasal cannula allows the patient greater mobility, which may increase interactions with the patient’s caregivers and environment. Nasal cannulas and nasal catheters are contraindicated in patients with nasal obstruction, such as facial trauma and choanal atresia. With facial trauma or choanal atresia, an oxygen hood would be the most appropriate oxygen delivery device to use because as long as the infant remains within the confine of the oxygen hood, he or she will breathe an elevated FiO2.

REF: p. 150 8. When weaning an infant receiving oxygen from a nasal cannula attached to a low-flow flow

meter set at 100%, what range represents the recommended oxygen flow reduction from the flow meter? a. Less than 0.1 L/minute b. 0.1 to 0.2 L/minute c. 0.2 to 0.3 L/minute d. 0.3 to 0.4 L/minute ANS: B

When weaning a patient from oxygen delivered by a nasal cannula, decrease the flow in small increments of 0.1 to 0.2 L/minute.

REF: p. 152 9. What is the concern when administering oxygen to a sedated infant who is wearing a nasal

cannula? a. Too low of an FiO2 may be delivered. b. Too high of an FiO2 may be given. c. Gastric distention may develop. d. The patient may stop breathing.

ANS: B

Sedated infants may have a decreased minute ventilation, resulting in an increased FiO2 received from a nasal cannula.

REF: p. 152 10. In order to decrease the risk of nasal irritation in newborns, what is the maximum flow rate

recommended? a. 0.5 L/minute b. 1 L/minute c. 2 L/minute d. 3 L/minute ANS: B

Excessive flows may result in drying of the nasal mucosa as well as mucosal irritation. It is recommended that maximum flow be limited to 2 L/minute in infants and newborns.

REF: pp. 152-153

11. Which of the following ranges of oxygen flow need to be set when administering oxygen to an

infant via a simple mask? a. Less than 1 L/minute b. 1 to 6 L/minute c. 6 to 10 L/minute d. Greater than 10 L/minute ANS: C

When a simple mask is used to provide supplemental oxygen to an infant, flows from 6 to 10 L/minute provide a variable FiO2 of 0.35 to 0.5. However, no data in newborns and infants are available to predict the effective FiO2.

REF: p. 153 12. The therapist notices that the reservoir bag on a partial rebreathing mask being worn by a

pediatric patient collapses completely during each inspiration. What should the therapist do at this time? a. Increase the oxygen flow to the device. b. Decrease the oxygen flow to the apparatus. c. Switch to a nonrebreathing mask. d. Continue monitoring the patient as the device is operating correctly.

ANS: A

Adjust the oxygen flow rate to a level sufficient to keep the bag partially inflated during inspiration; usually 6 to 15 L/minute is sufficient. If the reservoir bag becomes totally deflated when the patient inspires, increase the flow rate.

REF: p. 154 13. A child with an exacerbation of asthma is a candidate for the administration of heliox. Which

of the following gas delivery devices is most suitable for its administration? a. Nasal catheter b. Simple mask c. Partial rebreathing mask d. Nonrebreathing mask ANS: D

Because it is designed to provide almost 100% source gas, a nonrebreathing mask is the device recommended to deliver specific gas mixtures, as in helium-oxygen therapy, or specific concentrations from a blender.

REF: p. 154 14. The respiratory therapist is treating a hypoxemic child with a nasal cannula at 3 L/min.

However, after few hours the child becomes tachypneic, demonstrates shallow breathing, and becomes hypoxemic. What should the therapist do at this time? a. Increase flow rate on the cannula to 4 L/min. b. Switch to a partial rebreathing mask. c. Switch to an air-entrainment mask. d. Apply positive pressure ventilation.

ANS: C

In the hypoxic child with increased respiratory rates and tidal volumes, the air-entrainment mask is the preferred oxygen delivery system because it is capable of maintaining total flows in excess of the patient's inspiratory flow rate.

REF: pp. 154-155 15. Which of the following devices would be most appropriate to use for a 3-year-old patient who

experiences immediate postextubation hypoxemia? a. Blow-by setup b. Partial rebreathing mask c. Aerosol mask d. T-piece ANS: C

Both the aerosol mask and the face tent apparatus are indicated primarily for short-term administration of oxygen with high humidity, as in postextubation or postanesthesia hypoxemia.

REF: p. 155 16. How will excess condensate present in aerosol tubing affect the delivered FiO2? a. It will increase the FiO2. b. It will decrease the FiO2. c. It will only affect the FiO2 if in excess of 2 mL. d. It will produce an unpredictable effect on the FiO2.

ANS: A

Condensate can completely obstruct gas flow or cause increased resistance to flow, which can cause the FiO2 to increase above the desired setting.

REF: pp. 155-156 17. For which of the following condition(s) is a high-flow nasal cannula contraindicated?

I. Pneumothorax II. Apnea of prematurity III. Severe upper airway obstruction IV. Lack of spontaneous breathing a. I, III, and IV only b. I and III only c. II and IV only d. III and IV only ANS: A

Contraindications for use of the high-flow nasal cannula may include suspected or confirmed pneumothorax, severe upper airway obstruction, and absence of spontaneous ventilation.

REF: p. 156

Chapter 11: Aerosols and Administration of Medication Test Bank MULTIPLE CHOICE 1. When administering aerosol therapy to a pediatric patient, which of the following conditions

can affect aerosol deposition?

I. Airway diameter II. Respiratory rate III. Body weight IV. Nasal breathing a. I and II only b. II, III, and IV only c. III and IV only d. I, II, and IV only ANS: D

Compared with adults, infants and children have smaller airway diameters, higher and irregular breathing rates, engage in nose breathing (which filters out large particles), and often have difficulty with mouthpiece administration. Cooperation and ability to perform aerosol inhalation techniques effectively vary with the child's age and developmental ability.

REF: p. 164 2. The respiratory therapist verifies an order to administer albuterol 1.25 mg to a 2-kg infant.

Why does this dose have the same safety and efficacy profile as a 2.5-mg dose in the adult? a. The deposition efficiency in the infant results in a similar lung dose per kg of the adult patient. b. The liver of the infant metabolizes 95% of the drug. Therefore, the lung deposition is similar to that of the adult. c. Albuterol targets only a minimal number of beta-2 receptors in the infant’s airways. d. The infant gets a higher lung dose, but it does not produce side effects.

ANS: A

This reduced efficiency may result in infants receiving weight-appropriate dosing compared with adults. For example, the deposition efficiency of 0.5% of a standard dose of albuterol sulfate (2500 g) would result in a lung dose of 12.5 g, or 6.25 g/kg for a 2-kg infant, whereas a 70-kg adult with 10% deposition has a lung dose of 250 g, equivalent to 3.6 g/kg. In this example, the infant actually receives a similar but slightly greater dose per unit weight. To some extent, the reduced deposition of aerosolized bronchodilators results in safety and efficacy profiles for infants and children similar to those reported for adults.

REF: p. 164 3. The respiratory therapist is administering a nebulizer with a mask to a 2-year-old child. The

mask is being held away from the child’s face (“blow-by”) due to excessive crying. What should the RT consider doing to improve aerosol lung deposition?

a. b. c. d.

Comfortably hold the mask close to the face to minimize the leak.

Change the aerosol to a pMDI. Change the aerosol mask to a mouthpiece.

Ask the mother of the child to hold the mask and continue “blow-by” therapy.

ANS: A

Children aged between 18 months and 3 years with recurrent wheeze have reported that lung deposition with a face mask leak was 0.2% and 0.3% with pMDI and nebulizer, respectively.

Screaming children without face mask leak had 0.6% lung deposition with pMDI and 1.4% with nebulizer. Lung deposition in children who were quietly breathing and without face mask leak ranged from 4.8% to 8.2%.

REF: p. 165 4. By what percentage can breath holding increase particle deposition in the lungs? a. 5% b. 10% c. 15% d. 20% ANS: B

A breath hold can increase deposition of the aerosol by up to 10% and is associated with a shift of deposition from the central to peripheral airways.

REF: p. 166 5. Pneumatic nebulizers operate according to which of the following physical tenets? a. Venturi principle b. Bernoulli principle c. Law of continuity d. Law of conservation of energy ANS: B

Pneumatic nebulizers use the Bernoulli principle to drive a high-pressure gas through a restricted orifice and draw the medication and diluents into the gas stream through a capillary tube immersed in the solution. Shearing the fluid stream in the jet forms the aerosol stream that impacts against a baffle, removing larger particles that may return to the reservoir.

REF: p. 168 6. A conventional jet nebulizer with a dead volume of 1 mL is filled with a 3-mL solution of

albuterol. What percent of the medication is available for nebulization? a. 33% b. 50% c. 66% d. 100% ANS: C

With a residual volume of 1 mL, a fill of 2 mL would leave only 50% of the nebulizer charge available for nebulization, whereas a fill of 4 mL would make 3 mL, or 75%, of the medication available for nebulization.

REF: p. 168 7. When a conventional jet nebulizer is operated at a flow of 10 L/min versus 5 L/min, what

should the respiratory therapist expect? a. The particle size gets larger. b. The treatment time shortens. c. The particle size remains stable. d. The nebulizer will nebulize the full dose more slowly.

ANS: C

For any given nebulizer, the higher the flow to the nebulizer, the smaller the particle size generated and the shorter the time required to nebulize the full dose.

REF: p. 168 8. An aerosol treatment is being administered via a jet nebulizer. After 8 minutes the nebulizer

starts “sputtering.” What should the therapist do at this point? a. Tap the nebulizer cup until no more mist is produced. b. Terminate the treatment at this time. c. Allow the nebulizer to continue the treatment for 2 more minutes. d. Add more diluent to the nebulizer cup.

ANS: B

With three different fill volumes, albuterol delivery from a nebulizer was found to cease after the onset of inconsistent nebulization (sputtering). Aerosol output declined by one half within 20 seconds of the onset of sputtering. The concentration of albuterol in the nebulizer cup increased significantly once the aerosol output declined, and further weight loss in the nebulizer was caused primarily by evaporation. The conclusion was that aerosolization past the point of initial jet nebulizer sputter is ineffective.

REF: p. 168 9. Which of the following suggestions will have the most significant impact on the inhaled dose

of medications with nebulizers? a. Increasing the flow rate powering the nebulizer b. Terminating the treatment prior to “sputter” c. Adding a 6 inches of tubing on the expiratory side of the nebulizer d. Using breath-enhanced nebulizers ANS: D

Theoretically breath-enhanced nebulizers allow release of more aerosol during inhalation when ambient air vents through the nebulizer during inhalation and more aerosol is available.

When exhaled gas is routed out the expiratory one-way valve in the mouthpiece, aerosol is not cleared from the nebulizer. Thus, breath-enhanced nebulizers may increase inhaled dose by as much as 50% compared to continuous simple jet nebulizers.

REF: p. 168 10. In order to guarantee the same performance of the nebulizer after repeated use, what should be

suggested to the user? a. Rinse with vinegar and air dry.

b. Rinse with sterile water and dry with a clean paper towel. c. Rinse with a mixture of vinegar and sterile water and air dry. d. Rinse with sterile water and air dry.

ANS: D

Repeated use of a nebulizer will not alter the MMAD, or output, as long as it is properly cleaned (rinsed and dried between treatments). Failure to clean the nebulizer properly results in degradation of performance from clogging the jet (Venturi) nebulizer, increasing bacterial contamination, and the buildup of electrostatic charge in the device. The Centers for Disease Control and Prevention (CDC) recommend cleaning and disinfecting nebulizers or rinsing with sterile water between uses and then air drying.

REF: p. 170 11. Why are pass-over humidifiers preferred over pneumatic nebulizer humidifiers? a. Pass-over humidifiers produce smaller particles and have a greater output. b. The fraction of inspired oxygen (FiO2) used with pass-over humidifiers is easier to

control. c. Pass-over humidifiers transmit fewer pathogens than pneumatic nebulizers. d. Pass-over humidifiers have a smaller residual volume than pneumatic nebulizers.

ANS: C

Because nebulizers provide a route for transmission of pathogens, pass-over humidifiers and heater wire humidifiers are preferable.

REF: p. 170 12. Which of the following considerations is most important when using a large-volume nebulizer

to provide oxygen and humidification to an infant in an incubator? a. Meeting the inspiratory flow demands of the infant b. Supplying the infant with adequate humidification c. Delivering sufficient oxygen to meet the infant’s needs d. Preventing a high noise level from developing ANS: D

Caution should be exercised when using LVNs with incubators or hoods because of the noise produced. The American Academy of Pediatrics recommends a sound level less than 58 dB to avoid hearing loss in patients in incubators and hoods. Many LVNs are designed to deliver controlled concentrations of oxygen and use a Venturi system to entrain air into the stream of gas administered to the patient. Standard entrainment nebulizers may deliver a fractional concentration of delivered oxygen approaching 1.00 but cannot provide a fractional concentration of inspired oxygen (FiO2) greater than 0.40. High-flow nebulizers are designed to deliver high-flow rates of oxygen, bringing the FiO2 up to 0.60 to 0.80. Closed dilution and gas injection nebulizers provide high-flow access to the nebulizer from two gas sources, allowing gas to mix without compromising FiO2.

REF: p. 170 13. Which of the following nebulizers should be suggested to improve lung dose in patients

undergoing invasive mechanical ventilation? a. Jet nebulizer

b. Ultrasonic nebulizer c. Breath-actuated nebulizer d. Vibrating mesh nebulizer ANS: D

Because the VMN does not add gas to the patient airway or ventilator circuit, greater aerosol concentrations can be reached than with jet nebulizers. VMNs produce the same size aerosol particles with air, oxygen, or helium. Handheld VMN nebulizers tend to be much more efficient than continuous jet nebulizers or USNs, with inhaled mass ranging from 25% to 55%. When used with mechanical ventilators, VMNs do not change volumes or flows.

REF: p. 172 14. How can a patient avoid the problem of terminating inhalation when a plume from a

pressurized metered-dose inhaler (pMDI) impacts the oropharynx? a. Hold the pMDI closer the mouth. b. Use a valved holding chamber. c. Depress the nozzle only half the full distance. d. Instruct the patient to inspire a short, rapid breath.

ANS: B

A “cold Freon effect” can occur when the aerosol plume from a pMDI reaches the back of the mouth and the patient stops inhaling. This problem can be corrected by using a valved holding chamber connected to the pMDI. A valved holding chamber, which has a volume usually between 140 and 750 mL, enables the plume from a pMDI to expand. It incorporates a oneway valve that permits the aerosol to be drawn from the chamber during inhalation only, diverting the exhaled gas to the atmosphere and not disturbing the aerosol remaining in suspension in the chamber.

REF: p. 175 15. Which of the following functions are served by spacer and holding chambers in conjunction

with pMDIs? I. Reduction in oropharyngeal deposition of drug II. Elimination of the “cold Freon effect” III. Improvement in lower respiratory tract deposition IV. Decrease in treatment time without sacrificing efficacy a. I and III only b. II and IV only c. I, II, and III only d. I, III, and IV only ANS: C

Spacers and valved holding chambers (1) reduce oropharyngeal deposition of drug, (2) relieve the bad taste of some medications by reducing oral deposition, (3) eliminate the cold Freon effect, (4) decrease aerosol mass median aerodynamic diameter, (5) increase respirable particle mass, (6) improve lower respiratory tract deposition, and (7) significantly improve therapeutic effects.

REF: p. 175

16. Why should pMDIs containing steroids in particular be used with a valved holding chamber? a. To provide better lung deposition b. To increase the dose of the medication c. To enable the patient to take a deeper breath d. To reduce the risk of oral yeast infections ANS: D

Valved holding chambers reduce the pharyngeal dose of aerosol from the pMDI 10- to 15-fold over administration without a holding chamber. Using a valved holding chamber decreases total body dose from swallowed medications, which is an important consideration with steroid administration. The high percentage of oropharyngeal drug deposition with steroid pMDIs can increase the risk of oral yeast infections (thrush). Rinsing the mouth after steroid inhalation can reduce this problem, but most pMDI steroid aerosol impaction occurs deeper in the pharynx, which is not easily rinsed. For this reason, steroid pMDIs should always be used in combination with a valved holding chamber.

REF: pp. 175-176 17. For which of the following types of patients would using a dry powder inhaler (DPI) for

medication delivery likely be contraindicated? a. A 4-year-old child b. A patient with COPD c. A teenager able to generate an inspiratory flow of 40 L/min d. An 11-year-old diagnosed with stable asthma ANS: A

At present, DPIs may be considered alternatives to pMDIs for patients who can generate inspiratory flow rates greater than 30 to 60 L/minute but who are unable to use pMDIs effectively. DPIs are recommended for therapy for patients with stable asthma and chronic obstructive pulmonary disease but not for patients with acute bronchoconstriction or children less than 6 years of age.

REF: p. 179 18. The physician in the emergency department is attending to a 12-year-old child who has an

exacerbation of asthma. The physician asks the therapist to recommend a medication that has a synergistic effect with beta-2 agonists during asthma exacerbations. Which of the following medications should the therapist recommend? a. Montelukast b. Ipratropium bromide c. Fluticasone d. Triamcinolone ANS: B

Although beta-2 agonists are the first-line agents for treating an exacerbation of asthma, data in both adults and children suggest that ipratropium bromide is synergistic with beta-2 agonists for the therapy of acute asthma. Combination bronchodilator therapy using albuterol and ipratropium in patients with severe asthma significantly reduces the percentage of patients hospitalized.

REF: p. 181 19. An 18-month-old patient brought to the emergency department is exhibiting signs and

symptoms consistent with an acute asthma episode and is administered a beta-2 agonist to which the patient does not respond favorably. Which of the following conditions could be responsible for this patient’s problem? a. Aspiration of a foreign object b. Croup c. Bronchiolitis d. Pneumonia ANS: A

Poor relief of acute asthma with bronchodilators may signify a nonasthmatic cause of wheezing, such as foreign body aspiration or tracheitis. Infants with bronchiolitis respond poorly to bronchodilator medications, which are therefore not recommended for this condition.

REF: p. 181 20. Where in the ventilator circuit should a continuous jet nebulizer be placed to improve

efficiency of aerosol delivery? a. Between the “y” adapter and the endotracheal tube b. 30 cm from the ETT in the inspiratory limb c. 30 cm from the heated humidifier d. In the expiratory limb ANS: B

Placement of a continuous jet nebulizer 30 cm from the ETT is more efficient than placement between the patient “y” adapter and the ETT because the inspiratory ventilator tubing acts as a spacer for the aerosol to accumulate between inspirations.

REF: p. 183 21. The therapist receives an order to administer a bronchodilator in-line to an infant receiving

mechanical ventilation. The order also indicates that the nebulizer must not significantly increase the patient’s delivered tidal volume. Which of the following aerosol delivery devices should the therapist select?

I. Vibrating mesh nebulizer II. pMDI III. Jet nebulizer IV. Ultrasonic nebulizer a. II and III only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only ANS: B

In both adults and infants, the gas driving the jet nebulizer enters the ventilator circuit with the potential for changing delivered volumes, pressures, and parameters; this can set off alarms.

Because of the relatively low flow rates used in infant ventilator circuits, the addition of 2 to 6 L/minute of gas can more than double the delivered volume. With other aerosol generators such as pMDIs and ultrasonic and vibrating mesh nebulizers, there is no substantial increase in gas volume and ventilator parameters remain consistent.

REF: pp. 185-186 22. Which of the following methods is acceptable for delivering a drug via a pMDI to an

intubated neonate receiving mechanical ventilation? a. In-line with the ventilator b. Through a resuscitation bag c. Through a T-piece d. In-line with a spacer ANS: B

The administration of medication by pMDI to the mechanically ventilated neonate may not be well tolerated. Leaving a chamber device in-line is not practical because of the increased compressible volume incorporated into the ventilator circuit. Depending on the FiO2 and the propellant gas volume, an in-line pMDI actuation theoretically may result in the delivery of a hypoxic gas mixture to an infant receiving a tidal volume less than 100 mL. It is possible to deliver a pMDI aerosol medication to the intubated neonate, especially for medications available only in pMDI preparations. However, it may be preferable to hand-ventilate the pMDI delivery of medication to the patient. If a chamber adapter is used, the infant must be removed from the circuit, the chamber placed in-line, and the infant reattached to the circuit before the pMDI is administered. The large dead-space volume caused by placing a spacer or chamber at the end of the ETT must also be considered when administering pMDI medications to an infant.

REF: p. 186

Chapter 12: Airway Clearance Techniques and Lung Volume Expansion Test Bank MULTIPLE CHOICE 1. What are the main components of the traditional airway clearance techniques?

I. Palpation of the chest wall II. Postural drainage III. Percussion IV. Coughing a. II only b. I and III only c. II, III, and IV only d. I, II, III, and IV ANS: C

Traditional airway clearance techniques (ACT) are designed to remove secretions from the lungs and include postural drainage, percussion, chest wall vibration, and coughing.

REF: p. 198 2. On the basis of the following diagram, which of the following lung segments is being

drained?

a. b. c. d.

Posterior segment of the right upper lobe Apical segment of the right upper lobe Posterior basal segments of both lower lobes Anterior segments of both upper lobes

ANS: C

What is shown here (and in Figure 12-3E in the textbook) is the postural drainage position for draining the posterior basal segments of the right and left lower lobes.

REF: p. 200

3. On the basis of the following diagram, which of the following lung segments is being

drained?

a. b. c. d.

Right middle lobe Left lingular segment of the lower lobe Lateral basal segment of the right lower lobe Apical-posterior segment of the left upper lobe

ANS: A

What is shown here (and in Figure 12-4H in the textbook) is the postural drainage position for draining the right middle lobe.

REF: p. 200 4. The following postural drainage positions are shown for an infant patient:

Which of the diagrams demonstrates the postural drainage position for draining the lingular segments of the left upper lobe in an infant? a. Image A b. Image B c. Image C d. Image D ANS: C

What is shown here (and in Figure 12-3I in the textbook) are the lingular segments of the left upper lobe; choice A (see Figure 12-3F in the textbook) shows the lateral basal segment of the right lower lobe; choice B (see Figure 12-3G in the textbook) shows the anterior basal segment of the right lower lobe; and choice D (see Figure 12-3D in the textbook) shows the superior segments of both lower lobes.

REF: p. 200 5. The following postural drainage positions are shown for a pediatric patient:

Which of the diagrams demonstrates the postural drainage position for draining the posterior subsegment of the apical-posterior segment of the left upper lobe? a. Image B b. Image C c. Image A d. Image D ANS: C

What is shown here (and in Figure 12-4A in the textbook) is the apical segment of the right upper lobe and the apical subsegment of the apical-posterior segment of the left upper lobe; choice B (see Figure 12-4B in the textbook) shows the posterior segment of the right upper lobe and the posterior subsegment of the apical-posterior segments of the left upper lobe; choice C (see Figure 12-4C in the textbook) shows the anterior segments of the right and left upper lobes; choice D (see Figure 12-4D in the textbook) shows the superior segments of both lower lobes.

REF: p. 200 6. When performing endotracheal suctioning on a neonate, why should the therapist routinely

avoid advancing the catheter tip beyond the distal end of the endotracheal tube? a. To reduce the risk of inadvertent extubation with the suction catheter b. To prevent the development of bronchial stenosis and granulomas c. To decrease the chance of removing too much lung volume d. To minimize the risk of oxygen desaturation ANS: B

The trachea and bronchi of the newborn appear especially vulnerable to damaging effects from endotracheal tubes and suction catheters. Consequences of deep endotracheal suctioning include the development of bronchial stenosis and granulomas. Avoiding deep endotracheal suctioning minimizes these risks. Therefore when suctioning intubated infants after chest physical therapy (CPT), the therapist should not routinely advance the suction catheter beyond the distal end of the endotracheal tube. If evidence of persistent secretion retention exists despite adequate suctioning of the endotracheal tube, the suction catheter can be carefully and slowly advanced 1 or 2 cm beyond the tip of the endotracheal tube.

REF: p. 203 7. Which of the following maneuvers is characterized by having a patient forcibly exhale, from a

middle to low lung volume, through an open glottis? a. Autogenic drainage b. Directed cough c. Positive expiratory pressure d. Active cycle of breathing ANS: D

FET is also known as "huff" coughing. This maneuver requires the patient to forcibly exhale, from middle to low lung volumes, with an open glottis, but requires extreme cooperation and cannot be performed on infants or young children.

REF: p. 204 8. During autogenic drainage, at which of the following levels does the patient begin breathing? a. Total lung capacity b. Inspiratory reserve volume c. Expiratory reserve volume d. Tidal volume ANS: C

AD is a series of breathing exercises designed to mobilize secretions in patients with bronchiectasis or CF. To loosen secretions from the smallest airways, the patient begins breathing in a slow, controlled manner, first at the expiratory reserve volume level. The volume of ventilation is then increased, with the patient breathing in the normal tidal volume range but exhaling approximately halfway into the expiratory reserve volume.

REF: p. 205 9. By which of the following mechanisms are high-frequency chest compressions purported to

mobilize tracheobronchial secretions? a. By dislodging mucus directly from bronchial walls b. By advancing the mucociliary escalator at a faster than normal rate c. By mechanically lysing long molecules of mucus into smaller, more mobile segments d. By generating high expiratory air velocities ANS: D

Commercially available devices have been developed that compress the entire chest wall at high frequencies by means of a snug-fitting inflatable vest connected to a high-performance air compressor (see Figure 12-6 in the textbook). Intermittent chest wall compression produces brief periods of high expiratory airflow, which loosens and mobilizes mucus from bronchial walls. This type of device is widely used in patients with CF. REF: p. 205 10. What do postural drainage, positive expiratory pressure therapy, autogenic drainage, forced

expiration techniques, and high-frequency chest compressions have in common? a. They dislodge mucus from the bronchial walls of patients. b. They attempt to prevent dynamic airway collapse. c. They work toward increasing the functional residual capacity of patients. d. They are intended to promote the ability of patients to generate effective coughs.

ANS: B

Postural drainage, positive expiratory pressure (PEP), AD, FET, and HFCC attempt to prevent or compensate for dynamic airway collapse.

REF: p. 206 11. A patient with an excessive amount of secretions and atelectasis has been receiving ACT.

What is the most commonly cited complication of ACT? a. Hypoxemia b. Hypercapnia c. Alterations of blood pressure d. Tachycardia ANS: A

The most commonly cited adverse effect of ACT is hypoxemia.

REF: p. 207 12. A respiratory therapist has been assigned to administer ACT to a number of patients on the

ward. In which of the following conditions may ACT be beneficial? a. Asthma b. Pneumonia c. Bronchiolitis d. Atelectasis ANS: D

The majority of patients with acute atelectasis secondary to mucous plugs respond with one ACT treatment.

REF: p. 209 13. A respiratory therapist has been assigned to administer ACT to a number of patients on the

ward. In which of the following conditions may ACT be contraindicated?

I. Foreign body aspiration II. Frank hemoptysis III. Empyema

IV. Untreated pneumothorax a. I, II, III, and IV b. II and IV only c. III and IV only d. I and IV only ANS: A

Frank hemoptysis, empyema, foreign body aspiration, and untreated pneumothorax are often considered contraindications to all components of ACT. REF: p. 211 14. A respiratory therapist has been assigned to administer CPT to a patient with cystic fibrosis.

What areas of the body should the RT avoid when percussing the patient? a. Intercostal spaces b. Fractured ribs c. Precordium d. Areas between the scapulas ANS: B

Chest percussion should not be performed directly over fractured ribs, areas of subcutaneous emphysema, or recently burned or grafted skin.

REF: p. 211 15. A respiratory therapist has been assigned to administer ACT to a patient with acute lobar

atelectasis. What should the RT consider to determine the length and frequency of the treatment?

I. Most pediatric patients require ACTs for at least 45 minutes.

II. ACT is rarely needed more than every 4 hours.

III. ACT orders should be evaluated at least every 48 hours for patients in the ICU. IV. ACT for patients with atelectasis due to CF requires at least 30 to 45 minutes. a. I, II, and III only b. II and III only c. III and IV only d. II, III and IV only ANS: D

Treatments for patients with CF or bronchiectasis should be performed for at least 30 minutes, with many patients benefiting from therapy lasting 45 minutes or longer. Patients with severe dyspnea may require rest periods, which will further prolong therapy. Most pediatric respiratory care departments limit routine ACT treatments to 15 to 20 minutes. ACT is rarely needed more than every 4 hours, although selected patients may benefit from more frequent suctioning or coughing. ACT orders should be evaluated at least every 48 hours for patients in intensive care units, at least every 72 hours for acute care patients, or whenever there is a change in a patient's status.

REF: p. 211

16. A respiratory therapist has been assigned to administer FET to a 5-year-old patient. Since

small children are typically unable to perform such a maneuver, what should the RT do at this time? a. Request to cancel the order and change therapy. b. Try to instruct the child on how to perform FET. c. Apply gentle chest wall compression during the expiratory phase. d. Ask the child to forcefully cough after a deep breath.

ANS: C

Infants and small children are unable to perform maneuvers such as FET or AD. Some clinicians have attempted to mimic these techniques with gentle chest wall compression during the expiratory phase, allowing the child to exhale to less than functional residual capacity. Like AD or FET performed in cooperative older patients, this technique results in increased expiratory air velocity at low lung volumes, improving mucous mobilization.

REF: p. 212 17. What is the most important variable used to assess the efficacy of CPT? a. Quality of the chest radiograph b. Degree and persistence of coughing c. Changes in the color and consistency of mucus d. Amount of mucus obtained during and after treatment ANS: D

Because the goal of CPT is to promote the removal of excessive bronchial secretions, the most important variable for evaluating the effectiveness of CPT is the amount of secretions expectorated with therapy.

REF: p. 212 18. Which of the following clinical parameters are important to determine a positive response to

ACT? I. Changes in sputum color II. Breath sounds III. Vital signs IV. Lung mechanics a. I, II, and III only b. II and III only c. III and IV only d. II, III and IV only ANS: D

Changes in sputum production, breath sounds, vital signs, chest radiographic findings, blood gas values, and lung mechanics may indicate a positive response to the therapy.

REF: p. 212 19. For which of the following patients is incentive spirometry contraindicated?

I. Uncooperative

II. Physically disabled III. Grossly obese IV. Very young a. IV only b. I and II only c. I, II, and IV only d. I, II, III, and IV ANS: C

Incentive spirometry is contraindicated in patients who cannot cooperate or follow instructions concerning the proper use of the device. The child may be uncooperative, physically disabled, or simply too young to effectively perform the maneuvers. Alternative methods such as walking, getting up in a chair, frequent changes in position, or singing to improve lung volumes should then be considered.

REF: p. 213 20. The respiratory therapist has been asked to evaluate the effectiveness of incentive spirometry

in some patients during their postoperative stage. What will the RT find to be most influential on the outcome associated with IS? a. Frequency of therapy b. Level of inspiratory capacity achieved by the patient c. Level of supervision and instruction of therapy d. Patient’s age ANS: C

The majority of problems that patients experience with incentive spirometry are the result of inadequate supervision or instruction, or both. These two factors account for a large number of ineffective treatments.

REF: p. 213

Chapter 13: Airway Management Test Bank MULTIPLE CHOICE 1. Which of the following criteria are used to define ventilatory and hypoxemic dysfunction in

patients who may need intubation?

I. PaO2 < 80 mm Hg with FiO2 > 0.60 II. PaCO2 > 50-60 mm Hg III. pH < 7.3 IV. PaO2/FiO2 > 250 a. I and III only b. II and III only c. I, II, and III only d. I, III, and IV only ANS: B

The need for intubation, due to a lack of pulmonary function, results from deficits in oxygenation, ventilation, or both taken in concert with the patient's clinical condition. Acute ventilatory dysfunction can be defined as an arterial partial pressure of carbon dioxide (PaCO2) greater than 50 to 60 mm Hg with a pH less than 7.3. Pulmonary dysfunction due to hypoxemia is defined as an arterial partial pressure of oxygen (PaO2) less than 60 mm Hg with a fraction of inspired oxygen (FiO2) greater than or equal to 0.60. These definitions assume that there is no intracardiac right-to-left shunt resulting from a congenital cardiac defect.

REF: p. 223 2. Which of the following conditions associated with upper airway obstruction may cause

respiratory failure and require an artificial airway?

I. Laryngotracheobronchitis II. Pneumonia III. Epiglottitis IV. Subglottic stenosis a. I and III only b. II and IV only c. I, II, and III only d. I, III, and IV only ANS: D

Upper airway obstruction may also cause respiratory failure. Examples that are included in this category are diseases such as laryngotracheobronchitis (i.e., croup), epiglottitis, laryngeal papillomatosis, and severe subglottic stenosis.

REF: p. 223 3. The therapist is about to perform endotracheal intubation on a 2-year-old infant. What size

endotracheal tube needs to be used? a. 3.5 mm I.D.

b. 4.0 mm I.D. c. 4.5 mm I.D. d. 5.0 mm I.D. ANS: C

Using the following formula, the therapist can calculate the approximate size endotracheal tube to use to intubate a 2-year-old infant: Internal diameter (mm) = (age [yr] ÷ 4) + 4 = (2 yr ÷ 4) + 4 = 0.5 + 4 = 4.5 mm I.D. REF: p. 224 4. Prior to 2005, why were endotracheal tubes (ETTs) without cuffs routinely recommended for

children less than 8 years of age? a. Because some lung volumes are so small cuffs are unnecessary b. Because in some infants the ETT creates a seal against the cricoid cartilage c. Because less airway resistance develops without a cuff, promoting lower ventilation pressures d. Because ETTs without cuffs enable pressure venting when an infant cries ANS: B

Because the cricoid cartilage is the narrowest portion of the pediatric airway until about 8 years of age, use of an uncuffed ETT was traditionally recommended until that time. In 2005, the American Heart Association's Pediatric Advance Life Support program (PALS) stopped recommending uncuffed tubes because there was no evidence to support one over the other.

Today it is left up to the clinician to determine whether a cuff is needed for patients less than 8 years of age.

REF: p. 224 5. Where in the upper airway of an infant should the laryngoscope straight blade be placed to

expose the glottis during endotracheal intubation? a. The epiglottis is directly lifted with the tip of the laryngoscope blade. b. The tip of the laryngoscope blade is placed in the vallecula. c. The tip of the laryngoscope blade is placed in the uvula. d. The laryngoscope blade is used to sweep the tongue to the left.

ANS: A

When a straight blade is used, the epiglottis is lifted with the tip of the blade and pressed against the base of the tongue.

REF: p. 224 6. Which of the following statements describe the laryngeal mask airway (LMA)? a. The LMA should be used only with conscious patients. b. The potential for aspiration is lower than with translaryngeal intubation. c. The LMA is a good alternative as an emergency airway when positive-pressure

ventilation is needed. d. The LMA is placed into the larynx immediately above the epiglottis.

ANS: C

If endotracheal tube placement is unsuccessful, placement of an LMA can be used as a temporizing measure. It is essential to realize that the LMA does not provide a secure airway and that it may permit aspiration of gastric or oral secretions. The lubricated LMA is placed by itself into the pharynx above the epiglottis and can be used for gentle (<20 cm H2O) positive-pressure ventilation. The deflated mask is manually inserted into the patient's mouth and guided blindly along the hard palate. It is advanced until resistance is encountered (the distal tip of the LMA rests against the upper esophageal sphincter at this point).

REF: pp. 224-225 7. What is the purpose of placing a small towel under the occiput of a 4-year-old patient who is

undergoing oral intubation? a. To prevent unnecessary pressure from being exerted on the occiput b. To enable the clinician to more easily move the patient’s tongue to the left c. To obtain a better alignment and visualization of the airway d. To assist in maintaining the patency of the upper airway ANS: C

The occiput of babies and infants is larger than that of older children. A small roll placed under the shoulders of these younger patients facilitates view of the vocal cord during laryngoscopy. Direct laryngoscopy may be facilitated by placing a roll under the shoulders of any patient lying on a soft mattress.

REF: p. 226 8. Which of the following labeled structures identifies the vocal cords?

a. b. c. d.

A B C D

ANS: C

In the illustration depicting the glottis and surrounding structures, A indicates the aryepiglottic folds; B indicates the epiglottis; C refers to the vocal cords; and D represents the corniculate cartilage. The dark center of the illustration depicts the glottis, or rima glottidis.

REF: p. 226

9. How should the therapist determine the depth of insertion of an endotracheal tube marked

with three rings in an infant during the intubation procedure? a. Just when the Murphy eye clears the vocal cords and enters the trachea b. At the location where the second double-ring mark just passes the glottis c. At the point where the first heavy black line just moves beyond the glottis d. Just after the distal third of the tube passes into the trachea past the glottis ANS: B

The tip of the ETT is advanced through the glottic opening so that the single black ring is just distal to the opening of the glottis. If the ETT is marked with three rings, the ETT should be inserted until the double black ring is distal to the glottic opening.

REF: p. 226 10. How should the therapist confirm proper placement of an endotracheal tube? a. Presence of end tidal CO2 one breath after intubation b. Pulse oximetry > 88% c. Presence of end tidal CO2 five breaths after intubation d. Presence of vapor in the ETT ANS: C

The presence of vapor in the ETT is not an accurate test for proper ETT placement. Proper endotracheal, and not esophageal, placement of the endotracheal tube is confirmed with sustained presence of end tidal CO2. Capnography via a monitor is preferred over a single-use end tidal device (Pedi-Cap; Nellcor, Boulder, Colorado). End tidal CO2 should be monitored for at least five breaths after intubation. Even endotracheal tubes placed in the esophagus may have transient detection of CO2 due to the presence of CO2 in the stomach (which can occur due to bag-mask ventilations).

REF: p. 226 11. Where should the therapist secure a 4.0-mm endotracheal tube after the intubation procedure? a. 8 cm at the lip b. 9 cm at the lip c. 10 cm at the lip d. 12 cm at the lip ANS: D

The proper depth of the endotracheal tube can be estimated based on the size of the endotracheal tube used. Multiply the internal diameter of the endotracheal tube by three and tape the ETT at that centimeter mark at the lip (e.g., a 4.0-mm ETT should be taped at 12 cm at the lip). The proper length of the endotracheal tube can be estimated in premature infants according to their weight: add 6 to their weight in kg (e.g., in a 1-kg baby the ETT should be taped at 7). This formula cannot be used in children weighing more than 3 kg.

REF: p. 226 12. The therapist is trying to confirm the proper placement of an endotracheal tube of an infant.

Auscultation reveals breath sounds over both the stomach and the chest wall. What should the therapist do? a. Advance the ETT until breath sounds are not heard over the stomach.

b. Pull the ETT at least 4 cm until breath sounds are not heard over the stomach. c. Leave it in place because breath sounds over the stomach are simply transmitted

from the lungs. d. Pull the ETT because it is most probably in the esophagus.

ANS: D

The chest is auscultated after intubation as a method for assessing whether the ETT is in the trachea. Breath sounds should be heard bilaterally over the lateral chest wall. If breath sounds are auscultated over both the stomach and the chest wall, the ETT is in the esophagus and should be pulled. It should be noted that auscultation is not the most accurate method of assessing proper ETT placement.

REF: p. 226 13. Which of the following conditions are considered contraindications for nasotracheal

intubation?

I. Bleeding diathesis II. Facial trauma III. Temporal skull fracture IV. Choanal atresia a. I and II only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only ANS: B

The major contraindications to nasotracheal intubation are a bleeding diathesis, such as thrombocytopenia, abnormal clotting times, facial trauma, suspected basilar skull fracture, and abnormal anatomy such as choanal atresia.

REF: p. 228 14. Which of the following anatomic differences between the larynx of an infant and that of an

adult makes blind nasal intubation of the infant more difficult? a. The larynx of an infant is more cephalad and anterior. b. The upper airway in the laryngeal area is smaller in an infant. c. The cricoid cartilage in an infant acts as a partial airway obstruction. d. The upper airway structures in an infant are more pliable and compliant.

ANS: A

The larynx of an infant or small child is anterior and cephalad, making intubation more difficult in general. This anatomic difference between adults and children makes attempts at blind nasal intubation almost uniformly unsuccessful. Wisdom dictates that attempts at a blind nasal intubation be vigorously discouraged because of the potential for damaging the airway.

Mechanically generated damage and subsequent bleeding would make further intervention and attempts at intubation more difficult and dangerous.

REF: p. 228

15. Which of the following conditions is considered a disadvantage of nasotracheal intubation in

neonates? a. Postextubation atelectasis among very low–birth weight infants b. Pressure necrosis of the nares c. Deformation of the nasal turbinates d. Olfactory nerve damage ANS: B

Disadvantages to nasal intubation include a predisposition to sinusitis, pressure necrosis of the nares, and bleeding complications associated with passing the ETT through the nares and upper airway.

REF: p. 228 16. Which of the following techniques should be considered when intubating neonates with Pierre

Robin syndrome? a. Nasotracheal intubation b. Routine orotracheal intubation c. Fiberoptic laryngoscopy d. Finger intubation of the trachea ANS: C

Children with craniofacial syndromes (e.g., Treacher Collins syndrome or Pierre Robin syndrome) are assumed to have a difficult airway, even if they have undergone jaw advancement. Acquired causes of a difficult airway include limited mouth opening due to decreased temporomandibular joint mobility (as may occur in rheumatoid arthritis or muscular dystrophy), orofacial trauma, trauma to the neck, hematoma of the neck, and infections either of the anterior neck or the epiglottis. Patients with a history of burns or radiation to the face or neck are very difficult to intubate. The clinician should always have additional options available to secure the airway in the event that orotracheal intubation is not successful. An LMA should be readily available during intubation attempts. The Glidescope is a fiberoptic laryngoscope that greatly facilitates intubation of patients with a difficult airway. It is best to learn how to use the Glidescope on patients with a normal airway prior to using this device on patients with an abnormal airway.

REF: p. 228 17. A 5-year-old child is brought to the emergency department in severe respiratory distress with a

diagnosis of epiglottitis. What measures must be performed to secure the child’s airway? a. The child should be immediately intubated orally in the emergency department. b. A tracheotomy needs to be performed in the emergency department. c. The child is in urgent need of transport to the operating room to be intubated. d. Nebulized 2.2% racemic epinephrine needs to be given via face mask every 10 minutes.

ANS: C

The child with clinical manifestations of epiglottitis (drooling, stridor, and respiratory distress) should not undergo a visual examination in the emergency department. The child should not be stimulated and should be kept as calm as possible. If the patient is stable, a soft tissue lateral neck radiograph (refer to Figure 13-8 in the textbook) can be performed. Radiologic findings include thickening of the epiglottis and aryepiglottic folds and the classic "thumbprint" sign. If the patient is not stable or if the diagnosis of epiglottitis has been made, the patient should be immediately transported to the operating room to be managed by an ENT surgeon and an anesthesiologist.

REF: pp. 228-229 18. A child orally intubated because of laryngotracheal stenosis has an air leak at 25 cm H2O.

What action does the therapist take now? a. The therapist should recommend that a tracheotomy be performed. b. The therapist needs to insert an oral ETT smaller than the one in place. c. The therapist must insert an oral ETT large enough to stop the leak. d. The therapist should do nothing because this situation is acceptable for this type of patient.

ANS: B

Children with laryngotracheal stenosis who do not have a tracheotomy may require intubation.

The severity of the stenosis may dictate the approach used to access the airway. Plain magnified soft tissue radiographs may show subglottic narrowing or long-segment tracheal stenosis. In cases of mild subglottic stenosis, the patient may be intubated orally, but it would be essential to start with an endotracheal tube size at least one smaller than the ageappropriate tube, and air leakage must be checked. A leak between 10 and 20 cm H2O during the time of intubation is necessary so that further damage is not incurred. If the air leak is greater than 20 cm H2O, a smaller tube should be placed. In cases of severe laryngotracheal stenosis, an LMA may be used, or occasionally an emergency tracheotomy may be performed as an alternative.

REF: p. 229 19. The therapist is measuring the intracuff pressure of a pediatric ETT. Where should the

pressure be maintained to avoid complications? a. 5 to 10 cm H2O b. 10 to 20 cm H2O c. 20 to 25 cm H2O d. Not greater than 30 cm H2O ANS: C

Positive pressure applied through the ETT should produce an audible escape of air, or leak, at less than or equal to 20 cm H2O. The larynx should be auscultated to confirm the leak.

Intracuff pressures are maintained at less than 20 to 25 cm H2O because higher pressures are associated with ischemia and necrosis of the tracheal mucosa and can lead to tracheal stenosis.

REF: p. 229 20. What is considered the best predictor of a successful extubation? a. An oxygen saturation > 95% b. A respiratory rate < 35 breaths per minute

c. A cuff leak < 25 cm H2O d. A successful spontaneous breathing trial ANS: D

The best predictor of successful extubation is a successful spontaneous breathing trial.

Successful extubation appears to be inversely related to the duration of the intubation period.

REF: p. 230 21. Prolonged exposure to increased tracheostomy cuff pressure may cause which of the

following disorders? a. Tracheomegaly b. Tracheomalacia c. Tracheal granulomatosis d. Tracheal bleeding ANS: A

Prolonged exposure to increased pressure can lead to tracheal dilation, or tracheomegaly.

Careful management of the tube size and cuff may prevent this complication. Cuff pressure should be checked regularly and adjusted as needed.

REF: p. 233 22. Where is the tracheostomy tube usually placed in children? a. Between the second and fourth tracheal rings b. Between the fourth and fifth tracheal rings c. Between the cricoid and the thyroid cartilage d. Between the first and second tracheal rings ANS: A

The tracheotomy tube is usually placed between the second and fourth tracheal rings, depending on ease of exposure and size of the trachea and tube to be placed.

REF: p. 233 23. What are the most common causes of death in tracheotomy-dependent children? a. Hemorrhage b. Sepsis/infection c. Significant leaks d. Mucous plugging ANS: D

The two most common reasons for death of a tracheotomy-dependent child include plugging of the tube with mucus and accidental decannulation. Plugging with mucus occurs when thick, viscous mucus obstructs the lumen of the tracheotomy tube. Several factors that lead to this problem include dehydration, infection, and lack of humidity.

REF: p. 235 24. Ideally, how many hours after last feeding should a therapist consider before changing a

tracheostomy tube to minimize the risk of vomiting and aspiration? a. At least 2 hours

b. At least 4 hours c. At least 6 hours d. At least 12 hours ANS: A

Ideally, at least 2 hours should have passed after the last feeding before the tracheostomy tube is changed to minimize the risk of vomiting or aspiration during the tracheostomy tube change.

REF: p. 237 25. What conditions should be met before considering decannulation?

I. Original indication for tracheostomy has resolved II. Tolerance of a Passey-Muir valve most of the day III. No need for suctioning IV. Absence of fever a. I, II, and III only b. I and III only c. III and IV only d. I, II, III, and IV ANS: A

A patient may be considered for decannulation or removal of the tracheostomy when the following conditions have been met: The original indication for the tracheostomy tube has resolved or been corrected. The patient should be either tolerating a cap during most or all of their waking hours or tolerating a Passey-Muir valve most of the day. The patient should not require removal of either for suctioning or respiratory complaints. If these conditions have not been met, the patient should at a minimum tolerate downsizing of their tracheostomy tube.

REF: p. 237

Chapter 14: Surfactant Replacement Test Bank MULTIPLE CHOICE 1. According to Laplace’s law the pressure required to open an alveoli in the lung is: a. Directly proportional to the radius b. Inversely proportional to the length of the airway c. Directly proportional to the surface tension d. Indirectly proportional to the viscosity of the gas in the airway ANS: C

In his theory of capillary action Laplace described the relationship of trans-surface pressure and surface tension at a gas–fluid interface in a sphere as P = 2  ST/R (where P is the transsurface or distending pressure, ST is surface tension, and R is the radius of the sphere).

REF: pp. 245-246 2. Which of the following physiologic consequences would develop if the liquid–gas interface

were without surfactant? a. Large alveoli would empty into smaller ones at the end of exhalation. b. Every exhalation would demand ventilatory muscle activity. c. Every breath would require a considerable amount of pressure to expand the lung with each inspiration. d. Some alveoli would collapse during exhalation.

ANS: C

The lung can be thought of as a large number of interconnected bubbles that form the interface between the gaseous environment and the wet alveolar surface. If this interface were devoid of surfactant, two consequences would ensue: (1) every breath would take a considerable amount of pressure to expand the lung, comparable to the 80 to 90 cm H2O of pressure required for a newborn’s first breath, and (2) the lung would rapidly collapse during exhalation.

REF: p. 246 3. Which of the following physiologic conditions result from the presence of normal amounts of

pulmonary surfactant in the lung? a. Pulmonary compliance decreases. b. Uniform gas distribution during expiration occurs. c. The functional residual capacity is maintained. d. Pulmonary perfusion matches alveolar ventilation.

ANS: C

Functionally, surfactant increases lung compliance, promotes homogeneous gas distribution during inhalation, and allows a residual volume of gas to be evenly distributed throughout the lung during exhalation—that is, it maintains functional residual capacity. In the absence of surfactant, distribution of ventilation becomes uneven, the lungs become stiff, and atelectasis ensues during exhalation. The result is increased work of breathing, hypoxia, and respiratory failure, the clinical picture exemplified by preterm infants with respiratory distress syndrome (RDS). Surfactant functions are summarized in Box 14-1 in the textbook.

REF: pp. 246-247 4. Which of the following is the most important component of pulmonary surfactant?

I. Dipalmitoyl phosphatidylcholine II. Phosphatidylglycerine III. Phosphatidylinositol IV. Sphingomyelin a. I only b. I and IV only c. I, II, and IV only d. II, III, and IV only ANS: A

Surfactant composition is fairly constant among mammalian species. Surfactant is composed of approximately 90% lipids (of which 80% to 85% are phospholipids) and approximately 10% proteins (see Table 14-1 in the textbook). Phosphatidylcholine (PC) is the most abundant phospholipid (75% to 80%) and is mostly saturated (40% to 55%) in the form of dipalmitoyl phosphatidylcholine (DPPC). DPPC is the most important surfactant component in reducing surface tension; it consists of two molecules of palmitic acid and one molecule of phosphatidylcholine attached to a glycerol backbone. DPPC has a hydrophobic end (fatty acids) and a hydrophilic end (nitrogenous base) and aligns itself in the air–liquid interface with the hydrophobic end toward the gas phase and the hydrophilic end toward the liquid phase.

REF: pp. 247-248 5. What is the role of SP-D in human pulmonary surfactant?

I. Suppresses proinflammatory responses II. Enhances phagocytosis III. Enhances killing of microbes IV. Functions as an opsonin for bacteria a. II and III only b. III and IV only c. I, II, and III only d. I, III, and IV only ANS: C

SP-D is also a collectin and enhances binding, phagocytosis, and killing of microbes by alveolar macrophages. In addition, SP-D has a role in the suppression of proinflammatory responses. Lack of SP-D in transgenic mice leads to emphysema, macrophage activation, accumulation of oxygen-reactive species, and increased surfactant alveolar pools. SP-D also plays a key role in surfactant homeostasis.

REF: p. 250 6. A pregnant woman believed to be at 26 weeks gestation has been admitted for premature

labor. What should be administered to this woman to decrease the risk of RDS if the infant is delivered prematurely?

a. b. c. d.

Magnesium sulfate Terbutaline Systemic corticosteroids Lecithin

ANS: C

Antenatal steroids have been extensively studied and have been shown to decrease RDS in infants between 24 and 34 weeks of gestation. There is no increased infection risk with rupture of membranes including prolonged rupture of membranes or chorioamnionitis. A single course of corticosteroids is currently recommended by the American College of Obstetricians and Gynecologists (ACOG) for pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery within 7 days. This course may consist of betamethasone (2 doses, 24 hours apart) or dexamethasone (4 doses, 12 hours apart). A single rescue course may be considered if first course was given more than 2 weeks prior in women < 32 weeks’ gestation likely to deliver within the next week.

REF: p. 251 7. Which of the following relationships is correct regarding the analysis of amniotic fluid to

determine fetal lung maturity? a. Phosphatidylglycerol (PG) and phosphatidylcholine (lecithin) increase while sphingomyelin decreases during gestation. b. PG increases and lecithin and sphingomyelin decrease during gestation. c. PG and lecithin decrease while sphingomyelin increases during gestation. d. PG and lecithin increase while sphingomyelin decreases during gestation.

ANS: D

Measurement of phospholipids in the amniotic fluid can be used to determine fetal lung maturity because PG and phosphatidylcholine (lecithin) increase while sphingomyelin decreases during gestation.

REF: p. 251 8. Which of the following is the most common form of surfactant abnormality associated with

acute lung injury? a. Inactivation by proteins b. Altered surfactant metabolism c. Altered surfactant pool d. Altered surfactant composition ANS: A

Inactivation by proteins is the most common surfactant abnormality seen in acute lung injury.

These proteins competitively displace surfactant phospholipids from the alveolar monolayer and are less surface-active molecules than surfactant. Consequently, the result is a decreased capacity for reducing surface tension.

REF: p. 252 9. What appears to be the benefit of administering prophylactic surfactant replacement therapy to

preterm infants?

I. Decreased risk of mortality II. Reduced threat of pneumothorax III. Decreased incidence of diaphragmatic hernia IV. Reduced risk of developing pulmonary interstitial emphysema a. I and II only b. II and IV only c. I, II, and IV only d. II, III, and IV only ANS: C

Prophylactic surfactant is administered after initial stabilization in the first 15 minutes after birth, compared with 1.5 to 7.4 hours in rescue strategies. Initial studies comparing prophylactic to rescue surfactant favored the former, with noted decrease in mortality, pneumothorax, and pulmonary interstitial emphysema.

REF: p. 254 10. How do synthetic surfactants compare with bovine surfactants? a. Synthetic surfactants contain exclusively SP-A, SP-B, SP-C, and SP-D. b. Synthetic surfactants contain only SP-A. c. Bovine surfactants contain SP-B and SP-C, and synthetic surfactants contain SP-A

and SP-D. d. Bovine surfactants contain SP-A and SP-D, and synthetic surfactants contain SP-B

and SP-C. ANS: C

The bovine surfactants contain SP-B and SP-C, but not SP-A. Infasurf contains much more SP-B and SP-C than does Survanta. The synthetic surfactants contain no proteins.

REF: p. 256 11. The respiratory therapist administering surfactant to a premature newborn notices a significant

deterioration in vital signs. What should be done at this time? a. Pause the procedure and administer PPV until vital signs are stable. b. Rapidly infuse the rest of the dose and reconnect the patient to the mechanical ventilator. c. Extubate the patient and administer nasal CPAP until stable. d. Continue administration of the surfactant while administering PPV. ANS: A

Surfactant delivery should be paused until vital signs recover and ETT clears of visible surfactant. Infant may need to be repositioned prone and positive pressure ventilation increased for lung inflation.

REF: p. 256 12. A full-term infant received surfactant as rescue therapy for RDS. Despite redosing, the infant

has not been able to be extubated during the first 2 weeks of life. What should this neonate be evaluated for? a. 1-antitrypsin deficiency b. Vitamin B deficiency

c. SP-A deficiency d. SP-D deficiency ANS: A

Full-term infants with RDS, surfactant nonresponders, and infants who cannot be extubated in the first weeks of life because of a respiratory condition should be evaluated for SP-B deficiency, alveolar capillary dysplasia, and 1-antitrypsin deficiency.

REF: p. 258 13. Which of the following clinical conditions should be suspected in a neonate unresponsive to

surfactant due to its inactivation? a. Pulmonary hypertension b. Pulmonary hemorrhage c. Pneumonia d. Methemoglobinemia ANS: B

Blood is a strong inactivator of surfactant, with several of its components such as hemoglobin, fibrin, fibrinogen, red blood cell membrane lipids, immunoglobulins, and plasma proteins contributing to this process. Inactivation can occur as a result of pulmonary hemorrhage, hemorrhagic edema, or blood aspiration during birth or trauma.

REF: p. 258 14. A term baby with meconium aspiration syndrome is receiving mechanical ventilation per

protocol. On the third day, the therapist observes that the FiO2 requirement is increasing and both lung compliance and oxygenation index are worsening. What should be suggested at this time? a. Switch to a pressure-limited mode b. High-frequency chest oscillation c. ECMO d. Administer surfactant ANS: D

A meta-analysis confirmed that surfactant replacement for MAS decreases the need for ECMO with a number needed to treat of 6.

REF: p. 258

Chapter 15: Non-invasive Mechanical Ventilation and Continuous Positive Pressure of the Neonate Test Bank MULTIPLE CHOICE 1. Which of the following therapeutic interventions would be appropriate for a neonate with a

respiratory rate of 65 breaths/minute while displaying paradoxical chest wall movement with suprasternal and substernal retractions, grunting, nasal flaring, and cyanosis, along with the following blood gas data: pH 7.30; arterial partial pressure of carbon dioxide (PaCO2), 50 mm Hg; arterial partial pressure of oxygen (PaO2), 60 mm Hg? a. Intubation and mechanical ventilation b. High flow nasal cannula c. Extracorporeal membrane oxygenation d. Continuous positive airway pressure (CPAP) ANS: D

According to American Association for Respiratory Care (AARC) clinical practice guidelines, neonates presenting with a respiratory rate greater than 30% of normal and paradoxical chest wall movement with suprasternal and substernal retractions, grunting, nasal flaring, and cyanosis should be considered for placement on CPAP as long as they are able to demonstrate adequate ventilation as defined by PaCO2 less than 60 mm Hg and pH greater than 7.25.

REF: pp. 269-270 2. Which of the following conditions are contraindications for nasal CPAP?

I. Pneumonia II. Tracheoesophageal fistula III. Choanal atresia IV. Atelectasis a. I and II only b. II and III only c. III and IV only d. I, II, and III only ANS: B

Infants with persistent apneic episodes who are unable to maintain PaCO2 less than 60 mm Hg and pH greater than 7.25 should not be given CPAP. If they are already receiving CPAP, mechanical ventilation is indicated. Infants with congenital anomalies such as choanal atresia, cleft palate, tracheoesophageal fistula, or preoperative diaphragmatic hernia should not receive CPAP. CPAP is contraindicated in infants with neural muscular disorders, infants receiving CNS depressants, and infants with central apnea or frequent apneic episodes resulting in desaturation and/or bradycardia. In addition, severe cardiorespiratory instability and poor respiratory drive is also a contraindication to the initiation of CPAP. REF: p. 270

3. Which of the following complications of CPAP can develop when an infant experiences

inadvertent positive end-expiratory pressure (PEEP) from gas trapping resulting from tachypnea? a. Pulmonary hypertension b. Pneumothorax c. Atelectasis d. Diaphragmatic hernia ANS: B

CPAP is associated with some of the same hazards and complications that are frequently associated with mechanical ventilation. Pneumothorax is a complication occasionally reported in infants receiving CPAP. This is a result of inadvertent positive end-expiratory pressure related to gas trapping when infants are tachypneic and do not have a sufficient expiratory time. This may also occur after surfactant replacement therapy, when pulmonary compliance improves and the infant has not been weaned appropriately and, thus, is exposed to excessive airway and hence alveolar pressure.

REF: p. 270 4. What is considered the most effective interface option for delivering CPAP to infants? a. Binasal prongs b. Nasal mask c. Nasal pillows d. Oronasal mask ANS: A

Today, CPAP is most often administered through short binasal prongs, and this method is considered the most effective interface option for delivering CPAP to infants.

REF: p. 271 5. A preterm infant in respiratory distress is a candidate for CPAP. To minimize the work of

breathing, which device should be used? a. B-CPAP b. IF-CPAP c. Single probe CPAP d. V-CPAP ANS: B

IF-CPAP has been shown to significantly reduce inspiratory WOB in preterm infants.

REF: p. 272 6. Which of the following features are often components of CPAP systems incorporated within

infant ventilators?

I. Highly responsive demand flow systems II. Apnea backup breaths III. FiO2 compensation mechanisms IV. Leak compensation capabilities a. I and II only

b. II and III only c. III and IV only d. I, II, and IV only ANS: D

Today, a number of commercially available microprocessor-controlled infant ventilators allow non-invasive application of V-CPAP. In these systems CPAP is maintained with a variable demand–flow system. Flow rate and airway pressure are regulated by servo-controlling the aperture size of the exhalation valve. These ventilators also include the following: (1) highly responsive demand flow systems, (2) leak compensation, (3) airway graphics monitoring, and (4) apnea backup breaths.

REF: p. 273 7. How is the positive pressure level established in a bubble CPAP system? a. The therapist dials the desired CPAP level directly on the ventilator. b. The therapist immerses the distal end of the expiratory limb a certain distance

below the water surface. c. The CPAP level is established by stacking adaptors with weighted balls to the distal opening of the expiratory limb. d. The positive pressure is achieved by tightening a screw clamp attached to the expiratory limb until the desired pressure is achieved.

ANS: B

A measuring tape is attached to the outside of the water column. The CPAP level is maintained by submerging the distal end of the expiratory circuit straight down into the fluid from the surface of the water line to a measured depth in centimeters, thus creating the amount of CPAP in centimeters of water. If a higher level of CPAP is needed, the tube can be advanced farther down into the fluid column.

REF: p. 273 8. In order to rinse the system of exhaled CO2 and meet the inspiratory flow rate requirements of

infants placed on B-CPAP, the flow rate of humidified gas should be set at: a. 6 to10 L/minute b. 11 to 15 L/minute c. 16 to 20 L/minute d. at least 15 L/minute ANS: A

The flow rate of humidified gas (6 to10 L/min) is set to meet the inspiratory flow rate requirements of the patient, maintain the CPAP level, and rinse the system of exhaled carbon dioxide.

REF: p. 273 9. A bubble CPAP has been set up on an infant at 12 L/min and the water column is reading 4 cm

H2O. A chest X-ray reveals mild lung overdistention. What is the most feasible explanation for this finding? a. The amount of CPAP is excessive for this age group. b. The flow rate is very high and the CPAP measured at the nasal prongs is probably

> 4 cm H2O. c. The cannula is probably too large for the infant and causes inadvertent CPAP. d. The chest X-ray finding is consistent with the amount of CPAP set at the water chamber.

ANS: B

The pressure measured at the nasal prong could be slightly higher than the submersion depth of the expiratory tubing below the water surface when higher flow rates are used; therefore, airway pressure should always be monitored at the nasal prong to ensure proper CPAP levels.

REF: p. 274 10. Where in the CPAP delivery system should the pressure-relief/pop-off valve be placed to

detect circuit occlusion? a. Anywhere along the exhalation limb b. Anywhere along the inspiratory limb c. Inside the ventilator d. As close to the patient’s airway as possible ANS: D

A high-pressure pop-off can be placed as close to the patient as possible should the expiratory limb become occluded.

REF: p. 274 11. Which form of CPAP has been associated with a “thoracic wiggle”? a. IF-CPAP (infant flow CPAP) b. MV-CPAP (mechanical ventilator CPAP) c. B-CPAP (bubble CPAP) d. V-CPAP (ventilator-derived CPAP) ANS: C

Subjective accounts of a visible “thoracic wiggle” from bubbles are often reported by clinicians caring for infants receiving B-CPAP. The use of higher flows can result in more vigorous bubbling and higher pressure fluctuations in the delivery system. However, higher flows do not appear to improve gas exchange.

REF: p. 274 12. Which of the following CPAP systems delivers a more consistent pressure, lowers work of

breathing (WOB), is less sensitive to leaks, and is more effective at alveolar recruitment compared with other forms of CPAP? a. B-CPAP b. MV-CPAP c. V-CPAP d. IF-CPAP ANS: D

The IF-CPAP system has been shown to deliver a more consistent pressure, to lower WOB, to be less sensitive to leaks, and to be more effective at alveolar recruitment compared with other forms of CPAP.

REF: p. 275 13. Which of the following anatomic structures should be closely evaluated when using nasal

masks in the administration of IF-CPAP? a. Tragus b. Philtrum c. Sphenoid axis d. Lower lip ANS: B

Nasal prongs have been shown to result in nasal and septal wall skin breakdown, whereas nasal masks have been associated with breakdown low on the septum or at the base of the philtrum.

REF: pp. 275-276 14. When nasal cannulas are used in infants at high flows, which factors determine the amount of

pressure to the airways?

I. Flow rate II. Size of the leak around the cannula III. Degree of the mouth opening IV. FiO2 a. I and II only b. III and IV only c. II, III, and IV only d. I, II, and III only ANS: D

When the pressures delivered with this technique measured are highly variable, depend on the flow rate, the size of leak around the cannula, and the degree of mouth opening.

REF: p. 276 15. Which of the following outcomes are advantages of CPAP over mechanical ventilation in

infants?

I. Lower risk of sepsis II. Lower incidence of lung injury III. Fewer cases of chronic lung disease IV. Lower incidence of renal failure a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: C

Mechanical ventilation in preterm infants is associated with increased risk of sepsis, lung injury, arrested lung development, and chronic lung disease.

REF: p. 276

16. After increasing the level of CPAP delivered to an infant, the therapist notices that the

neonate’s PaCO2 rises and the PaO2 falls. What may have caused this situation? a. The FiO2 was not increased sufficiently. b. The CPAP level was not raised enough. c. The CPAP level was raised too high. d. A problem with the interface has likely developed.

ANS: C

A rise in PaCO2 or fall in PaO2 soon after the CPAP pressure has been increased may indicate that the optimal CPAP level has been exceeded. An increase in mean airway pressure can result in increased alveolar dead space because of mechanical compression of the pulmonary microvasculature. If gas exchange worsens in a patient who appeared to be improving, the CPAP pressure can first be reduced. If the patient’s situation does not improve, endotracheal intubation and mechanical ventilation may be indicated.

REF: pp. 277-278 17. After initiating B-CPAP in an infant at 6 cm H2O, the therapist notices that, although

“bubbling” is present, the pressure in the manometer fluctuates between 2 and 5 cm H2O. What may have caused this situation? a. The FiO2 was not increased sufficiently. b. The CPAP level was not raised enough. c. The flow through the CPAP system is too low. d. A problem with the interface has likely developed.

ANS: C

Small fluctuations in pressure are common because of the frequency and amplitude of the bubbles; however, if large fluctuations are noted and coincide with the inspiratory phase of the infant, additional flow should be added to the system.

REF: pp. 278-279 18. After initiating IF-CPAP in an infant at 8 cm H2O, the therapist notices a low-pressure alarm.

What should be done to correct this situation? a. Correct the leak by placing a chin trap. b. Change to a smaller cannula. c. Increase the flow through the CPAP system. d. Change the flow generator.

ANS: A

In the IF-CPAP and mechanical ventilator CPAP systems, low-pressure alarms usually indicate a leak caused by nasal prongs that are too small or an excessive oropharyngeal leak.

The oropharynx acts as a safety valve, preventing excessive accumulation of pressure in the airway. Oropharyngeal leaks are more common when using CPAP levels exceeding 8 to 10 cm H2O. A chin strap or pacifier can be helpful at gently sealing the leak and reestablishing the CPAP level.

REF: p. 279

19. How should a therapist determine the size of the nasal prongs to effectively administer CPAP

to infants? a. The prongs should occlude only 50% of the external nares diameter. b. The prongs should occlude at least 75% of the external nares diameter. c. The prongs should occlude 100% of the external nares diameter with minimal blanching. d. The prongs should occlude 100% of the external nares diameter without blanching.

ANS: D

The prongs should fill the entire nares without blanching the external nares. Selecting prongs that are too small can result in increased resistance and WOB, prong displacement, and excessive leaks.

REF: p. 279

Chapter 16: Noninvasive Mechanical Ventilation of the Child Test Bank MULTIPLE CHOICE 1. What are the primary objectives of noninvasive positive-pressure ventilation (NPPV)?

I. To increase the likelihood of successful weaning from mechanical ventilation II. To improve respiratory gas exchange III. To decrease the patient’s work of breathing IV. To reduce the risk of ventilator-associated pneumonia a. I and IV only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: B

The primary objectives of NPPV in children with acute respiratory distress are to decrease the work of breathing and improve respiratory gas exchange. These objectives are outlined in Box 16-2 in the textbook.

REF: p. 288 2. What effect should the therapist expect to observe after successful initiation of continuous

positive airway pressure (CPAP) on a neonate who has a restrictive lung disorder? a. Decreased arterial partial pressure of carbon dioxide (PaCO2) b. A lower mean airway pressure c. A normal alveolar–arterial oxygen tension difference [P(A–a)O2] gradient d. Increased lung volume ANS: D

An appropriate level of CPAP must increase end-expiratory lung volume (functional residual capacity) and thereby improve oxygenation. CPAP therapy may or may not improve tidal volume and alveolar ventilation. In children and neonates with restrictive respiratory dysfunction and decreased lung compliance, CPAP therapy can raise tidal volume.

REF: p. 289 3. Which of the following restrictive disorders are likely to respond to both NPPV and CPAP in

children?

I. Atelectasis II. ARDS III. Pneumonia IV. Morbid obesity a. I, II, and III only b. II and IV only c. I, III, and IV only d. II, III, and IV only

ANS: C

Children with restrictive lung disorders (including atelectasis, pneumonia, and neuromuscular weakness) and morbid obesity typically present with hypoxemia and a reduction in functional residual capacity. Both NPPV and CPAP are effective in this setting to restore end-expiratory volume.

REF: p. 289 4. A child with a chronic disorder complicated by alveolar hypoventilation is placed on

intermittent NPPV at night. What is the primary goal of this therapy? a. To decrease the work of breathing b. To decrease the need for inserting an endotracheal tube c. To improve the quality of sleep and reduce daytime symptoms d. To improve arterial oxygenation ANS: C

NPPV is offered to patients with chronic hypoventilation disorders as a clinical benefit used at night to reduce the severity of daytime symptoms associated with chronic hypercarbia— headache and fatigue.

REF: p. 289 5. HFNC has been ordered for a newborn at a rate of 3 L/min. What is the approximate

nasopharyngeal pressure at this setting? a. 3 cm H2O b. 2 cm H2O c. 1 cm H2O d. 1.5 cm H2O ANS: D

In a study of infants with bronchiolitis, nasopharyngeal pressures increased linearly (0.45 cm H2O for each 1 L/min increase) with HFNC rates up to 6 L/min.

REF: p. 289 6. What is considered the most successful therapeutic condition where NPPV can be used in

children? a. Treatment of hypoxemic exacerbation of children with chronic neuromuscular disorders b. Treatment of hypercapnic exacerbation of children with chronic neuromuscular disorders c. Treatment of exacerbation of children with acute asthma attacks d. Treatment of exacerbation of children with pulmonary edema due to congenital heart defects ANS: B

Perhaps the most successful experience with NPPV as a rescue therapy is its use in acute exacerbations of hypercarbic respiratory failure in children with chronic neuromuscular disorders.

REF: p. 291

7. In what particular setting has long-term use of NPPV on children with cystic fibrosis been

successful? a. As a bridge to transplantation b. As the routine treatment for bronchopulmonary hygiene c. As the primary indication for reduction of exacerbations d. As the primary treatment of hypoventilation ANS: A

In children with advanced cystic fibrosis lung disease, long-term NPPV has been successful as a bridge to lung transplantation.

REF: p. 291 8. When should NPPV be selected over CPAP in children with OSA? a. For every patient who is hypoxemic b. When OSA is complicated by alveolar hypoventilation and hypercarbia c. When OSA is complicated by hypoxemia d. For every patient who is hypoxemic and hypercapnic ANS: B

Although there are no clear guidelines, selection of NPPV over CPAP in children with OSA is typically made in OSAs complicated by alveolar hypoventilation and hypercarbia.

REF: p. 292 9. A patient receiving bilevel ventilation develops a small leak at the interface. What action

should the therapist take at this time? a. The therapist should increase the pressure limit. b. The therapist should increase the inspiratory flow. c. The therapist should increase the length of the inspiratory time. d. The therapist should verify that the ventilator automatically compensates for this leak.

ANS: D

Most bilevel ventilators available for commercial use are adept at delivering sufficient flow to reach the targeted level of inspiratory pressure. These devices also have a flow compensation feature that ensures that small leaks around the interface or through the mouth do not seriously impair performance. However, the capacity of NPPV devices to compensate for severe leaks is limited, and the result is greater patient/ventilation asynchrony, cited as a common reason for NPPV failure in the acute setting.

REF: p. 292 10. A patient receiving PAV is noticed to increase breathing effort. Which parameters will the

ventilator modify to respond to this patient’s increased respiratory demand?

I. Increase flow II. Increase tidal volume III. Increase pressure IV. Increase CPAP a. I and II only

b. II, III, and IV only c. III, IV, and V only d. I and III only ANS: D

Unlike PSV, which uses a preset inspiratory pressure, PAV provides inspiratory flow and pressure in proportion to the patient’s spontaneous breathing effort as determined by instantaneous feedback from an in-line pneumotachometer.

REF: p. 292 11. How should a volume-regulated ventilator for NPPV be adjusted to deliver the appropriate

tidal volume (VT) to a pediatric patient? a. The preset VT should be equal to the patient’s estimated anatomic dead space volume. b. The delivered VT should be equal to the estimated anatomic dead space divided by the patient’s respiratory rate. c. The VT should be set by dividing the patient’s PaCO2 by two. d. The delivered VT should be set at twice the child’s physiologic VT. ANS: D

To appropriately adjust a volume-controlled ventilator for NPPV, the delivered tidal volume should be approximately twice that of the child’s physiologic tidal volume to accommodate the dead space of the nasopharynx and conducting airways.

REF: p. 293 12. When considering NPAV devices, what is considered the most beneficial effect over NPPV? a. Its effect on CO2 clearance b. Its faster restoration of oxygenation c. Its effect on cardiac filling pressures and volumes d. Its effect on spontaneous tidal volume ANS: C

The advantage of these devices is a beneficial effect on cardiac filling pressures and volumes, a benefit found even in healthy individuals.

REF: p. 293 13. When a bilevel ventilator is used in the spontaneous/timed mode, at what point does the

ventilator employ the timed feature? a. During exhalation b. To terminate inspiration c. Throughout the ventilatory cycle d. Only in the event of prolonged apnea ANS: D

Most bilevel pressure-targeted ventilators suitable for NPPV feature CPAP, spontaneous, timed, and spontaneous/timed operating modes. In the spontaneous/timed mode, the flowtrigger feature is activated. The ventilator responds to a threshold level of inspiratory flow or to a change in volume that is initiated by the patient’s spontaneous respiratory effort. At the inspiratory flow threshold, the ventilator delivers additional gas flow to reach the preset inspiratory positive airway pressure (IPAP). Exhalation occurs after the inspiratory flow peaks and then decreases to a threshold level. The ventilator triggers in the timed mode only in the event of prolonged apnea.

REF: p. 293 14. When NPPV is used to ventilate pediatric patients, which operating mode of ventilation is

generally used? a. Timed b. Spontaneous c. CPAP d. Spontaneous/timed ANS: D

Most bilevel pressure-targeted ventilators suitable for NPPV feature CPAP, spontaneous, timed, and spontaneous/timed (assist-control) operating modes. Pediatric patients are typically managed in the spontaneous/timed mode. The chief advantage of this mode is patient comfort.

The child’s inspiratory efforts are assisted with the inspiratory pressure support feature, which responds favorably to the patient’s inspiratory efforts.

REF: p. 293 15. What is the most effective way for the therapist to promote effective triggering and prevent

asynchrony with NPPV? a. Optimize inspiratory flow. b. Titrate inspiratory pressure to achieve a tidal volume of 5 mL/kg. c. Set the device on spontaneous-timed mode. d. Minimize leaks around the interface.

ANS: D

The best way for the practicing therapist to promote effective triggering and prevent asynchrony with NPPV is to minimize leaks around the mask interface. In the presence of a significant leak, the inspiratory pressure target is never reached, resulting in a long inflation time as the unit delivers massive amounts of inspiratory flow in an attempt to attain the preset inspiratory pressure.

REF: p. 294 16. What is the clinical significance of the IPAP–EPAP gradient in bilevel NPPV? a. It represents the mean airway pressure to which the patient’s lungs are exposed. b. It determines the patient’s tidal volume. c. The IPAP–EPAP gradient determines the inspiratory time. d. This gradient determines the level of pressure support the patient will receive.

ANS: B

The IPAP should be set above the expiratory positive airway pressure (EPAP) to raise the child’s tidal volume, “unload” the respiratory muscles, and decrease respiratory distress. The differential between the IPAP and EPAP adjustment determines the tidal volume.

REF: p. 294 17. What level of IPAP is typically sufficient to achieve the goals of NPPV in pediatric patients? a. 20 to 25 cm H2O b. 15 to 20 cm H2O c. 8 to 12 cm H2O d. 5 to 10 cm H2O ANS: C

In day-to-day clinical practice, an IPAP setting between 8 and 12 cm H2O is typically sufficient to achieve the goals of NPPV in pediatric patients.

REF: p. 294 18. Which of the following bilevel ventilator settings influences upper airway stability? a. IPAP b. Mode c. Respiratory rate d. EPAP ANS: D

The EPAP adjustment with NPPV primarily determines the end-expiratory lung volume and maintains the stability of the upper airway. In a typical pediatric application of NPPV, EPAP levels of 6 to 8 cm H2O are effective in improving oxygenation and preventing obstructive apnea. Most children, regardless of the setting or indication, poorly tolerate EPAP levels above 10 cm H2O. REF: p. 294 19. Which of the following NPPV interfaces should the therapist consider when a child complains

of discomfort with a nasal mask?

I. Oronasal mask II. Nasal plugs III. Helmet IV. Nasal pillows a. I and II only b. I and III only c. II and IV only d. III and IV only ANS: C

Nasal plugs or pillows can be substituted for nasal masks in children who complain of discomfort with the nasal mask. Nasal plugs or pillows are not used as often because most children eventually adapt to the nasal mask very well. They may have some role in teenagers because they place no pressure on the face and do not interfere with vision.

REF: p. 295 20. What is the most common complication associated with NPPV among pediatric patients? a. Ventilator-associated pneumonia b. Gastric insufflation c. Claustrophobia d. Skin irritation caused by the interface ANS: D

The most common minor complication reported is skin irritation due to the nasal mask (48%), leading to skin necrosis in up to 8%.

REF: p. 296 21. What is the only absolute contraindication to a trial of NPPV in pediatric patients with acute

respiratory distress? a. Cardiovascular instability b. Nasopharyngeal obstruction c. Inability to handle oral secretions d. Extreme agitation or anxiety ANS: A

The only absolute contraindication to a trial of NPPV in pediatric patients with acute respiratory distress is cardiovascular instability. Relative contraindications include nasopharyngeal obstruction, inability to handle oral secretions, and extreme agitation or anxiety.

REF: p. 296

Chapter 17: Mechanical Ventilation of the Neonate and Pediatric Patient Test Bank MULTIPLE CHOICE 1. What frequency defines high-frequency modes of ventilation? a. > 40 breaths per minute b. > 100 breaths per minute c. > 150 breaths per minute d. > 200 breaths per minute ANS: C

Low-frequency ventilation (LFV) is identified as ventilation modes that provide breaths per minutes of < 150; high-frequency ventilation (HFV) as modes of ventilation that provide breaths per minute of > 150.

REF: p. 301 2. Which of the following are indications for HFV? a. Diffuse, heterogeneous lung disease b. Existing pulmonary air leak syndrome c. Severe bronchiolitis d. PaO2/FiO2 ratio of 300 ANS: B

The bulk of clinical data regarding appropriate application of HFV devices has been acquired from neonatal humans and animals. From these studies, two clear indications for HFV use during either routine or rescue circumstances have evolved. They include diffuse, homogeneous lung disease (or the atelectasis-prone lung), in which LFV management is failing or may lead to increased risk of pulmonary morbidity, and existing pulmonary air leak syndromes (e.g., pneumothorax and PIE).

REF: pp. 302-303 3. Which of the following forms of mechanical ventilation is the most efficacious method for

acquired bronchopleural fistulas? a. High-frequency jet ventilation (HFJV) b. High-frequency oscillatory ventilation (HFOV) c. High-frequency flow interruption (HFFI) d. Conventional ventilation (CV) ANS: A

The ability to provide adequate ventilation with low mean and peak pressures in children with otherwise normal lungs offers a substantial advantage of HFJV over HFOV and LFV. Furthermore, this feature makes HFJV a more efficacious method of treating traumatic or acquired bronchopleural fistulas than other forms of respiratory support.

REF: p. 303

4. During volume-controlled ventilation, which of the following factors influences the peak

inspiratory pressure? a. Pulmonary capillary perfusion b. Ventilation–perfusion relationships c. Pulmonary compliance d. Volume compressed in the ventilatory circuit at end inspiration ANS: C

A constant tidal volume and flow rate characterize volume ventilation, and the resulting peak inspiratory pressure varies with changes in respiratory system compliance and resistance.

When a flow-controlling valve is used, tidal volume is calculated by measuring the flow delivered over a preset inflation time.

REF: p. 306 5. Which of the following modes of ventilation attempts to maintain a minimum target tidal

volume with a constant pressure by manipulating the inspiratory flow? a. Synchronized intermittent mandatory ventilation (SIMV) b. Pressure support ventilation (PSV) c. Volume-assured pressure support (VAPS) d. Pressure-regulated volume control (PRVC) ANS: D

Pressure-regulated volume control (PRVC) attempts to maintain a minimum target tidal volume with a constant pressure by manipulating the flow waveform.

REF: p. 308 6. The therapist is about to mechanically ventilate a neonate with a ventilator that delivers the

volume guarantee mode. Which of the ventilator settings does the therapist need to set for this mode?

I. Minute ventilation II. Tidal volume III. Inspiratory time IV. Inspiratory flow a. I and II only b. II and IV only c. I, III, and IV only d. II, III, and IV only ANS: D

Volume guarantee (VG) is another form of adaptive-control ventilation that is used in one type of neonatal ventilator. The operator sets a tidal volume, inspiratory time, and flow rate. This mode can also be applied to pressure support ventilation. The ventilator incorporates a proximal flow sensor at the patient airway. The microprocessor assesses an eight-breath historical average of expired tidal volume and will increase pressure on the basis of these measurements up to the pressure limit to deliver the target volume.

REF: p. 309

7. When airway pressure release ventilation is used, what physiologic process occurs as the

higher pressure is released and the lower is achieved? a. Increased functional residual capacity b. Increased tidal volume c. Improved oxygenation d. Exhalation of carbon dioxide ANS: D

The short intermittent decreases in the CPAP level allow alveolar emptying of gases. Unlike conventional CPAP, however, the intermittent release of pressure augments ventilation and allows elimination of carbon dioxide.

REF: p. 310 8. Enhanced diffusion in HFV is a function of which of the following factors? a. Inspiratory flow b. Plateau pressure c. Inspiratory time d. Respiratory frequency ANS: D

The impact of enhanced diffusion, the product of tidal volume and rate, and the relationship between pulmonary units may all vary depending on the HFV technique used, the settings chosen, the patient's lung size, and pathologic conditions.

REF: p. 311 9. How is the high-volume strategy achieved when the goal is to deliver a high lung volume to a

neonate receiving HFV? a. By increasing the continuous distending pressure b. By reducing the peak–trough pressure gradient c. By increasing the expiratory flow resistance d. By decreasing the mean airway pressure ANS: A

One method is to increase the distending pressures ( or CDP) in small increments (1 to 2 cm H2O) while watching for improvement in oxygenation (arterial blood gas determinations, transcutaneous carbon dioxide, or pulse oximetry saturations) and mean lung volumes (MLV) determined by chest radiograph. Mean airway pressure is increased until oxygenation improves significantly or until MLV reaches desired levels, or both, which may be determined by the presence of a well-inflated lung on a radiograph (see Figure 17-6 in the textbook).

While using this method, care must be taken to anticipate silent lung recruitment and to reduce as appropriate to avoid serious impairment to venous return and reduction in cardiac output. Silent lung recruitment is gradual lung inflation taking place with static settings (see Figure 17-7 in the textbook). Clinical clues heralding this include rapid improvements with subsequent unexplained decrements in oxygenation, decreasing PaCO2 without changes in oscillatory amplitude (improving compliance), and, finally, clinical changes in perfusion.

These problems often can be avoided with diligence and anticipation. Silent recruitment, although more common during initial HFV management, can occur any time attempts are made to optimize MLV. Data confirm the pulmonary, central nervous system, and cardiovascular safety and efficacy of this technique.

REF: pp. 313-314 10. What is a frequent requirement when employing the low-volume strategy while ventilating a

neonatal patient with pulmonary interstitial emphysema by HFV? a. High inspiratory flow b. Positive end-expiratory pressure c. High inspired fraction of oxygen (FiO2) d. Longer inspiratory time ANS: C

Low-volume strategy is accomplished with all HFV systems by using a lower than the process creating the problem. Patients for whom this strategy is used are usually undergoing CV before being switched to HFV. This allows the lung to derecruit and isolate damaged areas from inflation pressures. The consequence of this, however, is the frequent requirement for a higher FiO2. In addition, tidal volume delivery must be decreased to further reduce tidal volume exposure while using I/E ratios and ventilatory frequencies that maximize gas egress.

REF: pp. 315-316 11. On the basis of the following flow/time scalar, which of the following conditions has

developed?

a. Trigger dyssynchrony

b. Excess tidal volume c. Air trapping d. Ventilator circuit leak ANS: C

Two disadvantages exist when manipulating frequency at higher rates or inverse I/E ratios.

The first is that, as frequency increases, air trapping is likely to occur. Figure 17-9 in the textbook illustrates this in a flow/time scalar graphic. Notice that flow does not come back to baseline. The second is that, when the I/E ratio is kept constant, minute ventilation does not change.

REF: p. 317 12. During high-frequency ventilation, as the diameter of the ETT increases, what happens to the

delivered tidal volume under the same pressure settings? a. It does not change. b. It increases. c. It increases only if compliance changes. d. It decreases.

ANS: B

As ETT dimensions and compliance decrease, so does tidal volume output from the HFV tested. This occurs in the presence of stable ventilator settings. Therefore any clinical change causing a decrease in ETT diameter, such as reintubation with a different-sized ETT or partial ETT obstruction with tracheal secretions, alters the delivered tidal volume in a direct proportion. Furthermore, improvements in lung compliance (e.g., volume recruitment) and decrements in lung compliance (e.g., patent ductus arteriosus or alveolar derecruitment) have a direct effect on tidal volume.

REF: p. 318 13. Which of the following adjustments should the therapist consider to improve ventilation on a

patient undergoing HFV? a. Increase frequency b. Increase c. Increase inspiratory time d. Decrease frequency ANS: D

Changes in ventilator rate at a given pressure amplitude cause an inverse change in tidal volume. Thus, when ventilation must be improved, a reduction in breathing frequency improves ventilation because the increased volume output per stroke has a greater impact on ventilation than does the decrease in stroke frequency. The converse is also true. When less ventilation is needed and pressure amplitude is already minimized, increasing breathing frequency will further decrease tidal volume and allow weaning from ventilation.

REF: p. 318 14. During HFOV, which of the following factors has a direct influence on a neonate’s delivered

tidal volume? a. Frequency

b. Oscillatory amplitude c. Peak inspiratory pressure d. IPAP (inspiratory positive airway pressure) and EPAP (expiratory positive airway

pressure) ANS: C

During HFOV, peak and trough pressures are measured, although they are not usually displayed. Because of the impact of the ETT on transmitted pressure, these values have only relative significance. Of more importance is the difference between peak and trough pressures, known as oscillatory amplitude or simply the delta P. Delivered volume is directly proportional to this peak–trough difference, and adjustments result in changes in tidal volume.

REF: p. 319 15. During HFOV manipulation of which of the following components establishes the continuous

distending pressure? a. Gas flow through the pneumotachometer during expiration b. Peak inspiratory pressure-trough pressure gradient c. Inspiratory valve aperture d. Bias flow ANS: D

During HFV, especially HFOV, this pressure is directly controlled by the combination of bias flow and expiratory valve aperture.

REF: p. 323 16. Which of the following factors influences the gas volume compressed in the ventilator circuit? a. Ventilation time constant b. Water level in the humidifier c. Location of the exhalation valve d. Size (inner diameter) of the endotracheal tube ANS: B

The humidifier also represents a source for gas compression and is included in calculating compressible volume. Using a constant-level, self-feeding humidifier is necessary to minimize variations in compressible volume in all pediatric ventilation situations.

REF: p. 324 17. While checking the ventilator of a pediatric patient, the therapist observes the following

volume–time scalar:

What action should the therapist take at this time? a. Increase the sensitivity setting. b. Increase the tidal volume and increase the pressure setting. c. Increase both the inspiratory flow and the pressure setting. d. Check the patient–ventilator system for the presence of auto-PEEP. ANS: C

In general, air leaks are monitored by the difference between the tidal volume delivered by the ventilator and the patient's exhaled tidal volume. Another way to identify an air leak is via flow graphics. Figure 17-19 in the textbook illustrates an air leak on a volume–time scale. In most clinical situations, an air leak greater than 15% of the delivered tidal volume makes volume ventilation difficult.

REF: p. 324 18. Which of the following factors need to be considered for HFV ventilator circuits?

I. Time for gas egress during exhalation II. Circuit compliance III. Endotracheal tube size IV. Intrinsic timing mechanisms a. I and II only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: C

With the exception of HFCV, all HFV devices have special patient circuit considerations.

Each of them must (1) use very low circuit compliance to reduce compressible volume and increase the precision of control over the small volumes delivered; (2) have intrinsic timing mechanisms to allow breathing frequencies between 4 and 28 Hz (varies by device); (3) provide control over inspiratory times and circuit design to allow sufficient time for gas egress during exhalation; (4) adequately humidify gases; and (5) include alarms and fail-safe devices for patient safety.

REF: p. 325 19. What is the recommended inspiratory time percent setting for HFOV? a. 20% b. 25%

c. 33% d. 50% ANS: C

The recommendation is a 33% inspiratory time for the HFOV devices approved in the United States. The result is that, for each completed respiratory cycle, one third is inspiratory and two thirds is expiratory. This relationship between the inspiratory and expiratory times enhances the egress of gas during exhalation because the 1:2 I/E ratio favors the expiratory phase, thereby reducing inadvertent air trapping or breath stacking.

REF: p. 323 20. The following pressure–volume loop was obtained from a patient receiving mechanical

ventilation in the pressure support mode. What type of problem does this ventilator graphic represent?

a. b. c. d.

Insufficient flow caused by insufficient driving pressure Pressure sensitivity set inappropriately low Excessive tidal volume Increased mechanical dead space

ANS: A

Ensuring that the initial inspiratory flow rate meets the patient's inspiratory demand is usually the best method of avoidance. An example of a pressure–volume loop demonstrating insufficient flow caused by insufficient driving pressure during PSV is shown in Figure 17-20 in the textbook.

REF: p. 328 21. On the basis of the following pressure–volume loop, what ventilator setting change should the

therapist make?

a. b. c. d.

Check the inflation pressure on the endotracheal tube cuff.

Increase the pressure limit.

Increase the delivered tidal volume.

Increase the inspiratory flow.

ANS: D

An example of a pressure–volume loop demonstrating insufficient flow caused by insufficient driving pressure during PSV is shown in Figure 17-20 in the textbook.

REF: p. 328 22. Over the last 90 minutes, the therapist has obtained three arterial blood samples from an

arterial line inserted in a neonate receiving mechanical ventilation and being monitored by capnometry. The PaCO2 values were as follows: (1) 47 mm Hg, (2) 46 mm Hg, and (3) 47 mm Hg. How should the therapist evaluate the following capnogram?

a. b. c. d.

Abrupt disconnection from mechanical ventilation Damped waveform caused by severe airflow obstruction Reduced pulmonary blood flow caused by overdistention of the lungs Secretions partially obstructing the sample line leading to the capnometer

ANS: C

Falling partial pressure of end-tidal carbon dioxide (PETCO2), possibly from an increase in tidal volume or, if PaCO2 is unchanged, a reduction in pulmonary blood flow from overdistention or low cardiac output.

REF: p. 330 23. The therapist is conducting a ventilator check for a neonate and makes the following notations

on the ventilator flow sheet: •PEEP: 5 cm H2O •Peak inspiratory pressure (PIP): 25 cm H2O •Mandatory rate: 15 breaths/minute

•FiO2: 0.35 On the basis of these observations, what should the therapist recommend for this neonate? a. Shunt study b. Weaning from mechanical ventilation c. Inhaled nitric oxide d. High-frequency ventilation ANS: B

It is difficult to define at exactly what point during mechanical ventilation the weaning process should begin; however, most would agree that ideally it is after significant resolution or reversal of the pathologic condition for which it was initiated. Before weaning begins, the patient's condition should be stable and the patient should be receiving adequate nourishment and be able to breathe spontaneously and maintain a clinically acceptable PaCO2. The ventilator should be on acceptable settings: usually PEEP less than 8 cm H2O; peak pressure less than 30 cm H2O; ventilator rate less than 20 breaths/minute for a neonate, 15 breaths/minute for an infant/toddler, and 10 breaths/minute for a child or adolescent; and FiO2 less than 0.4 to 0.5.

REF: p. 331 24. How is the minute ventilation decreased when a patient is being weaned from HFOV? a. By decreasing peak pressure b. By reducing oscillatory amplitude c. By minimizing d. By shortening the inspiratory time ANS: B

Minute ventilation can be weaned by reducing oscillatory amplitude during HFFI and HFOV and by decreasing peak pressure and on-time with HFJV. REF: p. 333 25. How is the radiographic assessment of neonatal lung volume performed? a. Counting the number of anterior ribs above the diaphragm b. Counting the number of posterior ribs above the diaphragm c. Counting the number of posterior ribs below the clavicle d. Counting the number of anterior ribs below the clavicle ANS: B

Radiographic assessment of lung volume takes considerable practice. The novice is cautioned that, although, in general, lung volume can be assessed by counting the number of posterior ribs seen above the diaphragm, radiographs of neonates are usually anterior-to-posterior views and counting ribs requires the juxtaposition of an anterior structure (the diaphragm) against a posterior structure (the rib interfacing with the diaphragm). This method assesses a threedimensional object (the lung) with a two-dimensional picture (the radiograph) and is vulnerable to technician-selected focus angles. It is possible, then, to underestimate or overestimate inflation.

REF: p. 333

26. The therapist notices that gas exchange has dramatically improved in a neonate undergoing

HFOV. However, weaning has not been implemented accordingly. What are the consequences of failing to quickly wean a neonatal patient from HFV? a. Pulmonary overdistention b. Pulmonary hypertension c. Alveolar derecruitment d. Decreased pulse rate ANS: A

The consequences of failing to wean the patient quickly enough are significant pulmonary overdistention and impairment of cardiac output. In neonates this complication can increase the risk of intracranial hemorrhage because venous return from vessels draining the head is impeded and venous hypertension and vessel rupture can ensue. Conversely, rapid weaning of can result in alveolar derecruitment, requiring reinitiation of lung recruitment procedures.

REF: p. 333 27. Which of the following actions should a therapist consider in a patient suspected of having an

airway obstruction while receiving HFV? a. Observe the patient’s chest wall for movement. b. Increase conventional ventilation. c. Increase mean airway pressure on the HFV. d. Reduce the oscillatory amplitude.

ANS: A

High-frequency ventilators are dependent on patient airway caliber for adequate volume delivery. A change in airway diameter (e.g., by accumulation of secretions or by migration of the tip of the ETT against the tracheal wall) may significantly reduce delivered volumes. The first step should be a quick assessment of chest wall movement. If chest wall motion is substantially decreased, a brief use of manual ventilation while troubleshooting the airway and ventilator may dramatically improve the situation. Steps should be taken to correct any problems with the ETT lumen or position (e.g., suctioning, chest radiograph).

REF: pp. 333-334 28. Why may HFOV be considered a suboptimal ventilation strategy for patients who have either

fresh particulate meconium aspiration or bronchopulmonary dysplasia? a. Ventilation time constants will be decreased. b. Large increases in tidal volume delivery can occur. c. Gas trapping may develop. d. Intrapulmonary shunting becomes likely.

ANS: C

Because a relatively high MLV is necessary for HFOV, this technique is not optimal for use in normal lungs. Furthermore, in conditions in which airway resistance is increased, such as fresh particulate meconium aspiration, bronchopulmonary dysplasia, and reactive airway disease, HFOV may not be optimal. Because of the tremendous impedance to flow created by reductions in airway lumen with these disorders (thus increasing pulmonary time constants), decreases in delivered tidal volume or gas trapping, or both, cause derangement in gas exchange. In contrast, HFJV or HFPV, using larger tidal volumes and lower breathing frequencies, may be more efficacious in conditions in which airway time constants are pathologically prolonged.

REF: p. 334

Chapter 18: Administration of Gas Mixtures Test Bank MULTIPLE CHOICE 1. Vascular smooth muscle is largely dependent on which of the following

intracellular ions? a. Na+ b. K+ c. Ca2+ d. Mg2+ ANS: C

Current understanding suggests that vascular smooth muscle is largely dependent on intracellular calcium ion (Ca2+) concentration. Smooth muscle tissue comprises bundles of myofibrils, threadlike contractile fibers encased by the sarcoplasmic reticulum, a network of tubes or channels that store Ca2+.

REF: p. 344 2. Which of the following substances prevents the release of Ca2+ from the sarcoplasmic

reticulum? a. Intracellular cGMP b. EDRF c. cGMP-dependent kinase d. Calmodulin ANS: C

In the body, the process of smooth muscle relaxation uses cyclic guanosine monophosphate (cGMP) to reduce Ca2+ levels. In smooth muscle cells cGMP activates cGMP-dependent kinase, preventing the release of Ca2+ from the sarcoplasmic reticulum, resulting in smooth muscle relaxation. In the early 1980s researchers reported a potent smooth muscle–relaxing agent, endothelium-derived relaxing factor (EDRF), now understood to be endogenous nitric oxide.

REF: p. 344 3. What is the primary physiologic activity of inhaled nitric oxide? a. Bronchodilation b. Pulmonary vasodilation c. Systemic vasodilation d. Cerebral vasodilation ANS: B

The underlying principle of inhaled nitric oxide (iNO) is its selectivity as a pulmonary vasodilator. Inhaled NO will relax only pulmonary smooth muscle adjacent to functioning alveoli. Atelectatic or fluid-filled lung units will not participate in iNO uptake.

REF: p. 344

4. Which of the following medications contributes to an increased right-to-left intrapulmonary

shunting? a. Dobutamine b. Dopamine c. Prostacyclin d. Prostaglandin A ANS: C

The intravenous vasodilators nitroprusside and prostacyclin will relax pulmonary vasculature globally, reducing pulmonary vascular resistance, but will also increase pulmonary blood flow past nonfunctioning alveoli and intrapulmonary right-to-left shunt.

REF: p. 344 5. The respiratory therapist has initiated iNO at 20 ppm for an infant with pulmonary

hypertension. After 2 hours a blood gas test reveals a 10% improvement in SaO2. What should the therapist do? a. Keep iNO at 20 ppm and wait at least 2 hours before considering any change. b. Increase iNO to 30 ppm and keep the same FiO2. c. Keep iNO at 20 ppm and wean the FiO2 by 10%. d. Increase iNO to 30 ppm with no changes in FiO2.

ANS: A

Several studies have used an increase in oxygen saturation of 20% over baseline as an indication that the infant is responsive.

REF: p. 345 6. The respiratory therapist has initiated nitric oxide for an infant with severe refractory

hypoxemia. The initial dose was 20 ppm and titrated up to 30 ppm for the last 4 hours due to lack of response. However, there still is no response. What should the therapist do? a. Increase iNO to 40 ppm b. Increase iNO to 60 ppm c. Increase iNO to 80 ppm d. Discontinue iNO and consider a different therapeutic intervention ANS: D

Studies have suggested that optimal dosing is usually in the 20- to 30-ppm range. Some infants will not respond positively. The Neonatal Inhaled Nitric Oxide Study (NINOS) trial indicated that only 6% of nonresponders will demonstrate a positive response when given NO at 80 ppm. Typically, a response would be seen almost immediately; however, it is recommended that the time allotted for determining an infant's response last no longer than 4 hours to limit the exposure to NO. REF: p. 345 7. Inhaled NO has been administered to an infant for nearly 4 hours. The respiratory therapist

notices suboptimal response and suggests HFOV. What is the principle behind the potential benefit of adding this ventilatory modality to this infant? a. HFOV improves ventilation and reduces the formation of NO2. b. Lung volumes are optimized with HFOV and further enhance the effects of iNO.

c. The high frequency accelerates the diffusion of NO through the alveolar surface. d. HFOV reduces the need for higher doses of iNO. ANS: B

If lung volume is optimized with HFOV, this could further enhance the effects of iNO. The use of HFOV improves oxygenation response to iNO. REF: p. 345 8. What is the product of the reaction between oxygen and nitric oxide? a. Oxygen radicals b. N2O c. NO2 d. The two molecules do not react with each other.

ANS: C

When combined with oxygen, NO produces NO2, a toxic gas. Although rare, the patient as well as health care providers can be adversely affected. Factors influencing NO2 production are oxygen concentration, NO concentration, and time of contact between NO and oxygen.

REF: p. 346 9. The therapist taking care of an infant on iNO observes that the NO2 levels have been

increasing. In order to correct the situation he increases the inspiratory flow of the ventilator.

What will be some of the limitations associated with this change?

I. It reduces time of contact between NO and O2.

II. It affects the mean airway pressure because it changes the inspiratory time.

III. It may increase the delivered tidal volume.

IV. It reduces the mean airway pressure and increases the inspiratory time. a. I only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: C

Decreasing the NO or oxygen concentration is usually not an option; therefore, to reduce NO2 delivery to the patient, reduce the duration of contact between NO and oxygen. Two methods accomplish this: (1) increase the inspiratory flow or (2) add the NO as close to the patient as possible. Each of these methods has practical limitations. Increasing the ventilator flow will reduce the time of contact between NO and oxygen before reaching the patient, but it may also affect inspiratory time, tidal volume, mean airway pressure, and so on.

REF: p. 346 10. After increasing the inspiratory flow of the ventilator to decrease the generation of NO2 the

therapist notices many changes in the ventilator parameters. The therapist adds the NO into the inspiratory limb of the ventilator circuit close to the patient. What will be a limitation of the procedure? a. A larger number of oxygen radicals are produced at this position. b. Adding NO too close to the patient reduces proper mixing, which is necessary to

ensure accurate NO measurement. c. Adding NO in this position of the circuit is contraindicated. d. The contact time between NO and O2 is too long to be clinically useful.

ANS: B

Adding NO into the inspiratory limb of the ventilator circuit close to the patient will reduce contact time, but it also creates monitoring difficulties. The practitioner must allow an adequate distance for proper mixing to ensure accurate NO measurement.

REF: p. 346 11. Although very small amounts of NO2 are present at the bedside, which health care workers

need to exert special precautions to minimize exposure to NO2? a. Nurses in the NICU b. Air transport team members c. Ground transport team members d. Respiratory therapists in the NICU ANS: B

At first, scavenging was advocated to reduce the possible harmful inhalation of nitrogen dioxide by other personnel in the vicinity. Studies have shown this to be unnecessary because of the relatively small amounts of NO2 present at the bedside. Modern hospitals have adequate room air exchange rates, and the chance of NO or NO2 accumulation is remote. A possible caveat involves interfacility transport. Pressurized aircraft may not allow an adequate cabin air exchange rate to ensure safety. The aircraft crew must be made aware of this so that proper measures are taken to reduce this risk.

REF: p. 346 12. An infant has been receiving iNO for the last 3 days. Which important level should be

monitored when ordering a co-oximetry? a. Methemoglobin b. Carboxyhemoglobin c. Reduced hemoglobin d. Oxyhemoglobin ANS: A

The half-life of iNO is extremely short, about 5 seconds. Once NO crosses the vascular endothelium, it is rapidly bound by hemoglobin, forming nitrosyl hemoglobin (methemoglobin). Methemoglobin production results from the oxidation of the iron in the hemoglobin. The quantity of methemoglobin depends on iNO concentration and concurrent nitrate-based drug therapy (e.g., nitroprusside, nitroglycerin). If the methemoglobin level is excessive, a reduction in iNO or other nitro-based vasodilators is warranted.

REF: p. 346 13. What is the purpose of administering helium–oxygen gas mixtures to patients? a. To reduce the work of breathing b. To improve gas exchange c. To increase the functional residual capacity d. To improve pulmonary compliance

ANS: A

It is important to note that helium is not used to treat the underlying cause of increased airway resistance but rather to decrease the work of breathing until more definitive therapies are effective. When helium is combined with oxygen, the resulting gas mixture density is one third that of air.

REF: p. 347 14. During the administration of aerosol therapy, how does a heliox mixture compare with an air–

oxygen mixture as a carrier gas? a. Less aerosol is deposited with heliox. b. More aerosol is deposited with heliox. c. The two gas mixtures are equally efficient. d. Definitive data are not available.

ANS: B

Patients who use the helium–oxygen mixtures show more improvement in expiratory peak flows than a group using air. Aerosol has deeper and prolonged deposition in the lung when it is delivered with heliox as the carrier gas.

REF: pp. 347-348 15. The therapist is using an oxygen flowmeter to deliver an 80:20 heliox mixture to a patient.

The reading on the flowmeter is 10 L/minute. What is the actual flow received by the patient? a. 5.5 L/minute b. 10 L/minute c. 12.5 L/minute d. 18 L/minute ANS: D

An 80:20 heliox mixture is 1.8 times more diffusible than oxygen. To correct for the difference in gas density, the indicated flow on the flowmeter is multiplied by 1.8. A 70:30 heliox mixture is 1.6 times more diffusible than oxygen. To obtain the accurate flow rate for this mixture, the indicated flow is multiplied by 1.6.

REF: p. 348 16. The therapist is treating a very irritable young child with upper airway obstruction. Which

oxygen device will be the most appropriate to administer the greatest concentration of helium? a. Close-fitting nonrebreathing mask b. Close-fitting partial rebreathing mask c. Nasal cannula d. High flow nasal cannula ANS: A

Spontaneously breathing patients with upper or lower airway obstruction can be given heliox via mask. Because the goal of heliox therapy is to reduce the density of the inspired gas, it is important to deliver the greatest concentration of helium. Therefore, the patient must be able to tolerate the lowest possible fractional concentration of inspired oxygen (FiO2), and room air entrainment must be minimized, resulting in a higher fractional concentration of inspired helium (FiHe). Nasal cannulas (with the exception of high flow nasal cannulas) and simple masks allow far too much room air entrainment, thereby diluting the helium concentration.

Therefore, a close-fitting nonrebreathing mask should be used. This limitation makes the treatment of young patients difficult. Children in distress may not tolerate the tightly fitting mask required to minimize air entrainment.

REF: p. 348 17. The therapist is evaluating a small tachypneic infant receiving heliox mixture 70:30 through

an infant hood. Although the SpO2 has improved, the child shows signs of worsening work of breathing. What is the most probable mechanism to explain this situation? a. The FiHe is too low in a 70:30 mixture to change work of breathing in this infant. b. The flow going through the infant hood is inadequate. c. A greater concentration of helium is present at the top of the hood and away from the infant's nose and mouth. d. The infant is breathing too fast; thus heliox is not reaching the airways.

ANS: D

Stillwell and colleagues investigated the use of heliox mixtures delivered through an infant hood. Not surprisingly, they found a greater concentration of helium at the top of the hood (due to its lower gas density), away from the infant's nose and mouth. This resulted in a lower FiHe and therefore a denser gas being delivered to the infant.

REF: p. 348 18. An infant on high-flow nasal cannula also requires administration of albuterol every 6 hours.

The flow of the cannula was adjusted from 4 to 5 liters per minute. How could this affect the aerosol delivery to this infant? a. It will be unchanged. b. It will decrease. c. It will increase. d. It will increase only if the infant’s respiratory rate increases.

ANS: C

Heliox has been shown to reduce turbulence and improve aerosol delivery in a range of clinical settings. Ari and colleagues assessed the effects of heliox on medication delivery by comparing with 100% oxygen while testing the infant, pediatric cannulas running at flows of 3 and 6 Lpm, and adult cannulas running at 10 and 30 Lpm. At higher flows they found that heliox increased aerosol deposition compared to oxygen. At lower flows there was less benefit from the use of heliox compared to oxygen in the pediatric and adult cannulas and no benefit for the infant.

REF: p. 348 19. What is the potential benefit of adding heliox to patients who have status asthmaticus while

undergoing mechanical ventilation?

a. b. c. d.

To improve pulmonary compliance To reverse bronchospasm To minimize air trapping To facilitate the removal of tracheobronchial secretions

ANS: C

The use of heliox mixtures has been advocated to minimize air trapping and hemodynamic compromise and to reduce peak inspiratory pressures.

REF: p. 348 20. Which of the following parameters of mechanical ventilation are affected negatively by the

use of heliox? a. PEEP b. Plateau pressure c. Peak pressure d. Volume ANS: D

The primary obstacle to heliox delivery via a mechanical ventilator is error in volume and flow measurement. Many mechanical ventilators rely on gas density to measure flows and volumes. Most errors result from underestimation of flow due to the low-density characteristics of helium. Volume is typically a mathematical integration of flow and time; therefore, volumes will be equally affected.

REF: p. 348 21. The therapist is performing a routine assessment and ventilator check on a patient who is

receiving heliox near the wye adapter of the ventilator circuit. He notices a serious discrepancy between the set tidal and the exhaled volume. What should the therapist do to correct this situation? a. Administer heliox through the heliox-approved inlet of the mechanical ventilator b. Add a 16-inch piece of corrugated tubing between the wye adapter and the place on the inspiratory limb where heliox is administered c. Reduce the liter flow on the heliox d. Adjust ventilator settings to compensate for the lower viscosity of heliox ANS: A

The safest method to deliver helium–oxygen mixtures via mechanical ventilation is to connect an 80/20 heliox mixture to the heliox-approved inlet of the mechanical ventilator. The practitioner then uses the ventilator's oxygen concentration control to adjust helium and oxygen to the desired mixture. This allows the practitioner to deliver a helium concentration up to the 80% helium. It is important to note that ventilators may not function properly with helium as a source gas.

REF: p. 348 22. A patient who has been admitted with status asthmaticus is receiving beta adrenergics every 2

hours and heliox with very limited response. What should the therapist suggest at this time? a. Change heliox to 100% helium b. Administer nitrogen

c. Administer inhaled anesthetics d. Add iNO ANS: C

Patients in status asthmaticus (SA) can be placed on helium–oxygen therapy as a temporizing measure to reduce the work of breathing until another therapy (-agonists, methylxanthines, and corticosteroids) is effective. However, these patients frequently have bronchospasm that is refractory to conventional therapy. Certain volatile inhaled anesthetics are known for their bronchodilatory properties. Although no clinical trials have investigated the use of inhaled anesthetics (IAs) in the routine treatment of SA, several case reports exist.

REF: p. 349 23. Which of the following inhaled anesthetic gases has/have demonstrated the possibility to treat

status asthmaticus?

I. Halothane II. Thromboxane III. Isoflurane IV. Sevoflurane a. II only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only ANS: C

Of the several inhaled anesthetics used clinically for anesthesia, only halothane, isoflurane, enflurane, and sevoflurane have been widely reported as potential treatments for status asthmaticus.

REF: p. 349 24. Which of the following inhaled anesthetics should the therapist recommend to administer via

a face mask to a conscious, spontaneously breathing pediatric patient who has status asthmaticus? a. Isoflurane b. Enflurane c. Sevoflurane d. Halothane ANS: D

Halothane is the gas of choice when delivering an inhaled anesthetic agent to a conscious, spontaneously breathing patient. The dose range for halothane is approximately 0.25% to 0.5%. The patient usually is sufficiently awake to communicate in short sentences.

Bronchodilation is usually rapid (15 to 20 min). The patient benefits by the reduced resistance as well as the sedative effect.

REF: p. 350

Chapter 19: Extracorporeal Life Support Test Bank MULTIPLE CHOICE 1. Which of the following groups of patients has the best overall survival when treated with

ECMO? a. Neonates with respiratory support b. Pediatric patients with cardiac support c. Neonates with cardiac support d. Pediatric patients with respiratory support ANS: A

Neonates treated with ECMO for respiratory support have the best survival rates of all groups, up to 75%. See table 19-1 in the textbook.

REF: p. 355 2. What is the key reason for making ECMO so successful in newborns? a. Newborns do not have as a high risk for bleeding as other age groups. b. Newborns require less ECMO flows. c. Newborns have fewer side effects when treated with heparin drips. d. Most clinical conditions treated with ECMO in newborns are reversible.

ANS: D

Over 26,000 newborns with respiratory failure have been reported in the ELSO Registry, which represents the bulk of the neonatal ECMO experience. This includes patients with the diagnosis of persistent pulmonary hypertension of the newborn (PPHN), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), sepsis, and air leak syndromes. All of these are reversible conditions, which is a key element for positive outcomes when providing ECMO. REF: p. 355 3. A neonate on mechanical ventilation with respiratory distress has a PaO2 of 50 mm Hg, a

of 20 cm H2O and FiO2 of 0.8. Why should the therapist suggest therapies other than ECMO? a. The FiO2 is not 100% yet. b. The is not high enough to justify ECMO. c. The OI does not meet ECMO criteria. d. The PaO2 is within normal limits.

ANS: C

Ortega and colleagues proposed the oxygenation index (OI), a calculation based on mean airway pressure (P), FiO2, and arterial oxygenation (PaO2), as follows: OI = P  (FiO2/ PaO2)  100. The authors found that when the OI exceeded 40 during conventional mechanical ventilation, the risk of mortality exceeded 80%. Their results have been reproduced by other institutions, and OI remains a widely accepted predictor of mortality in neonates with respiratory failure and is used as part of the selection criteria for using ECMO.

REF: p. 355 4. Which of the following strategies is greatly responsible for decreasing the need for ECMO in

neonates? a. High-flow oxygen therapy b. Airway pressure release ventilation c. Heliox d. HFOV ANS: D

The introduction of high-frequency oscillatory ventilation (HFOV) decreased the need for ECMO and is a standard of care in the management of hypoxemic respiratory failure. Since HFOV utilizes higher mean airway pressure than CMV, an OI of 60 has been considered a more realistic threshold for identifying mortality risk and the need for ECMO when this form of ventilation is used.

REF: p. 355 5. Which of the following conditions are considered contraindications for neonatal ECMO? a. Meconium aspiration b. Less than 2 kg of weight c. Prolonged mechanical ventilation (7 to 10 days) d. Less than 36 weeks of gestation ANS: B

Typically the need for ECMO is identified within the first couple of days. The need for ECMO following a prolonged period of mechanical ventilation, such as 7 to 10 days, suggests atypical lung pathology that may not be reversible. Another consideration for deciding not to use ECMO is the patient’s size and gestational age. There are ECMO catheter size limitations for newborns less than 2 kg, and newborns less than 32 weeks gestation may be at greater risk for developing intracranial hemorrhage when exposed to anticoagulants.

REF: p. 356 6. Which of the following parameters have been suggested as indications for pediatric ECMO?

I. PaO2 < 50 mm Hg II. PaO2/FiO2 < 75 III. OI > 35 IV. Pre-ECMO pH < 7.20 a. II, III and IV only b. I, II, and III only c. I, II, and IV only d. II and IV only ANS: A

There is no definitive consensus on when ECMO should be initiated in pediatric respiratory failure. Single-center reviews have attempted to identify pre-ECMO factors that may help predict outcome. Mehta and colleagues suggested that an OI > 35 or a pre-ECMO pH of < 7.20 may result in higher mortality. In a case series by Turner and colleagues, it was suggested that there are no true contraindications to using ECMO in pediatric patients with refractory respiratory failure. They further commented that ECMO is appropriate if patients are transferred to an ECMO center early, if lung-protective ventilation is used, and when severe neurologic injury is not present. A PaO2/FiO2 ratio of < 200 mm Hg is one criteria used to identify patients with ARDS. In severe cases the PaO2/FiO2 ratio may be < 75 and mortality risk exceeds 80%—a point when ECMO is considered.

REF: p. 356 7. Which of the following conditions are cardiac applications of ECMO?

I. ECPR II. CDH III. Fulminant myocarditis IV. Cardiomyopathy a. I and II only b. III and IV only c. I, III, and IV only d. I, II, III, and IV ANS: D

The availability of ECMO is an important facet in the medical-surgical management of congenital heart disease (CHD). In the preoperative period, ECMO is used to augment cardiac output and support organ function until palliative or corrective surgery is undertaken. ECMO is also used in the postoperative period, particularly in complex CHD, as more challenging surgical repairs are attempted. ECMO has also been used during interventional procedures.

Patients with cardiac muscle disease, such as fulminant myocarditis or cardiomyopathy, may have such poor heart function that the need for mechanical support with ECMO is necessary.

Although other mechanical circulatory support devices would provide equivalent support, ECMO systems are more readily available and can be implemented in the ICU. When cardiac function fails to recover, ECMO becomes a key support device while heart transplantation options or other support devices are considered. The use of ECMO for cardiac support continues to grow, particularly as an aid to resuscitation, or ECMO during cardiopulmonary resuscitation, referred to as ECPR. REF: p. 357 8. Which of the following statements describes venoarterial ECMO? a. A cannula is inserted into the subclavian vein for the removal of blood. b. Blood is removed from the venous circulation through the external jugular vein. c. Blood returns to the heart through the subclavian artery. d. A cannula is inserted into the right common carotid artery for arterial return.

ANS: D

ECMO support begins by accessing the vasculature in order to establish drainage and reinfusion sites. In newborns and infants, perfusion cannulas are surgically placed in a vein, commonly the right-internal jugular, and an artery, usually the right common carotid. This is the classic venoarterial (VA) configuration in which deoxygenated venous blood is drained from the patient and blood that is fully saturated with oxygen is artificially pumped and returned to the arterial system (refer to Figure 19-1A in the textbook).

REF: p. 357 9. During administration of venovenous ECMO, the therapist notices that the SvO2 is greater

than SaO2. What is the best explanation to this phenomenon? a. The blood flow through the pump is too slow. b. Recirculation is excessive. c. Native cardiac output has increased. d. iNO is being administered concomitantly.

ANS: C

If SO2 is greater than SaO2, the recirculation is excessive, which would require either an adjustment in cannula position or change in blood flow rate.

REF: p. 358 10. During venovenous ECMO, what effect does the cardiac output have on oxygenation? a. An increase in cardiac output will have a significant effect on the patient’s

oxygenation. b. A decrease in cardiac output will have a major impact on the patient’s oxygenation. c. Changes in cardiac output either way will have little influence on the patient’s

oxygenation. d. The influence of alterations in cardiac output on the patient’s oxygenation cannot

be predicted.

ANS: C

VV ECMO does not provide the same level of oxygenation as VA, and the maximal SaO2 achievable can be as low as 85% until lung function improves. Because VV ECMO is essentially operating in series with the native circulation, alterations in cardiac output will not have a significant effect on oxygenation. The volume of blood removed is equal to the volume reinfused, so there is also no effect on the patient's hemodynamics.

REF: p. 358 11. What are the major advantages of venovenous ECMO? a. Pulsatile flow in maintained. b. Cardiovascular support is uninvolved. c. It is less expensive than VA ECMO. d. The internal jugular vein is not cannulated twice.

ANS: B

One advantage of VV support is that carotid artery ligation is not required, full pulsatile native blood flow is maintained, and the potential for air or particulate emboli from the circuit is less.

A disadvantage is the lack of cardiovascular support. However, the presence of mild to moderate myocardial dysfunction should not discourage the use of the VV approach because the improved oxygenation and lower airway pressures achieved with implementation of VV ECMO often improve cardiac function.

REF: p. 358 12. Which of the following mechanisms affect the output of VV ECMO?

I. Size of the tubing II. The rotations per minute III. Tension of the rollers IV. Blood pressure a. I. II, and III only b. I and IV only c. II, III, and IV only d. I, II, III, and IV ANS: A

The output depends on the size of the tubing, the rotations per minute (RPMs), and the tension or occlusion of the rollers on the raceway.

REF: p. 359 13. The therapist should evaluate raceway occlusion because too much roller tension could be

associated with which of the following events? a. Inadequate flow b. Increased bladder tension c. Hemolysis d. Recirculation ANS: C

Evaluating raceway occlusion is essential: too much roller tension (overoccluded) may cause tubing damage and hemolysis, and too little roller tension (underoccluded) may result in inadequate flow.

REF: p. 359 14. What is the advantage of having the centrifugal pump automatically respond to resistances

against which it is pumping? a. It avoids placing increased pressures on the heart. b. It eliminates lowering pulmonary vascular pressures. c. It maintains regulated flow through the system. d. It ensures that the blood flows smoothly through the membrane oxygenator.

ANS: C

Centrifugal pumps are nonocclusive devices because energy is transferred to the blood by a rapidly rotating cone-shaped pump head that creates a constrained vortex. Blood is actively pulled inward and propelled outward by the energy created by the vortex, thus drainage is considered active. Because this type of pump is nonocclusive is it dependent on the patient’s preload and afterload. As preload decreases, such as decreased venous drainage, or if afterload increases due to increased systemic vascular resistance, flow will decrease.

REF: p. 360 15. In the gas membrane exchanger, what is one of the limiting factors to the transfer rate of

oxygen across the membrane? a. The flow of blood b. The concentration gradient of the gas across the membrane c. The thickness of the blood film between the membrane layers d. The flow of gas in relationship to the flow of blood ANS: C

The transfer rate of O2 is limited by the thickness of the blood film between the membrane layers. As the blood film becomes thicker, the oxygenating efficiency decreases.

REF: p. 361 16. Because the minimum flow rate required to remove condensation in the gas compartment

usually results in excessive elimination of carbon dioxide, what should the therapist do? a. Reduce pump flow b. Blend sweep gas with a carbogen mixture c. Reduce the amount of oxygen blended in the sweep gas d. Add more oxygen to the sweep gas ANS: B

Because the minimum flow rate required to remove condensation usually results in excessive elimination of carbon dioxide, sweep gas is often blended with a carbogen mixture, which reduces the driving pressure across the membrane and maintains normocarbia.

REF: p. 364 17. What are the most common causes of a decrease in venous return in ECMO?

I. Hypovolemic state II. Malpositioning of the venous cannula III. Kinking of the cannula IV. Shifting of the mediastinum a. I and III only b. II and III only c. I, II, and III only d. I, II, III, and IV ANS: D

The most common causes of a decrease in venous return include malpositioning of the venous cannula, kinking of the cannula, shifting of the mediastinum, or a hypovolemic state.

REF: p. 362 18. It is not uncommon for patients undergoing ECMO to experience renal failure. What can be

done to enhance renal function? a. Add either colloids or crystalloids to fluid challenge the patient. b. Perform hemofiltration. c. Add either vasodilators or vasoconstrictors. d. Conduct plasmapheresis.

ANS: B

It is not uncommon for patients requiring ECMO to develop renal insufficiency from preECMO fluid resuscitation, acute renal dysfunction, and blood product replacement. To augment renal function and remove larger quantities of fluid, a semipermeable membrane or hemofilter can be added to the ECMO circuit.

REF: p. 363 19. The ECMO specialist has noticed excessive clotting in the circuit despite increase doses of

heparin. What is the most feasible explanation for this event? a. Too many platelet transfusions b. Defective heparin c. Blood flow too slow d. Deficiency of ATIII ANS: D

If excessive clotting in the circuit is noted, a deficiency in ATIII is a possible cause. Heparin has no direct anticoagulant effect on the blood by itself but combines with a cofactor, antithrombin III (ATIII), to prevent thrombi from forming. This stops the conversion of fibrinogen to fibrin and ultimately prevents blood from clotting. A deficiency in ATIII can cause heparin to be ineffective, resulting in use of excessive amounts of heparin.

REF: p. 363 20. The therapist in charge of a patient on ECMO is monitoring ACT every 30 minutes. The last

ACT was 100 seconds. What should the therapist suggest at this time? a. Decrease the amount of platelets transfused. b. Increase the heparin dose. c. Add plasminogen. d. Increase blood flow to decrease contact time.

ANS: B

The classic method for monitoring anticoagulation is to measure the activated clotting time (ACT) with a point-of-care device. The heparin dose is titrated to achieve an ACT range of typically 160 to 180 seconds.

REF: p. 363 21. The therapist in charge of a patient on ECMO has noticed an increase in premembrane

pressures. What is the most probable explanation? a. Very high pump flow b. Clotting in the circuit

c. Damage of the raceway d. Excessive sweep flow ANS: B

As circuit or membrane resistance changes, as is common with clot formation, the pressures will change. As an example, a membrane that has been in use for a fairly prolonged duration will tend to develop clot and increased resistance, which would be identified by an increase in premembrane pressure.

REF: p. 363 22. How can membrane malfunction be suspected? a. Narrowing of the premembrane and postmembrane PaCO2 b. Widening of the premembrane and postmembrane PaO2 c. Presence of large clots in the circuit d. Presence of air bubbles ANS: A

Membrane function is also evaluated by periodically measuring premembrane and postmembrane blood gases. Gas exchange across the membrane may become less efficient over prolonged ECMO duration, which may be diagnosed by changes in the pre-and postblood gas values. For instance a narrower premembrane and postmembrane PaCO2 gradient is suggestive of a decrease in CO2 elimination.

REF: p. 363 23. Which of the following ventilator settings are typically used in ECMO for respiratory

support?

I. Vt 5-7 ml/kg II. PIP 25-25 cm H2O III. PEEP 2-3 cm H2O IV. Frequency 10-12 a. I and III only b. II and III only c. I, II, and IV only d. I, II, III, and IV ANS: C

The patient requiring ECMO primarily for a cardiac reason is not likely to have significant pulmonary issues, in which case the ventilator strategy is to maintain lung function near normal. In this scenario the ECMO ventilator settings are minimized to achieve a tidal volume of around 5 to 7 mL/kg and PEEP to maintain sufficient end-expiratory lung volume—typical settings would be PCV-SIMV, 10-12 breaths/min, PIP/PEEP 25-27 / 5-7 cm H2O. REF: p. 365 24. What is the ECMO flow considered as minimal support? a. 100 mL/Kg b. 80 ml/kg c. 50 mL/Kg

d. 30 mL/Kg ANS: D

Once ECMO flow rates are weaned to around 20 to 30 mL/kg ECMO, support is considered minimal. At this point if reasonable ventilator settings result in adequate gas exchange, the patient is isolated from the ECMO circuit.

REF: p. 366 25. What is considered the most concerning complication of ECMO in the newborn? a. Disseminated intravascular coagulopathy b. Pneumonia c. Intracranial hemorrhage d. Hemosiderosis ANS: C

The most concerning patient complication that can occur, particularly in the newborn, is an intracranial hemorrhage (ICH).

REF: p. 367

Chapter 20: Pharmacology Test Bank MULTIPLE CHOICE 1. Which of the following effects is related to activation of -adrenergic receptor sites? a. Activation of guanyl cyclase b. Skeletal muscle contraction c. Bronchial smooth muscle relaxation d. Release of inflammatory mediators ANS: C

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

REF: p. 373 2. Which of the following adverse effects is likely to be experienced by patients who use

nonselective 2-adrenergic agonists? a. Tremor b. Tachypnea c. Bradycardia d. Blurred vision ANS: A

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

REF: p. 374 3. Which of the following statements accurately describes levalbuterol? a. It is composed of both (R)- and (S)-albuterol. b. The d-isomer is the most active compound. c. A dose of 0.63 mg is equipotent to 1.25 mg of racemic albuterol. d. The d-isomer possesses a longer duration of action.

ANS: B

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

REF: p. 376 4. A patient with status asthmaticus has been admitted to the emergency department. The

physician would like to try a 2-agonist that can be administered parenterally. Which of the following drugs should the therapist suggest? a. Terbutaline b. Levalbuterol c. Epinephrine d. Pirbuterol ANS: A

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

REF: p. 377 5. The physician asks the therapist to recommend a long-acting -agonist for a patient. Which of

the following medications should the therapist recommend? a. Levalbuterol b. Formoterol c. Metaproterenol d. Terbutaline ANS: B

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

REF: p. 378 6. Which of the following medications is most suited for the treatment of postextubation edema? a. Racemic epinephrine b. Ephedrine c. Norepinephrine d. Fluticasone

ANS: A

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

REF: p. 378 7. Which of the following medications is an effective adjunctive therapy in relieving

bronchospasm in patients with acute bronchospasm when combined with albuterol? a. Pirbuterol b. Salmeterol c. Metaproterenol d. Ipratropium bromide ANS: D

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

REF: p. 379 8. While working at the bedside of a small child who has myasthenia gravis, the therapist notices

a new medication order prescribing glycopyrrolate for the control of secretions. What should the therapist do at this time? a. Inform the nurse that this medication is contraindicated for patients with myasthenia gravis. b. Inform the nurse that the dose is incorrect. c. Inform the nurse that this medication is contraindicated in children. d. Mention nothing because the prescription is correct.

ANS: A

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

REF: p. 379 9. How long should a patient wait to receive the maximal benefit of inhaled corticosteroids? a. 48 hours b. 5 days c. 1 to 2 weeks d. 1 month ANS: C

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

REF: p. 380 10. Which of the following responses are considered adverse effects of inhaled corticosteroids?

I. Oropharyngeal candidiasis II. Dry mouth III. Wheezing IV. Dysphonia a. I and II only b. II and III only c. II and IV only d. I, III, and IV only ANS: D

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

REF: p. 381 11. To reduce the adverse effects of inhaled corticosteroids, what should the therapist

recommend? a. Decrease the dosage b. Use a dry powder inhaler c. Use a holding chamber device d. Brush teeth after each inhalation ANS: C

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

REF: p. 381 12. Which of the following medications is the only drug that inhibits 5-lipoxygenase? a. Montelukast b. Omalizumab c. Zafirlukast d. Zileuton ANS: D

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

REF: p. 382 13. Which of the following side effects are consistent with chronic administration of

theophylline?

I. Nausea

II. Vomiting III. Tachycardia IV. Central nervous system stimulation a. I and II only b. II and III only c. III and IV only d. I, II, III, and IV ANS: D

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

REF: p. 383 14. Which of the following medications works to maintain the integrity of the mast cell? a. Ipratropium bromide b. Magnesium sulfate c. Cromolyn sodium d. Methylprednisolone ANS: C

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

REF: p. 384 15. Which of the following effects constitute adverse reactions to dornase alfa (recombinant

human deoxyribonuclease I (rhDNase))?

I. Chest pain II. Pharyngitis III. Rash IV. Hypovolemia a. I and IV only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only ANS: B

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

REF: p. 385

16. Which of the following agents should be considered in the rapid-sequence intubation of

patients with status asthmaticus? a. Atropine b. Magnesium sulfate c. Halothane d. Ketamine ANS: D

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

REF: p. 385 17. Which of the following benefits has been associated with the use of inhaled tobramycin?

I. Improvement of FEV1 II. Eradication of Pseudomona aeruginosa III. Reduction in hospitalization IV. Reduction in parenteral use of antibiotics a. I and IV only b. I, II, and III only c. I, III, and IV only d. I, II, III, and IV ANS: D

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

REF: p. 386 18. When should the therapist administer short-acting bronchodilators to improve penetration of

inhaled antibiotics? a. Immediately after the antibiotic b. No more than 4 hours after administration of the antibiotic c. 15 minutes to 4 hours before each dose d. At the same time as the administration of the antibiotic ANS: C

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

REF: p. 387 19. Nebulized pentamidine should be administered in a negative pressure room and through

which of the following nebulizer systems? a. Pari LC Plus

b. Nebutech c. Respirgard II d. SPAG ANS: C

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

REF: p. 388 20. Which of the following medications is a recombinant humanized monoclonal anti-IgE

antibody use for the treatment of severe persistent asthma? a. rhDNase b. RespiGam c. Omalizumab d. Palivizumab ANS: C

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

REF: p. 389

Chapter 21: Thoracic Organ Transplantation Test Bank MULTIPLE CHOICE 1. What typically makes lungs unsuitable for donation? a. Pulmonary edema b. Platelike atelectasis c. Tracheal tear d. Tracheitis ANS: A

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

REF: p. 398 2. When could kidneys, liver, and lungs be procured for transplantation from a patient with

anticipated cardiac arrest? a. If arrest is anticipated within the next 24 hours b. If arrest is anticipated within the next 12 hours c. If arrest is anticipated within the next 6 hours d. If arrest is anticipated within the next 1 hour ANS: D

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

REF: p. 399 3. Which of the following is the most common indication for heart transplantation? a. Cardiomyopathy b. Massive myocardial infarction c. External pacemaker placement d. Primary pulmonary hypertension ANS: A

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

REF: p. 399 4. What is the predominant problem leading to heart transplantation in children younger than 1

year of age?

a. b. c. d.

Cardiomyopathy Congenital cardiac lesions Valvular problems Lethal cardiac dysrhythmias

ANS: B

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

REF: p. 399 5. What is the predominant cause of early postoperative mortality associated with heart

transplantation? a. Cardiac dysrhythmias b. Sepsis c. Organ rejection d. Graft failure ANS: D

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

REF: p. 399 6. Which of the following problems is associated with long-term heart transplant patients? a. Coronary artery disease b. Recurrent pulmonary edema c. Coronary revascularization d. Cardiac dysrhythmias ANS: A

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

REF: p. 400 7. Which of the following cardiac problems is responsible for the vast majority of neonatal

cardiac transplants? a. Cardiomyopathy b. Ventricular septal defect c. Cardiac pacemaker abnormalities d. Hypoplastic left ventricle ANS: D

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

REF: p. 400

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

I. Difficulty in obtaining a donor II. Avoidance of cardiac rejection III. Averting premature coronary artery disease IV. Reducing the length of time on cardiopulmonary bypass a. I and IV only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: C

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

REF: p. 400 9. Which of the following chronic lung diseases is the most common indication for bilateral lung

transplantation? a. Severe asthma b. Cystic fibrosis c. Acute respiratory distress syndrome d. Tetralogy of Fallot ANS: B

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

REF: p. 400 10. Which of the following conditions is a frequent cause of graft failure occurring within the first

90 days after lung transplantation? a. Organ rejection b. The potency of the antirejection drugs among this population c. Ischemia-reperfusion d. High pulmonary vascular pressures ANS: C

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

REF: p. 401

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

I. Trimethoprim-sulfamethoxazole II. Cyclosporine III. Azathioprine IV. Mycophenolate mofetil a. I and III only b. II and III only c. I, II, and IV only d. II, III, and IV only ANS: D

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

REF: p. 402 12. Which of the following conditions are considered complications of thoracic organ

transplantation?

I. Respiratory failure II. Bronchiolitis obliterans III. Lung allografts IV. Infection a. III and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: C

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

REF: p. 402 13. Twenty-four hours after a pediatric patient has undergone lung transplantation, the therapist

notices on the patient’s chest X-ray features consistent with pulmonary edema. How should the therapist interpret this finding? a. The patient has experienced ischemia–reperfusion injury. b. The patient is developing bronchiolitis obliterans. c. A pneumonia-like infection has occurred. d. Graft failure is present.

ANS: A

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

REF: p. 402 14. The therapist notices the following signs in a pediatric patient who recently had a heart

transplant: Decreased cardiac contractility Congestive heart failure Tachycardia Tachypnea Malaise How should the therapist interpret these signs? a. These signs are normal and expected after heart transplantation. b. The patient has become hypovolemic. c. The patient requires cardioversion. d. The patient is in rejection.

ANS: D

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

REF: p. 403 15. Why does the pulmonary infection rate for lung transplantation appear to be higher than with

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

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

REF: p. 403 16. Which of the following microorganisms is associated with increased mortality among patients

with cystic fibrosis? a. Serratia marcescens b. Staphylococcus aureus c. Haemophilus influenza d. Burkholderia cepacia ANS: D

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

REF: p. 404 17. Months after receiving a lung transplant a patient with cystic fibrosis exhibits the following

signs and symptoms: Increasing dyspnea Increased coughing with sputum production Colonization with Pseudomonas species The patient also appears to be in respiratory failure. Which of the following conditions is likely developing? a. Bronchiolitis obliterans b. Bronchorrhea c. Acute respiratory distress syndrome d. Pulmonary hypertension ANS: A

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

REF: p. 404 18. Which of the following medications is associated with a decreased white blood cell count

caused by bone marrow suppression? a. Cyclosporine b. Tacrolimus c. Azathioprine d. Azithromycin ANS: C

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

REF: p. 404 19. Which of the following forms of interaction tend to occur between the respiratory therapist

and a patient who receives a lung transplant?

I. Mechanical ventilation II. Pulmonary rehabilitation III. Bronchopulmonary hygiene IV. Hyperbaric oxygenation a. I and III only b. II and III only c. I, II, and III only d. I, II, and IV only ANS: C

There are multiple areas of interaction between the respiratory therapist (RT) and the transplant patient. Care of the patient who undergoes thoracic transplantation always involves the teamwork of a variety of health care professionals. The child who receives a lung or heart– lung transplant is especially likely to require an RT on the team. Familiarity with the diseases leading to transplantation, as well as the transplantation process, will help the practitioner provide more comprehensive care to the patient as well as improve interaction with the health care team. The RT may already be familiar with the transplant candidate because of his/her role in providing routine care for the primary disease process, particularly for chronic pulmonary diseases such as cystic fibrosis. The RT may become a key contact with the transplant candidate in the initial evaluation process or during pulmonary function testing.

After the patient has been accepted to the transplantation list, the RT may be involved in providing an exercise evaluation and rehabilitation program in an effort to optimize the patient's condition while he or she is awaiting transplantation. Immediately after the transplantation procedure, the RT will be involved with the patient in the intensive care unit, primarily providing mechanical ventilatory support and maintenance of the artificial airway.

Because of the temporary interruption of ciliary function, the RT may be asked to provide aerosolized bronchodilators, mechanical aids to assist full inflation and cough, and bronchopulmonary hygiene. For most patients, this therapy is not required on a long-term basis. Shortly after the patient is taken off mechanical ventilation, the RT may be involved in additional mucus clearance measures. Exercise and rehabilitation should be resumed as soon as possible after extubation.

REF: p. 405

Chapter 22: Neonatal Complications and Pulmonary Disorders Test Bank MULTIPLE CHOICE 1. What is the incidence of respiratory distress syndrome (RDS) among infants born at less than

28 weeks of gestation? a. 30% to 40% b. 40% to 50% c. 60% to 80% d. >80% ANS: C

In the United States, respiratory distress syndrome (RDS) has been estimated to occur in 20,000 to 30,000 newborn infants each year and is a complication in about 1% of pregnancies.

Its incidence is inversely related to gestational age and birth weight. It occurs in 60% to 80% of infants < 28 wk of gestational age, in 15% to 30% of those between 32 and 36 wk, and rarely in those > 37 wk.

REF: p. 409 2. Which of the following conditions increase the risk for developing RDS?

I. Maternal diabetes II. Cesarean delivery III. Multiple births IV. Premature rupture of membranes a. I only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: C

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

REF: p. 409 3. What is the significance of an infant with RDS demonstrating a grunt during each exhalation? a. Resolution of the RDS b. An effort to maintain its functional residual capacity (FRC) c. An attempt to overcome increased airway resistance d. Impending death ANS: B

A characteristic grunt during expiration is an attempt to maintain the FRC. REF: p. 412

4. The therapist is reviewing the chest radiograph of a newborn, preterm infant and observes

diffuse, fine, reticulogranular densities, which provide a ground-glass appearance. On the basis of these radiographic findings, which of the following conditions should the therapist suspect is present? a. Persistent pulmonary hypertension of the newborn b. Respiratory distress syndrome c. Bronchopulmonary dysplasia d. Pulmonary interstitial emphysema ANS: B

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

REF: p. 412 5. How should the therapist interpret a lecithin-to-sphingomyelin (L:S) ratio of 2:1? a. The presence of lung maturity b. A gestational age of less than 28 weeks c. The likelihood of RDS d. Laboratory error ANS: A

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

REF: p. 412 6. How should the therapist interpret the lack of supernatant foam appearing during the shake

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

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

REF: p. 412 7. When should a therapist consider CPAP for a newborn with respiratory distress? a. FiO2 > 40% to 70% and SpO2 < 85% b. FiO2 > 90% and SpO2 < 95% c. Respiratory rate of 40 breaths per minute d. PaO2 50 to 60 mm Hg ANS: A

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

REF: p. 415 8. When should a therapist consider intubation and mechanical ventilation for a newborn with

respiratory distress?

I. FiO2 > 40% to 70% II. SpO2 < 85% III. CPAP of 5-10 cm H2O IV. pH < 7.20 a. I and II only b. II and III only c. I, II, and III only d. I, II, III, and IV ANS: D

Classic indications for endotracheal intubation and mechanical ventilation are infants with respiratory failure or persistent apnea. Reasonable measures of respiratory failure are: (1) arterial blood pH < 7.20, (2) arterial blood PaCO2 of 60 mm Hg or higher, and (3) oxygen saturation <85% at oxygen concentrations of 40% to 70% and CPAP of 5 to 10 cm H2O. REF: p. 415 9. What ventilator settings should a therapist select for a newborn with respiratory distress

syndrome?

I. PIP 25-30 cm H2O II. PEEP 3-6 cm H2O III. VT 5-6 mL/kg IV. Frequency 60 breaths per minute a. I and II only b. II only c. I, II, and III only d. I, II, III, and IV ANS: B

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

REF: p. 415 10. Which of the following risk factors contribute to the pathogenesis of BPD?

I. Lung immaturity II. Respiratory failure III. Oxygen supplementation IV. Positive-pressure ventilation a. I and II only b. IV only c. I, II, III, and IV d. III and IV only ANS: C

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

REF: p. 417 11. While reviewing the chest X-ray of a newborn, the therapist observes the following features:

Pulmonary vascular congestion Prominent perihilar streaking Fluid in the interlobular fissures Hyperexpansion Flat diaphragm Which of the following conditions does this patient likely have? a. RDS b. Persistent pulmonary hypertension of the newborn c. Transient tachypnea of the newborn d. Barotrauma ANS: C

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

REF: p. 424 12. Which of the following therapeutic interventions is generally needed to treat transient

tachypnea of the newborn (TTN)? a. Endotracheal intubation b. 40% oxygen hood c. Bronchial hygiene therapy d. Bronchodilator therapy ANS: B

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

REF: p. 425 13. In addition to Group B Streptococcus, which of the following microorganisms are responsible

for nosocomial pneumonia acquired after delivery? a. RSV b. Escherichia coli c. Pseudomona spp. d. Haemophilus influenza ANS: B

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

REF: p. 425 14. When neonatal pneumonia is suspected, how long does an infant generally receive broad-

spectrum antibiotics? a. 24 hours b. 48 hours c. 72 hours d. 96 hours ANS: C

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

REF: p. 428 15. Why does meconium staining occur predominantly in infants older than 36 weeks of

gestational age? a. Because these infants can generate strong inspiratory efforts b. Because infants this age have significant cardiac outputs c. Because these infants demonstrate strong peristalsis d. Because these newborns have weak anal sphincter tone ANS: C

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

REF: p. 429 16. What is the typical type of airway obstruction that occurs with MAS? a. Ball valve b. Complete c. No obstruction d. Airway inflammation ANS: A

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

REF: p. 429 17. What radiographic features is the therapist likely to see on a typical chest X-ray of an infant

with MAS? a. Ground-glass appearance b. Complete whiteout c. Decreased lung volume d. Patchy areas of atelectasis ANS: D

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

REF: p. 431 18. The therapist is contemplating the possibility of intubating and suctioning a nonvigorous

newborn with MAS. Which of the following clinical parameters confirms the indication for the procedure? a. Good muscle tone b. Presence of dark green meconium on the skin c. Heart rate < 100 beats per minute d. Presence of coarse crackles on auscultation ANS: C

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

REF: p. 431 19. Eight hours after being born, a baby presents with cyanosis despite administration of adequate

ventilation, tachypnea, and retractions. Which of the following conditions should the therapist suspect is affecting this newborn? a. RDS b. BPD c. PPHN d. GBS pneumonia ANS: C

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

REF: p. 434 20. Blood samples are simultaneously obtained from both the right radial artery and the umbilical

artery, and the arterial partial pressure of oxygen (PaO2) value from the right radial artery is 20 mm Hg greater than that analyzed from the umbilical artery sample. On the basis of this finding, which of the following conditions does the neonate likely have? a. PPHN b. MAS c. Neonatal pneumonia d. RDS ANS: A

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

REF: p. 435 21. Which of the following blood gas parameters should the therapist target when managing

patients with PPHN? I. SaO2 > 95% II. PaCO2 35-45 mm Hg III. pH 7.35-7.45 IV. PaO2 > 95 mm Hg a. I only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: C

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

REF: p. 436 22. Which of the following medications should the therapist recommend for an infant with apnea

of prematurity experiencing episodes of apnea? a. Caffeine b. Benzodiazepines

c. Antibiotics d. Doxapram ANS: A

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

REF: p. 438 23. The therapist is assessing a newborn on the mechanical ventilator. The neonate shows clear

signs of respiratory distress, and lung auscultation reveals shifting of the PMI towards the left and breath sounds decreased on the right. What should the therapist suspect this newborn developed? a. Right-sided pneumothorax b. Severe right lung atelectasis c. Right pleural effusion d. Left-sided atelectasis ANS: A

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

REF: p. 439 24. While reviewing the chest X-ray of a newborn, the therapist observes the following features:

continuous diaphragm sign and linear bands of air paralleling the left side of the heart and the descending aorta with extension superiorly along the great vessels into the neck. Which of the following conditions does this patient likely have? a. Pneumothorax b. Cardiac tamponade c. Pneumomediastinum d. Pneumopericardium ANS: C

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

REF: p. 440 25. A newborn suspected of having a pneumothorax is rapidly deteriorating. What should the

therapist suggest at this time? a. Intubation and mechanical ventilation

b. Mask CPAP c. Needle aspiration d. Confirm air leak with a chest X-ray and place a chest tube afterwards ANS: C

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

REF: p. 441 26. A neonate diagnosed with a pneumothorax was treated with a chest tube. After 36 hours, the

therapist noticed that bubbling is present in the chest tube system. What should the therapist do at this time? a. Suggest removal of the chest tube in 24 hours b. Clamp the tube and obtain a CXR c. Keep the chest tube until bubbling stops d. Remove the chest tube and obtain a follow-up CXR ANS: C

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

REF: p. 442

Chapter 23: Congenital and Surgical Disorders that Affect Respiratory Care Test Bank MULTIPLE CHOICE 1. What intervention should the therapist perform when an infant is born with choanal atresia? a. Perform nasotracheal intubation b. Recommend a tracheotomy procedure c. Insert an oropharyngeal airway d. Perform a cricothyroidotomy ANS: C

A newborn infant is an obligate nasal breather, so the presence of complete nasal obstruction caused by choanal atresia results in immediate respiratory distress and possible death by asphyxia. During the newborn’s first breaths, the tongue becomes directly associated with the hard and soft palates, creating a vacuum. An oral airway should be inserted and maintained to relieve the airway obstruction.

REF: p. 455 2. What should a respiratory therapist do to confirm a diagnosis of choanal atresia? a. Recommend lateral mandibular radiographs b. Inspect the nasal cavities with a rhinoscope c. Attempt to insert an 8 French suction catheter through each nasal cavity d. Gently pinch the infant’s nose closed until oral breathing occurs ANS: C

An 8 French catheter is the best diagnostic tool for atresia in the newborn intensive care unit.

If the catheter fails to pass through the nose into the oropharynx, choanal atresia should be suspected. The neonate is stabilized by immediately inserting an oral airway.

REF: p. 455 3. Which of the following interventions is used to treat macroglossia? a. Positioning the patient appropriately corrects most cases. b. Most cases are corrected surgically. c. Polysomnography to determine any effect on sleep is all that is required. d. Treatment is based on the severity of airway obstruction and etiology.

ANS: D

Treatment for macroglossia should be individualized, depending on the severity of respiratory obstruction and etiology. For isolated macroglossia, prone positioning usually relieves mild cases. More severe cases may require one of the many surgical techniques to reduce tongue size. Lymphangiomas and small hemangiomas of the tongue may require excision, and large congenital hemangiomas frequently respond to systemic corticosteroid or interferon therapy.

Chronic hypoxia and carbon dioxide retention are frequent sequelae of macroglossia and require close follow-up. Immediate intubation may be necessary along with tracheotomy to temporize for reduction surgery.

REF: p. 456

4. Which of the following conditions is consistent with micrognathia, glossoptosis, and cleft

palate in a newborn? a. Pierre Robin syndrome b. Choanal atresia c. Treacher Collins syndrome d. Esophageal atresia ANS: A

The primary features of the Pierre Robin syndrome include micrognathia, glossoptosis (or posterior displacement of the tongue), and cleft palate. These features result in pharyngeal obstruction and respiratory distress.

REF: p. 456 5. Which of the following acronyms is associated with esophageal atresia and tracheoesophageal

fistula? a. VACTERL b. PROM c. CHARGE d. PPHN ANS: A

For unknown reasons, a constellation of tracheal and esophageal abnormalities, which include esophageal atresia and tracheoesophageal fistula, may be associated with other midline vertebral, anal, cardiac, and renal or peripheral limb anomalies, which are referred to as the VACTERL (vertebral, anal, cardiac, tracheal, esophageal, renal, limb) syndrome.

REF: p. 456 6. Which of the following forms of tracheoesophageal fistula and esophageal atresia is most

common? a. Blind-ending upper esophageal pouch of variable length associated with a fistula from the lower trachea or main stem bronchi leading into the distal esophagus b. An isolated esophageal atresia with a proximal blind-ending pouch and a “long gap” of missing esophagus above a small distal esophageal pouch c. An esophageal atresia with a proximal and distal tracheoesophageal fistula d. An isolated tracheoesophageal fistula presenting without atresia and usually occurring in the lower cervical or upper thoracic area ANS: A

The most common combination of lesions is esophageal atresia associated with a distal tracheoesophageal fistula. More than 85% of patients will present with this form of the anomaly, which results in a blind-ending upper esophageal pouch of variable length associated with a fistula from the lower trachea or main stem bronchi that leads into the distal esophagus.

REF: p. 456 7. A newborn is brought to the emergency room for difficulty breathing. The mother of the baby

reports constant drooling, coughing, and episodes of cyanosis. What should the therapist suspect this condition is?

a. b. c. d.

Congenital diaphragmatic hernia Tracheoesophageal fistula Esophageal atresia Pyloric dilation

ANS: C

Drooling, along with frothing and bubbling at the nose and mouth, are the first symptoms in the majority of newborns with esophageal atresia. The first feedings result in choking, coughing, and episodes of cyanosis. The respiratory distress may be severe and progressive, which should prompt an immediate work-up for esophageal atresia. If esophageal atresia is suspected, a stiff nasogastric tube is introduced until resistance is met. The tube is connected to constant suction and irrigated with 1 to 2 mL of saline at frequent intervals.

REF: p. 457 8. What is the role of radiography in the determination of tracheoesophageal fistula and

esophageal atresia? a. The esophageal pouch can be observed. b. The opening into the airway can be located. c. The presence of left-to-right shunt can be seen. d. The location of the nasogastric tube may confirm obstruction of the proximal esophagus caused by atresia.

ANS: D

Chest and abdominal radiographs are critical to the diagnosis of esophageal atresia and tracheoesophageal fistula. Several important radiographic findings are specific for esophageal atresia. The course and end point of the nasogastric tube confirm obstruction of the proximal esophagus by atresia and determine the relative position of the upper esophageal pouch. The lung fields must be examined to determine the presence of parenchymal changes resulting from aspiration. Changes in mediastinal structures give an early indication of congenital heart disease, and a careful search is made for the aortic arch to determine its left- or right-sided position.

REF: p. 457 9. What are some of the complications associated with performing esophageal anastomoses to

repair esophageal atresia that the therapist needs to be aware of?

I. Apnea II. Bradycardia III. Hyperventilation IV. Recurrent pneumonia a. I and II only b. III and IV only c. I, II, and III only d. I, II, and IV only ANS: D

In esophageal atresia, the ability to successfully perform esophageal anastomoses has been lifesaving. The most significant complication of primary esophageal anastomosis is stricture or recurrent fistula formation. These complications have important implications for postoperative respiratory care. Even infants with successful anastomoses have persistent respiratory problems. With or without complications, postoperative respiratory symptoms have been noted in up to 50% of patients. Complications range from apnea and bradycardia to aspiration, recurrent pneumonia, and even respiratory arrest.

REF: p. 458 10. Which of the following clinical manifestations characterize congenital diaphragmatic hernia?

I. The herniated contents cause compression of the developing ipsilateral lung.

II. The ipsilateral side may be compressed from shifting of the mediastinum.

III. Histologic studies demonstrate increased musculature in the media of the arterioles.

IV. Lung tissue is hypoplastic, including the pulmonary vasculature, even on the contralateral side. a. I and III only b. II and III only c. III and IV only d. I, III, and IV only ANS: D

With congenital diaphragmatic hernia, the herniated contents cause compression of the developing ipsilateral lung bud. The contralateral lung may be compressed as well from shifting of the mediastinum. The lung tissue is hypoplastic, including the pulmonary vasculature, even on the contralateral side. Histologic studies demonstrate increased musculature in the media of the arterioles.

REF: p. 458 11. Which of the following conditions is consistent with the presence of a scaphoid abdomen in a

newborn with tachypnea? a. Neonatal pneumonia b. Congenital diaphragmatic hernia c. Tracheoesophageal fistula d. Esophageal atresia ANS: B

Infants with congenital diaphragmatic hernia (CDH) usually develop respiratory distress shortly after birth. The diagnosis of CDH is confirmed by chest radiography but is suggested in a tachypneic newborn with a scaphoid abdomen.

REF: p. 458 12. Which of the following interventions are used to treat congenital diaphragmatic hernia?

I. High-frequency oscillatory ventilation II. Gastrointestinal tract decompression III. Bag-mask ventilation immediately after birth IV. Thoracostomy tube insertion if necessary

a. b. c. d.

I and III only II and IV only I, II, and IV only II, III, and IV only

ANS: C

After the diagnosis of congenital diaphragmatic hernia is made, the following interventions are implemented: 1. A large orogastric tube is placed to decompress the gastrointestinal tract.

2. Bag-mask ventilation is avoided to keep the stomach in the chest from becoming distended and causing tension pneumothorax pathophysiology.

3. An endotracheal tube is inserted, and the infant is mechanically ventilated, avoiding high airway pressures.

4. Barotrauma may be avoided by using high-frequency oscillatory ventilation.

5. Maintaining alkalosis reduces the amount of pulmonary vasospasm. Traditionally, PaCO2 values were kept between 25 and 30 mm Hg, but more recently a protocol of “permissive hypercapnia” with increased PaCO2 and decreased pH values seems to be safe.

6. If a pneumothorax is seen, chest tube placement is indicated. The pneumothorax is seen on the contralateral side and results from excessive ventilation pressures.

REF: p. 459 13. After surgical repair of a congenital diaphragmatic hernia, what is the potential problem

generated by the rapid shift of the contralateral lung and mediastinum? a. Inducing a pneumothorax b. Causing pulmonary edema c. Rupturing vascular structures d. Tearing the sutured diaphragm on the ipsilateral side ANS: C

Too rapid a shift of the mediastinum and contralateral lung may cause lung rupture or obstruct the vascular structures.

REF: p. 459 14. What is the most common patient complaint associated with pectus carinatum? a. Cough b. Dyspnea at rest c. Cosmetic d. Cardiac palpitations ANS: C

This defect, which accounts for 5% of chest wall deformities, is the opposite of pectus excavatum. Pectus carinatum is usually seen later in life around a growth spurt. The protrusion is most commonly located on the lower sternum. Because the sternum is protruded, the underlying structures are not compressed.

REF: p. 460

15. Why is pulmonary development often stifled in children who have asphyxiating thoracic

dystrophy? a. Because of gas exchange problems b. Because the chest cavity is decreased c. Because the thorax is too compliant d. Because of a hypoplastic right ventricle ANS: B

Asphyxiating thoracic dystrophy, also known as Jeune’s syndrome, is a rare genetic disorder with an autosomal recessive inheritance pattern. This disorder is an osteochondrodystrophy that may have mild to severe expression. The chest cavity is decreased in both the anteroposterior and superior and inferior orientations. Pulmonary development is often blunted because of decreased cavity size, and postpartum the lungs are not able to fully expand. Multiple associated defects including polydactyly, hypoplastic iliac wings, and fixed clavicles may be seen.

REF: p. 460 16. Which of the following patterns are commonly found in the presentation of lung bud

anomalies?

I. Appear early in the newborn period II. Emerge later in childhood III. Frequent respiratory infections IV. Systemic hypertension a. I and III only b. II and III only c. II and IV only d. I, II, and III only ANS: D

Although lung bud anomalies have exceptionally different histopathologies, patterns in clinical presentation are common to all. The presentation seems to follow two distinct patterns: (1) the condition becomes obvious in the early newborn period and is manifested by respiratory distress; and (2) the condition occurs later in childhood and is characterized by repeated infections.

REF: p. 460 17. Which of the following conditions is the best explanation for the presentation of symptoms

beyond infancy in patients with bronchogenic cysts or congenital cystic adenomatoid malformations? a. Compromised immune system b. Administration of antibiotics against resistant strains c. Noncompliance with prescribed medications and bronchial hygiene techniques d. Lack of communication between cysts and the tracheobronchial tree ANS: D

After infancy the most common presentation is with repeated or prolonged episodes of pneumonia despite adequate antibiotic coverage. The infectious course arises because the contents of the cyst do not communicate with the tracheobronchial tree, allowing bacteria and debris to accumulate in the cyst. This material cannot be evacuated and acts as a nidus for infection, which often spreads to adjacent healthy tissue and lymph nodes in the hilum of the involved lung. Thus, a small infected cyst can result in pneumonia with fever and purulent cough. Although antibiotics are helpful, they are not curative, and the underlying cause, that is, the cyst, must be resected to prevent recurrence of pulmonary infections.

REF: p. 462 18. A newborn presents with respiratory distress and has a chest radiograph that reveals a circular

or ovoid mass with smooth edges. Which of the following lung bud anomalies is consistent with these clinical features? a. Bronchogenic cysts b. Congenital cystic adenomatoid malformations c. Pulmonary sequestration d. Congenital lobar emphysema ANS: A

The diagnosis of a bronchogenic cyst may be apparent radiographically in the newborn with respiratory distress where the radiograph reveals a circular or ovoid mass with smooth edges.

Similarly, the radiograph can suggest the diagnosis in an older child who presents with stridor, wheezing, or recurrent pneumonia.

REF: p. 463 19. What is a possible consequence of inadvertent rupture of the systemic arterial supply in cases

of pulmonary sequestration when this supply arises directly from the aorta? a. Hypoxemia b. Pulmonary hypoperfusion c. Significant blood loss or exsanguination d. Decreased anatomic shunt ANS: C

If a sequestration is suspected, an arteriogram can be diagnostic and helpful to define the arterial anatomy, which is crucial to successful resection. The systemic arterial supply may arise directly from the aorta, at times even through the diaphragm from the intra-abdominal aorta. Injury or inadvertent division of this vessel without proper control may result in a hemorrhagic catastrophe.

REF: p. 464 20. An infant presents with abdominal distension, intolerance to feeding, rectal bleeding, and

abdominal wall erythema. Laboratory findings include thrombocytopenia, neutropenia, and metabolic acidosis. An abdominal radiograph reveals distended loops and pneumatosis intestinalis. Which of the following conditions is consistent with these findings? a. Necrotizing enterocolitis b. Gastroschisis c. Omphalocele d. Umbilical coelom

ANS: A

Infants with NEC will present with abdominal distension, intolerance to feeds, rectal bleeding, and abdominal wall erythema. Laboratory values include thrombocytopenia, neutropenia, and metabolic acidosis. Severe acidosis may require intubation and mechanical ventilation. The diagnosis is confirmed radiographically. Distended loops will be seen and pneumatosis intestinalis is pathognomonic. Air may be seen in the portal system as well.

Pneumoperitoneum confirms a perforated viscus necessitating operation.

REF: p. 466

Chapter 24: Congenital Cardiac Defects Test Bank MULTIPLE CHOICE 1. Which of the following vessels return blood to the right ventricle?

I. Pulmonary vein II. Inferior vena cava III. Superior vena cava IV. Coronary sinus a. I and IV only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: D

To understand the normal anatomy of the heart, one can trace the path of blood as it travels through the heart. This begins with deoxygenated venous blood that enters the right atrium (RA) from one of three sources. Venous blood from organs superior to the heart drains to the RA by way of the superior vena cava (SVC). Venous blood from organs inferior to the heart enters the RA via the inferior vena cava (IVC). Finally, venous blood from the heart itself drains into the RA by way of the coronary sinus.

REF: p. 471 2. At birth, what factor causes dilation of the pulmonary vascular bed and a decrease in the

pulmonary vascular resistance? a. Increased arterial partial pressure of oxygen (PaO2) b. Decreased arterial partial pressure of carbon dioxide (PaCO2) c. Lung inflation d. Circulating indomethacin ANS: A

With inflation of the lungs and the beginning of their participation in gas exchange, PaO2 increases and PaCO2 decreases, both of which contribute to dilation of the pulmonary vasculature and a resultant reduction in pulmonary vascular resistance (PVR). This leads to reduced right ventricular pressures and increased pulmonary blood flow.

REF: p. 472 3. What factor is responsible for closure of the foramen ovale? a. Increased PaO2 b. Increased pressure on the left side of the heart c. Blood flowing through the lungs d. High pulmonary vascular resistance ANS: B

The increased fetal blood flow that results from the drop in PVR increases pulmonary venous blood return and, therefore, increases the left atrial pressure. At the same time, the RA pressure decreases when the umbilical cord is ligated and no longer provides placental blood flow to the IVC. The result of the higher LA pressures and the lower RA pressures is the closure of the foramen ovale.

REF: p. 472 4. For which of the following congenital cardiac defects may spontaneous closure of the ductus

arteriosus be catastrophic?

I. Tetralogy of Fallot with pulmonary atresia II. Atrial septal defect III. Severe coarctation of the aorta IV. Hypoplastic left heart syndrome a. I and III only b. III and IV only c. I, II, and IV only d. I, III, and IV only ANS: D

Shunting is potentially harmful, either due to prolonged cyanosis and decreased end organ oxygen delivery, or to increased PVR over time. However, shunting also has an important compensatory effect in patients with obstructed pulmonary or systemic blood flow. In these lesions, referred to as ductal-dependent lesions, the presence of a PDA provides lifesaving blood flow. Lesions with systemic outflow tract obstruction, such as critical coarctation of the aorta or hypoplastic left heart syndrome, rely on the PDA to provide systemic blood flow via a right-to-left shunt; these lesions have ductal-dependent systemic blood flow. With both rightto-left shunt (cyanotic cardiac defect) and left-to-right shunt (acyanotic cardiac defect), several lesions depend on a patent ductus arteriosus for adequate pulmonary and systemic blood flow. These anomalies are also called ductal-dependent lesions because spontaneous closure of the ductus arteriosus can prove catastrophic. Anomalies included in this group are severe coarctation of the aorta, hypoplastic left heart syndrome, and tetralogy of Fallot with pulmonary atresia.

REF: p. 472 5. How should the therapist interpret a preductal-to-postductal PaO2 difference of 8 mm Hg in a

neonate? a. Unreliable data b. Absence of ductal shunting c. Presence of ductal shunting d. Inconclusive data ANS: B

Clinical signs of a PDA depend on the degree of left-to-right shunting but may include tachypnea and a continuous murmur. In addition to signs on exam, one can detect the presence of shunting by looking for a difference in oxygenation of preductal and postductal blood. A preductal blood gas should be obtained from the right radial or temporal artery, while a postductal gas may be obtained from the umbilical artery or from a peripheral artery in the lower extremity. A difference in PaO2 > 15 mm Hg indicates significant shunting across the PDA. REF: p. 473 6. Which of the following methods is involved in the management of a PDA? a. Increasing the circulating volume b. Maintaining/optimizing the hematocrit at the low end of normal hemoglobin level c. Administering indomethacin d. Administering digoxin ANS: C

Medical management includes maintaining euvolemia and by optimizing the hemoglobin to ensure adequate oxygen delivery. In mechanically ventilated patients, increasing PEEP may serve to decrease the pulmonary blood flow by increasing PVR. In addition nonsteroidal antiinflammatory agents such as indomethacin and ibuprofen are often used in the medical management of PDA. Indomethacin may be used prophylactically to prevent PDA and therapeutically to treat a symptomatic PDA. A dose of indomethacin (0.2 mg/kg/dose IV) given in the first 24 hours of life can be effective in preventing a PDA. Therapy later in life is usually given over a 48-hour period. Doses of 0.1 to 0.2 mg/kg/dose IV every 12 to 24 hours are effective. Side effects are uncommon but include oliguria, renal insufficiency, and dilutional hyponatremia. Ibuprofen may also be used, though a recent meta-analysis found that the use of ibuprofen was associated with increased incidence of chronic lung disease when compared to indomethacin.

REF: p. 473 7. Which of the following clinical manifestations is consistent with an atrial septal defect

(ASD)? a. An ASD often causes congestive heart failure (because of decreased pulmonary blood flow). b. The right ventricle may become hypertrophic (right ventricular hypertrophy). c. Most patients with an ASD are symptomatic in the neonatal intensive care unit, presenting with right atrial enlargement. d. Chest radiographs are usually abnormal.

ANS: B

The pathophysiology of an ASD involves left-to-right shunting, leading to right atrial enlargement, right ventricular volume overload, and increased pulmonary blood flow. Over time this may result in right ventricular hypertrophy, congestive heart failure, and pulmonary vascular disease. Infants with ASDs rarely are symptomatic and may remain so well into adulthood. Only 8% of children with ASDs develop symptoms before 2 years of age. Chest radiographs are typically normal, unless the child has congestive heart failure, which may result in cardiomegaly and prominent pulmonary vascular markings.

REF: p. 473

8. Which of the following clinical pathophysiologic manifestations are consistent with a large

ventricular septal defect (VSD)?

I. The majority of the blood flow is shunted from left right to right left.

II. Shunting typically occurs during ventricular diastole, which causes left atrial enlargement.

III. Chest radiography reveals an enlarged cardiac silhouette and increased pulmonary vascular markings, increasing pulmonary blood flow.

IV. Thickening and fibrosing of the pulmonary veins develop, decreasing pulmonary artery pressure. a. II and III only b. I and IV only c. I, II, and III only d. II, III, and IV only ANS: A

The pathophysiology of VSDs involves left-to-right shunting, left ventricular volume overload, left atrial enlargement, and increased pulmonary blood flow. The size of the defect and the pulmonary vascular resistance determines the amount of shunting, which usually occurs during systole. Large defects may lead to large shunts, sometimes termed nonrestrictive VSDs, and may result in congestive heart failure and pulmonary hypertension.

REF: p. 474 9. Why must supplemental oxygen be judiciously administered to patients with an

atrioventricular canal defect? a. To prevent the development of retinopathy of prematurity b. To avoid oxygen-induced hypoventilation c. To minimize pulmonary vascular dilation d. To reduce oxidative stress ANS: C

Oxygen saturations in these children may be low (75% to 90%) due to venous admixing but are tolerated well by most patients. Supplemental oxygen may be given judiciously, given the potential for oxygen to induce pulmonary vascular dilation and increased pulmonary blood flow.

REF: p. 476 10. Which of the following clinical features characterize a critical aortic stenosis in a neonate? a. Chest radiography reveals pleural effusion and pulmonary engorgement. b. The neonate often has metabolic alkalosis. c. The neonate presents in cardiogenic shock with hypotension. d. These infants are rarely symptomatic during the first month of life.

ANS: C

The clinical presentation and natural history of aortic stenosis is determined by the time of presentation and the degree of stenosis. Neonates who present with critical aortic stenosis frequently present in cardiogenic shock with hypotension, poor perfusion, and metabolic acidosis. The chest radiograph frequently includes cardiomegaly and pulmonary edema.

REF: p. 476 11. Identify the congenital cardiac defect depicted in the following illustration:

a. b. c. d.

Atrial septal defect Hypoplastic left ventricular syndrome Hypoplastic right ventricular syndrome Atrioventricular canal defect

ANS: B

The cardiac anomaly depicted in this question is hypoplastic left ventricular syndrome, which can be viewed in the textbook in Figure 24-8.

REF: p. 478 12. Identify the following congenital cardiac anomaly:

a. b. c. d.

Truncus arteriosus Hypoplastic left ventricle Transposition of the great vessels Ventricular septal defect

ANS: A

The cardiac anomaly depicted in this question is truncus arteriosus, which can be viewed in the textbook in Figure 24-16.

REF: p. 483 13. Which of the following medications is the most common preoperative treatment to minimize

preductal constriction until surgical correction of coarctation of the aorta can be achieved? a. Indomethacin b. Prostaglandin E1 c. Negative inotropes d. Diuretics ANS: B

Treatment of neonates with severe coarctation includes prostaglandin E1 to restore patency of the ductus arteriosus. These patients may also have significant ventricular dysfunction, congestive heart failure, and acidosis, requiring inotropes, diuresis, and ventilatory support.

REF: p. 477 14. Which of the following physiologic mechanisms need to be in place to ensure adequate

systemic perfusion in infants with HLHS? a. Presence of an ASD b. Presence of a mitral regurgitation c. Adequate left atrial function d. Presence of a PDA ANS: D

Adequate systemic perfusion in these infants depends on the presence of a nonrestrictive atrial septal connection, adequate right ventricular function, a patent ductus arteriosus, and a balance between the pulmonary and systemic circulations.

REF: p. 478 15. Which of the following strategies can be used to increase PVR in infants with HLHS? a. FiO2 < 0.21 b. Induce hypocapnia c. Administer indomethacin d. Close the PDA ANS: A

A number of interventions may be employed to balance the systemic and pulmonary circulations. As the PVR decreases, minimizing the amount of administered oxygen can decrease pulmonary vasodilation and pulmonary blood flow. Occasionally, subambient oxygen concentrations (FiO2 < 0.21) are used to increase PVR. Target FIO2s are usually in the 0.17 to 0.21 range in order to keep systemic oxygen saturations 70% to 80%. Hypercarbia can also be utilized to elevate PVR. REF: p. 480 16. What should the therapist select as target gas exchange parameters after surgical intervention

for infants with hypoplastic left ventricular syndrome HLHS? a. pH < 7.35 b. PaO2 of 60 mm Hg and PaCO2 of 60 mm Hg c. pH > 7.45 d. PaO2 of 40 mm Hg and PaCO2 of 40 mm Hg ANS: D

Goal gas exchange in these infants should follow the “rule of forties,” which targets PaO2 approximately 40 mm Hg and PaCO2 40 mm Hg. Any manipulation of the endotracheal tube in these patients should be conducted with caution.

REF: p. 480 17. The therapist is treating a child with TOF who appears to be having a “tet” spell. What should

the therapist suggest to treat this event?

I. Beta blockers II. Knee-chest position to increase SVR III. Morphine sulfate IV. Oxygen a. IV only b. I and III only c. I and IV only d. I, II, III, and IV ANS: D

See Box 24-1 in the text (Treatment of “tet” spells). Knee-chest position increases systemic vascular resistance and promotes blood flow from the right ventricle to the pulmonary artery rather than the aorta. Morphine sulfate decreases irritability and may lead to pulmonary artery dilation, which will increase pulmonary blood flow. Oxygen improves oxygenation and decreases pulmonary vascular resistance. Beta blockers (propranolol) may relax RVOT spasms. Systemic vasoconstrictors (phenylephrine) increase systemic vascular resistance to promote pulmonary blood flow. Sodium bicarbonate, administered to treat acidosis, decreases PVR. REF: p. 483 18. Which of the following congenital cardiac anomalies is classified as conotruncal, associated

with a “boot-shaped” appearance of the heart? a. Tetralogy of Fallot b. Transposition of the great vessels c. Coarctation of the aorta d. Atrioventricular canal defect ANS: A

Chest radiography of patients with TOF classically reveals a “boot-shaped” appearance of the heart, which is a result of the narrow mediastinum and the effects of right ventricular outflow tract obstruction that leads to right ventricular hypertrophy.

REF: p. 482 19. Which of the following statements describe truncus arteriosus?

I. The pulmonary artery arises from the left ventricle, and the aorta stems from the right ventricle.

II. If PVR increases relative to systemic vascular resistance (SVR), more blood flows to the lungs through the truncus, decreasing systemic cardiac output.

III. If SVR decreases relative to PVR, blood flow will be shunted from right to left, bypassing the lungs.

IV. A large VSD allows total mixing of blood from the two ventricles. a. I and III only b. II and IV only c. I, II, and IV only d. I, III, and IV only ANS: D

Truncus arteriosus refers to a rare defect where a single great artery arises from the ventricles of the heart, supplying the systemic, pulmonary, and coronary arteries (see Figure 24-18 in the textbook). A large VSD allows complete mixing of blood in the ventricles. The blood passes through a truncal valve before passing into the common truncus. The cardiac output and systemic oxygen saturations are determined by the balance between PVR and SVR. As PVR drops in the first several days of life, more blood flows to the lungs relative to the body, resulting in decreased systemic perfusion. If SVR decreases, blood will flow more to the body, leading to decreased pulmonary blood flow and hypoxemia.

REF: p. 483

20. Which of the following blood flow patterns occurs in complete transposition of the great

arteries? a. The systemic venous blood passes through the right heart chambers. b. The pulmonary venous blood traverses the left side of the heart and then returns to the systemic circulation. c. When PVR increases relative to SVR, blood flow increases through the ductus arteriosus. d. Systemic venous blood flows to the lungs after leaving the right ventricle.

ANS: A

In TGA the positions of the aorta and the pulmonary artery are reversed, with the aorta arising from the RV and the pulmonary artery arising from the LV (see Figure 24-17 in the textbook).

The physiologic result is that the two circulations are in parallel rather than in series with each other. Deoxygenated systemic venous blood passes through the right heart and to the body without flowing through the lungs. Oxygenated pulmonary venous blood passes through the left heart and back to the lungs without flowing to the body. Survival depends on mixing at one or more points in the circulation. The potential sites for mixing of blood are ASDs, VSDs, or the PDA. REF: p. 484 21. The therapist is treating a child with a congenital heart defect who is unresponsive to oxygen

therapy. Although the chest X-ray is relatively normal, the heart is described as “egg-shaped.”

Which of the following heart defects is more consistent with this description? a. Complete transposition of the great arteries b. Coarctation of the aorta c. Truncus arteriosus d. Tetralogy of Fallot ANS: A

The main clinical sign of TGA is cyanosis that is not responsive to oxygen therapy. Chest radiography of TGA is frequently normal, though the cardiac silhouette may have the classic “egg on a string” appearance.

REF: p. 484 22. The therapist is setting pulse oximetry to determine the presence of right-to-left shunt in an

infant suspected of having a heart defect. Where should the therapist place the pulse ox probe to obtain the most accurate measure of preductal oxygen saturation? a. Any finger of the right hand b. Any finger of the left hand c. Left earlobe d. Lower extremities ANS: A

Pulse oximetry is a fundamental monitoring device in children with congenital heart disease.

In addition to measuring systemic oxygenation, it can also be used to measure the degree of right-to-left shunting in lesions where this is a possibility. This is done by measuring preductal and postductal saturations. Preductal saturations are measured by placing the pulse oximeter on the right upper extremity. Postductal saturations are reflected by placing the pulse oximeter on any other extremity, though the lower extremities are preferred as preductal and postductal blood may be incompletely mixed at the left upper extremity. If postductal saturations are 5% to 10% lower than preductal saturations, then right-to-left shunting should be suspected.

REF: p. 487 23. A therapist monitoring an infant after a Blalock-Tausig shunt placement notices a significant

drop in the end-tidal carbon dioxide (ETCO2) despite no changes in the infant’s respiratory rate. How should the therapist interpret this change? a. The infant has dramatically improved ventilation by breathing deeply. b. The ETCO2 monitor is not accurate. c. Loss of pulmonary blood flow through the shunt d. Tricuspid regurgitation ANS: C

The magnitude of the ETCO2 tracing may be used as a surrogate of efficacy of cardiopulmonary resuscitation (CPR). Finally, in children with a Blalock-Taussig shunt, a precipitous drop in the ETCO2 may indicate a loss of pulmonary blood flow due to shunt thrombosis.

REF: p. 488 24. When using subambient oxygen therapy, what range of oxygen saturations should the

therapist target? a. >95% to 95% b. 85% to 90% c. 75% to 85% d. 70% to 80% ANS: C

When using this setup, special care must be taken in order to avoid inadvertent delivery of low oxygen. A continuous oxygen analyzer must be placed in the line with alarms for high and low levels of oxygen. Another safeguard that may be employed is requiring two clinicians to check the setup before applying it to the patient. Typically clinicians target oxygen saturations of 75% to 85%, utilizing an FiO2 as low as 0.16 to 0.17.

REF: p. 490

Chapter 25: Sudden Infant Death Syndrome & Sleep Disorders Test Bank MULTIPLE CHOICE 1. The mother of an 11-month-old infant suspected of suffering from sleep-disordered breathing

reports that her child sleeps 15 hours per day. What should the therapist tell her regarding the sleep duration of her infant? a. The sleep duration is consistent with the infant’s age. b. The sleep duration is consistent with an infant in the first 24 hours of life. c. The sleep duration is consistent with a that of a 10-year-old child. d. The sleep duration is consistent with a midadolescent child.

ANS: A

Refer to Box 25-1 in the textbook (Sleep Duration by Age). Full-term Infant:16 to 18 hours; 1 year: 15 hours; 2 years: 13 to 14 hours; 4 years: 12 hours; 10 years: 8 to10 hours; midadolescence: 8.5 hours; later adolescence: 7 to 8 hours.

REF: p. 494 2. Which age group is more often affected by periodic breathing? a. Newborns b. Infants c. Children d. Adults ANS: D

Periodic breathing, a breathing pattern also common in infants, may be defined as a pattern of cycles of rapid breathing followed by pauses greater than 3 seconds in duration.

REF: p. 494 3. A 28-week-gestation newborn is demonstrating periods of apnea. In addition to ventilatory

support, what other treatment can the therapist suggest? a. Placement of an oropharyngeal airway b. Caffeine c. Theophylline d. Beta blockers ANS: B

Apnea of prematurity (AOP) is often treated with caffeine, which is thought to stimulate the respiratory centers.

REF: p. 495 4. Which of the following statements best describes central sleep apnea? a. Absence of respiratory effort and airflow b. Only abdominal movements occur with no airflow. c. Only thoracic movements occur. d. Paradoxical breathing movements occur.

ANS: A

In central sleep apnea (CSA) there is an absence of respiratory effort and airflow.

REF: p. 495 5. What is the leading cause of death in infants? a. Congenital malformations (e.g., heart defects) b. CSA c. SIDS d. ALTE ANS: C

Sudden infant death syndrome (SIDS) is a devastating event that accounted for 2226 infant deaths in 2009. It is the leading cause of death in infants in the first 12 months of life and is the third leading cause of death in infants overall in the United States.

REF: p. 495 6. According to the American Academy of Pediatrics, in addition to cessation of breathing,

which of the following clinical signs is associated with central sleep apnea? a. Tachycardia b. Cyanosis c. Hypertension d. Hypertonia ANS: B

The American Academy of Pediatrics defined CSA as "an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia.”

REF: p. 495 7. Which of the following statements best describes the condition sudden infant death syndrome

(SIDS)? a. More than 70% of victims are found in the late evening hours after the afternoon naps. b. Infants are most likely to experience SIDS in the first 12 to 24 months of life. c. SIDS is uncommon after infants are 6 months old. d. SIDS occurs exclusively when the infant is presumed to have been asleep during the night.

ANS: C

SIDS almost always takes place when the infant is presumed to have been asleep, either during the day or night. However, more than 70% of its victims are found in the early morning hours after the nighttime sleep. The incidence peaks in infants from 2 to 4 months of life (see Figure 25-2 in the textbook). This period of time coincides with significant changes known to occur in sleep organization and in the modulation of brainstem centers involved in respiratory and arousal state control. SIDS is uncommon after 6 months of age, with 90% of SIDS victims affected in the first 6 months of life. It is rare after the first birthday.

REF: p. 495

8. Which of the following risk factors are associated with SIDS?

I. Maternal cigarette smoking II. Breastfeeding III. Loose bedding IV. Bed sharing a. I and III only b. I, II, and III only c. I, II, and IV only d. I, III, and IV only ANS: D

There are other risk factors that may be modified to reduce the incidence of SIDS. Maternal cigarette smoking during pregnancy has been found to be a major risk factor for SIDS and appears to be dose dependent. Postnatal exposure to cigarette smoke further increases the risk.

Some studies have found breastfeeding to be partly protective against SIDS, but this finding has been inconsistent. Overheating and loose bedding have both been associated with SIDS. Bed sharing has been shown to be a hazardous practice. Overlying remains an important cause of unexplained death in infants and should be considered along with other forms of inadvertent suffocation during a death scene investigation. The most effective means of providing a safe sleeping environment is through meticulous risk mitigation. Box 25-3 in the textbook lists additional risk factors.

REF: p. 495 9. While working with a preterm neonate, the therapist notices the infant become apneic,

cyanotic, and hypotonic. Consequently, the therapist nudges and stimulates the infant. On the basis of this scenario, what type of episode has occurred? a. Sudden infant death syndrome b. An apparent life-threatening event c. A resuscitative event d. An epileptiform activity ANS: B

An Acute Life-Threatening Event (ALTE) is defined as “an episode that is frightening to the observer and is characterized by some combination of apnea (central and occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging.”

REF: p. 495 10. Which of the following body systems is the most important to evaluate when considering

differential diagnoses for ALTE? a. Gastrointestinal b. Neurologic c. Respiratory d. Cardiac ANS: A

Box 25-4 in the textbook (Differential Diagnosis of ALTE). Gastrointestinal (50%), neurologic (30%), , respiratory (20%), cardiac (5%), metabolic disease (under 5%).

REF: p. 498 11. Which of the following conditions is the major cause of OSA in children without any

predisposing factor? a. Choanal atresia b. Macroglossia c. Adenotonsillar hypertrophy d. Pierre Robin Syndrome ANS: C

The major cause of OSA in children without another predisposing condition (see Box 25-6 in the textbook) is adenotonsillar hypertrophy.

REF: p. 498 12. What is the age group with the highest prevalence of OSA? a. First 6 months b. 6 months to 1 year c. 1 to 2 years d. 2 years to 8 years ANS: D

It may occur in children of all ages but the prevalence peaks between 2 and 8 years of age, which coincides with the time at which the size of the tonsils is at its peak relative to the upper airway size.

REF: p. 499 13. Which of the following are typical features of the obstructive hypoventilation syndrome?

I. Disruption of sleep architecture II. Degradation of sleep quality III. Abnormal gas exchange IV. Significant daytime symptoms a. I and III only b. II and IV only c. I, II, and IV only d. I, II, III, and IV ANS: D

Obstructive hypoventilation (obstructive hypopnea) may occur in the absence of complete obstruction of the airway and cessation of airflow. These sleep-related events lead to disruption of sleep architecture, degradation of sleep quality, and gas exchange abnormalities that may cause significant daytime symptoms.

REF: p. 500 14. The childhood syndrome of OSA is distinct from adult OSA. Which of the following features

are common in adult OSA but infrequent or less common in pediatric OSA? a. Large neck circumference b. Snoring

c. Excessive daytime sleepiness d. REM abnormality ANS: C

While obesity and excessive daytime sleepiness are common in adult patients with OSA, they are infrequent or less common in pediatric patients with OSA. Refer to Box 25-5 in the textbook for more details.

REF: p. 499 15. Which of the following are typical daytime symptoms associated with SDB in children?

I. Poor school performance II. Hypoactivity III. Inattention IV. Passive behavior a. I and III only b. II and IV only c. I, II, and IV only d. I, II, III, and IV ANS: A

Daytime symptoms include poor school performance, hyperactivity, and inattention or aggressive behavior.

REF: p. 500 16. A 7-year-old child was diagnosed with OSA due to tonsillar hypertrophy. Although

adenotonsillectomy was performed, the child continues having daytime sleepiness and poor school performance. What should the therapist suggest at this time? a. Consider uvulectomy. b. Administer antireflux medications. c. Perform allergy tests to confirm that airway obstruction is due to other clinical condition. d. Provide continuous positive airway pressure.

ANS: D

Continuous positive airway pressure (CPAP) is the treatment of choice in patients who either are not a suitable candidate for surgery or have persistent SDB. REF: p. 500

Chapter 26: Pediatric Airway Disorders and Pulmonary Infections Test Bank MULTIPLE CHOICE 1. Relative to an adult’s larynx, where is an infant’s larynx situated? a. C1-2 b. C2-3 c. C3-4 d. C4-5 ANS: C

The epiglottis is long, floppy, and angled away from the tracheal axis. It shrouds the laryngeal opening because of poor support by the surrounding tissues. Structurally, the infant’s larynx is positioned higher in the neck (near C3-4) compared with an adult’s larynx (at C4-5). Because of this superior location, the tongue base tends to “hide” the larynx from view during direct laryngoscopy.

REF: p. 506 2. Why does a respiratory syncytial viral infection have little adverse effect on an older child but

is often life threatening to a younger child? a. The older child has a better developed immune system. b. The younger child has a less effective cough mechanism. c. The older child has a better developed mucociliary escalator. d. The younger child has fewer respiratory bronchioles.

ANS: D

Because of the developmentally small airway cross-sectional area, small amounts of inflammation at the level of the respiratory bronchioles can result in severe respiratory embarrassment. In young children the respiratory bronchioles are commonly attacked by viruses, such as respiratory syncytial virus (RSV), resulting in respiratory failure. The same infection will have little or no respiratory effect on an adult or older child with a larger number of terminal airways.

REF: p. 507 3. As the therapist auscultates over an infant’s larynx, he hears a very low-pitched sound. On the

basis of this finding, what impression is he likely to have regarding the nature of the upper airway obstruction? a. Mild obstruction b. Moderate obstruction c. Severe obstruction d. Complete obstruction ANS: A

Auscultation of air movement during inspiration and expiration aids in determining the severity and location of the obstruction. The pitch of the stridor can be used to assess improvement or worsening of the obstruction. Low-pitched sounds signify mild obstruction, whereas a higher pitch indicates that the child is in more distress and is attempting to generate a higher air flow rate.

REF: p. 508 4. Why does an infant’s respiratory distress from choanal atresia seem to lessen when the infant

cries? a. Because the anterior nares widen more b. Because the infant breathes more through the mouth c. Because the infant is able to generate a stronger inspiratory effort d. Because accessory muscles of ventilation help stabilize the chest wall ANS: B

Choanal atresia, the stenosis or absence of the nasal passages (choanae), typically presents in the immediate postnatal period. The infant presents with severe respiratory distress that appears to lessen with crying, when the infant manages to exchange air through the mouth, and is exacerbated again once the crying stops.

REF: p. 508 5. A 30-month-old child is brought to the emergency room (ER) by the parents. The child

appears to have a sore throat along with dysphagia, fever, and voice changes. The child exhibits “hot potato voice.” Visualization of the posterior pharynx reveals a displaced retropharynx. What condition does this child likely have? a. Peritonsillar abscess b. Retropharyngeal abscess c. Tonsillar enlargement d. Pierre Robin syndrome ANS: B

Retropharyngeal abscess commonly occurs in children younger than 3 years of age and can cause obstruction from forward displacement of the posterior pharyngeal wall. Infectious agents involved are Group A Streptococcus, Staphylococcus aureus, and, occasionally, anaerobic bacteria. The child often presents with a sore throat, fever, dysphagia, and voice changes. The voice sounds as if the child is attempting to speak without moving the tongue while maximally expanding the oropharyngeal airway. This is described as “hot potato voice.”

A lateral neck radiograph is obtained to determine the tissue thickness surrounding the abscess. Visualization of the posterior pharynx may reveal a displaced retropharynx. Surgical drainage is the preferred treatment, along with administration of appropriate antibiotics based on culture results of the aspirated material.

REF: p. 509

6. A 4-year-old child is brought into the emergency room (ER) by her parents, who state that an

abrupt high fever developed along with a severe sore throat, dysphagia with drooling, and cough. In the ER the girl exhibits stridor, muffled voice without hoarseness, air hunger, and cyanosis. She also has suprasternal, substernal, and intercostal retractions, with nasal flaring, bradypnea, and dyspnea. The child is sitting upright with her chin thrust forward and her neck hyperextended in a tripod position. What condition is she likely exhibiting? a. Laryngotracheobronchitis b. Tracheomalacia c. Bacterial tracheitis d. Epiglottitis ANS: D

Onset of bacterial epiglottitis is usually abrupt and associated with high fever; severe sore throat; dysphagia with drooling; cough, progressing rapidly over a few hours to stridor; muffled ("hot potato") voice without hoarseness; air hunger; and cyanosis. Suprasternal, substernal, and intercostal retractions, along with nasal flaring, bradypnea, and dyspnea, are frequently displayed. The child assumes a characteristic position of sitting upright with the chin thrust forward and with the neck hyperextended (sniffing position) in a tripod position.

The streptococcal variant of epiglottitis may be associated with a longer prodrome lasting more than 24 hours.

REF: p. 510 7. A 10-month-old child has been brought into the emergency room (ER) by her parents, who

state that after few days with low-grade fever, malaise, and rhinorrhea, their child presented with a “barking” cough and increased work of breathing. What condition is this child likely exhibiting? a. Epiglottitis b. Laryngotracheobronchitis (LTB) c. Bronchitis d. Bronchiolitis ANS: B

The child with LTB presents with a gradual prodrome of low-grade fever, malaise, rhinorrhea, and hoarse voice. Over several days the illness progresses to inspiratory stridor and a “barky” cough, often described as sounding like the bark of a seal. Physical examination reveals nasal flaring, nasal congestion, use of accessory muscles, and suprasternal, subcostal, and intercostal retractions that, along with the stridor, become worse when the child is agitated.

REF: p. 511 8. Which of the following lateral neck radiographic presentations is characteristic of

laryngotracheobronchitis?

a. b. c. d.

Posterior pharyngeal shadow Thumb sign Steeple sign Penumbra effect

ANS: C

A lateral neck radiograph, sometimes obtained to help differentiate laryngotracheobronchitis from epiglottitis, demonstrates a large retropharyngeal air shadow without epiglottic swelling.

The anteroposterior (A-P) chest radiograph reveals the classic “steeple sign,” a sharply sloped, wedge-shaped, linear narrowing of the trachea. This demonstrates the subglottic tracheal edema that extends from the larynx to the thoracic trachea.

REF: p. 511 9. Which of the following medications should be administered to a 4-year-old child who

develops postextubation stridor? a. Phenylephrine b. Racemic epinephrine c. Prednisolone d. Antibiotics ANS: C

Today, patients are treated with dexamethasone and racemic epinephrine and discharged from the emergency department to home if they are free of intercostal retractions and stridor after a 2-hour waiting period.

REF: p. 512

10. A 3-year-old child has been diagnosed with epiglottitis and was intubated due to severe

respiratory distress. After 24 hours of antibiotics the therapist is considering extubation. What will be an acceptable leak before considering extubation? a. 20 cm H2O b. 21-30 cm H2O c. 31-35 cm H2O d. An audible leak at any pressure level is enough to consider extubation.

ANS: A

Extubation is usually considered within 24 hours when signs of toxicity (e.g., fever) diminish and when an air leak at 20 cm H2O pressure develops around the ETT. REF: p. 511 11. While performing auscultation on a 2-month-old child, the therapist hears wheezes equal in

pitch across all regions of the chest; however, they seem loudest in the vicinity of the sternum.

From which of the following anatomic structures is the wheezing likely originating? a. Trachea b. Terminal bronchioles c. Segmental bronchi d. Alveoli ANS: A

Discerning where the wheezes originate in a small child is often difficult. Wheezes that remain equal in pitch across all regions of the chest but are heard loudest around the sternum most likely have originated in the trachea. Larger bronchial lesions produce similar manifestations but are more localized to the side of the lesion.

REF: p. 513 12. Tracheomalacia is a condition of dynamic tracheal collapse. Which of the following injurious

events can be associated with this condition? a. Neonatal ventilation with high pressures b. Excessive use of racemic epinephrine c. Tracheal trauma due to CPT d. Neonatal ventilation with high oxygen concentrations ANS: A

Common injurious events include neonatal ventilation with high pressures, chronic trauma to the trachea from a malpositioned ETT or aggressive endotracheal suctioning, and external compressive structures, such as a vascular ring.

REF: p. 513 13. An 11-month-old child has been treated with bronchodilators for persistent wheezing without

a positive clinical response. Which of the following conditions should the therapist suspect? a. Bronchitis b. Aspergillosis c. Bronchiolitis d. Endobronchial compression ANS: D

The diffuse, chronic wheeze associated with these disorders is often confused with asthma.

Endobronchial compression is suspected in an infant or child with persistent wheezing that does not respond to bronchodilator therapy.

REF: p. 514 14. A therapist has been asked to evaluate a child suspected of having foreign body aspiration.

Which of the following clinical conditions would guide the therapist to the diagnosis? a. Recurrent bronchitis b. Wheezing partially responsive to bronchodilators c. Unilateral wheezing d. Stridor ANS: C

Signs and symptoms of foreign body aspiration vary with the location of impaction and the degree of airway obstruction. They can range from unilateral wheezing or recurrent pneumonia, as when peanuts or popcorn obstruct the smaller airways, to immediate occlusion of the upper airway with complete absence of air movement and rapid death from suffocation, as seen in hot dog or balloon aspiration fatalities. It is not necessary for the foreign body to be in the trachea: a big enough object stuck in the esophagus can elicit very similar symptoms of respiratory distress.

REF: p. 514 15. Which of the following radiographic techniques is best for determining the presence of a ball-

valve type obstruction? a. A standard portable A-P chest X-ray b. A lateral neck radiograph c. Either a right or left lateral decubitus film d. Inspiratory and expiratory A-P chest X-rays ANS: D

Asymmetric lung hyperinflation can result from a ball-valve effect of foreign material localized in a major bronchus. This defect is most often apparent on an expiratory film.

Comparison between expiratory and inspiratory films can also yield the diagnosis but depends greatly on the cooperation of the child.

REF: p. 515 16. The therapist is evaluating a child in the emergency department who displays the following

signs: inability to cry, ineffective cough, high-pitched inspiratory sound, and cyanosis. What should the therapist suspect? a. Tracheomalacia b. Severe or complete airway obstruction c. Vascular ring d. Status asthmaticus ANS: B

Pediatric Advanced Life Support (PALS) guidelines state that signs of severe or complete airway obstructions that require intervention are: inability to speak or cry audibly; weak, ineffective cough; high-pitched sound or no sound during inhalation; increased difficulty breathing with distress; cyanosis; and universal choking sign (thumb and index finger clutching neck).

REF: p. 515 17. The therapist has been asked to evaluate the chest radiograph of a 3-month-old boy with

atelectasis. Which pulmonary lobe has the greatest tendency to collapse in young infants? a. RUL b. RML c. Lingula d. LUL ANS: B

The right middle lobe, which has the poorest collateral air circulation and smallest bronchial opening of the major lung segments, is particularly prone to mucus plugging and collapse.

Intubated patients, particularly young infants, have a propensity toward right upper lobe collapse. This is most likely related to their supine positioning and tendency toward obstruction of the right upper lobe bronchus (the most proximal of all the lobar bronchi) by a migrating ETT. REF: p. 516 18. In the ER, a chest radiograph reveals dilation of the segmental and subsegmental bronchi. The

patient complains of expectorating copious amounts of thick mucus and frequent lung infections over the last year. Which of the following conditions does this child likely have? a. Atelectasis b. Bronchiectasis c. Foreign body aspiration d. Postoperative laryngotracheobronchitis ANS: B

Bronchiectasis is defined as irreversible dilation of the bronchial tree. Typically, the segmental and subsegmental bronchi become irregularly shaped and dilated, leading to a loss of the typical funnel configuration that allows smooth central flow of secretions. Additionally, ciliary activity in the area of the dilation is inadequate and further contributes to the difficulty in mobilizing secretions. The secretions become infected as they pool. The lower lobes, particularly the left lower lobe, are most frequently involved.

REF: p. 517 19. A 3-year-old child has the following clinical presentations in the ER:

Profound nasal congestion and productive cough Chest auscultation revealing diffuse coarse, “sticky” crackles (sounding like Velcro) Chest radiograph revealing lung hyperinflation with flattened hemidiaphragms What pulmonary condition does this infant likely have? a. Bronchiectasis

b. Primary ciliary dyskinesia c. Supralaryngeal obstruction d. Bronchiolitis ANS: D

Physical findings vary considerably with the patient’s age. Infants (younger than 1 year) develop coryza, cough, respiratory distress, wheezing, and tachypnea. The symptoms of infection usually peak at about 48 to 72 hours, and a previously healthy infant can progress from what was thought to be a simple cold to severe respiratory distress during that time. In contrast, the principal symptoms in children older than 2 years of age include profound nasal congestion and productive cough. Chest auscultation reveals diffuse coarse, “sticky” crackles (sounding like Velcro) that may be accompanied by wheezes. A chest radiograph typically reveals intense lung hyperinflation with flattened hemidiaphragms (obstructive), with occasional films showing evidence of collapse or consolidation.

REF: p. 518 20. An 18-month-old child has been admitted with a diagnosis of bronchiolitis due to RSV. The

therapist has administered a single dose of albuterol and racemic epinephrine, but the child shows no signs of improvement. What should the therapist suggest at this time? a. Alternate albuterol and racemic epinephrine every 4 hours b. Use albuterol every 1 hour for 4 hours and then space treatments to every 4 hours c. Discontinue therapy d. Add an inhaled corticosteroid to the albuterol every 12 hours ANS: C

A single inhalation trial using epinephrine or albuterol can be considered for respiratory distress on an individual basis, such as when there is history of asthma, allergy, or atopy. It is recommended to discontinue inhalation therapy if there is no clinical response such as improved respiratory distress or improved bronchiolitis scores. Nebulized racemic epinephrine demonstrates better short-term improvement in pulmonary physiology and clinical scores but only in the outpatient setting. However, continuation of inhalation therapy despite documented nonresponse exposes the patient to unnecessary therapy and cost.

REF: p. 519 21. Which of the following agents has been shown to significantly reduce bronchiolitis scores? a. Prednisone b. Nebulized 3% hypertonic saline c. Dexamethasone d. Theophylline ANS: B

Nebulized hypertonic saline (3%) is considered an effective and safe treatment for infants with mild-moderate respiratory distress and has been shown to reduce LOS. The optimal treatment regime for nebulized hypertonic saline in the inpatient setting in acute bronchiolitis remains unclear. A recent RCT using Q2 hour hypertonic saline for 3 doses, every 4 hours for 5 doses, and every 6 hours until discharge has shown promising results and is an alternative; however, more evidence is needed on efficacy and dosing regimen. Hypertonic saline therapy significantly reduces bronchiolitis scores (pre/post) in patients with mild-moderate bronchiolitis.

REF: p. 520 22. A child presents to the emergency department with fever, tachypnea, nasal flaring, and

shallow breathing. The physical exam of the chest reveals the presence of crackles, increased tactile fremitus, and dullness to percussion. What should the therapist suspect the diagnosis is? a. Bronchitis b. Bronchiectasis c. Bronchiolitis d. Pneumonia ANS: D

Prodromal symptoms are often nonpulmonary and include headache, fever, malaise, and abdominal pain. Productive cough, with sputum often swallowed, and chest pain during inspiration (pleuritic pain) are common complaints. Physical examination usually reveals nasal flaring, accessory muscle use, intercostal and subcostal retractions, tachypnea, and shallow breathing. Crackles, decreased breath sounds, increased fremitus, and dullness to percussion are often found during auscultation and examination of the chest.

REF: p. 523 23. Diagnosis of TB in children requires which of the following special considerations? a. Three consecutive days of gastric washings b. A positive skin test c. A positive chest X-ray d. One positive respiratory washing ANS: A

Diagnosis in the adult is based on identification of stains of gastric or respiratory washings that have bacteria uniquely resistant to acid decoloration (“acid fast”). In children, owing to the low number of bacilli, 3 consecutive days of gastric washings may increase the sensitivity of this test.

REF: p. 526 24. Which of the following clinical interventions are used to treat complications of sickle cell

anemia?

I. Supplemental oxygen II. Bronchodilators III. Diuretics IV. Red blood cell transfusions a. I and IV only b. II and III only c. I, II, and IV only d. II, III, and IV only ANS: C

Adequate hydration is an essential therapeutic modality and is used cautiously to avoid pulmonary edema. Red blood cell transfusions are provided to improve the ability of hemoglobin to transport oxygen and to reduce the incidence of acute chest syndrome, myocardial ischemia, and sickle cell chronic lung disease. Aerosolized bronchodilators for bronchiole constriction, incentive spirometry, and adequate pain control can be important adjuvants. Supplemental oxygen is used when indicated but, depending on the case, can foster additional sickling. In cases of impending respiratory failure, mechanical ventilation is instituted. Successful treatment of acute chest syndrome with venovenous extracorporeal membrane oxygenation (ECMO) has been reported in patients experiencing life-threatening acute chest syndrome despite maximal conventional ventilation support.

REF: p. 528

Chapter 27: Asthma Test Bank MULTIPLE CHOICE 1. Which of the following types of cells play a role in the pathophysiology of asthma?

I. Mast cells II. Eosinophils III. Neutrophils IV. Basophils a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: C

Many cells and cellular elements play a role in the disease—in particular, mast cells, eosinophils, T lymphocytes, IgE, macrophages, neutrophils, and epithelial cells.

REF: p. 533 2. Which of the following pathophysiologic events are responsible for airway obstruction?

I. Airway remodeling II. Airway edema III. Gas velocity IV. Mucous plugging a. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: C

Airway obstruction is the consequence of six significant components. These include inflammation, acute bronchoconstriction, airway edema, mucous plugging, airway hyperresponsiveness, and airway remodeling.

REF: p. 534 3. Which of the following immunoglobulins has been identified as a key molecule in mediating

allergic asthma and should be measured in serum? a. IgA b. IgE c. IgM d. IgD ANS: B

Asthma has been shown to be predominately allergic in nature with 80% of children and more than 50% of adults with asthma. IgE has been identified as a key molecule in mediating allergic asthma. Total serum IgE levels have been shown to have a close association with selfreported asthma.

REF: p. 533 4. Which of the following events occurs during the first phase of airway inflammation? a. Release of preformed mediators b. Antigen–antibody reactions on the surface of mast cells c. Inhalation of offending antigen d. Bronchial mucosal edema ANS: A

The first phase involves the preformed mediators that are released with degranulation: histamine, heparin, tryptase.

REF: p. 534 5. Persistent inflammation in asthma leads to a remodeling phase that is characterized by which

of the following processes? a. Bronchoconstriction b. Mucous hyporsecretion c. Airway smooth muscle hypertrophy d. Ciliary paralysis ANS: C

Features of airway remodeling include inflammation, mucous hypersecretion, subepithelial fibrosis, airway smooth muscle hypertrophy, and angiogenesis.

REF: p. 534 6. What appears to be the strongest identifiable predisposing factor for developing asthma? a. Atopy b. Genetics c. Socioeconomic status d. Race ANS: A

Atopy seems to be the strongest identifiable predisposing factor for developing asthma, with atopic dermatitis often preceding its onset.

REF: p. 535 7. A 2-year-old child diagnosed with asthma has a family history of frequent respiratory

infections. What is the most common respiratory virus isolated from infants who wheeze? a. Adenovirus b. Parainfluenza virus c. Respiratory syncytial virus (RSV) d. Coxsackievirus ANS: C

RSV is the most common viral respiratory tract pathogen isolated from infants who wheeze.

Many of these infants with severe infection with respiratory syncytial virus develop recurrent wheezing and asthma later in life.

REF: p. 535 8. On the basis of the National Asthma Education and Prevention Program (NAEPP) guidelines,

when a diagnosis of asthma is being made, which of the following criteria are recommended?

I. That the patient be free of any comorbidity II. That a physical examination be performed III. That spirometry is conducted to determine the presence of reversible disease IV. That a detailed medical history be conducted a. I and III only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only ANS: D

The NAEPP guidelines recommend a detailed medical history, physical examination, and spirometry to determine reversible disease. It is also important to determine the severity, control, and responsiveness to therapy to determine the patient's current asthma status. Once a diagnosis has been made, it is important that the clinician use methods (e.g., testing for allergies and determining IgE levels) to identify precipitating factors.

REF: p. 536 9. Which of the following spirometric measurements is sensitive to small changes in airway

caliber and decreases in value with increasing obstructive disease? a. Forced vital capacity (FVC) b. Forced expiratory flow between 200 and 1200 mL of the FVC (FEF200-1200) c. Mean forced expiratory flow during the middle half of the FVC (FEF25-75) d. Forced expiratory volume in 1 second (FEV1) ANS: C

The FEF25-75 is also known as the maximum midexpiratory flow. It is sensitive to small changes in airway caliber and also decreases with increasing obstructive disease; however, it is highly variable.

REF: p. 536 10. Which of the following spirometric criteria are used to determine the presence of airway

obstruction? a. FEV1 less than 80% of predicted and FEV1/FVC less than 80% b. FEV1 less than 60% of predicted and FEV1/FVC less than 60% c. FEV1 less than 80% of predicted and FEV1/FVC less than 65% d. FEV1 less than 65% of predicted and FEV1/FVC less than 80% ANS: C

Airway obstruction is indicated when the FEV1 is less than 80% of the predicted value and FEV1/FVC values are less than 65% (or below the lower limit of normal).

REF: p. 536 11. How is significant clinical airflow limitation determined from pre- and postbronchodilator

spirometry? a. When the patient’s FEF25-7% increases by 12% and 200 mL/second b. When the patient’s FEV1 increases by 12% and 200 mL c. When the FVC increases by 20% and 200 mL d. When the FEV1/FVC ratio increases by 25% ANS: B

Significant reversibility is established when there is a greater than 12% increase in the postbronchodilator FEV1 measurement.

REF: p. 536 12. The therapist has been asked to check the FENO on a patient with asthma. The level is < 15

ppb. How should the therapist interpret this data? a. The asthma is well controlled. b. The patient is less likely to respond to corticosteroids. c. The patient is likely to require immunotherapy. d. The patient has a neutrophilic phenotype of asthma.

ANS: B

Many clinicians today use FENO to determine the eosinophilic response to corticosteroids, unmasking of otherwise unsuspected nonadherence to therapy, and routine monitoring.

According to the ATS Clinical Practice Guidelines, a patient with a low FENO level of less than 25 parts per billion (ppb) is considered less likely to respond to corticosteroids than one with a high FENO level of > 50 ppb who is symptomatic. An intermediate is considered to be between 25-50 ppb.

REF: p. 537 13. Which of the following pharmacologic agents may be used for bronchoprovocation challenge

testing? a. Albuterol b. Ipratropium bromide c. Heparin d. Histamine ANS: D

Airway responsiveness can be assessed using pharmacologic (e.g., histamine, methacholine) and nonpharmacologic (e.g., exercise, cold air hyperventilation) challenges.

REF: p. 537 14. The respiratory therapist is assisting the pulmonologist on a methacholine challenge. After

inhalation of the fourth concentration of methacholine, the FEV1 decreases 12%. What should the therapist suggest at this time? a. Stop the challenge because a drop in the FEV1 is consistent with a positive test b. Stop the challenge because only four concentrations are delivered c. Administer one more concentration to confirm that FEV1 drop is in fact 12%

d. Continue administering methacholine until FEV1 decreases 20% ANS: D

The patient's FEV1 is measured after inhalation of each concentration until there is a 20% decrease in the FEV1 or until all nine concentrations have been delivered. A 20% decrease in the FEV1 is considered a positive challenge.

REF: p. 537 15. The respiratory therapist is performing an exercise challenge for a child suspected of having

exercise-induced bronchospasm. After 30 minutes of stopping exercise, the FEV1 has decreased 15% from baseline. How should the therapist interpret this information? a. The challenge is consistent with a positive test for EIB. b. The challenge is consistent with a positive test for asthma. c. The challenge test is inconclusive for EIB. d. The therapist needs to wait 30 more minutes before interpreting the results.

ANS: A

Most children are exercised until their heart rate reaches at least 170 beats per minute or more than 85% of the predicted maximum heart rate for their sex and age for 5 to 8 minutes. The FEV1 is measured immediately and at 5-minute intervals for 20 to 30 minutes after exercise has stopped. A decrease in the FEV1 of 15% or more from the pretest baseline indicates a positive response and exercise-induced bronchospasm (EIB).

REF: p. 537 16. Which of the following medications are considered the first line of chronic treatment for

patients with asthma? a. Short-acting beta-2 adrenergic agonists b. Leukotriene modifiers c. Methylxanthines d. Inhaled corticosteroids ANS: D

Inhaled corticosteroids are the most consistently effective controller medication for asthma and are considered first-line therapy for its chronic treatment.

REF: p. 538 17. The therapist is asked to explain to a 10-year-old how to use a corticosteroid inhaler. Which of

the following side effects should the therapist mention to the patient and caregiver? a. Headache b. Blurred vision c. Changes in pupillary size d. Oral candidiasis ANS: D

Although there is much less risk of developing adverse events with inhaled compared with systemic corticosteroids, the potential for side effects remains. Dysphonia, voice change, reflex cough, and oral candidiasis occur most often with higher doses, although these manifestations can occur at any dose.

REF: p. 538 18. The therapist is asked to recommend a quick-onset, long-acting beta-2 agonist to be added to

the inhaled corticosteroid for a patient with asthma. Which of the following medications should the therapist recommend? a. Formoterol b. Salmeterol c. Tiotropium bromide d. Albuterol ANS: A

Salmeterol and formoterol are long-acting inhaled beta-2 agonists (LABAs) available in the United States. Formoterol is available in a dry powder inhaler device alone and as combination therapy and most recently in a liquid form for nebulization. The biggest difference between the two long-acting bronchodilators is their onset of action. Salmeterol can take from 30 minutes to 90 minutes to have peak effect while formoterol begins to work in 3 to 5 minutes.

REF: p. 538 19. Which of the following medications is indicated for a 15-year-old patient with moderate

asthma who is not controlled with inhaled corticosteroids and exhibits the following signs: (1) a positive skin test or positive in vitro test for aeroallergens and (2) an IgE level of 500 IU/L? a. Zileuton b. Salmeterol c. Xopenex d. Omalizumab ANS: D

Omalizumab, the only drug that specifically binds circulating IgE, is indicated for the moderate to severe asthmatic over 12 years of age with a positive skin test or positive in vitro test for aeroallergens, a quantitative IgE level between 30 and 700 IU/L, and who is not controlled on ICS therapy.

REF: p. 539 20. In order to establish the personal best peak flow, which instructions should the asthma

educator give the patient?

I. Record peak flows when free of symptoms II. Record peak flows once a week for 2 to 3 weeks III. Record peak flows preferably in early afternoon IV. Maintain peak flow values within 80% of the best peak flow a. I, III, and IV only b. II and IV only c. I, II, and III only d. I, III, and IV only ANS: D

There are predicted "normal" peak flow values that are determined by height, age, gender, and race. However, it is necessary to determine a child's "personal best" peak flow reading. This is defined as simply the highest or best measurement obtained when the patient is free of symptoms and asthma is under control. To determine the personal best reading, the patient records peak flow readings at least once a day for 2 to 3 weeks. The best peak flow reading will usually occur in the early afternoon. Once a patient's personal best peak flow has been established, every effort is made to maintain the peak flow values within 80% of this number.

REF: p. 542 21. What is typically the first pharmacologic intervention instituted by the therapist to treat a

patient who enters the emergency room with an asthmatic episode? a. Three 20-minute administrations of salmeterol via a small-volume nebulizer in the first hour b. Three treatments with albuterol given every 20 to 30 minutes by nebulization c. Intravenous administration of corticosteroids d. Combination therapy with a short-acting agonist and an anticholinergic bronchodilator via a metered dose inhaler (MDI) ANS: B

One of the first lines of therapy is with beta-2 agonist agents, such as albuterol or levalbuterol.

The EPR-3 recommends that the patient receive three treatments given every 20 to 30 minutes by either nebulization or MDI. If there is an inadequate response to this, continuous nebulization of albuterol may be initiated. In severe exacerbation the addition of ipratropium bromide to beta-2 agonists should be considered.

REF: p. 545 22. When endotracheal intubation and mechanical ventilation are indicated for a pediatric patient

with asthma, which of the following ventilator setting adjustments should the therapist consider making? a. 25% inspiratory pause b. Tidal volume 10 mL/kg c. Low to moderate positive end-expiratory pressure (PEEP) d. Low FiO2 ANS: C

After intubation, the child is mechanically ventilated with 6-8 mL per kg IBW with low to moderate positive end-expiratory pressure (PEEP) to assist with distal airway collapse and degree of auto-PEEP present. Larger tidal volumes may be required if prolonged expiratory times and low rates are utilized. The mode of ventilation and set respiratory rate is determined according to the patient's degree of sedation, peak inspiratory pressures generated, oxygenation, and acceptable levels of PaCO2. Initially the FiO2 is 1.0, with the goal to decrease the level to 0.5 or less when able.

REF: p. 545

Chapter 28: Cystic Fibrosis Test Bank MULTIPLE CHOICE 1. What are the primary characteristics of cystic fibrosis?

I. Chronic obstruction and inflammation of the airways II. Exocrine pancreatic insufficiency III. Malabsorption and small bowel obstruction IV. Decreased sweat chloride concentration a. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: B

The signs and symptoms of classic CF are related to the overproduction of thick, viscous secretions in multiple organ systems: Chronic obstruction, infection, and inflammation of the airways; Exocrine pancreatic insufficiency with malabsorption and small bowel obstruction; Infertility in males; Elevated sweat chloride levels.

REF: p. 549 2. What are the chances of two CFTR gene carriers having a normal child? a. 100% b. 75% c. 50% d. 25% ANS: D

An individual with CF is a homozygote, or an individual possessing two abnormal CFTR alleles. Each parent of a child with CF is an obligate carrier (or heterozygote), possessing one normal CFTR allele and one mutated allele. Each child of two carriers has a 1 in 4 chance of having CF, a 2 in 4 chance of being a carrier, and a 1 in 4 chance of having two normal alleles.

REF: p. 551 3. Which of the following respiratory signs and symptoms should prompt the therapist for

evaluation of cystic fibrosis in a child?

I. Recurrent wheezing II. Frequent thick sputum production III. Chronic cough IV. Nasal polyps a. I and II only b. III and IV only

c. I, II, and III only d. I, II, III, and IV ANS: D

Box 28-1 Signs and Symptoms That May Prompt Evaluation for Cystic Fibrosis Recurrent wheezing Chronic cough Frequent thick sputum production Severe, prolonged, or recurrent sinopulmonary infections Respiratory infections with pathogens associated with cystic fibrosis Persistently abnormal chest radiograph Nasal polyps Clubbing of the nail beds REF: p. 550 4. A 10-year-old child has had two sweat tests, each indicating a sweat chloride concentration of

30 mEq/L. How should the therapist interpret these data? a. The child is a carrier of CF. b. The child has CF. c. The child is likely to develop CF. d. The child does not have CF. ANS: D

The gold standard for the diagnosis of CF is the sweat chloride test. Normal secretion and resorption of chloride in the sweat glands are dependent on adequate CFTR function. A sweat chloride concentration 60 mmol/L confirms the diagnosis. A concentration between 40 and 59 mmol/L in infants older than 6 months is considered intermediate and should be repeated along with CFTR mutation analysis. Normal individuals can occasionally have elevated sweat chloride concentrations not related to CFTR dysfunction.

REF: p. 550 5. A sweat chloride test is performed in a 14-year-old child who has adrenal insufficiency. What

effect can this condition have on the results of this diagnostic test? a. It can produce a false-positive sweat test. b. It can generate a false-negative sweat test. c. Adrenal insufficiency can cause either a false-positive or a false-negative result. d. Adrenal insufficiency has no known effect on the result of a sweat test.

ANS: A

The sweat is obtained by stimulating the skin on the forearm with pilocarpine iontophoresis (see Figure 28-1 in the textbook). Technical error can result in false-negative and falsepositive results. In addition to inadequate sweat collection, malnutrition, edema, and hypoalbuminemia can also give false-negative results. Therefore, patients with clinical features suggestive of CF but normal or borderline sweat test results should have the test repeated. Conditions that can produce false-positive results include malnutrition, eczema, adrenal insufficiency, pseudohypoaldosteronism, and hypothyroidism.

REF: p. 552

6. A sweat chloride test and CFTR mutation analysis performed in a 10-year-old child with signs

and symptoms consistent with CF are inconclusive. Which of the following tests should the therapist suggest at this time? a. Sodium in urine b. Nasal potential difference c. CT scan of the chest with contrast d. Immunoreactive trypsinogen ANS: B

Measuring the difference in voltage potentials across the nasal epithelium is another method used in the diagnosis of CF, particularly when sweat chloride and/or CFTR mutation analysis results are inconclusive.

REF: p. 551 7. Which of the following methods is the most commonly recommended for newborn screening? a. Sodium in urine b. Nasal potential difference c. CT scan of the chest with contrast d. Immunoreactive trypsinogen ANS: D

As of January 2010, all 50 states and the District of Columbia included CF in standard newborn screening. The most common method is measurement of serum immunoreactive trypsinogen (IRT) obtained from a dried heel-stick blood sample.

REF: p. 551 8. Which of the following is the earliest pathologic change that causes airway dysfunction? a. Infection b. Inflammation c. Bronchospasm d. Plugging of the submucosal glands ANS: D

Airway dysfunction begins during the first year of life, with the earliest pathologic change being thickened mucus and plugging of the submucosal gland ducts in the large airways.

These changes appear to precede infection and inflammation.

REF: p. 553 9. Which of the following microorganisms commonly colonize the airways of patients with

cystic fibrosis?

I. Actinomyces israelii II. Haemophilus influenzae III. Pseudomonas aeruginosa IV. Staphylococcus aureus a. III only b. I and II only

c. II and IV only d. II, III, and IV only ANS: D

The presence of endobronchial pathogens changes with age. Staphylococcus aureus and Haemophilus influenzae typically appear early in life, with S. aureus reaching maximum prevalence at ages 6 to 17 years and H. influenzae peaking at 2 to 5 years of age.

REF: p. 552 10. What percentage of patients with adult cystic fibrosis are chronically infected with

Pseudomonas? a. More than 5% b. More than 20% c. More than 50% d. More than 70% ANS: D

More than 73% of adults with CF in the United States are chronically infected with Pseudomonas. It is strongly associated with accelerated lung function decline and survival.

REF: p. 552 11. Approximately what percentage of patients with cystic fibrosis present with pulmonary

symptoms? a. 100% b. 80% c. 50% d. 30% ANS: C

Nearly half of all patients with CF are diagnosed as a result of pulmonary symptoms. The diagnosis of CF should be considered in every patient who presents with chronic or recurrent lower respiratory tract disorders, including bronchitis, bronchiectasis, pneumonia, and refractory asthma. Children with CF have frequent pulmonary exacerbations, with the most consistent feature being a chronic cough.

REF: p. 553 12. Which of the following radiographic features is consistent with CF? a. Air bronchograms b. Dome-shaped diaphragms c. Bronchiectatic changes d. Meniscus sign ANS: C

The chest radiograph initially shows hyperinflation with flattened diaphragms secondary to air trapping (see Figure 28-2 in the textbook). Mucus plugging and patchy atelectasis can also be seen. Diffuse fibrosis, bronchial wall thickening, and bronchiectasis are found predominantly in the upper lobes. However, over time all lung fields are involved.

REF: p. 553

13. On pulmonary function testing, which of the following lung abnormalities is/are common in

patients with severe cystic fibrosis?

I. Obstructive pattern II. Restrictive pattern III. Airway hyperreactivity IV. Normal pattern when asymptomatic a. I only b. I and IV only c. II and III only d. I, II, and III only ANS: D

Pulmonary function testing initially demonstrates air flow obstruction. As the disease progresses, both a restrictive and an obstructive pattern can be seen, along with a decrease in air flow. About 50% of patients with CF have a positive methacholine challenge test, which indicates airway hyperreactivity.

REF: p. 553 14. Which of the following therapeutic interventions should be the focus of the treatment of

patients with cystic fibrosis? a. Airway clearance techniques b. Bronchodilators c. Antihistamines d. PEP therapy ANS: D

Treatment of the pulmonary manifestations of CF focuses on routine therapy aimed at physically removing thickened mucus from the airways. Pharmacologic control of infection with the aggressive use of antibiotics is crucial.

REF: p. 554 15. Which of the following medications should the therapist routinely administer during the

management of hospitalized patients with cystic fibrosis?

I. Albuterol II. Hypertonic saline III. DNAse IV. Salmeterol a. I and II only b. II and III only c. I and IV only d. I, II, and III only ANS: D

Aerosol therapy is an important aspect of CF respiratory care in the hospital and in the home.

A number of medications are designed to address specific aspects of CF pulmonary disease.

Put together, a commonly utilized sequence is as follows: bronchodilator, hypertonic saline, recombinant human DNAse, airway clearance therapy, maintenance medication (inhaled corticosteroid and/or antibiotic).

REF: p. 554 16. Which of the following drugs should the therapist give before administering nebulized 7%

saline to a patient with CF? a. rhDNase b. N-Acetylcysteine c. Albuterol d. Amiloride ANS: C

Because hypertonic saline causes bronchospasm in some patients, it is generally recommended to premedicate with a beta-2 agonist.

REF: p. 554 17. Which of the following aerosolized antibiotics is nebulized to treat infections caused by

Pseudomonas aeruginosa in patients with CF? a. Gentamycin b. Tobramycin c. Amiloride d. Ibuprofen ANS: B

Aerosolized antibiotics such as tobramycin are frequently used as chronic suppressive therapy to treat patients infected with P. aeruginosa to prolong the time between pulmonary exacerbations and to slow the progression of lung function decline. A Cochrane review of inhaled tobramycin for CF concluded that aerosolized antipseudomonal antibiotics improved lung function. A unit dose of 300 mg/5 mL is considered standard. It is given twice a day for 28-day cycles every other month.

REF: p. 554 18. Which of the following antiinflammatory agents should be considered in patients with CF to

slow the progression of the lung disease? a. Prednisone b. Any inhaled corticosteroid c. Aspirin d. Ibuprofen ANS: D

Ibuprofen has been demonstrated to slow the progression of lung disease over a 2-year period.

However, specific dosing and close pharmacokinetic monitoring is required when using this medication.

REF: p. 555

Chapter 29: Acute Respiratory Distress Syndrome Test Bank MULTIPLE CHOICE 1. On the basis of the Berlin definition of Acute Respiratory Distress Syndrome (ARDS), the

definition of moderate acute respiratory distress syndrome comprises which of the following components?

I. PaO2/FiO2 200 mm Hg II. Onset of respiratory symptoms within 1 week of clinical insult III. Pulmonary capillary wedge pressure greater than 18 mm Hg IV. Chest radiograph with bilateral infiltrates not fully explained by effusions or collapse a. I and II only b. I and III only c. II and IV only d. I, II, and IV only ANS: C

Within 1 week of known clinical insult or new/worsening respiratory symptoms; Bilateral opacities that are not fully explained by effusions, lobar/lung collapse, or nodules. Can be either on CXR or CT scan; With PEEP  5, mild ARDS: PaO2/FiO2 201-300, moderate ARDS: PaO2/FiO2 200, severe ARDS: PaO2/FiO2 00; Risk factors for ARDS must be present.

Respiratory failure that is not fully explained by cardiac failure or fluid overload. If no risk factors are present, objective assessment (e.g., echocardiography) is required to exclude hydrostatic edema.

REF: p. 562 2. A therapist is evaluating the progress of a patient with ARDS. The arterial blood gas reveals a

PaO2 of 55 mm Hg and a PaCO2 of 65 mm Hg. The PEEP is set at 12 cm H2O, and the mean airway pressure is 18 on an FiO2 of 0.60. What is the OI in this patient? a. 20.7 b. 13.1 c. 1.31 d. 200 ANS: A

OI = ( FiO2)/PaO2  100 REF: p. 562 3. Which of the following indirect insults can cause ARDS? a. Pneumonia b. Chest trauma c. Closed head injury d. Cor pulmonale ANS: C

ARDS can be caused by numerous insults (risk factors) that both directly and indirectly affect the lung via the generation of inflammatory mediators. Direct pulmonary insults include pneumonia, aspiration, chest trauma, and smoke inhalation. Indirect lung injury may be the result of generalized systemic conditions, such as sepsis, closed head injury, multiple trauma, transfusion reactions, and hemorrhagic shock.

REF: p. 563 4. What acid-base abnormality does a patient generally display when experiencing stage 2 of

ARDS? a. Mixed acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic acidosis ANS: B

The clinical course of ARDS is characterized by distinct clinical, radiographic, and pathologic manifestations. The first stage consists of direct or indirect acute injury to the lung tissue.

Clinically, patients may display mild tachypnea and dyspnea and tend to have normal radiographic findings. The second stage, or latent period, lasts a variable period of time after the onset of acute injury. During this time the patient may appear clinically stable but begins to develop early signs of pulmonary injury or insufficiency manifested by hyperventilation with hypocarbia and a respiratory alkalosis.

REF: p. 563 5. Which of the following clinical signs characterizes the onset of the third stage of ARDS? a. Refractory hypoxemia b. Hypocarbia c. Increased anatomic dead space d. Decreased cardiac output ANS: A

The third stage, acute respiratory failure, is heralded by the rapid onset of respiratory failure with hypoxemia refractory to supplemental oxygen. Diffuse pulmonary edema and worsening compliance cause significant atelectasis and intrapulmonary shunting. Clinically, patients develop rapid, shallow tachypnea with increased work of breathing.

REF: p. 563 6. What are some of the physical signs of respiratory failure among children?

I. Head bobbing II. Nasal flaring III. Crying IV. Grunting a. I and II only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only

ANS: B

The physical signs of respiratory failure will vary with age and include subcostal and supraclavicular retractions, grunting (i.e., an attempt to generate increased intrinsic positive end-expiratory pressure, PEEP), nasal flaring, and head bobbing.

REF: p. 563 7. The therapist is auscultating a 2-year-old patient with ARDS. Which of the following is a

common auscultatory finding in ARDS? a. Wheezing b. Stridor c. Crackles d. Pleural rub ANS: C

Lung examination usually reveals diffuse crackles on auscultation.

REF: p. 563 8. Radiographically, what features are typically seen in ARDS?

a. b. c. d.

Horizontal ribs Bilateral consolidations Flattened diaphragms Pleural effusions

ANS: C

Radiographically, there are bilateral areas of consolidation with air bronchograms that reflect alveolar filling and atelectasis.

REF: p. 564 9. Which of the following interventions should the therapist implement to decrease mortality in

patients with ARDS? a. High PEEP b. Alveolar recruitment maneuvers c. Low tidal volume d. High respiratory rate ANS: D

Except for low tidal volume ventilation, no single intervention for adult ARDS has been clearly shown to decrease mortality. This highlights the pressing need for development of effective management strategies for ARDS. REF: p. 565 10. Which of the following pathophysiologic conditions contribute to the decreased pulmonary

compliance associated with ARDS? a. Destruction of alveolar type II cells b. Inactivation of pulmonary surfactant c. Fluid accumulation in the pleural spaces d. Rapid removal of fluid by the pulmonary lymphatics ANS: B

Pulmonary compliance is significantly worsened by the presence of edema and can result in widespread atelectasis. Pulmonary compliance is further impacted by the inactivation of surfactant that results from the presence of plasma protein, such as fibrin, and inflammatory mediators, such as proteinases, in the alveolar space.

REF: p. 564 11. Which of the following pathophysiologic changes seen in ARDS is responsible for the

decrease in available surface area for gas exchange? a. Hyperinflation of the lungs b. Decreased right ventricular cardiac output c. Pulmonary hypertension d. Obliteration of small precapillary vessels ANS: D

Vascular changes occur throughout the later stages of ARDS with obliteration of small precapillary vessels and an increase in the medial thickness of intra-acinar pulmonary arteries.

Overall, these changes markedly decrease the available surface area for gas exchange and result in intractable respiratory failure or chronic lung disease, potentially requiring prolonged ventilator support.

REF: pp. 564-565 12. What pathophysiologic change accounts for the alteration of the hysteresis curve during

ARDS? a. High transpulmonary pressures b. High transairway pressures

c. Hyperinflated lungs d. Refractory hypoxemia ANS: A

During ARDS, marked hysteresis of the pressure–volume loop occurs, making significantly higher transpulmonary pressures during inspiration than during expiration necessary to achieve a given lung volume.

REF: p. 565 13. How should the therapist use the point on the pressure–volume loop where the shape changes

from concave to exponential? a. To set PEEP b. To set VT c. To set Ti d. To set PIP ANS: A

The point on the pressure–volume loop where the shape changes from concave to exponential is known as the lower inflection point. It reflects the pressure point at which alveoli begin to open and is located above functional residual capacity (see Figure 35-2 in the textbook). This suggests that many gas exchange units will collapse at normal transpulmonary pressures in acutely injured lungs and may need significant PEEP to maintain patency during expiration.

REF: p. 565 14. Which of the following regions of the lungs is most likely to be unaffected by

pathophysiology associated with ARDS? a. The dependent regions of the lung b. The nondependent regions of the lung c. The middle zone of the lung d. Depends on the etiology ANS: B

Lung injury and areas of involvement in ARDS are heterogeneous and not uniform through all lung units. Some areas of the lung, typically in the dependent regions, are grossly affected.

Other regions of the lung, typically in the nondependent regions, may be relatively unaffected.

This creates varying areas of compliance within the lung itself. Dependent regions are generally fluid filled, atelectatic, and noncompliant. Nondependent areas are relatively normal and, thus, at risk for overdistention (i.e., volutrauma) and/or barotrauma during mechanical ventilation.

REF: p. 565 15. What level of FiO2 should the therapist avoid using long term in patients with ARDS? a. 40% b. 50% c. 60% d. Any level above 30% ANS: C

Every patient with ARDS is hypoxemic by definition. Prolonged administration of high concentrations of oxygen can damage the lungs, owing to the formation of highly reactive oxygen free radicals. Human and animal studies suggest that a prolonged FiO2 greater than 0.60 should be avoided to prevent oxygen-induced pulmonary damage.

REF: p. 566 16. The therapist was titrating PEEP levels to maintain an SaO2 of 85% and found that 13 cm H2O

were required to achieve this goal. What should the most important concern with this level of PEEP? a. Risk of pneumothorax b. Decreased cardiac output c. Auto-PEEP d. Overdistention ANS: B

PEEP is typically increased to a level that allows adequate oxygenation as defined by an arterial oxygen saturation (SaO2) of 85% or greater at an acceptable FiO2 of 0.60 or less. It should be noted that the minimal acceptable arterial oxygen saturation remains very controversial. A PEEP level of 10 to 15 cm H2O, or even higher, may be required to achieve adequate oxygenation. However, as PEEP levels exceed 12 to 15 cm H2O, the increase in intrathoracic pressure may adversely affect cardiac output, primarily by decreasing systemic venous return. As PEEP is increased, the ARDS patient should be monitored for a decrease in cardiac output with a decrease in peripheral perfusion.

REF: p. 566 17. Which of the following ventilatory strategies is appropriate when mechanically ventilating a

patient with ARDS? a. PEEP less than 15 cm H2O and tidal volume (VT) between 8 and 10 mL/kg b. Peak inspiratory pressure (PIP) less than 40 cm H2O and Pplateau less than 30 cm H2O c. VT less than 6 mL/kg and Pplateau less than 30 cm H2O d. A high or low level of PEEP and a VT between 8 and 10 mL/kg ANS: C

The ARDS Network investigated the optimal PEEP-FiO2 strategy for adults with ARDS. The results of this prospective, randomized, multicenter study indicate that in adult ARDS patients who are ventilated with 6 mL/kg tidal volumes and an end-inspiratory plateau pressure of less than 30 cm H2O, a "moderately high" or "very high" PEEP strategy produced similar survival rates. It must be noted that this study investigated two relatively aggressive PEEP strategies.

Subsequent studies performed outside the United States also showed similar results. In a study involving 30 ICUs and 983 adult patients with ARDS, there was no difference in hospital mortality despite the reduction in the need of rescue therapies in the “high” PEEP group. A recent systematic review on the effect of PEEP in ARDS showed that the subgroup of ARDS patients who may stand to benefit most from a “high” PEEP strategy are those with the worst degree of hypoxemia.

REF: p. 566 18. What level of Pplateau should the therapist target to improve outcomes in patients with ARDS?

a. b. c. d.

35 cm H2O 32 cm H2O 25 cm H2O 20 cm H2O

ANS: B

The data support the conclusion that for adult patients with ARDS, the Pplateau should be limited to < approximately 32 cm H2O to improve outcome. The applicability of this conclusion to pediatric ARDS patients requires investigation. It is very possible that the "critical" limit on plateau pressure for infants and children will be < 32 cm H2O and may vary with patient age and size.

REF: p. 567 19. During the implementation of permissive hypercapnia, which of the following concepts is the

most critical to prevent complications of this strategy? a. The PaCO2 should never reach 100 mm Hg. b. The pH should never remain below 7.30. c. The rate at which the CO2 rises may be more important than the actual PaCO2. d. The target PaCO2 should be reached in 48 hours.

ANS: B

Recent data from a laboratory model of ischemia-reperfusion acute lung injury indicate that hypercapnic acidosis is protective and that buffering of the hypercapnic acidosis attenuates its protective effects. In allowing permissive hypercapnia, the rate at which carbon dioxide rises may be more important than the actual value itself. A rapid regression to normocapnia may be more deleterious to the cardiac system than hypercapnia itself.

REF: p. 569

Chapter 30: Shock, Sepsis and Anaphylaxis Test Bank MULTIPLE CHOICE 1. A 7-year-old patient with insulin-dependent diabetes is evaluated in the emergency department

due to ketoacidosis. What type of shock is most commonly associated with diabetic ketoacidosis? a. Hypovolemic b. Cardiogenic c. Obstructive d. Distributive ANS: A

In hypovolemic shock, rapid restoration of the vascular volume is paramount. For hemorrhagic shock, a subtype of hypovolemic shock, blood loss causes shock and thus treatment requires replacement of the lost blood volume. Other potential causes of hypovolemic shock include osmolar diuresis such as from diabetic ketoacidosis or from infectious enteritis.

REF: p. 573 2. Which of the following types of shock is the most common among children? a. Hypovolemic b. Cardiogenic c. Obstructive d. Distributive ANS: A

Typically, shock can be classified in four general states: hypovolemic, cardiogenic, obstructive, and distributive. The first, hypovolemic shock, is most common worldwide among children, most often resulting from severe dehydration.

REF: p. 573 3. A respiratory therapist has intubated a child with septic shock who has also received

intravenous fluids and vasopressors. What condition could explain a lack of response to therapy? a. Administration of the wrong fluid b. Inadequate dose of vasopressors c. Hypoxia d. Adrenal insufficiency ANS: D

When septic shock is refractory to fluid and/or catecholamines, consideration must also be given to adrenal insufficiency as a component of the shock state, particularly in patients who are at risk for impairment in their hypothalamic-pituitary-adrenal axis or who have had a history of steroid exposure. In such patients, the clinical status may not improve unless the patient receives “stress-dose” steroids with hydrocortisone.

REF: p. 575 4. A respiratory therapist is gathering equipment to intubate a patient with anaphylactic shock

who has severe bronchospasm. What is one of the most prominent inflammatory mediators responsible for the increase in airway resistance and fall in the PaO2? a. Epinephrine b. Histamine c. Interleukin d. IgE ANS: B

Histamine is one of the most prominent mediators and is believed to be responsible for the increase in airway resistance and the fall in partial pressure of oxygen due to its contractile action on the smooth muscle of the lung.

REF: p. 576 5. What is the mainstay of therapy for patients with anaphylactic shock? a. Vasopressin b. Dopamine c. Epinephrine d. IV fluids ANS: C

Providing oxygen will help ensure adequate oxygenation, and the wheezing often abates with the administration of epinephrine for circulatory support. Epinephrine is the mainstay of therapy. Circulatory dysfunction and shock are the next most pressing issues. For circulatory collapse, large volume infusions, as in other types of shock, help to restore the circulating blood volume. Hypotension can be severe and resistant to therapy. Circulatory support with repeated doses of epinephrine and a continuous epinephrine infusion help support the patient until the directed therapy can begin.

REF: p. 577 6. A child admitted to the emergency department with a diagnosis of shock has a cardiac index is

3.5 L/min/m2. How should the therapist interpret this value? a. This cardiac index is associated with an increased risk of mortality. b. This cardiac index is in the high range of normal, and it is an indication to wean vasopressors and fluids. c. This cardiac index is within normal limits but still requires close monitoring because it is in the low range of normal. d. This cardiac index is normal and no action is required.

ANS: C

In children, normal values for the cardiac index are in the range of 3.3 to 6.0 L/min/m2. A cardiac index of < 2.0 L/min/m2 has been associated with an increase in mortality.

REF: p. 576 7. A measure of the resistance or force against which the heart must pump defines which of the

following terms?

a. b. c. d.

Preload Afterload Inotropy Chronotropy

ANS: B

Afterload is a measure of the resistance or force against which the heart must pump.

REF: p. 577 8. Which of the following signs is one of the first to indicate decreased peripheral perfusion in

children? a. Tachycardia b. Bradycardia c. Hypotension d. Dyspnea ANS: A

Infants and children have a limited ability to increase stroke volume. As a result, they will attempt to compensate for a reduction in cardiac output by increasing their heart rate.

Tachycardia is one of the first signs of decreased peripheral perfusion in children.

Hypotension is an unreliable and late finding of shock in children occurring when the child's compensatory mechanisms have already failed.

REF: p. 578 9. A therapist is calculating oxygen delivery for a patient admitted with a diagnosis of shock.

Which of the following parameters should the therapist measure?

I. Hemoglobin II. Oxygen bound to hemoglobin III. Dissolved oxygen IV. Cardiac output a. I, II, and IV only b. II, III, and IV only c. I, II, III, and IV d. I, II, and III only ANS: C

Oxygen delivery depends on oxygen-carrying capacity (% hemoglobin), oxygen provided (oxygen bound to hemoglobin plus dissolved oxygen), and cardiac output.

REF: p. 578 10. How should the therapist interpret a capillary refill time of approximately 1 second in a

pediatric patient? a. Adequate cardiac output b. Increased afterload c. Inadequate cardiac output d. Decreased preload ANS: A

Capillary refill (the process of blanching the skin for several seconds and timing the return of blood flow to the blanched skin) is a quick, useful, and noninvasive test that provides important information regarding perfusion in the acute setting. The normal capillary refill time should be less than 2 seconds and correlates with a cardiac index of > 2.0 L/min/m2.

REF: p. 579 11. Assessment of an infant suspected of having shock reveals skin that is warm, pink, and well

perfused. How should the therapist interpret these findings? a. The infant has hypovolemic shock. b. The infant has late cardiogenic shock. c. The patient has decreased cardiac output. d. The patient may have early septic shock.

ANS: D

Evaluation of skin color and temperature is easily performed. The skin of children in shock may be pale, cyanotic, or mottled because of poor perfusion. Traditionally, practitioners have described two phases of septic shock. In early septic shock the skin appears well perfused, warm, and pink. These signs are caused by vasodilation and increased cardiac output. Later in the course of shock, the cardiac output begins to fall. Skin examined during this period is likely to be cool, cyanotic, or mottled, representing a decrease in the amount of substrate reaching the skin.

REF: p. 580 12. Which vascular site would provide the most reliable measurement of the beat-to-beat

monitoring of the blood pressure in an infant who is suspected of having shock? a. Any vessel b. Any peripheral vein c. A peripheral or central artery d. A central vein ANS: C

The placement of a catheter in a peripheral or central artery can be performed for the monitoring of blood pressure on a continuous basis in the intensive care unit. Arterial catheterization can provide beat-to-beat monitoring of the blood pressure.

REF: p. 581 13. Which of the following can be obtained from a central venous pressure measurement? a. Stroke volume b. Afterload c. Preload d. Myocardial contractility ANS: C

The placement of a catheter in the central venous system allows for an assessment of the volume status of the child with shock. The catheter, when attached to a continuous column of fluid and a pressure transducer, measures the downstream intravascular pressure, or CVP, in the right atrium. This intravascular pressure represents preload, one of the contributors to the stroke volume, which contributes to the cardiac output.

REF: p. 580 14. Which of the following hemodynamic assessments can be obtained from a pulmonary

capillary wedge pressure measurement? a. Central venous pressure b. Right ventricular preload c. Left ventricular afterload d. Left ventricular preload ANS: D

The use of PA catheters in children is supported by the American College of Critical Care Medicine for circumstances in which irreversible shock manifesting as poor perfusion, acidosis, and hypotension persists despite the use of therapies directed at the arterial blood pressure, CVP pressure, and oxygen saturation indices. In addition to the measurements obtained directly from the catheter, a number of derived values provide information regarding the homeostatic function of the child, including systemic vascular resistance as a measure of afterload and oxygen consumption and oxygen extraction.

REF: p. 581 15. A child has been treated for shock with 60 mL/kg of normal saline. What should be

considered at this time? a. Administer an additional 20 mL/kg bolus of fluids b. Switch to lactated Ringer’s solution c. Start vasopressors d. Alternate normal saline and Ringer’s solution ANS: C

Large fluid deficits typically exist and initial volume resuscitation usually requires 40 to 60 mL/kg but can require as much as 200 mL/kg in some cases of septic shock. Continued fluid losses and persistent hypovolemia due to capillary leak can persist despite fluid resuscitation.

Ongoing fluid replacement is necessary to maintain adequate tissue perfusion, and large volumes may be required as vascular permeability results in peripheral and third space losses.

When total administered volumes of 60 mL/kg are reached, intravascular monitoring and initiation of vasoactive support should be considered.

REF: p. 581 16. In which of the following clinical situations may the administration of packed red blood cells

be indicated? a. When a patient demonstrates leukopenia b. When a patient shows evidence of anemia c. When the risk of sepsis is present d. When a patient shows evidence of hypovolemic shock ANS: B

If there is evidence of anemia or suspected losses of blood, repletion of the intravascular volume with packed red blood cells should be performed.

REF: p. 582

17. When cardioversion is indicated, at what point during the cardiac cycle must it be applied? a. In synchrony with the QRS complex b. Synchronously with the appearance of the P wave c. Immediately before the ST segment d. At any point during the cardiac cycle ANS: A

An unstable tachycardia manifested with hypotension or signs of shock should be treated with electrical therapy in the form of synchronized cardioversion or defibrillation. Cardioversion synchronizes the delivery of the shock with the QRS complex to prevent deterioration to a more lethal arrhythmia and should be used in patients who have a palpable pulse.

REF: p. 581 18. A child is receiving aggressive therapy for shock. Cardiac failure has developed. Which of the

following inotropes is the most frequently used under these circumstances? a. Epinephrine b. Dopamine c. Norepinephrine d. Digitalis ANS: B

Inotropic agents are used to increase contractility and cardiac output. Dobutamine is a beta-1 adrenergic agonist with chronotropic and inotropic actions, as well as afterload reduction.

Dopamine, the most frequently used inotrope, increases renal blood flow but also has vasoconstrictive properties at high doses due to release of norepinephrine. Epinephrine is a naturally circulating neurohormone that increases contractility during stress and shock. At low dose it provides inotropy but at higher doses increases peripheral vascular tone and acts as a vasopressor. Patients with heart failure and increased systemic vascular resistance may be harmed by these higher doses unless epinephrine is combined with an inodilator or vasodilator.

REF: p. 582 19. During the treatment of sepsis, what intervention may be needed if hypotension persists

despite the maximal application of inotropic and vasomotor support? a. Endotracheal intubation and mechanical ventilation b. High-frequency oscillatory ventilation c. Extracorporeal membrane oxygenation d. Hyperbaric oxygenation ANS: C

Patients remaining in shock despite the supportive therapies may benefit from mechanical cardiac support, such as extracorporeal membranous oxygenation (ECMO). ECMO is highly effective for cardiogenic shock because it helps support the ailing heart, but it is less successful in septic shock, except possibly in treating refractory low–cardiac output septic shock.

REF: p. 583 20. Which of the following microorganisms are likely responsible for neonatal meningitis?

I. Klebsiella species II. Neisseria meningitidis III. Escherichia coli IV. Listeria monocytogenes a. I and IV only b. II and III only c. III and IV only d. I, III, and IV only ANS: D

The common causative agents for meningitis are age specific. For neonates, the primary bacterial agents include Streptococcus agalactiae, Klebsiella species, Escherichia coli, and uniquely Listeria monocytogenes.

REF: p. 583 21. Which of the following microorganisms are currently the leading causes of childhood

meningitis?

I. Group B Streptococcus II. Streptococcus pneumoniae III. Methicillin-resistant Staphylococcus aureus IV. Neisseria meningitides a. I and IV only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: B

In older infants through the early toddler years, Streptococcus pneumoniae, Neisseria meningitides, and Haemophilus influenzae are most likely.

REF: p. 584

Chapter 31: Pediatric Trauma Test Bank MULTIPLE CHOICE 1. Which of the following anatomic considerations in children are important to better understand

trauma in this age group?

I. Children have less body fat.

II. Children have a small surface area relative to volume.

III. Children’s skeletons are more pliable.

IV. Children have a greater distribution of force per unit body area of smaller body mass. a. I and III only b. II and IV only c. I, II, and III only d. I, III, and IV only ANS: D

Children are not just small adults. It is important to understand the fundamental differences between adults and children. Notable are the size and shape differences. There is a greater distribution of force per unit body area because of smaller body mass resulting in greater acceleration. The child’s body has less fat, elastic connective tissue, and close proximity of multiple organs. This can place the child with a penetrating injury at risk of multiple organ involvement. Children also have a large surface area relative to volume, predisposing them to thermal evaporative loss resulting in hypothermia. A child’s skeleton is more pliable due to incomplete calcification. Trauma can result in serious organ injury without overlying skeletal fracture.

REF: p. 588 2. What should be always assumed in the case of traumatic injury regardless of the mechanism? a. Head injury b. Pulmonary contusion c. Cervical spine injury d. Leg fracture ANS: C

The initial assessment is the same for all pediatric patients who have sustained a traumatic injury regardless of mechanism. Always assume cervical spine injury and take necessary precautions during the assessment. The head and neck should be held in line with the body by placing a cervical collar or by assigning an individual to hold the patient in C-spine precautions.

REF: p. 588 3. A respiratory therapist arrives at the scene of an accident to assist a victim of a motor vehicle

accident. What would the best method to open the airway until a full assessment is completed? a. Jaw thrust b. Head tilt c. Sniff position

d. Chin lift ANS: A

A patent airway can be initiated by means of a jaw thrust maneuver to open the airway.

Maintain the airway with orotracheal intubation, nasotracheal intubation, cricothyrotomy, or tracheostomy. In order to maintain cervical spine stabilizations, do not use the head tilt, sniff position, or chin lift maneuvers because these procedures change the orientation of the spinal column and increase the risk of additional spinal injury. The jaw thrust technique may be used in these children unless otherwise contraindicated.

REF: p. 588 4. A respiratory therapist is asked to rapidly assess adequacy of peripheral circulation while an

intravenous line is placed. Which of the following methods should the therapist use? a. Measure blood pressure b. Measure pulse pressure c. Assess pulse intensity d. Assess capillary refill ANS: D

Assessing capillary refill is a quick and specific method of checking the adequacy of peripheral circulation. One method of determining capillary refill is to depress the patient's thumb nail with moderate force. This will cause the underlying tissue to blanch (turn white or pale pink) by forcing blood from the tissue. Releasing the pressure allows blood to refill the tissue's capillaries. Normal capillary refill time is less than 2 seconds. Inadequate capillary refill on initial assessment may be caused by regional perfusion problems. To rule out this possibility, repeat the capillary refill test on the opposite hand.

REF: p. 589 5. Which of the following areas is evaluated on the Glasgow Coma Scale, used for the

neurologic assessment of adults, older children, and adolescents? a. Respiratory b. Verbal c. Circulatory d. Olfactory ANS: B

Immediate assessment of neurologic status is beneficial in acute trauma management. The most common way to perform this assessment is with the Glasgow Coma Score (GCS).

Patients are scored in three areas: eye opening, verbal response, and motor response. Although the standard GCS is accurate for use in adults, older children, and adolescents, the agespecific GCS combines adult and child forms so it is applicable to all ages. The age-specific GCS is particularly useful in nonverbal children.

REF: p. 589 6. A respiratory therapist working in the emergency department has received report of a patient

who suffered a traumatic brain injury and whose Glasgow Coma Scale score is 8. What should the therapist anticipate doing when the patient arrives? a. Place a cervical collar

b. Place an intravenous catheter c. Obtain a head CT scan d. Intubate ANS: D

If the GCS is less than or equal to 8, the patient likely does not have the ability to protect his/her airway and a more definitive airway should be established. Intubation is the most common option for a definitive airway, with cricothyroidotomy being a secondary option.

REF: p. 589 7. Why are infants and children highly vulnerable to head injury?

I. Their head is large and heavy compared with the rest of the body.

II. They lack mature judgment.

III. They are uncoordinated.

IV. They tend to move too fast. a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: C

A child's head is large and heavy in relation to the body. Therefore, the center of gravity shifts toward the head. In addition, a child’s balance, coordination, gait, and judgment are immature, which results in children being especially vulnerable to falls with head injury.

REF: p. 589 8. What is the meaning of the word plasticity when used to describe brain damage in infants? a. The infant’s brain has the ability to absorb more energy per square centimeter than

the adult brain. b. The infant’s brain is more rigid than the adult brain up to 2 years of age. c. The infant’s brain is capable of transferring functions from damaged to undamaged

regions. d. The brain of an infant has the ability to completely replace damaged neurons with new neurons.

ANS: C

The brains of infants and children apparently have a large degree of plasticity (i.e., adaptability) in redistributing function from a damaged area to an undamaged area. In adults the ability of brain segments to adapt to new functions seems to be rarely, if ever, present.

REF: p. 591 9. Which of the following factors provide infants and young children protection against head

trauma by allowing a degree of expansion of the cranial volume?

I. Reduced cranial weight II. Less cranial ossification III. Presence of fontanels

IV. Presence of flat bones a. I and III only b. II and III only c. I, II, and IV only d. II, III, and IV only ANS: D

Infants and young children also have malleable skulls because of the large fontanels (“soft spots”) and the flat bones of the skull, which have not yet fused and still may be cartilaginous before ossification. These factors allow for elasticity of the cranial vault and lessen or prevent both fractures and pressure-related brain injuries during passage through the birth canal. Skull malleability also protects against damage from other sources, such as trauma or illness, causing increased pressures in the cranial vault. This protection occurs by allowing a degree of expansion of the cranial volume.

REF: p. 591 10. Which of the following respiratory procedures must be avoided in a patient suspected of

having direct cranial trauma?

I. Oral airway insertion II. Nasotracheal suctioning III. Nasotracheal intubation IV. Nasogastric tube insertion a. I only b. I and III only c. II and III only d. II, III, and IV only ANS: D

In patients with direct cranial trauma, avoid nasotracheal intubation, nasotracheal suctioning, or inserting nasogastric tubes because inadvertent cranial intubation may result through open fractures of the cranial vault, especially in patients who may have basilar skull injuries or paranasal fractures. In addition, irritating procedures such as nasopharyngeal or nasotracheal suctioning, insertion of a nasogastric tube, or intubation may result in an exacerbation of an already increased intracranial pressure.

REF: p. 592 11. The respiratory therapist has intubated a patient with a traumatic brain injury whose

respiration has deteriorated. Which of the following ventilatory strategies should the therapist try to minimize the effects on intracranial pressures? a. Minimize peak inspiratory pressure b. Increase mean airway pressure c. Prolong inspiratory time d. Decrease respiratory rate ANS: A

If respirations deteriorate or the patient's state of consciousness declines, mechanical ventilation should be instituted immediately. Minimize peak inflation pressure (PIP) and mean airway pressure (), and select inspiratory and expiratory times that favor prolonged expiration if possible. Decreasing minimizes outflow tract resistance from the cerebral vasculature, enhancing cerebral perfusion by minimizing effects on intracranial pressure (ICP). Remember to minimize suctioning to prevent coughing and gagging on the tracheal tube or suction catheter, which may increase ICP. REF: p. 589 12. A child with a head injury displays bruising discolorations around the orbits, or “raccoon

eyes.” What does this indicate? a. Direct trauma to the eyes b. Frontal trauma c. Basilar skull fracture d. Brain herniation ANS: C

Some classic "signs" are associated with certain head injuries. These signs indicate fractures of the basilar skull. Traumatic head injury may be highlighted by the presence of Battle's sign or "raccoon eyes." Battle's sign represents ecchymosis, or bruised areas behind the ear that indicate basilar skull fractures. The self-explanatory term raccoon eyes represents bruising discolorations around the orbits. Both Battle's sign and raccoon eyes are the body's attempts to show internal injury with as simple a sign as a small bruise.

REF: p. 593 13. What is the normal value for intracranial pressure? a. 10 mm Hg b. 20 mm Hg c. 30 mm Hg d. 40 mm Hg ANS: A

Normal intracranial pressure is 130 mm H2O (10 mm Hg).

REF: p. 593 14. Intracranial pressure (ICP) monitoring has been initiated for a patient with brain injury. The

child’s ICP is 10 mm Hg, and mean blood pressure is 80 mm Hg. What is this child’s CPP? a. 90 mm Hg b. 70 mm Hg c. 50 mm Hg d. 40 mm Hg ANS: B

Compression of the brain tissue inhibits blood flow by reducing cerebral perfusion pressure (CPP) and causes cerebral tissue hypoxia, ischemia, and coma. CPP = mean BP - ICP and averages 85 ± 15 mm Hg. REF: p. 593

15. A 3-month-old baby suspected of having a life-threatening encephalopathy is being

transported from a rural area. Which of the following signs may assist in the confirmation of intracranial hypertension? a. Diplopia b. Bulging fontanels c. Seizures d. Miosis ANS: B

Increased ICP can be a life-threatening feature of an encephalopathy. CSF and blood acting on the brain and bony structures of the skull generate ICP. In the newborn and infant, measuring the head circumference and palpating the anterior fontanel allow rapid assessment of ICP. Bulging of the fontanels may be a key sign of increased ICP that requires a response by caregivers.

REF: p. 593 16. The therapist is instituting hyperventilation to a child with intracranial hypertension. What

should be the lowest PaCO2 before brain ischemia can occur? a. 50 mm Hg b. 40 mm Hg c. 35 mm Hg d. 25 mm Hg ANS: D

ICP declines within seconds of beginning hyperventilation. The mechanism is vasoconstriction resulting from hypocarbia. The goal is to lower the partial pressure of arterial carbon dioxide (PaCO2) from 40 to 25 mm Hg. Further reduction can result in cerebral ischemia and is contraindicated.

REF: p. 594 17. What is the mechanism of action of the osmotic diuretic mannitol in the setting of increased

ICP? a. Mannitol crosses the blood–brain barrier and removes water from the cerebral vascular spaces. b. Mannitol increases the permeability of the loop of Henle, causing water to leave the nephrons. c. Mannitol enters the ventricles of the brain, causing fluid to leave the choroid plexus and enter the circulation for delivery to the kidneys. d. Mannitol remains in the plasma, creating an osmotic gradient that draws water from the brain into the cerebral capillaries.

ANS: D

Mannitol is given intravenously as a 20% solution. It does not cross the blood–brain barrier and remains in the plasma, creating an osmotic gradient that draws water from the brain into the capillaries, reducing cerebral fluid volume and therefore ICP. The effect is short term, and infusions must be given 3 to 6 times each day.

REF: p. 594

18. A patient with status epilepticus has been treated with benzodiazepines and phenobarbital

without success. Now a pentobarbital coma is indicated. What should the therapist do at this time? a. Place the patient on an oxygen cannula prior to the administration of pentobarbital b. Place an oropharyngeal airway to avoid patient’s biting the tongue c. Prepare to intubate and start mechanical ventilation d. Place the patient on noninvasive mechanical ventilation ANS: D

If none of the medications administered are effective in stopping the seizure, a pentobarbital coma may be necessary. For this, the patient should be intubated and mechanically ventilated, and vital signs need to be monitored closely.

REF: p. 596 19. A child is admitted to the emergency department displaying an abnormal breathing pattern

consisting of random, ineffective, haphazard breaths and pauses. What is the name of this breathing pattern? a. Apneustic b. Ataxic c. Cheyne Stokes d. Primary alveolar hypoventilation ANS: B

Hypothalamic and midbrain damage results in rapid, sustained, deep hyperventilation (central neurogenic hyperventilation). Injury to the medulla and the pons affects the respiratory centers and produces several different patterns: apneustic breathing, with a prolonged pause at full inspiration; ataxic breathing, which consists of random, ineffective, haphazard breaths and pauses without a predictable pattern; and primary alveolar hypoventilation (Ondine's curse), a failure to breathe while sleeping, which is the failure of automatic breathing centers when asleep.

REF: p. 597 20. Which of the following conditions results from the fracture of adjacent ribs in at least two

places along the same ribs? a. Pneumothorax b. Respiratory alternans c. Flail chest d. Condochondritis ANS: C

When several adjacent ribs are fractured in two areas, a flail segment of the chest wall may be produced. This segment of the chest moves in paradoxical fashion with respiratory effort, collapsing with inspiratory effort and expanding with expiration. This paradoxical motion interferes with tidal ventilation of the ipsilateral lung and, in conjunction with pulmonary parenchymal contusion, may cause serious respiratory embarrassment.

REF: p. 599

21. Which of the following conditions is the most commonly associated with penetrating chest

trauma? a. Pulmonary contusion b. Hemothorax c. Empyema d. Pleural effusion ANS: B

The most common injury sustained with penetrating thoracic trauma is a pneumothorax or hemothorax with accumulation of air or blood within the pleural space.

REF: p. 599 22. What range of systolic pressure should be sufficient to maintain adequate tissue perfusion

during fluid resuscitation of a victim of a penetrating chest injury before controlling the source of bleeding? a. 40 to 60 mm Hg b. 60 to 80 mm Hg c. 80 to 100 mm Hg d. 100 to 120 mm Hg ANS: C

For most pediatric patients, systolic blood pressures of 80 to 100 mm Hg should be sufficient to maintain adequate tissue perfusion during this interval.

REF: p. 600 23. For victims of penetrating chest wall trauma demonstrating respiratory distress, which of the

following therapeutic interventions generally need to be administered before radiologic studies are obtained to ascertain the status of intrathoracic organ injuries? a. Arterial puncture procedure b. Noninvasive ventilation c. Neurological assessment d. Ipsilateral tube thoracotomy ANS: D

Although the diagnosis of penetrating thoracic trauma is usually rapidly evident from the history of the mechanism of injury and the physical examination, specific information regarding injuries to intrathoracic organs will require radiologic and interventional procedures. Patients presenting with severe respiratory distress should be treated immediately by intubation and ipsilateral tube thoracotomy, before any radiologic studies are obtained.

Patients with less severe symptoms and those who have been stabilized are initially investigated with an anteroposterior chest radiograph.

REF: p. 600 24. Which of the following signs indicate injury of a major thoracic vessel? a. Evacuation of 200 mL of blood from the pleural space after placing the chest tube b. Continuous bleeding through the chest tube c. Presence of pneumothorax d. Presence of respiratory distress

ANS: B

The evacuation of more than 300 mL of blood from the pleural space after placement of a chest tube, or continuous bleeding through the chest tube, should prompt evaluation for a major vessel injury.

REF: p. 600 25. The presence of entrance wounds below the level of the nipples suggests which of the

following types of injury? a. Spinal cord injury b. Thoracic cage damage c. Esophageal injury d. Intra-abdominal injury ANS: D

Patients with penetrating injury in whom either entrance wounds or exit wounds are below the level of the nipples should be suspected of having diaphragmatic and intra-abdominal injuries.

These patients should undergo an abdominal computed tomography (CT) scan to assess for that possibility.

REF: p. 600 26. A penetrating chest wall trauma that produces a ball–valve type injury of the visceral pleura

frequently produces which type of condition? a. Empyema b. Hydrothorax c. Flail chest d. Tension pneumothorax ANS: D

The injuries associated with penetrating thoracic trauma include pneumothorax, hemothorax, pulmonary parenchymal injuries, major airway injuries, great vessel injuries, esophageal injuries, and diaphragmatic injuries. Pneumothorax is seen as a consequence of virtually all penetrating thoracic trauma because the pleural space is opened to atmospheric pressure even if the visceral pleura is not violated. The presence of both blood and air in the pleural space is referred to as hemopneumothorax. Air under pressure in the pleural space, as might occur with a ball–valve type injury of the visceral pleura, is termed a tension pneumothorax.

REF: p. 600 27. Patients experiencing penetrating thoracic trauma presenting with a significant pneumothorax

with a continuous air leak through the chest tube should be suspected of having what type of problem? a. Decreased pulmonary compliance b. Aspiration of stomach contents c. Gastric inflation d. Major airway injuries ANS: D

Patients with penetrating thoracic trauma presenting with a significant pneumothorax with a continuous air leak through the chest tube should be suspected of having major airway injuries. The majority of these patients will be found to have a pneumomediastinum on plain chest radiographs or chest CT scans. Airway penetration should be confirmed by bronchoscopy.

REF: p. 601 28. Injury to which of the following structures should be suspected in a young child who has a

penetrating chest wound located at the 5th intercostal space? a. Diaphragm b. Esophagus c. Trachea d. Vertebrae ANS: A

Some patients with penetrating thoracic trauma may also have sustained significant intraabdominal injury. In most of the respiratory cycle the apex of the diaphragm is as high as the fourth intercostal space. This is because intraabdominal pressure exceeds intrapleural pressure throughout all phases of ventilation. Penetrating injuries at or below this level, the level of the nipples, must be suspected of having diaphragm penetration and potential intraabdominal injuries. These patients should be evaluated with a chest-abdomen CT scan. In otherwise stable individuals, thoracoscopy has been reported to be helpful in diagnosing traumatic diaphragm lacerations.

REF: p. 601 29. What type of ventilation strategy is often employed when a patient with a penetrating chest

wall injury has a massive air leak while receiving mechanical ventilation? a. Sedation and paralysis along with patient-triggered, volume-controlled ventilation b. Sedation and paralysis along with inverse ratio ventilation c. Noninvasive positive pressure ventilation d. Ventilation to achieve reduced mean airway pressures ANS: D

Children with penetrating thoracic injuries who require intubation may present significant ventilatory difficulties because of a massive air leak. Ventilator strategies in these patients generally include reducing peak inspiratory pressures and mean airway pressures to minimize the air leak. Lowering these pressures can often be accomplished by reducing the tidal volume and using minimal positive end-expiratory pressure (PEEP), with an increase in respiratory rate.

REF: p. 601 30. Which ventilation strategy should the therapist suggest for patients with very large leaks? a. Volume-controlled ventilation b. Inverse ratio ventilation c. High-frequency ventilation d. Airway pressure release ventilation ANS: C

Patients with very large air leaks may benefit from the use of high-frequency or oscillating ventilators.

REF: p. 601 31. Which of the following procedures can cause an iatrogenic pneumothorax? a. Oropharyngeal suctioning b. Central venous catheter placement c. Orogastric tube placement d. Nasogastric tube placement ANS: B

A variety of procedures can produce an iatrogenic pneumothorax. These may include endotracheal suctioning, laceration of the trachea during endotracheal intubation, penetration of the airway during endoscopy, high-pressure mechanical ventilation, central venous catheter placement, or thoracentesis.

REF: p. 601 32. When a suction catheter is inserted beyond the distal tip of an endotracheal tube, which of the

following segmental bronchi is prone to injury? a. The posterior basilar segment of the right lower lobe b. The inferior segment of the right middle lobe c. The medial basilar segment of the right lower lobe d. Either lingular segment of the left upper lobe ANS: C

Iatrogenic airway injuries are known to occur as a consequence of overzealous endotracheal suctioning in young infants. The suction catheter should be carefully measured and passed down only to the level of the end of the endotracheal tube in order to avoid direct tracheal or bronchial injury. The most common site of injury is in the medial-basal segment of the right lower lobe. This segmental bronchus is on a straight line beyond the end of the endotracheal tube, and catheters that are passed without attention to the depth will puncture the visceral pleura in this segment.

REF: p. 602 33. What is the purpose of the “rule of nines”? a. To categorize the degree of burn injury b. To triage the body to determine which area demands immediate attention c. To estimate the percent body surface area burned d. To ascertain the percent of skin grafting needed ANS: C

The “rule of nines” is the method most frequently used to estimate percent body surface area burned. This estimate is based on various anatomic regions representing 9% of body surface area, or a multiple of nine. However, because infants and younger children have body proportions different from those of an adult, a modified “rule of nines” may be used for them.

Figure 31-7 in the textbook describes the percentages of various anatomic regions as the child ages.

REF: p. 605 34. Which of the following medications should be considered during the hypermetabolic state of a

patient who has a burn injury? a. Catabolic agents b. Antiadrenergics c. Diuretics d. Inotropes ANS: B

The metabolic rate can increase as much as two to three times normal after burn injury and is generally related to the size of the burn. This is accompanied by constant hyperthermia.

Nutritional support is extremely important and is best accomplished by calculating caloric needs and correcting electrolyte disturbances that are common to burn patients.

Pharmacologic support of the hypermetabolic response consists of using anabolic agents to alleviate muscle wasting and preserve lean body mass and antiadrenergic drugs to decrease myocardial oxygen consumption and cardiac work.

REF: p. 605 35. What management practice has accounted for the drop in mortality from burn injuries over the

decades? a. Systemically administered antibiotics b. Aggressive wound excision c. Aggressive application of topical corticosteroids d. Aggressive administration of topical antibiotics ANS: B

Aggressive wound excision and grafting, along with the use of topical antibiotics, have dramatically decreased the incidence of burn wound sepsis. Inhalation injury has now emerged as the most frequent cause of death in patients with severe burns.

REF: p. 606 36. What are characteristics of direct thermal burns to the upper airway?

I. Edema II. Hemorrhage III. Ulceration IV. Pseudomembranous casts a. IV only b. I and II only c. I, II, and III only d. II, III, and IV only ANS: C

Direct thermal trauma is limited to the upper airway and results in obstruction from edema, hemorrhage, and ulceration of the mucosa. In only a few hours, mild pharyngeal edema can rapidly progress to complete upper airway obstruction with asphyxia. The worsening of upper airway edema is most prominent in supraglottic structures. Serial nasopharyngoscopic evaluations demonstrate obliteration of the aryepiglottic folds, arytenoid eminences, and interarytenoid areas by edematous tissue that prolapses and occludes the airway.

REF: p. 606 37. A smoke inhalation victim is having his oxygenation status evaluated in the emergency room

by a therapist using a pulse oximeter, which indicates an SpO2 (oxygen saturation as determined by pulse oximetry) of 87%. How should the therapist interpret this value? a. As accurate b. Falsely high c. Falsely low d. Inconsistent ANS: B

Pulse oximetry measurement does not accurately reflect oxygen saturation in the presence of carboxyhemoglobin (COHb). The pulse oximeter equates COHb with oxygenated hemoglobin and measures the percentage of saturation of available binding sites, regardless of whether the sites are occupied by CO or oxygen. This causes the pulse oximeter to read falsely elevated oxygen saturation values in the presence of COHb. Direct measurement of COHb by cooximetry is recommended.

REF: p. 607 38. In the emergency room, a patient with smoke inhalation injury will tend to display which of

the following clinical signs? a. Chest radiograph demonstrating focal infiltrates b. Singed nasal vibrissae c. Inspiratory and expiratory stridor d. Mucoid sputum ANS: B

The clinical diagnosis of inhalation injury has traditionally rested on various unreliable observations. Smoke inhalation injury is more likely to be present in those with a history of burn injury in an enclosed space, the appearance of facial burns, singed nasal vibrissae and facial hair, erythema of the oropharynx, and the presence of carbonaceous sputum and debris around the nose, mouth, and pharynx. Rhonchi, crackles, wheezes, stridor, dyspnea, cough, and hoarse voice are seldom present on admission, occurring only in persons with the most severe injury and implying an extremely poor prognosis. The admission chest radiograph is often normal and is a poor indicator of severity of acute lung injury. However, two thirds of patients develop changes, including diffuse or focal infiltrates or pulmonary edema, within 5 to 10 days of injury.

REF: p. 607 39. When should endotracheal intubation be performed on a smoke inhalation victim? a. As soon as possible b. Only if the patient demonstrates inspiratory and expiratory stridor

c. When the airway appears to be narrowing as determined by bronchoscopy d. When the signs and symptoms of respiratory failure are present ANS: A

Whenever airway obstruction is suspected, the most experienced clinician should perform endotracheal intubation. It is better to intubate early than to wait and find that the obstruction has progressed to where visualization of the larynx is reduced.

REF: p. 608 40. Which of the following medications is/are used to treat patients who have inhalation injury?

I. Beta-2 agonists II. Inhaled corticosteroids III. Racemic epinephrine IV. N-Acetylcysteine a. I only b. I, II, and III only c. I, III, and IV only d. II, III, and IV only ANS: C

Inhalation injury is best managed with beta-2 agonists, especially in patients who also have preexisting asthma or reactive airway disease. Aerosolized bronchodilators are effective by providing bronchial smooth muscle relaxation and stimulating mucociliary clearance.

However, when using these agents, it is important to remember they also increase overall metabolic rates in a patient who is already hypermetabolic secondary to thermal injuries.

Racemic epinephrine may be used as an aerosolized vasoconstrictor, bronchodilator, and secretion bond breaker. The vasoconstrictive action of racemic epinephrine is useful in reducing mucosal and submucosal edema within the walls of the pulmonary airways. A secondary bronchodilator action serves to reduce potential spasm of the smooth muscle of the terminal bronchioles. Racemic epinephrine has also been used in the treatment of postextubation stridor. N-Acetylcysteine is a powerful mucolytic agent used in respiratory care. It contains a thiol group, the free sulfhydryl radical of which is a strong reducing agent that ruptures the disulfide bonds that stabilize the mucoprotein network of molecules in mucus. Agents that break down these disulfide bonds produce the most effective mucolysis.

N-Acetylcysteine has been proven effective in combination with aerosolized heparin for the treatment of inhalation injury in animal studies. Heparin and N-acetylcysteine combinations have been used as scavengers for the oxygen-free radicals produced when alveolar macrophages are activated, either directly by chemicals in smoke or by one or more compounds in the arachidonic cascade. Animal studies have shown an increased ratio of PaO2 to FiO2, decreased peak inspiratory pressures, and a decreased amount of fibrin cast formation with heparin/N-acetylcysteine combinations. Pediatric patients treated with aerosolized heparin/N-acetylcysteine combinations showed a reduction in the incidence of atelectasis, number of ventilator days, incidence of reintubation for progressive respiratory failure, and mortality.

REF: p. 608 41. When mechanically ventilating a victim of inhalation injury, what tidal volume should the

therapist initially recommend?

a. b. c. d.

Less than 6 mL/kg 6 to 8 mL/kg 8 to 10 mL/kg 10 to 12 mL/kg

ANS: B

Conventional mechanical ventilation does not reverse the pathologic process, is not characterized by improved clearance of secretions, and may actually compound the existing injury. Conventional volume-limited ventilation in patients with inhalation injury is usually instituted at a tidal volume of 6 to 8 mL/kg. Numerous factors, such as lung/thorax compliance, system resistance, compressive volume loss, oxygenation, ventilation, and barotrauma, must be considered when tidal volumes are selected.

REF: p. 610 42. What appears to be the advantage of using high-frequency percussive ventilation instead of

conventional mechanical ventilation?

I. Less barotrauma II. Lower oxygen concentrations III. Lower tidal volumes (VTs) IV. Lower inspiratory pressures a. I and IV only b. II and III only c. I, II, and IV only d. II, III, and IV only ANS: C

High-frequency ventilation has also been employed after inhalation injury. This mode provides oxygenation at lower inspired oxygen concentrations and adequate ventilation at lower peak and mean airway pressures. In addition, a few reports have indicated increased secretion clearance with some forms of high-frequency ventilation.

REF: p. 609 43. Which of the following conditions is considered a late mechanical complication of inhalation

injuries? a. Tracheomalacia b. Atelectasis c. Stridor d. Infection ANS: A

Late complications of inhalation injury may be related to mechanical damage or to the consequences of an inflammatory response. Mechanical complications occur most often as a result of iatrogenic injury from endotracheal or tracheostomy tube cuffs. This damage may cause erosion of the tracheal cartilage and result in tracheomalacia. Injuries to the tracheal epithelium may result in fibrosis and stenosis of the trachea, which lead to subglottic stenosis.

Cuff erosion into adjacent structures (e.g., innominate artery) may result in exsanguinating hemorrhage. The injuries are difficult to diagnose and often develop slowly.

REF: p. 611 44. When a victim’s airway moves below the surface of a liquid, what is that person’s first

physiologic response? a. Voluntary breath holding b. Laryngospasm c. Hypercarbia and hypoxemia d. Aspiration ANS: A

The drowning process begins when the victim’s airway moves below the surface of the liquid, at which time the victim has a period of voluntary apnea or breath holding.

REF: p. 611 45. What occurs to the victim during drowning after the victim has been immersed in water to the

point of becoming hypercarbic, hypoxemic, and acidemic? a. Laryngospasm stops, and the victim actively inspires water. b. The victim begins to vomit. c. Laryngospasm continues and the hypercarbia, hypoxemia, and acidemia worsen. d. The victim stops breathing, and water flows into the lungs, causing asphyxia.

ANS: A

Breath holding is usually followed by an involuntary period of laryngospasm secondary to the presence of liquid in the oropharynx or larynx. If immersion continues, the victim becomes hypercarbic, hypoxemic, and acidotic and begins to swallow large amounts of water. As the victim becomes more hypoxic, the laryngospasm relaxes, and the victim actively breathes in liquid.

REF: p. 611 46. What form of injury is the major determinant of subsequent survival and long-term morbidity

in cases of near drowning? a. Pulmonary injury b. Cardiovascular injury c. Renal injury d. Neurologic injury ANS: D

CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of near drowning. Primary CNS (neurologic) injury is initially associated with tissue hypoxia and ischemia.

REF: p. 611 47. Which of the following conditions often results as a complication among survivors of

submersion injury? a. Pneumonia b. Acute respiratory distress syndrome c. Empyema d. Hypersensitivity pneumonitis

ANS: B

Acute respiratory distress syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common complication in survivors of submersion injury.

REF: p. 612 48. During resuscitation after cold water submersion, which of the following cardiovascular

responses tends to occur when the patient is rewarmed? a. Cardiac dysrhythmia b. Pulmonary hypertension c. Hypotension d. Myocardial infarction ANS: C

Profound hypotension may occur during and after the initial resuscitation period, especially when vasodilation occurs as the patient is rewarmed.

REF: p. 612 49. When should a rescuer begin applying airway management and rescue breathing at the scene

of a drowning event? a. As soon as the victim is removed from the water b. Once water is removed from the victim’s lungs after the victim is removed from the water c. By the emergency medical crew after the victim is removed from the water d. If possible, before the victim is out of the water ANS: D

The most important point in treatment is the quality of resuscitation at the scene of a drowning event. Airway management and rescue breathing should begin before the victim is out of the water, if possible, and CPR should be started as soon as an adequate surface is available.

REF: p. 613 50. Which of the following conditions should be anticipated in a near-drowning victim brought to

the emergency department?

I. Cardiac dysrhythmia II. Hypoxia III. Acidosis IV. Hypothermia a. I only b. II and III only c. I, II, and III only d. II, III, and IV only ANS: D

In the emergency department (ED), stability of the airway and adequacy of ventilation should be assessed. The first priority for managing drowning victims is to reverse hypoxemia by restoring adequate oxygenation and ventilation. All victims should be assumed to be hypoxic, acidotic, and hypothermic.

REF: p. 613 51. What should be the least amount of time required to rewarm a hypothermic near-drowning

victim who has a core temperature of 29° C in the emergency department? a. 1 hour b. 2 hours c. 3 hours d. 4 hours ANS: B

Some degree of hypothermia (core temperature less than 35° C) is almost always present after significant submersion, and severe hypothermia is associated with characteristic physical examination findings. The goals of management are to prevent a further fall in core temperature and to establish a safe and steady rewarming rate while maintaining cardiovascular stability. The health care team should attempt to rewarm the patient 1° C to 2° C per hour to a range of 33° C to 36° C. Aggressive rewarming above this range should be avoided because hyperthermia has been shown to worsen underlying cerebral injury in post– cardiac arrest patients.

REF: p. 614 52. What is the most effective means of rewarming a near-drowning victim whose core

temperature in the emergency room is 27° C? a. Radiant warmers b. Heated aerosol therapy c. Extracorporeal membrane oxygenation (ECMO) d. Mechanical ventilation with heated humidity ANS: C

Extracorporeal bypass is the most effective means of increasing body temperature for patients presenting with temperature less than 28° C. In some cases this technique should be considered early in the course of management, although evidence of success in the pediatric population has not been thoroughly studied to date.

REF: p. 613 53. Which of the following types of victims should be admitted to the hospital despite being

stable in the emergency room after a submersion injury?

I. Patients with any degree of respiratory compromise II. Victims who needed rescue breathing III. Patients who experienced a loss of consciousness IV. Victims who were combatant at the scene a. I and III only b. II and IV only c. I, II, and III only d. II, III, and IV only ANS: C

Victims evaluated in the ED who are minimally affected with no history of loss of consciousness, no altered mental status, and no respiratory signs and symptoms may be observed for a period of hours in the ED and discharged home if no complications arise.

Patients with any degree of respiratory compromise, history of need for rescue breathing, or loss of consciousness should be admitted to the hospital even if stable in the ED, because both neurologic injury and lung injury may progress over the first hours to days.

REF: p. 615

Chapter 32: Disorders of the Pleura Test Bank MULTIPLE CHOICE 1. Excessive amounts of pleural fluid may require drainage through a chest tube. What is the

normal amount of fluid present in the pleural space? a. 1 L b. 5 to 10 L c. 10 to 50 mL d. 1 to 5 mL ANS: D

The pleural "space" is generally only a potential space with a normal fluid volume of 1 to 5 mL. The pleural membranes, however, are very thin and permeable to both liquid and gas; an estimated 5 to 10 L of fluid per day crosses from the parietal pleura to the visceral pleura in a normal adult.

REF: p. 623 2. Which of the following factors determines the amount of fluid present in the pleural space? a. Intracapillary hydrostatic pressure b. Subatmospheric pressure in the pleural space c. Pleural pressure d. Intra-alveolar pressure ANS: B

Several factors determine the amount of fluid in the pleural space. The intracapillary hydrostatic pressures tend to drive fluid out of the capillaries, whereas the pericapillary hydrostatic pressures tend to counterbalance this force. The plasma colloid osmotic pressures exert a force to retain fluid within the capillaries, whereas the pericapillary colloid osmotic pressure tends to favor fluid movement out of the capillaries. Changes in the balance of these forces determine how much fluid is retained within the pleural space.

REF: p. 623 3. Which of the following clinical conditions causes fluid to accumulate in the pleural space? a. Congestive heart failure b. Asthma c. Cor pulmonale d. Chronic obstructive pulmonary disease ANS: A

Increased capillary permeability (e.g., acute respiratory distress syndrome), decreased intravascular colloid osmotic pressure (e.g., low serum albumin), and increased pulmonary venous pressure (e.g., heart failure) are common contributors to accumulation of fluid in the pleural space. Obstructed lymphatic drainage is another factor that favors accumulation of fluid in the pleural space.

REF: p. 623

4. Which of the following mechanisms explains the accumulation of fluid in the pleural space of

patients with ARDS? a. Increased capillary permeability b. Decreased osmotic pressure c. Increased hydrostatic pressure d. Obstructed lymphatic drainage ANS: A

Increased capillary permeability (e.g., acute respiratory distress syndrome), decreased intravascular colloid osmotic pressure (e.g., low serum albumin), and increased pulmonary venous pressure (e.g., heart failure) are common contributors to accumulation of fluid in the pleural space. Obstructed lymphatic drainage is another factor that favors accumulation of fluid in the pleural space.

REF: p. 623 5. In which of the following body positions are radiographs generally taken to reveal the

presence of excess fluid in the pleural space? a. Anteroposterior (AP) recumbent b. Posteroanterior (PA) recumbent c. Fowler d. Lateral decubitus ANS: D

In healthy individuals the chest radiograph seldom demonstrates any pleural fluid. An estimated 4% of normal adults may have minor radiographic evidence of pleural fluid if the films are taken in the decubitus or Trendelenburg position.

REF: pp. 623-624 6. What type of auscultatory and percussion findings often reveal evidence of a pleural effusion? a. Wheezing; hyperresonance b. Crackles; bronchovesicular c. Crackles; dull d. Diminished; dull ANS: D

Pleural effusions may be suspected clinically when there is an area of decreased-intensity breath sounds on chest auscultation with an associated dullness to percussion over the corresponding area.

REF: p. 624 7. Which of the following clinical symptoms is associated with a pleural effusion? a. Chest pain b. Productive cough c. Dyspnea d. Dysphagia ANS: A

The patient may experience few symptoms from a small pleural effusion but usually has symptoms of respiratory distress with larger accumulations. Chest pain, chest wall tenderness, dyspnea, and pain with coughing or deep breathing are often associated with pleural effusions.

REF: p. 624 8. Which of the following conditions is considered a complication of a thoracentesis? a. Increased intracranial pressure b. Pneumothorax c. Pneumonia d. Consolidation ANS: B

Complications of thoracentesis include pneumothorax, hemorrhage, and infection.

REF: p. 624 9. What is the most common cause of pleural effusion in the pediatric population? a. Empyema b. Congestive heart failure c. Parapneumonic effusion d. Adenobacterial effusion ANS: C

The most common cause of pleural effusion in pediatrics is a parapneumonic effusion, which indicates that the pleural fluid is the result of an underlying pneumonia. Although typically a bacterial pneumonia, parapneumonic effusion can also result from a virus, fungus, or parasite, or from tuberculosis. If the pneumonia extends to infect the pleural space as well, the effusion is termed an empyema.

REF: p. 625 10. Fluid drained from a thoracentesis has the appearance of pus. Which of the following

microorganisms should the therapist typically suspect in children with empyema? a. Staphylococcus aureus b. Streptococcus pneumoniae c. Klebsiella pneumoniae d. Mycoplasma pneumoniae ANS: B

Streptococcus pneumoniae is the most common organism causing pneumonia and empyema in children.

REF: p. 626 11. Which of the following laboratory analyses would the respiratory therapist possibly conduct,

using a sample of pleural fluid? a. Determination of the causative microorganism b. pH determination c. Determination that the effusion is an exudate or a transudate d. Composition testing

ANS: B

The respiratory therapist may be asked to determine the pleural fluid pH using a blood gas analyzer. The specimen must be collected anaerobically in a heparinized syringe and kept on ice until it is analyzed. A pH < 7.0 or < 0.15 pH unit below the arterial pH in a patient with parapneumonic effusion may indicate that the patient is at risk for prolonged effusion and subsequent lung entrapment. This has not been extensively studied in children.

REF: p. 626 12. Which of the following are the most common symptoms associated with pneumothorax? a. Cough and headache b. Shortness of breath and chest pain c. Hemoptysis and chest pain d. Dry cough and dyspnea ANS: C

A small percentage of patients with a pneumothorax are asymptomatic or have only mild and vague symptoms; however, it is much more common for chest pain and shortness of breath to accompany the pneumothorax.

REF: p. 626 13. What procedure should the therapist suggest to relieve a tension pneumothorax while awaiting

more definitive treatment? a. Insertion of thoracostomy tubes b. Thoracotomy c. Thoracentesis with a large-bore needle d. Needle thoracostomy ANS: C

Treatment of the pneumothorax depends on whether it is under tension. The tension pneumothorax is an emergency and should be relieved as soon as possible. The pleural space is drained by thoracentesis with a large-bore needle while awaiting more definitive therapy.

REF: p. 627 14. The therapist is assessing a water seal and a collection chamber and observes bubbling in the

water seal chamber. What should the therapist do at this time? a. Nothing because bubbling indicates normal function b. Increase the suction pressure c. Reassess the patient because bubbling indicates presence of air leak d. Remove the chest tube ANS: C

The level of water in the suction control chamber determines the amount of negative pressure applied to the pleural space. Bubbling in the water seal chamber indicates ongoing air leaks, which are usually from the pleural space.

REF: p. 627

Chapter 33: Neurologic and Neuromuscular Disorders Test Bank MULTIPLE CHOICE 1. What are the names of the separate pathways in the spinal cord that support both voluntary

and involuntary ventilation and transmit signals through descending pathways to motor neurons? a. Voluntary, reticulospinal; involuntary, corticospinal b. Voluntary, cervicothoracic; involuntary, reticulospinal c. Voluntary, corticospinal; involuntary, reticulospinal d. Voluntary, corticospinal; involuntary, cervicothoracic ANS: C

Separate pathways in the spinal cord support both voluntary (corticospinal) and involuntary (reticulospinal) ventilation and transmit signals through descending pathways to motor neurons in the cervicothoracic portion of the spinal cord. These motor neurons transmit signals through peripheral nerves and across the neuromuscular junctions to the muscles of respiration. Dysfunction in any part of this control system, from brainstem to respiratory muscles, can result in respiratory failure.

REF: p. 633 2. Which of the following muscles is considered a primary muscle of inspiration? a. Internal intercostal muscles b. Transversus abdominis c. Sternocleidomastoid muscles d. Diaphragm ANS: D

The main inspiratory muscle is the diaphragm, which contributes almost three quarters of the inspiratory capacity and increases the vertical dimension of the thorax. Cervical nerves 3 to 5 contribute to form the phrenic nerve, which drives the diaphragm. Additional inspiratory force is provided by the external intercostal muscles, which contract to expand the rib cage during inspiration. The innervation of the intercostal muscles occurs via the intercostal nerves, which come off the thoracic spinal nerve roots.

REF: p. 633 3. What are the consequences of bulbar muscle dysfunction?

I. Dysphagia II. Impaired coughing III. Dysarthria IV. Impaired inspiration a. II and IV only b. I and III only c. I, II, and III only d. II, III, and IV only

ANS: C

The bulbar muscles are enervated by the motor neurons emanating from the brainstem. This muscle group controls the epiglottis and other glottic structures, tongue, mouth, larynx, and throat. Bulbar muscle weakness impairs swallowing, coughing, speech, and other throat and pharyngeal activities. Bulbar muscle weakness also leads to severe fixed and variable extrathoracic upper airway obstruction on forced inspiratory and expiratory respiratory efforts.

REF: p. 634 4. Ondine’s curse, or congenital central hypoventilation syndrome, occurs during which activity? a. Laughing b. Sleeping c. Eating d. Crying ANS: B

One of the best examples of a CNS disorder that affects breathing is congenital central hypoventilation syndrome. Also known as Ondine’s curse, this represents a condition involving hypoventilation associated with sleep.

REF: p. 634 5. The therapist is asked to evaluate a young child with a diagnosis of Chiari malformation.

Which of the following signs and symptoms should the therapist expect to see?

I. Irregular breathing II. Difficulty swallowing III. Vomiting IV. Choking a. II and IV only b. III and IV only c. I, II, and III only d. I, II, and IV only ANS: D

Younger children with Chiari malformations may present with difficulty swallowing, choking, irregular breathing patterns, or apnea.

REF: p. 635 6. The therapist is performing an airway clearance technique to a 5-month-old child with a

diagnosis of aspiration pneumonia. The child has a very weak cough and, although he appears alert, he cannot move. Which of the following disorders of the motor nerve should the therapist suspect? a. Polio b. Myasthenia gravis c. Spinal muscular atrophy d. Guillian-Barré ANS: C

SMA type I, also called Werdnig-Hoffmann disease, is the acute infantile form, which usually presents within the first 6 months of life. In these children, limb weakness develops rapidly, whereas the facial muscles are slower to fail and the extraocular muscles are essentially spared. The result is a child who appears alert and responsive but cannot move. The respiratory effects of SMA type I include weakness of the bulbar, abdominal, and intercostal muscles, which makes feeding difficult and leads to aspiration and a weak, ineffective cough.

A weak cough results in recurrent pneumonias and poor airway clearance. Even relatively minor viral infections result in severe airway and ventilator compromise. Without intervention, most infants will die of respiratory insufficiency and infection before reaching 1 year of age.

REF: p. 635 7. Which of the following forms of poliomyelitis affects the nerves in the cervical spine region

that control diaphragmatic function? a. Spinal b. Bulbar c. Bulbospinal d. Bulbosacral ANS: C

Depending on the site of paralysis, paralytic polio is classified as spinal, affecting the nerves of the trunk and extremities; bulbar, affecting the nerves that control breathing, speaking, and swallowing; or bulbospinal, representing a combination of these two forms. Bulbospinal polio is particularly problematic because it affects the nerves in the cervical spine region that control diaphragm function. Destruction of these nerves makes independent respiration, swallowing, and effective coughing impossible. Lifelong ventilator support and airway clearance is essential for the survival of these patients.

REF: p. 635 8. Which of the following diseases is characterized by demyelination of sheaths that coat

peripheral nerves? a. Poliomyelitis b. Guillain-Barré syndrome c. Chiari malformations d. Infantile botulism ANS: B

Although its cause is not completely understood, Guillain-Barré syndrome (GBS) is probably triggered by an acute infectious process, which leads to antibody-mediated destruction of the myelin sheaths that coat peripheral nerves.

REF: p. 635 9. A therapist is administering incentive spirometry to a patient who demonstrates ptosis,

diplopia, and a weak cough. The patient has a history of a minimal chronic respiratory disease.

Which of the following disorders is likely affecting this patient? a. Guillain-Barré syndrome b. Becker muscular dystrophy c. Duchenne muscular dystrophy

d. Myasthenia gravis ANS: D

The initial features of both the ocular and generalized forms are usually ptosis, diplopia, or both. Prepubertal onset is associated with a slight male bias and ocular symptoms only, whereas postpubertal onset is associated with a strong female bias and generalized myasthenia. Patients with myasthenia gravis (MG) often have little chronic respiratory compromise and are symptomatic only during periods of myasthenia crisis, when symptoms, particularly bulbar symptoms, suddenly escalate. During one such crisis patients may have sudden paralysis of the respiratory muscles, temporarily requiring assisted ventilation.

REF: p. 636 10. Which of the following neuromuscular diseases is characterized in early childhood by

progressive muscle weakness, followed by skeletal and respiratory muscle weakness, and in adolescence by confinement to a wheelchair and requirement for ventilatory assistance? a. Amyotrophic lateral sclerosis b. Duchenne muscular dystrophy c. Glycogen storage disease d. Becker muscular dystrophy ANS: B

The muscle weakness is progressive and eventually leads to profound skeletal and respiratory muscle weakness in all cases. By adolescence, all patients with DMD are wheelchair bound and require assistance with ventilation.

REF: p. 637 11. Which of the following diseases is characterized by chronic, slowly progressive muscle

wasting and weakness, cataracts, heart conduction defects, and endocrine disorders? a. Glycogen storage disease b. Spinal muscular atrophy c. Myotonic dystrophy d. Becker muscular dystrophy ANS: C

Myotonic dystrophy is a highly variable inherited disease characterized by chronic, slowly progressive muscle wasting and weakness, cataracts, heart conduction defects, and endocrine disorders.

REF: p. 637 12. Which of the following glycogen storage diseases has the most severe respiratory symptoms? a. Pompe disease b. Diabetes c. Von Gierke d. Forbes-Cori disease ANS: A

In terms of respiratory involvement, glycogen storage disease type II (also called Pompe disease or acid maltase deficiency) has the most severe symptoms.

REF: p. 637 13. Which of the following measurements is the main determinant of respiratory compromise in

pediatric patients with neuromuscular disease? a. Forced vital capacity b. Forced expiratory volume in 1 second c. Forced inspiratory volume d. Flows during coughing ANS: D

The use of pulmonary function tests (PFTs) in diagnosing and monitoring the progression of neuromuscular disease has been well established in adults, but pediatric testing remains a challenge. Although newer techniques for respiratory muscle strength testing are being introduced, the majority of school-age children and adolescents are best monitored by standard spirometry with maximal inspiratory and expiratory pressure monitoring. Additional testing includes assessment of cough flows because they are the main determinant of respiratory compromise.

REF: p. 638 14. Which of the following diagnostic evaluations is/are appropriate for children with

neuromuscular dysfunction who exhibit progressive carbon dioxide retention, increasing muscle weakness, and advancing concerns regarding nighttime hypoventilation? a. Spirometry studies b. Complete pulmonary function studies c. Home overnight oximetry d. Arterial blood gas analysis and pulse oximetry ANS: C

With further progression of carbon dioxide retention and muscle weakness and advancing concerns regarding nighttime hypoventilation, home overnight oximetry or polysomnography may be useful in determining the early need for assisted respiratory support.

REF: p. 638 15. Which of the following therapeutic strategies should the therapist deem as the most important

in patients with neuromuscular disease? a. Airway clearance techniques b. Oxygen therapy c. Ventilatory support d. Hydration ANS: A

Children with neuromuscular weakness may have trouble with each phase of coughing.

Inspiratory muscle weakness reduces vital capacity and maximal inhaled volume, bulbar muscle weakness can lead to impaired glottic closure, and expiratory muscle weakness reduces the maximal intrathoracic pressure and expulsive force. The significance of this cannot be overstated: in patients with neuromuscular disease, most episodes of acute respiratory failure result from the inability to eliminate airway secretions and mucus during otherwise benign chest infections. A peak cough flow less than 160 L/minute is associated with impaired secretion clearance, but early intervention at 250 to 270 L/minute is recommended for beginning cough assistance.

REF: p. 639

Chapter 34: Transport of Infants and Children Test Bank MULTIPLE CHOICE 1. Which of the following types of health care providers generally compose the crew for infant

transport? a. Discharge planner and nurse b. Respiratory therapist and nurse c. Physician and nurse d. Discharge planner and physician ANS: B

Data show that most pediatric transport teams in the United States are led by a nurse and accompanied by a respiratory therapist.

REF: p. 648 2. Which of the following professional organizations have developed educational requirements

or training programs for pediatric transport personnel?

I. National Board for Respiratory Care II. American Association for Respiratory Care III. American Academy of Pediatrics IV. Air & Surface Transport Nurses Association a. I and II only b. III and IV only c. I, II, and III only d. II, III, and IV only ANS: D

Several different professional organizations have developed training/ educational requirements for pediatric transport teams. The Air & Surface Transport Nurses Association (ASTNA, Greenwood Village, CO), American Association for Respiratory Care (AARC, Irving, TX), Commission on Accreditation of Medical Transport Systems (CAMTS, Anderson, SC), and the American Academy of Pediatrics (AAP, Elk Grove Village, IL) National Certification Corporation (NCC, Chicago, IL) are commonly recognized.

REF: p. 649 3. What is the most expensive component of a pediatric transport program? a. Personnel salaries b. Cost associated with training personnel c. Transport vehicles d. Updating equipment ANS: C

The single largest expense of a transport program is the operation and maintenance of its transport vehicles.

REF: p. 650 4. What are some of the operational features that characterize a pediatric transport unit?

I. 110-V AC electrical power II. Point-of-care radiographic equipment III. Medical air and oxygen IV. Suction capabilities and equipment a. III and IV only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only ANS: C

All vehicles used to transport patients must comply with local, state, and federal guidelines for both air and ground ambulances. The vehicles must have 110-V AC electrical power available for the medical equipment used during transport. There should be sufficient medical gas (medical air and oxygen) capacity for all transport operations plus reserve capacity for use in the event of mechanical breakdown. The vehicles must also have provisions for suction equipment. The medical equipment used in transport, as well as the stretcher/incubator, must be safely secured within the vehicle during transport. The vehicle must have interior room, which will allow the transport team to treat and assess the patient and on occasion perform procedures safely during transport. All transport vehicles must have two-way communication capability, using radios or cellular phone. Each mode of transport—ground, rotor wing (helicopter), and fixed wing (airplane)—has advantages and disadvantages. The vehicle chosen should be appropriate for the patient population and geographic area served.

REF: p. 650 5. Which of the following distances is generally considered the maximum mileage in one

direction for ground transport of a critically ill child? a. 15 miles b. 30 miles c. 45 miles d. 60 miles ANS: B

Ground transport should be considered when distances are 30 miles or less one way for critical patients and, for stable patients, less than 80 miles one way.

REF: p. 650 6. How large should the interior of an ambulance be for accommodating equipment and

personnel? a. Large enough for two incubators and eight personnel b. Large enough for one large incubator and two team members c. Large enough to secure two transport incubators and room to seat enough team members to provide care d. Large enough to be versatile regardless of the equipment and personnel needs ANS: C

The ambulance interior should be large enough to secure two transport incubators for transport of twins and room to seat the transport team members required for the care of two patients.

REF: p. 650 7. Which of the following distances is considered the effective radius for rapid transport of

critically ill patients via helicopter? a. Less than 30 miles b. Between 30 and 150 miles c. Between 150 and 250 miles d. Between 250 and 300 miles ANS: B

Helicopters are effective for rapid transport of critical patients within a 30- to 150-mile radius.

REF: p. 650 8. Why must fixed-wing aircraft have the ability to control cabin pressure during the transport of

critically patients? a. To avoid the crew “blacking out” b. To provide the patient’s oxygenation needs c. To avoid the patient becoming hypercarbic d. To reduce the risk of fire ANS: B

All airplanes used for critical patient transport should have the ability to control the cabin altitude (pressurization), which makes transporting critically ill patients with marginal arterial oxygenation possible.

REF: p. 651 9. Which of the following communication systems is the most advantageous for fixed-wing

ambulances to have to accomplish air-to-hospital communications? a. UHF/AM transceiver b. Walkie-talkie type phone c. VHF radios d. Satellite-type cell phone ANS: D

Because of the short-range limitations of UHF radios, fixed-wing air ambulances should be equipped with a satellite-type cell phone for air-to-hospital communication. This will allow communication from just about any location around the world.

REF: p. 651 10. During transport, how is the decision made to provide volume- or pressure-controlled

ventilation? a. The patient always receives volume-controlled ventilation. b. The patient always receives pressure-controlled ventilation. c. The type of ventilation used is determined by the physician’s order. d. The type of ventilation used depends on the patient’s needs.

ANS: D

The decision to use a volume-limited or a pressure-limited ventilator should be based on the patient's size and ventilatory requirements.

REF: p. 652 11. What has proved to be the benefit of point-of-care blood analysis during transport? a. Cost-effectiveness b. Durability of the equipment c. Reduced patient stabilization time d. The need for fewer blood samples ANS: C

Studies have shown that point-of-care testing reduces stabilization times and has the potential to improve the quality of care during transport.

REF: p. 653 12. How much medical gas needs to be taken on a transport? a. Enough to last 30 minutes beyond the calculated duration b. Twice the calculated amount c. Three times the calculated amount d. Enough gas is always on board ANS: B

The amount of gas taken should be approximately double that required. This allows for emergency usage in the event of mechanical breakdown of a vehicle.

REF: p. 653 13. Which of the following effects are expected during ascent in air transport? a. Decreased urine output b. Respiratory rate decreases c. Endotracheal tube cuff pressure decreases d. Depth of breathing increases ANS: D

As the aircraft and patient rise in altitude, the volume of contained gases will expand. This expansion has the following clinical implications for patient care: increased respiratory rate and depth, changes in intravenous flow rates, nausea and vomiting, increased need to urinate, increased pain, endotracheal tube cuff expansion (prevented by filling the cuff with normal saline), and increased sinus pressure in the case of head colds or blocked sinuses.

REF: p. 654 14. What are the negative effects of an aircraft flown with a sea-level cabin altitude? a. A higher flight altitude is necessary. b. Air-to-ground communications become difficult. c. Fuel consumption often increases. d. The aircraft may encounter more altitude-related concerns.

ANS: C

Cabin pressurization creates an artificial atmospheric pressure inside the aircraft, known as cabin altitude. The cabin altitude can be adjusted from sea level to a maximal differential (usually 5000 to 6000 ft) depending on patient requirements and aircraft operations. An aircraft flown with a sea-level cabin altitude will not experience any of the effects of high altitude, but this could have a negative effect on the operation of the aircraft. Because of the pressure differential, the aircraft might need to be flown at a lower flight altitude to allow for the sea-level cabin pressurization. This lower flight altitude might increase the fuel burn (possibly requiring a fuel stop), slow the aircraft and thus increase transport time, and expose the aircraft to more severe weather concerns. Documentation of the cabin altitude during the patient transport should be included in the patient transport record. If for any reason flight cabin altitude may compromise the patient’s condition, medical control should be contacted.

REF: p. 654

Chapter 35: Home Care Test Bank MULTIPLE CHOICE 1. At what point during the patient’s admission to the hospital should discharge planning begin? a. On admission b. Once the patient gets situated in a private or semiprivate room c. Once the patient stabilizes d. When the patient stabilizes and after all resources have been evaluated ANS: A

When patients arrive at a neonatal or pediatric intensive care facility, the unit is already planning for discharge to an alternative site of care.

REF: p. 659 2. What are the goals of discharge planning?

I. To reduce the number of hospitalizations II. To have the patient resume activities of daily living III. To reduce the number of emergency room visits IV. To reduce the patient’s length of stay a. I and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: D

The intent for discharge planning is to reduce the hospital stay, which minimizes medical costs and risk of additional infection.

REF: p. 659 3. Before the patient is discharged home, who needs to meet and assess the needs of both the

child and family? a. The family and the physician b. The nurse and the family c. The physician and nurse d. The family and the health care team ANS: D

The entire discharge planning team should meet and assess the needs of both the child and family. Before discharge home, the child must be medically stable and receiving optimal ventilatory, nutritional, and developmental support. Assessment includes evaluation of the family's ability, availability, and commitment to care for their child as well as a psychosocial assessment for parenting risk factors that could potentially result in adverse outcomes.

Limitations, including language, physical, and cognitive, may delay discharge until appropriate support can be provided to the family to help overcome these barriers.

REF: p. 659 4. Who is responsible for deciding the type of oxygen delivery system that will be used in the

home? a. Physician b. Patient c. Durable medical equipment (DME) company d. Discharge planner ANS: C

The three types of oxygen systems available for the home environment are liquid oxygen, oxygen concentrators, and compressed oxygen cylinders. Selection of the system is commonly the responsibility of the DME provider. Regardless of the type of oxygen system provided, it is essential that the DME provider be advised of the specific flow rate the child requires. This will determine which flowmeter to use with the system.

REF: p. 663 5. Which of the following is the most important disadvantage of a liquid oxygen system? a. It is very heavy. b. It requires a power source. c. It requires filling every 6 months. d. It vents regardless of whether the flow is on or off.

ANS: D

A disadvantage to using this system is that the base unit requires regular refilling by the DME provider. Frequency depends on both the oxygen flow rate and the size of the reservoir and can be as often as once a week to every other month. Another disadvantage to the liquid oxygen system is that it vents continually to prevent pressure from building within the reservoir, resulting in a loss of oxygen regardless of whether the flow is on or off.

REF: p. 663 6. What are the advantages of an oxygen concentrator? a. It provides an unlimited supply of oxygen. b. It does not require a power source. c. It does not require gas analysis. d. It is ideal for transport situations.

ANS: A

Most concentrators provide greater than 90% oxygen. On some concentrators the flowmeters can be changed to provide low flow rates (see Figure 35-3 in the textbook) whereas others have dual flowmeters to accommodate the varied needs of the patient (see Figure 35-4 in the textbook). The DME provider needs to evaluate each concentrator's specifications before use with pediatric patients to ensure it can be used with low flows. When using concentrators, oxygen cylinders are provided for the patient to use for transport and for backup in the case of an electrical power outage. As long as there is an electrical source, an oxygen concentrator provides an unlimited supply of oxygen and does not need to be refilled.

REF: p. 663

7. Why are compressed gas cylinders of oxygen becoming more commonplace for patient

transport in the home care setting? a. Because patients generally cannot afford liquid oxygen b. Because compressed gas cylinders are being made smaller and lighter c. Because they are being made safer and people can smoke near them d. Because the grade of oxygen in compressed gas cylinders is higher than in liquid systems ANS: B

Portable cylinders are available in a variety of sizes and are identified by letter designations.

At one time the E cylinder was the smallest available in portable cylinders, making liquid oxygen the number one choice for pediatric patients. Today, however, compressed gas cylinders are gaining in popularity thanks to the availability of smaller cylinders with custom carrying cases and regulators that allow flows as low at 1/32 Lpm. REF: p. 664 8. What is the utility of downloading information from an apnea monitor? a. It facilitates billing the patient for services. b. It helps monitor oxygen use. c. It enables differentiating among different types of apnea. d. It helps decide the next laboratory evaluation.

ANS: C

The information obtained from a download can be used to distinguish the type of apnea, decide the type of medical treatment needed, and determine compliance and when to discontinue the monitor.

REF: p. 665 9. Which of the following infants may benefit from using an apnea monitor at home?

I. Infants who were born preterm II. Infants who have experienced a life-threatening event III. Infants who have been diagnosed with gastroesophageal reflux disease IV. Infants who have experienced an apneic episode for any reason in the hospital a. II and III only b. I, II, and IV only c. I, III, and IV only d. II, III, and IV only ANS: A

An apnea monitor may be considered medically necessary for infants who: • Have apnea of prematurity • Are receiving caffeine or theophylline for treatment of apnea or bradycardia • Have experienced an apparent life-threatening event • Have pertussis with positive cultures • Are diagnosed with gastroesophageal reflux disease accompanied by apnea, bradycardia, or oxygen desaturation • Have neurologic or metabolic disorders affecting respiratory control

• Have chronic lung disease and require noninvasive or invasive ventilatory support • Have two siblings who died of sudden infant death syndrome REF: p. 665 10. What considerations need to be taken into account when applying external positive end-

expiratory pressure (PEEP) to a home ventilator?

I. The ventilator circuit must be able to accommodate the weight of the PEEP valve.

II. The PEEP valve must be able to function at any angle.

III. Thoracostomy tubes need to be available to treat a pneumothorax.

IV. The exhalation ports must be free from obstructions. a. II and IV only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only ANS: C

Another factor to be considered when selecting a home ventilator concerns the compatibility of the circuit and the positive end-expiratory pressure (PEEP) valve. PEEP is often accomplished by using an external PEEP valve, which can be heavy and may also have exhalation ports that can be easily blocked. The combination of the PEEP valve and circuit must have minimal exhaled resistance. The PEEP valve must also be able to function at any angle; this precludes gravity and water columns for home use.

REF: p. 672 11. What is a major advantage of using a portable ventilator? a. It is easy to analyze the inspired fraction of oxygen (FiO2). b. No humidification is necessary. c. It provides a variety of ventilation modes. d. A variety of power sources can be used.

ANS: D

A major advantage of a portable ventilator is the ability to use a variety of power sources, including house current, an internal battery for short periods, and an external battery for extended periods. Some portable ventilators can operate from a car battery by connecting to the cigarette lighter.

REF: p. 672 12. Which of the following backup equipment needs to be provided for a home-ventilated infant

who (1) lacks the ability to breathe spontaneously for at least 4 successive hours, (2) lives 2 hours away by automobile from medical assistance, and (3) requires mechanical ventilation for mobility? a. Point-of-care blood gas analyzer b. Second oxygen concentrator c. Additional source of oxygen d. Additional ventilator and ventilator circuits ANS: D

A second ventilator, or backup ventilator, should be provided in the home for the child who (1) cannot maintain spontaneous ventilation for at least 4 consecutive hours, (2) lives in an area where a replacement ventilator cannot be provided within 2 hours, or (3) requires mechanical ventilation during mobility. An emergency backup ventilator must be available in the event of a ventilator malfunction. Without a backup ventilator in the home, the home care company must assume the responsibility for providing immediate service. It is also best to have extra ventilator circuits and a spare temperature probe in the home.

REF: p. 673 13. Which of the following circumstances constitute obstacles to discharging a child who requires

home mechanical ventilation?

I. Lack of family access to public transportation II. Large number of siblings III. Delays in approval for home care funding IV. Unsuitable home environment a. I and II only b. II and III only c. III and IV only d. II, III, and IV only ANS: C

In spite of the most valiant attempts at organization, communication, and planning within the discharge process, obstacles to discharge will still occur. The major barriers for chronically ventilated children include failure to obtain qualified nursing staff, delays in approval for home care funding, an unsuitable home environment, complex family issues, and arrangements for out-of-home placement.

REF: p. 673 14. What is the outcome when delays in funding for the home care services occur? a. The process continues because eventually the funding will materialize. b. Only the essential components of the discharge plan are initially implanted. c. The discharge process is delayed until the caregivers receive education to perform

additional services. d. The discharge is delayed indefinitely.

ANS: D

Funding delays are often the greatest hurdle to getting the child home. Without reimbursement, home equipment cannot be obtained. The greatest difficulty arises when little or no reimbursement is available for the ventilator. Community resources, such as nursing, speech therapy, physical therapy, and occupational therapy, are also unattainable without funding. Without reimbursement, discharge is delayed indefinitely.

REF: p. 673 15. What effect does an extended hospital stay tend to have on the discharge planning process for

a child expected to receive mechanical ventilation at home? a. It helps the family become more familiar with providing health care at home. b. It provides the family with the opportunity to earn more income to facilitate the

discharge process. c. It affords the family more time to recruit additional health care providers to be used in the home. d. It often results in a negative change in the family dynamics.

ANS: D

Family issues are all too often the most difficult barriers to overcome. The longer the hospital stay, the more likely that family dynamics will change. Strained finances, guilt, fatigue, worry, and emotional distress are all issues faced by most families of ventilator-assisted children.

However, issues such as divorce, which often results in loss of one of the primary caregivers, and drug abuse and mental illness, are the types of issues that tend to cause the longest delays.

REF: p. 674 16. Before a ventilator-dependent child can be discharged home, which of the following criteria

must be met? a. The ventilator setting must be stable for at least 3 weeks. b. Arterial blood gas measurements must be stable and within normal limits. c. The patient’s FiO2 must be 0.80 or less. d. If PEEP is used, it must be no more than 10 cm H2O. ANS: B

Before a ventilator-dependent child can be discharged home, the following criteria must be met: Ventilator settings must be stable for at least 1 week. The oxygen concentration must be less than 40%, and blood gas measurements must be stable and within normal limits. The home environment must be acceptable, and the home equipment available either at the hospital or at the child’s home.

REF: p. 674

Chapter 36: Quality and Safety Test Bank MULTIPLE CHOICE 1. Lack of skills and/or failure to follow or deviation from standard practices/procedures is

known as: a. Sentinel event b. Six Sigma c. Negligence d. Health failure mode ANS: C

Negligence (described as a lack of skills and/or failure to follow or deviation from standard practices/procedures) was determined to be the cause in 27.6% of adverse events.

REF: p. 681 2. What is the most common serious error observed in the NICU? a. Medication related b. Patient misidentification c. Error in the diagnosis d. Delayed diagnosis ANS: A

NICU data revealed 47% of errors were medication related, 11% involved patient misidentification, 7% involved delay or errors in diagnosis, and 14% involved errors in the administration or methods of using a treatment.

REF: p. 681 3. What has been described by the IOM as a necessary component of change needed to occur to

improve patient safety? a. Increase the number of physicians b. Increase the number of nurses and allied health professionals c. Develop teams of caregivers for multidisciplinary communication d. Involve the family in the health care team ANS: C

Developing teams of caregivers for multidisciplinary communication was described early on

by IOM as a necessary component of change that needed to occur to improve patient safety.

REF: p. 682 4. The wrong dose of albuterol is administered to the patient, but the patient does not have any

adverse response. What is the name of this event? a. Near miss b. Precursor safety event c. Serious safety event d. Sentinel event

ANS: B

The second classification is a precursor safety event, an event that reaches the patient but results in minimal to no detectable harm. If that same dose error is not detected by the pharmacist or nurse and gets delivered to the patient but the patient does not have any adverse response, it is a precursor safety event.

REF: p. 683 5. A therapist is assisting the pulmonologist during a bronchoscopy. While the child’s oxygen

saturation was reading above 90%, the patient had been apneic for approximately 1 minute and suffered a mild anoxic injury. What is the name of an event like this? a. Near miss b. Precursor safety event c. Serious safety event d. Sentinel event ANS: D

The Joint Commission (TJC) also reviews errors, which are classified as sentinel events. The Joint Commission defines a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”

REF: p. 683 6. Which of the following processes enables organizations to continuously measure services,

practices, costs, and products using best practices to improve care? a. Self-reporting b. Benchmarking c. Quality measure reporting d. Quarterly budget ANS: B

Measures of quality and safety can track progress of improvement initiatives using reporting benchmarks. Benchmarking in health care is defined as the continual and collaborative discipline of measuring and comparing the results of key work processes with those who have what is considered best practices. This process enables organizations to continuously measure services, practices, costs, and products using best practices to improve care.

REF: p. 683 7. Prevention of safety events is critical in pediatric patients because, when a safety event

occurs: a. Hospital stay is 10 times longer b. Hospital mortality may be as high as 18 times greater c. Hospital charges are 50 times higher d. Hospitals do not get reimbursed ANS: B

More recent reviews of potential pediatric safety issues reveal the hospitalized child who experiences a safety event, as compared with those who did not, has a length of stay 2 to 6 times longer, hospital mortality 2 to 18 times greater, and hospital charges 2 to 20 times higher.

REF: p. 687 8. What is the most common complication of hospital care that the therapist should be aware of? a. Errors in administration of medications b. Accidental extubations c. Pneumonia d. Health care–associated infections ANS: D

Health care–associated infections (HAI) are infections patients acquire while receiving treatment for another condition in some type of health care facility. Millions of infections with thousands of deaths occur annually, making HAIs the most common complication of hospital care.

REF: p. 687 9. Which of the following types of infections are considered HAIs?

I. Catheter-associated blood stream infections II. Catheter-associated urinary tract infections III. Ventilator-associated pneumonias IV. Surgical site infections a. II and III only b. I, II, and IV only c. I, III, and IV only d. I, II, III, and IV ANS: D

Financially, HAIs add $28 to $33 billion to health care costs. AHRQ researches barriers and challenges in preventing the most frequent and therefore most costly HAIs. These infections cause extended hospital stays and increased cost and risk of mortality. Types of infections include: blood stream infections (BSIs), catheter-associated urinary tract infections (CATIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), which together account for more than 80 percent of all HAIs. REF: p. 687 10. Which of the following postsurgical respiratory issues are associated with reintubation or

prolonged mechanical ventilation?

I. Lack of use of incentive spirometry II. Oversedation III. Exacerbation of underlying cardiovascular condition IV. Exacerbation of underlying respiratory condition a. II and III only b. II, and IV only c. I, II, and IV only d. II, III, and IV only ANS: D

Respiratory issues postsurgery are not uncommon; reintubation or prolonged mechanical ventilation may be necessary. Causes include: oversedation, exacerbation of underlying cardiovascular or respiratory conditions, and ventilator-associated pneumonia (AHRQ, 2011).

Close attention should be paid to these risk factors.

REF: p. 688 11. What is a statistical method that measures standard deviations or known variance and the

degree to which almost perfect production can occur? a. Six Sigma b. Systemic variability c. Analysis of variance d. Power ANS: A

Six Sigma was developed by Motorola as a quality improvement (QI) strategy. The term itself is derived for the Greek letter sigma, which statisticians use to measure standard deviations or known variance and the degree to which almost perfect production can occur. Six Sigma is based on a scientific method that involves improving, designing, and monitoring processes to minimize or eliminate waste while optimizing satisfaction and increasing financial stability.

REF: p. 688