SAN PEDRO COLLEGE COMPETENCY APPRAISAL - OXYGENATION

Name: __________________________ Date: _____________

1. The ER physician asks you to review a chest radiograph from a patient with history of severe
emphysema. Which of the following findings would you expect to observe on this film?

I. a wide mediastinum
II. an increase in peripheral vascular markings
III. lowered, flattened diaphragm
IV. an increased radiolucency in the lung fields
V. presence of bullae and blebs
A) II and III only

B) III, IV, and V only

C) II, III, and V only

D) I, II, III, IV, and V

Ans: B

Response:
Flat diaphragms and increased radiolucency throughout the lung fields are common in the
chest X-ray of a any patient with a COPD condition, as are a decrease in peripheral vascular
markings, an increased retrosternal airspace, and a narrow mediastinum.

2. When using a pulse oximetry device, the most common source of error and false alarms is:
A) patient motion artifact

B) presence of HbCO

C) presence of vascular dyes

D) ambient light detection

Ans: A

Response:
The most common source of error and false alarms with pulse oximetry is motion artifact.
Securing the sensor properly or relocating of the sensor to an earlobe, a toe, or an external
naris can help minimize this problem.

3. A patient receiving mechanical ventilation in the CMV control mode is making asynchronous
breathing efforts against the ventilator's controlled breaths. This will result in:
A) decreased ventilatory drive

B) increased physiologic deadspace

C) increased work of breathing

D) acute metabolic acidosis

Ans: C

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Response:
Controlled ventilation is poorly tolerated by many patients, often resulting in asynchronous
breathing efforts or strenuous attempts to breathe spontaneously. Both conditions can increase
the work of breathing, and with it, the oxygen consumption of the respiratory muscles. It is for
this reason that sedation or paralysis is often required when controlled ventilation is necessary.

4. A patient on a 30% aerosol oxygen mask has the following arterial blood gas results:

pH 7.54
PaCO2 27 torr
PaO2 80 torr
HCO3 23 mEq/L
BE –2 mEq/L

Which of the following is the correct interpretation of the arterial blood gas?
A) acute alveolar hyperventilation without hypoxemia

B) partially compensated respiratory alkalosis

C) respiratory acidemia with hypoxemia

D) hypochloremic metabolic alkalosis

Ans: A

Response:
The high pH indicates alkalemia. The low PaCO2 indicates hyperventilation, consistent with
the high pH (respiratory alkalosis). The normal HCO3 and BE indicate no metabolic
involvement, hence compensation has not begun yet (acute process). The PaO2 is in the
acceptable range at a low FIO2 (no hypoxemia present). Conclusion: acute respiratory alkalosis
due to alveolar hyperventilation without hypoxemia.

5. You find a patient receiving SIMV with a preset rate of 6 breaths/min, a VT of 1000 mL, and a
PEEP of 10 cm H2O. You note a peak inspiratory pressure of 50 cm H2O for each SIMV
mechanical breath. Which of the following alarm settings are appropriate for this patient?

I. low exhaled minute ventilation at 8 L/min

II. high inspiratory pressure limit at 65 cm H2O
III. low PEEP/CPAP pressure alarm at 5 cm H2O
A) I, II, and III only

B) II and III only

C) I and III only

D) II only

Ans: B

Response:
The high-pressure-limit alarm should be set about 10–15 cm H2O above the peak airway
pressure of the mechanical controlled breaths. The low-PEEP/CPAP alarm should always be
set 3–5 cm H2O or 20% below the set baseline pressure. A low exhaled volume alarm should
trigger when either the VT or <V>E falls 20% below preset values (6 L/min in this question).

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6. Arterial hemoglobin saturation (%HbO2) should be kept above what level in order to
guarantee adequate oxygen delivery to the tissues?
A) 65%

B) 70%

C) 75%

D) 90%

Ans: D

Response:
Normal SaO2 should be more than 95% breathing room air. Levels below 90% indicate the
need for supplemental O2 therapy. Drops in oxyhemoglobin content are usually the result of
cardiac, pulmonary, or combined cardiopulmonary disease. Hb saturation data must always be
interpreted with knowledge of Hb/Hct levels. For example, a patient with an SpO2 of 97% and
severe anemia (Hb < 7 g/dL) is still suffering from hypoxemia, due to reduced blood O2
content.

7. A new medical resident asks for your help in calculating the static lung compliance for an ICU
patient receiving volume-cycled ventilation. The patient has the following settings and
monitoring data:

VT 700 mL
Rate 12/min
Peak pressure 50 cm H2O
Plateau pressure 30 cm H2O
PEEP 10 cm H2O
Mechanical deadspace 100 mL

The patient's static lung compliance is:

A) 18 mL/cm H2O

B) 35 mL/cm H2O

C) 22 mL/cm H2O

D) 26 mL/cm H2O

Ans: B

Response:
Static compliance equals corrected tidal volume divided by the plateau pressure – PEEP. In
this instance, static compliance = 700 ÷ (30 – 10) = 700 ÷ 20 = 35 mL/cm H2O.

8. A doctor wants your recommendation on how to monitor the cardiopulmonary status of a

patient undergoing a bronchoscopy procedure during moderate sedation. You should
recommend the following:
A) pulmonary function testing

B) noninvasive pulse oximetry

C) frequent ABGs via radial puncture

D) transcutaneous PaO2 monitoring

Ans: B

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Response:
Besides vital signs, a noninvasive techniques like continuous pulse oximetry is the standard of
care to monitor the cardiopulmonary status of a patient during moderate sedation procedures.
More expensive, invasive techniques such as PFTs or an A-line insertion are required only
when more critical, invasive procedures are being done.

9. A patient is receiving continuous mandatory ventilation (CMV) in the control mode at a rate
of 12 breaths/min. The percent inspiratory time (%I-time) is set at 20%. What is the patient's
inspiratory time?
A) 0.75 sec

B) 1.00 sec

C) 1.25 sec

D) 1.50 sec

Ans: B

Response:
Given the rate (f) and percent inspiratory time (%I-time), the inspiratory time (I-time) can be
computed as: total cycle time × %I-time. Total cycle time = 60/f = 60/12 = 5 sec. I-time = 5
sec × 0.20 = 1.00 sec.

10. A mechanically ventilated patient is being monitored by a capnograph in the ICU. The nurse
calls you STAT to the room and you note that the PETCO2 dropped suddenly from 36 to 0 torr.
All of the following are possible causes of this finding except:
A) ventilator disconnection

B) increased cardiac output

C) obstructed artificial airway

D) cardiac arrest

Ans: B

Response:
Causes of a PETCO2 of zero include (1) a large system leak or disconnection, (2) esophageal
intubation, (3) cardiac arrest, and (4) a totally obstructed/kinked artificial airway. Increased
cardiac output would cause a rise in end-tidal CO2.

11. During a patient-ventilator system check you notice the following airway pressures on an
adult mechanically ventilated patient receiving 5 cm H2O of PEEP:

Time
Measure 0400 0500 0600
Peak pressure (cm H2O) 42 47 53
Plateau pressure (cm H2O) 32 36 42

Knowing that no ventilator setting changes have been made, what is the most likely cause of
these changes?
A) the patient is developing bronchospasm

B) the patient's lungs are becoming more compliant

C) the patient is performing a Valsalva maneuver

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D) the patient is developing atelectasis

Ans: D

Response:
The cause of the increased peak inspiratory pressures cannot be increased airway resistance
since the (peak – plateau) pressure difference remains constant at ~10 cm H2O. What is
changing is the (plateau – PEEP) pressure difference, which is increasing due to a gradual rise
in plateau pressures. This indicates a decrease in either lung or thoracic compliance.
Atelectasis, which causes consolidation, decreases lung compliance. Bronchospasm causes an
increase in airway resistance with a widening of the PIP-Pplat difference.

12. Common arterial sites used for percutaneous arterial blood sampling include all of the
following except:
A) carotid

B) radial

C) brachial

D) femoral

Ans: A

Response:
The radial artery is the preferred site for arterial blood sampling because (1) it is near the skin
surface, (2) the ulnar artery provides for good collateral circulation, and (3) the artery is not
near any large veins. Other sites include the brachial, femoral, and dorsalis pedis arteries.
These sites carry greater risk and should be used only by those with training in alternative site
sampling. Carotid arteries are never to be used for arterial puncture.

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

B) acute (uncompensated) metabolic acidosis

C) compensated respiratory alkalosis

D) acute (uncompensated) respiratory alkalosis

Ans: A

Response:
First, you should recognize that compensation is occurring with this patient because both the
PaCO2 and BE are abnormally low Second, because the pH is less than 7.40, you can conclude
that the primary problem is the one causing acidosis, in this case the low BE (–10 mEq/L).
Therefore, the low PaCO2 must represent compensation for the low BE. Conclusion: the
patient has a compensated metabolic acidosis.

14. A first-year resident has just inserted an indwelling arterial catheter in an ICU patient. A good
indication that the catheter has been successfully inserted in an artery is:
A) a positive Allen test

B) a good blood return

C) ability to flush the line

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D) proper blood pressure and waveform

Ans: D

Response:
The Allen test is indicated only to assess for collateral circulation on the radial artery site
before performing the procedure. Blood return and ability to flush the line can also occur if
the catheter has been inserted on a venous vessel. The best indication that the line has been
properly inserted on an artery is the return of arterial blood pressure values accompanied by a
good arterial waveform once the line is connected to the transducer and the monitor.

15. A sample obtained from the distal port of a pulmonary artery catheter has a PO2 of 95 torr and
an Hb oxygen saturation of 97%. Which of the following statements could explain these
results?

I. the catheter balloon remained inflated during sampling

II. the catheter is misplaced in the right ventricle
III. the blood sample was withdrawn too quickly
IV. the patient has an abnormally low cardiac output
A) I, II, and IV only

B) II, III, and IV only

C) I and III only

D) I, II, and III only

Ans: C

Response:
When obtaining a mixed venous sample, if the balloon is not deflated or the sample is
withdrawn too quickly, you may contaminate the venous blood with blood from the
pulmonary capillaries (oxygenated blood). The result is always a falsely high oxygen level.
Rapid flow of IV fluid can also dilute the blood sample and affect oxygen content measures.

16. You need to provide continuous monitoring of the FIO2 for a ventilator that uses a heated
humidifier delivery system. The only analyzer available is a galvanic cell analyzer. Where
should you place the analyzer's sensor?
A) distal to the heated humidifier

B) on the expiratory side of the circuit

C) proximal to the heated humidifier

D) as close to the patient as possible

Ans: C

Response:
Inaccurate readings can occur with electrochemical oxygen analyzers due to either condensed
water vapor or pressure fluctuations. Galvanic cells are particularly sensitive to condensation.
To avoid this problem during continuous use in humidified ventilator circuits, place the
analyzer sensor proximal to any humidification device.

17. All of the following statements regarding a capillary blood gas sample are true, except:
A) it should not be performed to assess oxygenation status

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B) it should not be performed in infants less than 72 hrs old

C) it should not be performed in swollen or edematous tissue

D) it should not be performed in the posterior curvature of the heel

Ans: B

Response:
A capillary blood puncture should not be performed in infants less than 24 hours old due to
the immaturity of the capillary bed after birth. Capillary blood sampling also should be
avoided on the heels of infants that have just begun walking; on inflamed, swollen, or
edematous tissue; on cyanotic or poorly perfused areas; and when accurate analysis of the
oxygenation status is needed.

18. After performing a modified Allen test on the left hand of a patient, you note that his palm and
fingers do not become pink for more than 15 seconds after releasing pressure on the ulnar
artery. At this point you should:
A) use the left brachial site for sampling

B) repeat the test on the right hand

C) use the femoral site for sampling

D) go ahead and draw the sample from that site

Ans: B

Response:
The results of the initial Allen test indicate lack of collateral circulation on the left hand. You
should repeat the Allen test on the opposite hand and proceed accordingly. Brachial puncture
should be considered if the Allen test fails to show proper collateral circulation in both radial
arteries.

19. A 20-year-old 65-kg (143-lb.) patient is receiving volume-oriented SIMV with a set rate of 14
breaths/min, a total rate of 14 breaths/min, a VT of 500 mL, and an FIO2 of 0.50. Blood gas
results are as follows:

pH 7.52
PaCO2 26 torr
HCO3 23 mEq/L
PaO2 94 torr

What are the appropriate recommendations for you to make?

A) decrease the SIMV rate

B) add mechanical deadspace

C) decrease the FIO2

D) add pressure support

Ans: A

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Response:
The blood gas results suggest normal oxygenation with an uncompensated respiratory
alkalosis due to hyperventilation. The fact that there is no spontaneous ventilation (total rate =
set rate) indicates suppression of the respiratory drive probably due to hypocapnia. In order to
stimulate the patient to breathe spontaneously, you need to eliminate the hypocapnia. On the
SIMV mode this is best done by decreasing the set respiratory rate on the ventilator.

20. You observe a sudden drop in the peak inspiratory pressure when monitoring a patient on
volume-targeted ventilation. Which of the following may explain this change?

I. a defective exhalation valve

II. a burst endotracheal tube cuff
III. a high VT setting
IV. patient disconnection
A) II and IV only

B) III only

C) I, II, and IV only

D) II, III, and IV only

Ans: C

Response:
During volume-controlled ventilation a sudden fall in peak inspiratory pressure can be caused
by any of the following events: (1) improved compliance or resistance; (2) a decrease in either
the volume or flow setting; and (3) patient-ventilator system leaks, such as an ET tube cuff
leak, a malfunctioning exhalation valve, or tubing disconnection/leak.

21. The ER physician asks you to evaluate a trauma patient who was the victim of a house fire. In
order to properly evaluate the cardiopulmonary status of this patient you should perform all of
the following procedures except:
A) auscultation of breath sounds

B) pulse oximetry

C) assessment of sensorium

D) rate, depth, and pattern of breathing

Ans: B

Response:
Due to the patient's involvement in a house fire you should immediately suspect the presence
of carbon monoxide poisoning. Carbon monoxide's high affinity for hemoglobin will cause
profound hypoxemia. Pulse oximetry is unable to measure carbon monoxide saturations and is
contraindicated to assess patients with suspected smoke inhalation. In order to assess for the
presence of carbon monoxide in the blood you must run a CO-oximetry blood gas test.

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22. During the assessment of a mechanically ventilated patient in the ICU you notice the
following vital signs:

Heart rate: 118/min

BP: 135/90
Set resp rate: 8/min
Total resp rate: 35/min
Temp: 99.3 °F

A surgical resident has just inserted a right pleural chest tube to drain a significant pleural
effusion. At this point you should recommend that the resident:
A) paralyze the patient

B) reposition the chest tube

C) ask the patient to relax

D) assess for pain

Ans: D

Response:
It is very common for a patient after any invasive procedure to develop surgical pain. Since
the patient is mechanically ventilated and cannot verbally communicate, abnormal vital signs
(usually on the high side of normal) are a common indication of the presence of pain. Asking
the patient to indicate if he or she is in pain and providing for proper pain management is the
right course of action. Paralytics are indicated for patient-ventilator asynchrony. A chest tube
should not be repositioned without assessing a chest X-ray first; asking the patient to relax
will not alleviate the pain.

23. A patient with a size 8 tracheostomy tube is being suctioned by the nurse. While suctioning
the patient you observe several PVCs on the patient's monitor. You should recommend that
the nurse:
A) use a larger suction catheter

B) preoxygenate the patient with 100% O2

C) sedate the patient prior to suction

D) suction less often

Ans: B

Response:
Hypoxia and mechanical stimulation of the myocardium are common causes of premature
ventricular contractions (PVCs). Several respiratory procedures can cause hypoxia and
produce PVCs. Preoxygenating and hyperinflating the patient before suctioning is always
required to avoid hypoxia and myocardial irritability, especially in patients suffering from pre-
existing cardiac diseases. Using a larger catheter, sedating the patient, and suctioning less
often will not prevent the hypoxia and the PVCs caused by the hypoxia itself.

24. A pulmonologist asks you to assess airway responsiveness during a pulmonary function exam.
He wants to rule out asthma from chronic bronchitis in a patient complaining of nocturnal
wheezing. You should consider all of the following tests except:
A) thoracic gas volume

B) graded exercise test

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C) histamine challenge test

D) methacholine bronchoprovocation test

Ans: A

Response:
Tests that are indicated to assess for the presence and the degree of airway responsiveness are:
methacholine bronchoprovocation studies, histamine challenge, and exercise challenge tests.
They are also indicated to screen individuals who may be at risk from environmental or
occupational exposure to allergens. Thoracic gas volume (via body plethysmography) does
not assess for airway responsiveness and reactivity.

25. Which of the following tests should you recommend for a patient with suspected hepatitis and
history of alcohol and drug abuse?
A) cardiac enzymes

B) complete blood count

C) liver enzymes

D) partial prothrombin time

Ans: C

Response:
Liver enzymes are indicated to assess suspected liver damage due to infections, alcohol and
drug abuse, among others. Cardiac enzymes are indicated when myocardial damage is
suspected due to an MI or ischemia. Complete blood count and partial prothrombin time are
indicated to evaluate red and white blood cell counts and coagulation status of the blood.

26. You are assisting with the endobronchial intubation of an adult patient in the ICU. You
confirm the presence of bilateral breath sounds. In order to properly assess tracheal tube
placement you should order the following procedure:
A) CAT Scan test

B) laryngoscopy

C) AP chest radiograph

D) bedside spirometry

Ans: C

Response:
Taking a chest X-ray is the most common method used to confirm proper placement of an ET
or tracheostomy tube after endotracheal intubation has been confirmed. On the X-ray, the tube
tip should be positioned about 4 to 6 cm above the carina or between T2 and T4. This position
minimizes the chance of the tube moving down into the mainstem bronchi (endobronchial
intubation) or up into the larynx (extubation).

27. A sudden rise in end-tidal CO2 levels can be caused for all of the following except:
A) sudden release of a tourniquet

B) injection of sodium bicarbonate

C) sudden increase in cardiac output

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D) sudden malignant hypothermia

Ans: D

Response:
Causes of a sudden rise in end-tidal CO2 levels include (1) a sudden increase in cardiac output,
(2) a sudden release of a tourniquet, (3) seizure, shivering, pain, and (4) injection of sodium
bicarbonate. Hypothermia would cause a FALL in end-tidal CO2 levels.

28. The following arterial blood gases are obtained on five patients. Which of these patients is
most in need of ventilatory support?

Patient pH PaCO2 HCO3

mm Hg mEq/L
A 7.33 60 33
B 7.36 50 28
C 7.38 56 32
D 7.20 65 23
A) A

B) B

C) C

D) D

Ans: D

Response:
All patients have PCO2s above 50 mm Hg, however, only patient D has a life-threatening
UNCOMPENSATED respiratory acidosis (with a pH of 7.20). The other patients all exhibit
varying degrees of COMPENSATED respiratory acidosis, and are thus suffering from chronic
or acute-on-chronic (as opposed to acute) hypercapnic respiratory failure.

29. While doing a ventilator-patient assessment you observe 'scalloping' of the inspiratory airway
pressure waveform (Paw) occurring after the beginning of inspiration. Which of the following
can explain this finding?
A) improper sensitivity setting

B) presence of auto-PEEP/air-trapping

C) a leak in the patient-ventilator system

D) inadequate inspiratory flow setting

Ans: D

Response:
A drop in pressure ('scalloping') during flow-limited ventilation indicates inadequate
inspiratory flow. Normally, pressure should rise after inspiration begins. To correct this
problem during flow-limited ventilation adjust the inspiratory flow until the “scalloping” of
the pressure waveform disappear.

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30. Which of the following characteristics can be found in the sputum of a patient with acute
pulmonary edema?

I. offensive in odor
II. watery
III. pinkish
IV. frothy
A) I and II only

B) II and III only

C) II, III and IV only

D) I, II and III only

Ans: C

Response:
Pulmonary edema secretions are mainly watery, often tainted with blood. The resulting
sputum is watery, pink and frothy. No odor is associated with pulmonary edema unless there
is an underlying infection.

31. Which of the following statements best describes the correct steps for an Allen test before an
arterial puncture is performed?
A) compress both the radial and ulnar arteries then release the radial artery

B) compress the brachial artery only and observe circulation to the hand

C) compress both the radial and ulnar arteries then release both arteries at once

D) compress both the radial and ulnar arteries then release the ulnar artery

Ans: D

Response:
To perform an Allen's test: (1) both the radial and ulnar arteries should be compressed at the
same time while the patient clenches the fist three times for about 5 seconds, (2) the patient
then opens his/her hand, (3) the therapist then release compression on the ulnar artery only
while maintaining pressure on the Radial artery (4) The palmar surface should flush within 5
seconds, prolonged delay before flushing indicates decreased ulnar artery flow. If the radial
artery is unsuitable as a puncture site, the other wrist should be assessed. If both radial arteries
lack collateral circulation, the brachial artery is the second choice, followed by the femoral
artery.

32. All of the following are recommended alarms settings for an adult patient on the SIMV +
pressure support mode except:
A) low pressure 5-10 cm H2O below mechanical peak pressures

B) oxygen analyzer alarm ± 5 or 6% of set FIO2

C) low PEEP/CPAP alarm 3 to 5 cm H2O below set PEEP

D) high PIP alarm 10-15 cm H2O above mechanical breath pressures

Ans: A

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Response:
During SIMV mode with pressure support (PSV), peak machine breath pressures are
significantly higher than those of the PSV spontaneous breaths. Hence, the low inspiratory
pressure alarm should be set 5 to 10 cm H2O pressure below the patient's SPONTANEOUS
generated pressures. Otherwise the ventilator will alarm every time the patient generates a
PSV breath.

33. While obtaining the vital signs on a respiratory patient you notice an SpO2 measurement of
70%. If this is an accurate measure of this patient's hemoglobin saturation, what should be the
patient's approximate PaO2?
A) 40 mm Hg

B) 50 mm Hg

C) 60 mm Hg

D) 70 mm Hg

Ans: A

Response:
A good rule of thumb to remember when measuring SpO2 is the "40-50-60"/ "70-80-90" rule.
The first set of numbers is the approximate PaO2 corresponding to the second set of Hb
saturation. In this case, a SpO2 or 70% corresponds to a PaO2 of about 40 mm Hg.

34. You are assisting with the nasal intubation of an adult patient. After positive end-tidal
colorimetry confirmation, you notice that breath sounds are diminished on the left compared
with the right lung. The most likely cause of this finding is:
A) The cuff of the endotracheal tube has been over-inflated

B) The tip of the tube is in the right mainstem bronchus

C) The endotracheal tube has been inserted into the esophagus

D) The tip of the tube is in the left mainstem bronchus

Ans: B

Response:
The right mainstem bronchus is more in line with the trachea than the left, therefore, right
mainstem intubations are more common than left side intubations. If right mainstem
intubation occurs, breath sounds will be significantly decreased on the left side together with
decreased chest expansion on that side. Proper ET tube position must be confirmed with a
chest X-ray and corrected by withdrawing the ET tube until it is 4 to 6 cm above the carina.

35. Possible hazards and complications of arterial blood gas puncture include:

I. arteriospasm
II. nerve damage
III. infection
IV. hemorrhage
A) I, II and III only

B) II and IV only

C) I, II, III and IV

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D) II and III only

Ans: C

Response:
Complications of arterial puncture include arteriospasm, air or clotted-blood emboli,
anaphylaxis from local anesthetic, patient or sample contamination, hematoma, hemorrhage,
trauma to the vessel or nerve, arterial occlusion, vasovagal response and pain.

36. You are called to the ER to perform a blood gas puncture in a patient breathing room air
complaining of shortness of breath. Blood gas results are as follows:

pH 7.31
PCO2 51 mm Hg
PaO2 62 mm Hg
HCO3 24 mEq

The most likely cause of this patient's mild hypoxia is:

A) alveolar hypoventilation

B) moderate shunting

C) severe V/Q imbalance

D) metabolic acidosis

Ans: A

Response:
Hypoxemia due to alveolar hypoventilation occurs in the presence of (1) normal a/A ratios,
(2) hypercapnia, and (3) acidemia. This type of hypoxemia can be corrected by increasing the
patient's alveolar ventilation and normalizing the PaCO2.

37. All of the following are indications for arterial blood sampling except:
A) the need to monitor the severity of airway obstruction

B) the need to assess the adequacy of tissue oxygenation

C) the need to evaluate ventilation and acid-base status

D) the need to evaluate a patient's response to therapy

Ans: A

Response:
Some of the indications for arterial blood sampling include the following: (1) the need to
evaluate ventilation (PaCO2), acid-base (pH and PaCO2), and oxygenation (PaO2 and SaO2)
status, and the oxygen-carrying capacity of blood (PaO2, HbO2, total Hb, and
dyshemoglobins); (2) the need to assess the patient's response to therapy and/or diagnostic
tests (e.g., O2 therapy, exercise testing); and (3) the need to monitor severity and progression
of a documented disease process.

38. You are asked to assess a mechanically ventilated patient for his readiness to be weaned off
the ventilator. What minimum maximum inspiratory pressure (MIP; NIF) the patient needs to
achieve before any weaning attempt is made?
A) -15 cm H2O

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B) -10 cm H2O

C) -35 cm H2O

D) -20 cm H2O

Ans: D

Response:
For MIP/NIF normal values should be in the range of -80 to -100 cm H2O pressure, actual
values will depend on patient age and sex. When the absolute MIP value is less than 20 to 30
cm H2O, it is unlikely that the patient has sufficient muscle strength to support adequate
spontaneous ventilation and weaning should not be attempted.

39. Which of the following measurements done before and after would best determine the
effectiveness of an aerosolized albuterol (Proventil) treatment administered to an asthmatic
patient?
A) arterial blood gas analysis

B) maximum inspiratory pressure (MIP)

C) peak expiratory flow rate measurement

D) vital capacity

Ans: C

Response:
When monitoring the effectiveness of a bronchodilator treatment pre and post PEFR
measurement should be done. The highest pre/post results should be use to calculate percent
change (%) or percent improvement. A change of 15 to 20% indicates a significant
improvement of the bronchospasm. If no improvement is seen, you may want to recommend a
change on the bronchodilator, the dose or the frequency.

40. Co-oximetry analysis should be performed whenever the following information is needed,
except:
A) actual blood oxygen content

B) levels of abnormal hemoglobins

C) whenever pulse oximetry results (SpO2) need validation

D) evaluation of acid-base status

Ans: D

Response:
Co-oximetry offers a true measurement of the actual levels of abnormal hemoglobin using the
principle of spectrophotometry. Unlike SpO2 and PaO2 procedures, co-oximetry measures the
total hemoglobin in a blood sample and fractions of the total bound to oxygen and other
chemicals. Typically, the sample undergoes analysis for total hemoglobin (THb, g/dL),
percent oxyhemoglobin saturation (HbO2% or SaO2), percent carboxyhemoglobin saturation
(HbCO%), percent methemoglobin saturation (metHb%) , and percent sulfhemoglobin
saturation (SHb%) . In addition, total O2 content (CaO2 in mL/dL) of the sample is calculated
(total Hb x 1.34 x HbO2%).

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41. In assessing a patient receiving ventilatory support in the assist-control, volume mode you
hear the high pressure limit alarm sounding and note a decrease in expired volume. No
settings has been changed on the ventilator. Which of the following best explains these
findings?
A) an increase in patient-triggered respiratory frequency

B) the presence of a leak in the patient-ventilator system

C) increased airway resistance or decreased compliance

D) improperly set trigger sensitivity level

Ans: C

Response:
On a volume-cycled ventilator a decrease in expired volume occurring together with an
INCREASED airway pressure (high pressure limit activated) usually indicates an increase in
total impedance, as occurs with either an increase in airway resistance or a decrease in
compliance. Tube kinking or obstruction, patient-ventilator asynchrony or cough would have
a similar effect.

42. Which of the following procedures would be most helpful in identifying the presence of a
pneumothorax?
A) arterial blood gas analysis

B) auscultation

C) chest palpation and percussion

D) chest X-ray

Ans: D

Response:
The only choice that will allow you to "see" the pneumothorax an officially confirm it is a
chest X-ray. Auscultation helps to the initial diagnosis of a pneumothorax but it does not
confirm its presence.

43. Pulse oximetry when use to monitor patient's oxygenation status has the following major
disadvantage:
A) skin burns due to using incompatible probes

B) pressure sores at the measuring site

C) false results leading to incorrect decisions

D) electrical shock at the measuring site

Ans: C

Response:
When using pulse oximetry to asses and monitor patient's response to therapy the greatest
hazard is not understanding the device limitations. Device limitations can result in false-
negative results for hypoxemia and/or false-positive results for normal oxygen levels or
hyperoxia (PaO2 > 100 mm Hg). False readings may then lead to inappropriate treatment of
the patient.

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44. You are about to switch a patient from volume-oriented assist/control ventilation to pressure
control ventilation with inverse I:E ratio. The patient will be paralyzed in order to avoid
ventilator dyssynchrony. Which of the following alarms will be most important to the patient
safety in this new mode of ventilation?
A) inverse I:E ratio alarm

B) low pressure/disconnect alarm

C) FIO2 alarm

D) High pressure alarm

Ans: B

Response:
Since unrecognized disconnection of a paralyzed patient from a ventilator can quickly lead to
injury and death, the low pressure/disconnect alarm setting is critical in this scenario. This
alarm will sound when the airway pressure during machine breaths drops below the set level
(5 - 10 cm H2O below the set PIP in PCV). Such a pressure drop signals either a significant
leak or patient disconnection from the ventilator.

45. You note an increase in I:E ratio from 1:3 to 1:2 in a patient receiving CMV in the assist-
control mode via a volume-cycled ventilator. Which of the following changes can explain this
finding?

I. a change in the flow setting

II. a change in patient's breathing rate
III. a change in the FIO2
IV. a change in the tidal volume
A) II and IV only

B) I, II and III only

C) I, II and IV only

D) I, II, III and IV

Ans: C

Response:
In the CMV assist-control mode, the I:E ratio can change whenever any time-related machine
parameter changes (including the preset flow, volume and rate), or when the patient's assisted
breath rate changes altering the total cycle time.

46. An intubated patient is receiving volume control ventilation. The patient's condition has not
changed, but you observe higher peak inspiratory pressures than before. Which of the
following is the most likely cause of this problem?
A) there is a leak in the patient-ventilator system

B) the endotracheal tube cuff is deflated or burst

C) the endotracheal tube is partially obstructed

D) the endotracheal tube is displaced into the pharynx

Ans: C

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Response:
A rise in airway pressure during volume control ventilation indicates either (1) an increase in
impedance (increased airway resistance, decreased compliance), or (2) a mechanical
obstruction to gas flow. Applying this knowledge to this case, the most likely cause of the rise
in airway pressure is a partially obstructed ET tube. All the other possibilities would tend to
cause leaks, which would cause the peak inspiratory pressure to fall, not rise.

47. Over a 3 hour period, you note that a patient's plateau pressure has remained stable, but her
peak pressure has been steadily increasing. Which of the following is the best explanation for
this observation?
A) the patient's airway resistance has increased

B) the patient is developing atelectasis

C) the patient's compliance has decreased

D) the patient is developing pulmonary edema

Ans: A

Response:
With a constant flow, differences between the peak and plateau pressure are directly
proportional to the airway resistance. In this case, an increase in the peak - plateau pressure
difference signals an INCREASE in airway resistance. All other choices suggest decreased
compliance, which would affect the plateau – PEEP pressure difference, not the peak - plateau
pressure. Remember "R-C-P": R = Resistance (peak pressure); C = compliance (plateau
pressure); P = PEEP (baseline pressure).

48. A patient receiving long-term positive pressure ventilatory support exhibits a progressive
weight gain and a reduction in the hematocrit. Which of the following is the most likely cause
of this problem?
A) leukocytosis

B) chronic hypoxemia

C) water retention

D) leukocytopenia

Ans: C

Response:
Many patients receiving long-term positive pressure ventilatory support exhibit significant salt
and water retention, as manifested by either a weight gain or failure to lose weight as
anticipated. In addition, such patients typically show a reduction in hematocrit, consistent with
hypervolemia due to water retention.

49. You obtain an SpO2 measurement on a patient of 80%. Assuming this is an accurate measure
of hemoglobin saturation, what is the patient's approximate PaO2?
A) 40 torr

B) 50 torr

C) 60 torr

D) 70 torr

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Ans: B

Response:
The rule of thumb used to equate hemoglobin saturation to PO2 is "40-50-60 (PO2) = 70-80-90
(saturation)." So with a SpO2 of 80%, this patient's PO2 would be approximately 50 torr (mm
Hg).

50. At the bedside of a patient receiving volume-control ventilation, you suddenly observe the
simultaneous sounding of the high pressure and low volume alarms. Which of following is the
most likely cause of this problem?
A) a leak in the ET tube cuff

B) a mucous plug in the ET tube

C) ventilator circuit disconnection

D) development of pulmonary edema

Ans: B

Response:
During volume-control ventilation, a high pressure/low volume condition signals an
obstruction (increased impedance). Although either the mucous plug or the development of
pulmonary edema increases impedance, only a plugged ET tube would cause a sudden rise in
airway pressure.

51. During auscultation of a patient's chest, you hear intermittent "bubbling" sounds at the lung
bases. Which of the following chart entries best describe this finding?
A) "bronchial sounds heard at lung bases"

B) "wheezes heard at lung bases"

C) "rhonchi heard at lung bases"

D) "crackles (rales) heard at lung bases"

Ans: D

Response:
The preferred term for short, discontinuous adventitious lung sounds that are crackling or
bubbling in nature is crackles. Many clinicians still use the term rales for these sounds.
Crackles are caused either by movement of excessive secretions in the airways, or by
collapsed airways opening during inspiration.

52. You obtain an SpO2 reading of 90% using an oximeter with an accuracy of ±5%. This could
indicate a PO2 as low as:
A) 70 mm Hg

B) 65 mm Hg

C) 60 mm Hg

D) 55 mm Hg

Ans: D

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Response:
With some oximeters' accuracy being only ±5%, an SpO2 reading of 90% could mean an
actual SaO2 of as low as 85%, corresponding to a PO2 of 55 mm Hg or less!

53. You obtain an SpO2 reading of 100% on a patient receiving oxygen via a nonrebreathing
mask. What range of arterial PO2s is possible in this patient?
A) 60-90 mm Hg

B) 90-100 mm Hg

C) 100-200 mm Hg

D) 100-600 mm Hg

Ans: D

Response:
At the high end, pulse oximetry data can be meaningless. Due to the characteristics of the
oxyhemoglobin dissociation curve, a patient with a SpO2 of 100% could have a PaO2
anywhere between about 100 and over 600 mm Hg! It is for this reason that pulse oximeters
should never be use to monitor for hyperoxia (as may be important in neonates).

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

A) ventilator disconnection

B) hypoventilation

C) rebreathing

D) increased cardiac output

Ans: A

Response:
This capnogram shows disconnection, indicated by the immediate transition from a normal
pattern to PCO2 = 0 torr baseline. Other problems that this display could indicate include
esophageal intubation, ventilator malfunction/failure, or an obstructed /kinked ET tube.

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

A) ventilator disconnection

B) hyperventilation

C) rebreathing

D) increased cardiac output

Ans: B

Response:
This capnogram shows a progressive reduction in expired CO2, most commonly indicating
hyperventilation. Other problems that this display could indicate include hypothermia/reduced
metabolism, or sedation/neuromuscular paralysis.

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

A) ventilator disconnection

B) hyperventilation

C) rebreathing

D) increased cardiac output

Ans: C

Response:
This capnogram shows a progressive rise in the baseline end-expired PCO2, most commonly
indicating rebreathing/increased mechanical dead space.

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57. While working in the intensive care unit, you notice the following airway pressures on a
mechanically ventilated adult patient receiving 5 cm H2O PEEP:

Time Plateau Peak

Pressure Pressure
cm H2O cm H2O
0900 34 44
1000 38 49
1100 44 55
Knowing that no ventilator setting changes have been made, what is the most likely cause of
these changes?
A) endotracheal suctioning is needed

B) the patient's lungs are becoming more compliant

C) the patient is developing pneumonia

D) the patient is developing bronchospasm

Ans: C

Response:
Peak pressures are progressively increasing, indicating increased impedance to inflation. The
cause of the increased impedance cannot be increased airway resistance, since the PIP-Pplat)
pressure difference remains relatively constant at 10 cm H2O. What is changing is the (Pplat -
PEEP) pressure difference, which is increasing due to a gradual rise in plateau pressures. This
indicates a decrease in either lung or thoracic compliance. Pneumonia causes consolidation,
which decreases lung compliance.

58. Before connecting the sample syringe to an adult's arterial line stopcock, you would:
A) flush the line and stopcock with the heparinized IV solution

B) aspirate the deadspace volume of fluid/blood using a waste syringe

C) align the stopcock off to the patient, on to the flush solution

D) increase the flush solution bag pressure by 20-30 mm Hg

Ans: B

Response:
Before connecting a sample syringe to an adult's arterial line stopcock, you should aspirate the
deadspace volume of fluid/blood using a waste syringe, reposition the stopcock handle to
close off all ports and disconnect and properly discard the waste syringe.

59. After placing a patient on a volume-cycled ventilator in the CMV assist/control mode, you
note that 45 cm H2O pressure are required to deliver the preset tidal volume of 700 ml. What
high pressure limit would you now set for this patient?
A) 50 cm H2O

B) 60 cm H2O

C) 70 cm H2O

D) 80 cm H2O

Ans: B

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Response:
The high pressure limit on a volume-cycled should generally be set about 10-15 cm H2O
above the peak pressure needed to deliver the volume. In this case, the high pressure limit
would be set to about 60 cm H2O (45+15).

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