Deck 18: Troubleshooting and Problem Solving

Question 1

The respiratory therapist enters the room of an intubated and mechanically ventilated patient to find the high pressure,low exhaled volume,and low Vᴇ alarms active.This situation could be caused by which of the following?

A) Improper flow rate and flow pattern
B) Migration of the ET into the upper airway
C) The patient is out of synchrony with the ventilator.
D) The ventilator has an internal malfunction.

Answer 1

C
A high pressure alarm may also be triggered when a patient actively breathes out of synchrony with the ventilator.The PIP rises if the patient actively exhales while the ventilator is in the inspiratory phase,and this can activate the high pressure alarm.

Question 2

The respiratory therapist is called to the bedside of a patient mechanically ventilated in the VC-CMV mode because the low pressure,low exhaled tidal volume,and low exhaled minute volume alarms all have activated.Which of the following could be the cause of this situation?

A) Patient biting the endotracheal tube
B) Rupture of the endotracheal tube cuff
C) Slipping of the endotracheal tube into the right mainstem
D) Plugging of the airways by airway secretions and mucus

Answer 2

B
With rupture of the ET tube cuff,volume escapes the system rather than being delivered to the patient.This activates the low pressure alarm and eventually leads to activation of the low tidal volume and low minute volume alarms.All the other options would activate the high pressure alarm.

Question 3

A 68-year-old woman was admitted to the ICU with pneumonia and was intubated when she developed progressive hypoxemia.She has been on the ventilator for 5 days and has been tolerating this therapy well.The patient has suddenly become severely agitated and appears to be fighting the ventilator.The ventilator's high pressure alarm is sounding continuously.The respiratory therapist disconnects the patient from the ventilator and begins manual ventilation with 100% oxygen and PEEP.The resuscitator bag is difficult to squeeze,breath sounds are present on the left with no adventitious sounds and absent on the right side,and percussion reveals hyperresonance over the right side.The most appropriate action to address this situation is which of the following?

A) Pull the endotracheal tube back until bilateral breath sounds are heard.
B) Administer a bronchodilator and suction the endotracheal tube.
C) Extubate the patient and reintubate with a larger endotracheal tube.
D) Insert a 14-gauge needle in the second intercostal space, midclavicular line, right side.

Answer 3

D
If the endotracheal tube had slipped into the right mainstem bronchus,breath sounds would be heard on the right side and not on the left.The absence of breath sounds on the right side indicates that the endotracheal tube has not slipped into the right mainstem bronchus.No adventitious breath sounds are heard over the left lung,the patient has no history of bronchospasm,and no wheezing is heard-this essentially eliminates bronchospasm as the problem.The patient had been tolerating mechanical ventilation well for 5 days; therefore,the ET tube is not too small.The presence of auto-PEEP would cause hyperresonance to percussion bilaterally.The patient apparently has a pneumothorax on the right side,as evidenced by the absence of breath sounds and hyperresonance to percussion on that side.

Question 4

The flow-volume loop below is representative of which of the following conditions?

A) System leak
B) Intrinsic PEEP
C) Inadequate flow
D) Active exhalation

Question 5

The respiratory therapist is assessing a mechanically ventilated patient for whom the high pressure alarm is active and the flow-volume loop shows the following:

The action that could alleviate this problem is which of the following?

A) Place a bite block into the patient's mouth.
B) Perform a recruitment maneuver and increase PEEP.
C) Administer a fast-acting bronchodilator and suction the ET tube.
D) Insert a 14-gauge needle into the second intercostal space, midclavicular line, and right side.

Question 6

Removing a patient from a ventilator to ventilate manually can lead to which of the following?
1)Barotrauma
2)Lung derecruitment
3)Increased airway resistance
4)Ventilator-acquired pneumonia

A) 1, 2, and 3
B) 1, 2, and 4
C) 2, 3, and 4
D) 3 and 4

Question 7

The graphics below indicate which of the following conditions?

A) Auto-PEEP
B) Active exhalation
C) Inadequate flow setting
D) Increased expiratory resistance

Question 8

At 1030 the respiratory therapist is called to the bedside of a patient being mechanically ventilated with VC-IMV.The patient is a 55-kg female who has been intubated with a size 8 endotracheal tube.Currently,the ET tube is located 20 cm at the gum line.During spontaneous breathing,the patient shows lack of coordinated chest wall movement,and the respiratory therapist notes some retraction of the intercostal spaces.The respiratory therapist performs a system check.The current and past few patient-ventilator system checks reveal the following information:

The most appropriate action to take in this situation is which of the following?

A) Deflate the cuff and reposition the endotracheal tube.
B) Request that the patient receive haloperidol and midazolam.
C) Administer albuterol via an in-line metered-dose inhaler.
D) Switch the mode to PC-IMV and increase the rate.

Question 9

When an alarm is activated on a ventilator,the respiratory therapist's first priority is to ______________.

A) assess the patient's level of consciousness
B) ensure adequate ventilation and oxygenation
C) assess lung compliance and airway resistance
D) ensure that bilateral and equal breath sounds are present

Question 10

The graphic below for a patient receiving mechanical ventilation shows which of the following conditions?

A) Leak in the circuit
B) Active inspiration
C) Active exhalation
D) Intrinsic PEEP

Question 11

The respiratory therapist enters the room of an intubated and mechanically ventilated patient to find the low pressure,low exhaled volume,and low Vᴇ alarms active.The ventilator circuit is connected to the patient's endotracheal tube.This situation could be caused by which of the following?

A) Improper flow rate and flow pattern.
B) Poorly responsive internal demand valve.
C) Migration of the ET tube into the upper airway.
D) The patient is continuing to actively inhale.

Question 12

The following two graphic loops show which of the following conditions?

A) Leak in the patient-ventilator circuit
B) Increased airway resistance
C) Decreased lung compliance
D) Active exhalation

Question 13

A patient is intubated and set up on VC-CMV.After stabilization and suctioning of the ET tube,the peak inspiratory pressure (PIP)is 25 cm H₂O.The low pressure and high pressure alarms should be set at _____________ cm H₂O and _____________ cm H₂O,respectively.

A) 5; 35
B) 10; 30
C) 12; 40
D) 15; 35

Question 14

Reduction of preload and afterload is important in the management of which of the following?

A) Pulmonary embolism
B) Dynamic hyperinflation
C) Cardiogenic pulmonary edema
D) Noncardiogenic pulmonary edema

Question 15

An increased arterial-to-end-tidal partial pressure CO₂ gradient can help identify which of the following?

A) Pulmonary embolism
B) Dynamic hyperinflation
C) Cardiogenic pulmonary edema
D) Noncardiogenic pulmonary edema

Question 16

The initial step in the management of patient-ventilator asynchrony is which of the following?

A) Lower the high pressure alarm setting.
B) Check the endotracheal tube cuff pressure.
C) Ventilate the patient with a manual resuscitator bag.
D) Check the low and high pressure alarm settings.

Question 17

A patient with a past medical history of COPD was placed on a ventilator after upper abdominal surgery for a serious wound infection.Although the patient was medically stable,a tracheostomy was performed 2 weeks later because the patient was unable to be weaned from the ventilator.The patient is on VC-CMV,rate = 12,Vᴛ = 700 mL,FɪO₂ = 40%,PEEP = 5 cm H₂O,with an HME.The respiratory therapist notes that the patient is assisting at a rate of 18 and has bilaterally decreased breath sounds in the bases.The respiratory therapist suctions a moderate amount of very thick,tenacious yellow sputum from the tracheostomy tube.What action should the respiratory therapist take?

A) The HME should be replaced with an active heated humidifier system.
B) No action is necessary, because there seems to be no patient problem.
C) The patient should be suctioned on a regular schedule instead of when needed.
D) PEEP and the FɪO₂ should be increased, and diuretic and positive inotropic agents should be administered.

Question 18

An intubated patient is receiving mechanical ventilation with the following settings: VC-CMV,rate = 18,Vᴛ = 850 mL (10 mL/kg),PEEP = 5 cm H₂O,flow rate = 40 L/min.The patient is sedated and is not assisting the ventilator.During a patient-ventilator system check,the respiratory therapist observes the following ventilator graphic:

The respiratory therapist should do which of the following?

A) Decrease the flow rate.
B) Increase the PEEP.
C) Decrease the rate.
D) Increase the Vᴛ.

Question 19

Which of the following can activate an apnea alarm?

A) Secretions
B) Auto-PEEP
C) Loss of PEEP
D) Active inhalation

Question 20

The flow-time curve shows small oscillations after the peak flow rate has been reached.The respiratory therapist can alleviate this by making which of the following ventilator adjustments?

A) Increase the set flow rate.
B) Increase the inspiratory time.
C) Decrease the inspiratory rise time.
D) Increase the inspiratory rise time.

Question 21

The respiratory therapist is performing a patient-ventilator system check on a patient who was in a motor vehicle accident 2 days earlier.The therapist gathers the following information from the flow sheet:

Which condition most likely has produced the changes reflected in these data?

A) Bronchospasm
B) Abdominal distention
C) Secretion retention
D) Mucosal edema

Question 22

Use of an externally powered,small-volume nebulizer for aerosol delivery during partial ventilatory support with PSV may cause which of the following?
1)High Vᴛ alarm activation
2)Triggering difficulties
3)Low pressure alarm activation
4)Ventilator inoperative alarm

A) 1 and 2
B) 2 and 3
C) 3 and 4
D) 1 and 4

Question 23

A mechanically ventilated patient with COPD is receiving partial ventilatory support with PSV.The respiratory therapist notes a sudden rise at the end of each breath on the pressure-time graphic.What action should the respiratory therapist take at this time?

A) Change the mode to PRVC.
B) Change the mode to VC-CMV.
C) Lower the flow cycle setting.
D) Adjust the pressure support level.

Question 24

The high-pressure alarm activates on a patient receiving mechanical ventilatory support.The patient is tachycardic and tachypnic with absent breath sounds on the right side.Which of the following condition(s)could be the cause?
1)Pneumothorax
2)Pulmonary edema
3)Disconnection from the ventilator
4)Increased airway resistance

A) 1 only
B) 4 only
C) 1, 2, and 3 only
D) 1 and 4 only

Question 25

You are called into a patient's room by the nurse because blood is spurting from the tracheostomy site,which was placed 2 weeks ago.The patient is receiving mechanical ventilatory support and has a history of liver failure and CHF.Which of the following conditions is the most likely cause?

A) Acute pulmonary edema
B) Rupture of the innominate artery
C) Pulmonary hemorrhage
D) Pneumothorax

Question 26

During ventilation with VC-CMV,pleural drainage leaks sometimes can be compensated for by increasing which of the following?

A) The number of chest tubes
B) The set tidal volume
C) The set pressure limit
D) The set peak inspiratory flow