Deck 4: Establishing the Need for Mechanical Ventilation

Question 1

The first arterial blood gas for an asthma patient in the emergency department reveals: pH 7.49; PₐCO₂ 30; PₐO₂ 82; SₐO₂ 95%; HCO₃⁻ 24 on a nasal cannula 3 L/min.The patient's peak expiratory flow rate was 165 L/min,respiratory rate was 16 breaths/min,and pulse 106 beats/min.After continuous aerosolized albuterol over the past hour,the patient's current ABG results are as follows: pH 7.34; PₐCO₂ 45; PₐO₂ 49; SₐO₂ 79%; HCO₃⁻ 25 on a high flow nasal cannula 15 L/min.The patient's peak expiratory flow rate is 95 L/min,respiratory rate 35 breaths/min,pulse 128 beats/min,and the patient is diaphoretic.The respiratory therapist should suggest which of the following at this time?

A) Change to a nonrebreather mask.
B) Begin continuous positive airway pressure.
C) Intubate and initiate mechanical ventilation.
D) Initiate noninvasive positive pressure ventilation.

Answer 1

Intubate and initiate mechanical ventilation.

Question 2

A 52-year-old male with a medical history of congestive heart failure and hypertension arrives in the emergency department because of an acute onset of dyspnea.The patient has pink frothy secretions at the mouth.A rapid physical assessment reveals a pulse of 128 beats/min,respiratory rate 28 breaths/min and labored,and blood pressure 82/56 mm Hg.Bilateral coarse crackles are heard in the lung bases.Arterial blood gas results on a 12 L/min nonrebreather mask are: pH 7.32,PₐCO₂ 49 mm Hg,PₐO₂ 50 mm Hg,arterial SₐO₂ 74%.The most appropriate immediate action for this patient is which of the following?

A) Intubation and mechanical ventilation
B) Increase flow to the nonrebreather mask
C) Continuous positive airway pressure via mask
D) Nasotracheal suctioning and a high flow nasal cannula

Answer 2

Intubation and mechanical ventilation

Question 3

A 28-year-old female was admitted last night for weakness and what appears to be ascending muscle paralysis.The patient is alert and oriented.Physical findings reveal: pulse 96 beats/min,regular; blood pressure 134/83 mm Hg; temperature 37° C; respiratory rate 24 breaths/min shallow with bilateral decrease in air entry; and no adventitious breath sounds.The patient's ABG results on room air are: pH 7.46; PₐCO₂ 39 mm Hg; PₐO₂ 80 mm Hg; Sat 97%; and HCO₃⁻ 26 mEq/L on room air.The most appropriate suggestion that the respiratory therapist should make for this patient includes which of the following?

A) Vital capacity every 2 hours
B) Continuous positive airway pressure
C) Noninvasive positive pressure ventilation
D) Peak expiratory flow rate

Answer 3

Vital capacity every 2 hours

Question 4

A patient with inadequate oxygenation of the brain may display which of the following conditions?
1)Confusion
2)Excitement
3)Somnolence
4)Compliance

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

Question 5

The underlying physiological process leading to pure hypercapnic respiratory failure is which of the following?

A) Ventilation/perfusion mismatch
B) Intrapulmonary shunting
C) Diffusion impairment
D) Alveolar hypoventilation

Question 6

Respiratory failure due to inadequate ventilation is known as which of the following?

A) Hypoxemic
B) Hypercapnic
C) Compensated
D) Chronic

Question 7

A 64-year-old female patient having an acute exacerbation of chronic obstructive pulmonary disease (COPD)was admitted to the hospital yesterday.During rounds today the respiratory therapist finds the patient to be difficult to arouse and has the following physical findings: heart rate 102 beats/min,respiratory rate 23 breaths/min shallow and slightly labored,breath sounds are bilaterally decreased with rhonchi in both bases.The patient has a frequent but weak cough.The respiratory therapist draws an ABG with the following results on a 2 L/min nasal cannula: pH 7.52,PₐCO₂ 30 mm Hg,PₐO₂ 45 mm Hg,SₐO₂ 86%,HCO₃⁻ 24 m Eq/L.The most appropriate action is which of the following?

A) Intubate and mechanically ventilate.
B) Increase the nasal cannula to 4 L/min.
C) Administer incentive spirometry.
D) Begin noninvasive positive pressure ventilation.

Question 8

An 80-year-old female with a diagnosis of pneumonia was admitted to the hospital 2 days ago from a nursing home.The patient is responsive only to painful stimuli.She has a peripheral IV and a feeding tube in place.Physical examination reveals: pulse 98 beats/min; respiratory rate 24 breaths/min and shallow; blood pressure 100/48 mm Hg; and temperature 39.2° C.Auscultation reveals decreased breath sounds with crackles in the bases.The patient has an occasional weak,nonproductive cough.Arterial blood gas on NC 4 L/min is pH 7.42,PₐCO₂ 38 mm Hg,PₐO₂ 40 mm Hg,SₐO₂ 76%,HCO₃⁻ 24 mEq/L.A portable chest X-ray shows patchy basilar infiltrates in both lungs.The most appropriate action to take at this time is which of the following?

A) Intubate and initiate mechanical ventilation.
B) Administer a bronchodilator and mucolytic.
C) Initiate noninvasive positive pressure ventilation.
D) Change the nasal cannula to a nonrebreather mask.

Question 9

A patient seen in the emergency department exhibits paralysis of the lower extremities that is getting progressively worse.Vital capacity is 6 mL/kg,maximum inspiratory pressure (MIP)is -17 cm H₂O,and oxygen saturation measured by pulse oximeter (SₚO₂)is 89%.Arterial blood gases are pending.The physician suspects Guillain-Barré syndrome.The most appropriate action at this time is which of the following?

A) Intubate and mechanically ventilate.
B) Place patient on a nonrebreather mask.
C) Initiate continuous positive airway pressure.
D) Initiate noninvasive positive pressure ventilation.

Question 10

The disorders that cause respiratory failure due to increased work of breathing include which of the following?
1)Myasthenia gravis
2)Cardiogenic pulmonary edema
3)Interstitial pulmonary fibrosis
4)Amyotrophic lateral sclerosis

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

Question 11

A postoperative patient complaining of dyspnea is found to have tachypnea and tachycardia,and is somewhat confused.Breath sounds reveal end inspiratory crackles in both lung bases.An arterial blood gas (ABG)is drawn and reveals the following: pH 7.49; PₐCO₂ 33 mm Hg; PₐO₂ 51 mm Hg; SₐO₂ 87%; HCO₃⁻ 25 mEq/L while on a 30% air entrainment mask.The most appropriate respiratory therapy intervention includes which of the following?

A) Initiate noninvasive positive pressure ventilation (NPPV).
B) Initiate continuous positive airway pressure (CPAP) by mask.
C) Administer bronchodilator therapy.
D) Intubate and mechanically ventilate.

Question 12

The respiratory assessment of a 44-year-old female patient diagnosed with myasthenia gravis shows: vital capacity 475 mL,maximum inspiratory pressure (MIP)-18 cm H₂O.The patient is 5 feet 6 inches tall and weighs 188 lb.The most recent ABG on a 2 L/min nasal cannula is pH 7.32,PₐCO₂ 49 mm Hg,PₐO₂ 77 mm Hg,SₐO₂ 95%,HCO₃⁻ 24 mEq/L.The most appropriate recommendation for this patient is which of the following?

A) 50% air entrainment mask
B) Continuous positive airway pressure
C) Noninvasive positive pressure ventilation
D) Intubation and mechanical ventilation

Question 13

Which of the following values are indicative of acute respiratory failure and the need for ventilatory support?
1)Maximum inspiratory pressure (MIP)= −25 cm H₂O
2)Dead space to tidal volume ratio (VD/Vᴛ)= 0.4
3)Vital capacity (VC)= 8 mL/kg IBW
4)pH = 7.20

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

Question 14

Acute hypercapnic respiratory failure may be caused by which of the following?

A) Decreased fractional inspired oxygen (FɪO₂)
B) Pulmonary shunt
C) Respiratory muscle fatigue
D) Perfusion/diffusion impairment

Question 15

A 46-year-old male presents to the emergency department with a chief complaint of shortness of breath.Physical assessment reveals: pulse 102 beats/min,blood pressure 138/80 mm Hg,respiratory rate 25 breaths/min with accessory muscle use,and breath sounds are decreased with bilateral inspiratory and expiratory wheezing with a prolonged expiratory phase.The peak expiratory flow rate is 100 L/min.The immediate action by the respiratory therapist should include which of the following?

A) Intubate and mechanically ventilate.
B) Administer oxygen via nonrebreather mask.
C) Administer continuous bronchodilator therapy.
D) Initiate noninvasive positive pressure ventilation.

Question 16

A 28-year-old man is admitted to the emergency department with suspected drug overdose.The patient is obtunded and slightly cyanotic.The ABG results obtained while the patient was breathing room air were: pH 7.24; PₐCO₂ 58 mm Hg; PₐO₂ 52 mm Hg; HCO₃⁻ 24 mEq/L.The most appropriate interpretation of these results is which of the following?

A) Chronic respiratory failure
B) Hypoxemic respiratory failure
C) Hypercapnic respiratory failure
D) Acute or chronic respiratory failure

Question 17

A patient with an opiate drug overdose is unconscious and has the following ABG results on room air: pH 7.20; PₐCO₂ 88 mm Hg; PₐO₂ 42 mm Hg; HCO₃⁻ 25 mEq/L.Which of the following best describes this patient's condition?

A) Chronic hypoxemic respiratory failure
B) Chronic hypercapnic respiratory failure
C) Acute hypoxemic respiratory failure
D) Acute hypercapnic respiratory failure

Question 18

Which of the following values are indicative of acute respiratory failure and the need for ventilatory support?
1)Maximum inspiratory pressure (MIP)= −38 cm H₂O.
2)Vital capacity (VC)= 650 mL for a 70 kg male.
3)Alveolar-to-arterial partial pressure of oxygen [P₍ᴀ₋ₐ₎O₂] = 150 on 100% oxygen.
4)Maximum expiratory pressure (MEP)= 25 cm H₂O.

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

Question 19

Hypercapnic respiratory failure due to increased work of breathing will be caused by which of the following?

A) Drug overdose
B) Myasthenia gravis
C) Asthma exacerbation
D) Pulmonary embolism

Question 20

A 55-year-old male with acute dyspnea is admitted to the hospital.He is alert and oriented.His physical examination reveals: heart rate 120 beats/min and regular; blood pressure 146/88 mm Hg; temperature 38° C; respiratory rate 28 breaths/min shallow and labored.Breath sounds are decreased throughout with fine late crackles on inspiration,chest expansion is decreased in both bases.The patient is not coughing.The ABG on room air is: pH 7.52; PaCO₂ 30 mm Hg; PₐCO₂ 42 mm Hg; Hb-O₂ 80%; HCO₃⁻ 24 mEq/L.This patient is retired after working in a steel factory for 38 years and he has a 50-pack-year history of smoking.The most appropriate action for the respiratory therapist to take is which of the following?

A) Intubate and initiate positive-pressure ventilation.
B) Initiate noninvasive positive pressure ventilation.
C) Administer oxygen via a high flow nasal cannula.
D) Initiate bronchodilator and mucolytic therapy.

Question 21

After oxygen is administered,a patient's heart rate changes from 110 to 85 beats/min.The initial tachycardia was most likely caused by which of the following?

A) Anxiety
B) Hypoxemia
C) Hypercapnia
D) Pain

Question 22

A 28-year-old man with botulism poisoning is beginning to develop progressive paralysis.The respiratory therapist has been monitoring the patient's MIP and VC every 2 hours.The most recent results show that the patient continues to deteriorate: MIP = -27 cm H₂O,VC = 32 mL/kg.Which of the following could be appropriately recommended?

A) Gastric lavage
B) Oxygen therapy
C) Medication to reverse the paralysis
D) Mechanical ventilatory support

Question 23

A 45-year-old woman arrives in the emergency department after ingesting an unknown quantity of pain medication and alcohol.Her friend found her unconscious in her apartment.She is currently unresponsive to verbal stimuli.Vital signs reveal: pulse 56 beats/min; respiratory rate 10 breaths/min and shallow; and BP 90/50 mm Hg.Her ABG on room air reveals: pH 7.21; PₐCO₂ 64 mm Hg; PₐCO₂ 52 mm Hg,HCO3 -24 mEq/L.The appropriate treatment for this patient includes which of the following?
1)Naloxone hydrochloride (Narcan)
2)Nasal cannula 4 L/min
3)Nonrebreather mask
4)Intubation and ventilatory support

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

Question 24

Which of the following patients is showing the signs of acute respiratory distress?

A) One who is in a semi-Fowler position, watching TV, with a 2 L/min nasal cannula
B) One who is in the high Fowler position, diaphoretic, anxious, and unable to complete a sentence
C) One who is leaning forward on a table, using accessory muscles, and purse-lip breathing
D) One who is in the high Fowler position, with a 2 L/min nasal cannula, eating breakfast

Question 25

Which of the following are goals of mechanical ventilation?
1)To provide support to the pulmonary system to maintain an adequate level of alveolar ventilation
2)To reduce the WOB until the cause of respiratory failure can be eliminated
3)To restore ABG levels to normal
4)To prevent or treat atelectasis with adequate end-inspiratory lung inflation

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

Question 26

A 59-year-old patient is in severe respiratory distress in the emergency department.The patient is being treated for congestive heart failure and pulmonary edema.Vital signs are pulse 98 beats/min,respiratory rate 23 breaths/min,and BP 138/98 mm Hg.The patient's ABG results on a nonrebreather mask are as follows: pH 7.35; partial PₐCO₂ 45 mm Hg; PₐO₂ 49 mm Hg; SₐO₂ 79%; and HCO₃⁻ 24 mEq/L.The respiratory therapy that is most appropriate at this time is which of the following?

A) 6 L/min nasal cannula
B) 50% air entrainment mask
C) Mask continuous positive airway pressure (CPAP) with 100% oxygen
D) Intubate and mechanically ventilate

Question 27

A 14-year-old boy who had previously been diagnosed with mild persistent asthma has a PEFR of 100 L/min.This indicates which of the following?

A) Increased airway resistance
B) Heart failure
C) Increased lung compliance
D) Inability to take in a deep breath and cough