Deck 36: Airway Management

Question 1

You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case?

A) 8 Fr
B) 10 Fr
C) 12 Fr
D) 14 Fr

Answer 1

D

Question 2

To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following?

A) Manually ventilate the patient with a resuscitator.
B) Preoxygenate the patient with 100% oxygen.
C) Give the patient a bronchodilator treatment.
D) Have the patient hyperventilate for 2 min.

Answer 2

B
Explanation: First, preoxygenation helps minimize the incidence of hypoxemia during suctioning.

Question 3

While suctioning a patient, you observe an abrupt change in the electrocardiogram waveform being displayed on the cardiac monitor. Which of the following actions would be most appropriate?

A) Change to a smaller catheter and repeat the procedure.
B) Stop suctioning and immediately administer oxygen.
C) Stop suctioning and report your findings to the nurse.
D) Decrease the amount of negative pressure being used.

Answer 3

B
Explanation: If any major change is seen in the heart rate or rhythm, immediately stop suctioning and administer oxygen to the patient, providing manual ventilation as needed.

Question 4

What is the normal range of negative pressure to use when suctioning children?

A) -60 to -80 mm Hg
B) -80 to -100 mm Hg
C) -100 to -120 mm Hg
D) -120 to -150 mm Hg

Question 5

Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning?
1) Limit the amount of negative pressure used.
2) Hyperinflate the patient before and after the procedure.
3) Suction for as short a period of time as possible.

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

Question 6

Which of the following can help to minimize the likelihood of mucosal trauma during suctioning?
1) Use as large a catheter as possible.
2) Rotate the catheter while withdrawing.
3) Use as rigid a catheter as possible.
4) Limit the amount of negative pressure.

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

Question 7

How often should patients be suctioned?

A) At least once every 2 to 3 hr
B) Whenever they are moved or ambulated
C) When physical findings support the need
D) Whenever the charge nurse requests it

Question 8

What is the primary indication for tracheal suctioning?

A) Presence of pneumonia
B) Presence of atelectasis
C) Ineffective coughing
D) Retention of secretions

Question 9

Complications of tracheal suctioning include which of the following?
1) Bronchospasm
2) Hyperinflation
3) Mucosal trauma
4) Elevated intracranial pressure

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

Question 10

You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case?

A) 6 Fr
B) 8 Fr
C) 10 Fr
D) 14 Fr

Question 11

To maintain positive end expiratory pressure (PEEP) and high FiO₂ when suctioning a mechanically ventilated patient, what would you recommend?

A) Limit suction time to no more than 5 sec.
B) Use a closed-system multiuse suction catheter.
C) Limit suctioning to once an hour.
D) Use the smallest possible catheter.

Question 12

What is the most common complication of suctioning?

A) Hypoxemia
B) Hypotension
C) Arrhythmias
D) Infection

Question 13

What is the normal range of negative pressure to use when suctioning an adult patient?

A) -100 to -120 mm Hg
B) -80 to -100 mm Hg
C) -60 to -80 mm Hg
D) -20 to -30 mm Hg

Question 14

Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem?

A) Secretions are still present and the patient should be suctioned again.
B) The patient has hyperactive airways and has developed bronchospasm.
C) A pneumothorax has developed and the patient needs a chest tube.
D) The patient has developed a mucous plug and should undergo bronchoscopy.

Question 15

After repeated nasotracheal suctioning over 2 days, a patient with retained secretions develops minor bleeding through the nose. Which of the following actions would you recommend?

A) Perform a tracheotomy for better access to the lower airway.
B) Discontinue nasotracheal suctioning for 48 hr and reassess.
C) Stop the bleeding and use a nasopharyngeal airway for access.
D) Orally intubate the patient for better access to the lower airway.

Question 16

Total application time for endotracheal suction in adults should not exceed which of the following?

A) 20 to 25 sec
B) 15 to 20 sec
C) 10 to 15 sec
D) 3 to 5 sec

Question 17

Which of the following equipment is needed to perform nasotracheal suctioning?
1) Suction kit (catheter, gloves, basin, etc.)
2) Laryngoscope with MacIntosh and Miller blades
3) Oxygen delivery system (mask and manual resuscitator)
4) Bottle of sterile water or saline solution

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

Question 18

What general condition requires airway management?
1) Airway compromise
2) Respiratory failure
3) Need to protect the airway

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

Question 19

Which of the following conditions require emergency tracheal intubation?
1) Upper airway or laryngeal edema
2) Loss of protective reflexes
3) Cardiopulmonary arrest
4) Traumatic upper airway obstruction

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

Question 20

Absolute contraindication for nasotracheal suctioning includes which of the following?
1) Epiglottitis
2) Croup
3) Irritable airway

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

Question 21

Compared with the nasal route, the advantages of oral intubation include which of the following?
1) Reduced risk of kinking
2) Less retching and gagging
3) Easier suctioning
4) Less traumatic insertion

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

Question 22

What is the purpose of a tracheostomy tube obturator?

A) To minimize trauma to the tracheal mucosal during insertion
B) To provide a patent airway should the tube become obstructed
C) To help ascertain the proper tube position by radiograph
D) To provide a means to inflate and deflate the tube cuff

Question 23

Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following?
1) Laryngoscope light source
2) Endotracheal tube cuff
3) Suction equipment
4) Cardiac defibrillator

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

Question 24

While checking a crash cart for intubation equipment, you find the following: suction equipment, oxygen apparatus, two laryngoscopes and assorted blades, five tubes, Magill forceps, tape, lubricating gel, and local anesthetic. What is missing?
1) Obturator
2) Syringe(s)
3) Resuscitator bag and mask
4) Tube stylet

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

Question 25

Which of the following types of artificial airways are inserted through the larynx?
1) Pharyngeal airways
2) Tracheostomy tubes
3) Nasotracheal tubes
4) Orotracheal tubes

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

Question 26

Compared with translaryngeal intubation, the advantages of tracheostomy include which of the following?
1) Greater patient comfort
2) Reduced risk of bronchial intubation
3) No upper airway complications
4) Decreased frequency of aspiration

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

Question 27

What size endotracheal tube would you select to intubate an adult female?

A) 6 mm
B) 7 mm
C) 8 mm
D) 9 mm

Question 28

What size endotracheal tube would you select to intubate a 1500-g newborn infant?

A) 2.5 mm
B) 3.0 mm
C) 3.5 mm
D) 4.0 mm

Question 29

What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube?

A) To help ascertain proper tube position
B) To minimize mucosal trauma during insertion
C) To monitor cuff status and pressure
D) To protect the airway against aspiration

Question 30

The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes?
1) Aid in routine tube cleaning and tracheostomy care
2) Prevent the tube from slipping into the trachea
3) Provide a patent airway should it become obstructed

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

Question 31

Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management?
1) Hypotension
2) Bradycardia
3) Cardiac arrhythmias
4) Laryngospasm

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

Question 32

What size endotracheal tube would you select to intubate a 3-year-old child?

A) 3.0 to 4.0 mm
B) 4.5 to 5.0 mm
C) 5.5 to 6.0 mm
D) 6.0 to 7.0 mm

Question 33

What is the standard size for endotracheal or tracheostomy tube adapters?

A) 22-mm external diameter
B) 15-mm external diameter
C) 15-mm internal diameter
D) 22-mm internal diameter

Question 34

What is the purpose of the additional side port (Murphy eye) on most modern endotracheal tubes?

A) Protect the airway against aspiration.
B) Help ascertain proper tube position.
C) Minimize mucosal trauma during insertion.
D) Ensure gas flow if the main port is blocked.

Question 35

Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement?
1) Length markings on the curved body of the tube
2) Imbedded radiopaque indicator near the tube tip
3) Additional side port (Murphy eye) near the tube tip

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

Question 36

Which of the following indicate an inability to adequately protect the airway?
1) Wheezing
2) Coma
3) Lack of gag reflex
4) Inability to cough

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

Question 37

In the absence of neck or facial injuries, what is the procedure of choice to establish a patent tracheal airway in an emergency?

A) Surgical tracheotomy
B) Orotracheal intubation
C) Nasotracheal intubation
D) Cricothyrotomy

Question 38

While checking a Miller and a MacIntosh blade on an intubation tray during an emergency intubation, you find that the Miller blade "lights" but the MacIntosh blade does not. What should you do now?

A) Swap the defective MacIntosh for the good Miller blade.
B) Check and replace the bulb in the MacIntosh blade.
C) Replace the batteries in the laryngoscope handle.
D) Check and clean the laryngoscope handle electrical contact.

Question 39

What is the purpose of a cuff on an artificial tracheal airway?

A) To seal off and protect the lower airway
B) To stabilize the tube and prevent its movement
C) To provide a means to determine tube position via radiograph
D) To help clinicians determine the depth of tube insertion

Question 40

Compared with the oral route, the advantages of nasal intubation include which of the following?
1) Reduced risk of kinking
2) Less retching and gagging
3) Less accidental extubation
4) Greater long-term comfort

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

Question 41

Successful tube passage through the larynx during blind nasotracheal intubation is indicated by which of the following?
1) Louder breath sounds
2) Harsh cough
3) Vocal silence

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

Question 42

Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube?
1) Patient's tolerance of the endotracheal tube
2) Relative risks of continued intubation versus tracheostomy
3) Patient's severity of illness and overall condition
4) Length of time that the patient will need an artificial airway
5) Patient's ability to tolerate a surgical procedure

A)1, 3, and 4 only
B)3, 4, and 5 only
C)2, 3, 4, and 5 only
D)1, 2, 3, 4, and 5

Question 43

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action?

A) Remove the oral tube just before tracheostomy tube insertion.
B) Remove the oral tube before the tracheotomy is performed.
C) Pull the oral tube only after the tracheostomy tube is placed.
D) Withdraw the oral tube 2 to 3 in while the incision is made.

Question 44

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned approximately how far above the carina?

A) 1 to 3 cm
B) 3 to 6 cm
C) 7 to 9 cm
D) 4 to 6 in

Question 45

Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachea?

A) Auscultation
B) Observation of chest movement
C) Tube length (cm to teeth)
D) Fiberoptic laryngoscopy

Question 46

After an intubation attempt, an expired capnogram indicates a CO₂ level near zero. What does this finding probably indicate?

A) Abnormally high ventilation/perfusion ratio ()
B) Placement of the endotracheal tube in the esophagus
C) Placement of the endotracheal tube in the trachea
D) Failure of the cuff to properly seal the airway

Question 47

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in a false-negative finding (i.e., no CO₂ present even when the tube is in the trachea)?

A) Cardiac arrest
B) Gastric CO₂ diffusion
C) Right main stem intubation
D) Delivery of a high FiO₂

Question 48

You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support. Which of the following airway approaches would you recommend?

A) Intubate via the oral route.
B) Insert an oropharyngeal airway.
C) Perform an emergency tracheotomy.
D) Intubate via the nasal route.

Question 49

What should be the maximum time devoted to any intubation attempt?

A) 30 sec
B) 60 sec
C) 90 sec
D) 2 min

Question 50

To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend?

A) Nasal spray of 0.25% phenylephrine
B) SVN aerosol delivery of 2% lidocaine for 10 min
C) Mixture of 0.25% phenylephrine and 3% lidocaine
D) SVN aerosol delivery of 0.25% phenylephrine for 10 min

Question 51

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area?

A) Through or between the first and second tracheal rings
B) Through the ligament between the thyroid and cricoid cartilages
C) Through or between the second and third tracheal rings
D) Between the cricoid cartilage and the first tracheal ring

Question 52

Serious complications of oral intubation include which of the following?
1) Cardiac arrest
2) Acute hypoxemia
3) Bradycardia
4) Tongue lacerations

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

Question 53

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far?

A) Until its cuff has passed the cords
B) Just far enough so that the tube cuff is no longer visible
C) Until its cuff has passed the cords by 2 to 3 in
D) Until its tip has passed the cords by 2 to 3 cm

Question 54

To make oral intubation easier, how should the patient's head and neck be positioned?

A) Neck extended over the edge of the bed, with head dangling down
B) Neck extended, with head supported by towel and flexed forward
C) Both the neck and head fully extended, with neck supported by towel
D) Neck flexed, with head supported by towel and tilted back

Question 55

After intubation of a cardiac arrest victim, you observe a slow but steady rise in the expired CO₂ levels as measured by a bedside capnometer. Which of the following best explains this observation?

A) Return of spontaneous circulation
B) Abnormally high
C) Placement of the endotracheal tube in the esophagus
D) Failure of the cuff to properly seal the airway

Question 56

What is the purpose of an endotracheal tube stylet?

A) It helps ascertain proper tube position.
B) It adds rigidity and shape to ease insertion.
C) It minimizes mucosal trauma during insertion.
D) It protects the airway against aspiration.

Question 57

What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man?

A) 16 to 18 cm
B) 19 to 21 cm
C) 21 to 23 cm
D) 24 to 26 cm

Question 58

Immediately after insertion of an oral endotracheal tube on an adult, what should you do?
1) Stabilize it with your right hand.
2) Inflate the tube cuff.
3) Provide ventilation or oxygenation.

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

Question 59

When using a bulb-type esophageal detection device (EDD) during an intubation attempt, how do you know that the endotracheal tube is in the esophagus?

A) The bulb fails to reexpand upon release.
B) The bulb quickly reexpands upon release.
C) The bulb cannot be completely squeezed closed.
D) The bulb cannot be attached to the endotracheal tube.

Question 60

What is the primary indication for tracheostomy?

A) When a patient loses pharyngeal or laryngeal reflexes
B) When a patient has a long-term need for an artificial airway
C) When a patient has been orally intubated for more than 24 hr
D) When a patient has upper airway obstruction due to secretions

Question 61

A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheotomy and is now receiving 40% oxygen through a T tube (Briggs adapter). Which of the following would be the best way to limit tube movement in this patient?

A) Give a neuromuscular blocker to prevent patient movement.
B) Secure the T tube delivery tubing to the bed rail.
C) Tape the T tube to the tracheostomy tube connector.
D) Switch from the T tube to a tracheostomy collar.

Question 62

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem?

A) Vocal cord paralysis
B) Tracheoesophageal fistula
C) Glottic edema or cord inflammation
D) Tracheomalacia

Question 63

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem?

A) Paralysis of the vocal cords
B) Underinflated tube cuff
C) Tracheoesophageal fistula
D) Tracheoinnominate fistula

Question 64

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better?
1) Use a letter, phrase, or picture board.
2) Consider switching to a fenestrated tracheostomy tube.
3) Consider a "talking" tracheostomy tube.

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

Question 65

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur?
1) Cuff site
2) Tip of the tube
3) Stoma site

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

Question 66

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend?

A) STAT-heated aerosol treatment with saline
B) STAT racemic epinephrine aerosol treatment
C) Careful observation of the patient for 6 hr
D) Immediate reintubation via the nasal route

Question 67

To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?

A) 32° to 35° C
B) 37° to 40° C
C) 30° to 32° C
D) 40° to 42° C

Question 68

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H₂O. What is most likely the problem?

A) The tube chosen is too small for the patient.
B) The cuff pilot balloon and line are obstructed.
C) The tube is in the right main stem bronchus.
D) The cuff has herniated over the tube tip.

Question 69

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma?
1) Regular aseptic stoma cleaning
2) Adherence to sterile techniques
3) Regular change of tracheostomy dressings

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

Question 70

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following?

A) Increase cuff pressure.
B) Not affect cuff pressure.
C) Decrease cuff pressure.
D) Rupture the cuff.

Question 71

Which of the following injuries are seen with tracheostomy tubes?
1) Tracheomalacia
2) Tracheal stenosis
3) Glottic edema
4) Vocal cord granulomas

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

Question 72

Which of the following techniques may be used to diagnose injury associated with artificial airways?
1) Laryngoscopy or bronchoscopy
2) Physical examination
3) Air tomography
4) Pulmonary function studies

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

Question 73

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 2 cm above the carina. Which of the following actions would you recommend?

A) Withdraw the tube by 2 to 3 cm (using tube markings as a guide).
B) Withdraw the tube by 7 to 8 cm (using tube markings as a guide).
C) Advance the tube by 2 to 3 cm (using tube markings as a guide).
D) Advance the tube by 7 to 8 cm (using tube markings as a guide).

Question 74

Compared with traditional surgical tracheostomy, which of the following are true about percutaneous dilatational tracheostomy?
1) Percutaneous dilatational tracheostomy has a lower incidence of complications.
2) Percutaneous dilatational tracheostomy is faster than traditional tracheostomy.
3) Percutaneous dilatational tracheostomy can be performed at the bedside.
4) Percutaneous dilatational tracheostomy does not require anterior neck dissection.

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

Question 75

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?

A) Maintaining cuff pressures below 20 to 25 mm Hg
B) Using the minimal leak technique for inflation
C) Using a low-residual-volume, low-compliance cuff
D) Monitoring intracuff pressures every 1 to 2 hr

Question 76

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons?
1) Lower levels of humidification
2) Increased aspiration of pharyngeal material
3) Contaminated equipment or solutions
4) Ineffective clearance through cough

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

Question 77

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?

A) Tracheomalacia
B) Laryngeal web
C) Cord paralysis
D) Tracheal stenosis

Question 78

What is the maximum recommended range for tracheal tube cuff pressures?

A) 15 to 20 mm Hg
B) 20 to 25 mm Hg
C) 25 to 30 mm Hg
D) 30 to 35 mm Hg

Question 79

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?

A) 1 to 2 cm
B) 2 to 4 cm
C) 3 to 6 cm
D) 6 to 8 cm

Question 80

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?

A) Difficulty in swallowing
B) Wheezing
C) Orthopnea
D) Hoarseness