Name: __________________________ Date: _____________

1. A patient admitted to the Emergency Department is suspected of having suffered airway

injury due to inhalation of toxic fumes. To determine the location and extent of potential
injury you would recommend which of the following procedures?
A) V/Q scan

B) chest X-ray

C) blood gas analysis

D) bronchoscopy

Ans: D

Response:
Injury from toxic inhalation or aspiration most immediately affects the airways. In these
patients the location and extent of injury is best determined initially using fiberoptic
bronchoscopy.

2. Your patient in ICU is suspected of having developed a bacterial ventilator-associated

pneumonia. Which of the following procedures would you recommend as best able to
diagnose the cause of this problem?
A) sputum culture and sensitivity

B) chest X-ray

C) bronchoalveolar lavage

D) CT scan

Ans: C

Response:
A sputum culture and sensitivity could help diagnose this problem. However, bronchoalveolar
lavage (BAL) is one of the principal best tools available to diagnose bacterial ventilator-
associated pneumonia (VAP), and is thus the better choice for this patient. According to the
American Thoracic Society, bronchoalveolar lavage (BAL) is indicated in patients with non-
resolving pneumonia, unexplained lung infiltrates (interstitial and/or alveolar), and suspected
alveolar hemorrhage.

3. To estimate the metabolic rate of a patient receiving mechanical ventilation, you would
recommend:
A) hemoximetry

B) ABG analysis

C) capnography

D) maximum voluntary ventilation

Ans: C

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 Response:
Capnography (expired CO2 analysis) is used primarily to noninvasively monitor the
effectiveness (PetCO2) and efficiency (PaCO2-PetCO2) of ventilation, usually during
mechanical ventilation. Most capnographs also can compute the accumulated volume of CO2
over time if the expired minute ventilation is known or measured. CO2 production per minute
is one measure of metabolic activity, the other being O2 consumption.

4. To evaluate and follow the course of a patient with interstitial lung diseases, which of the
following pulmonary function testing procedures would you recommend?
A) diffusing capacity (DLco)

B) He dilution FRC and TLC

C) forced expiratory volumes/flows

D) methacholine challenge test

Ans: A

Response:
The primary indication for the carbon monoxide diffusing capacity (DLco) test is to evaluate
and follow the course of parenchymal and interstitial lung diseases such as pulmonary
fibrosis, pneumoconiosis and sarcoidosis, In addition the DLco test can be used to
differentiate among the various patterns of airway obstruction (emphysema patients typically
have a low DLco) and is helpful in following the course of emphysema and cystic fibrosis.
The DLco test also can help predict arterial desaturation during exercise in patients with lung
disease.

5. Which of the following tests of lung mechanics would you recommend to detect the presence
of auto-PEEP on a patient receiving ventilatory support?
A) pressure-volume loop

B) flow-volume loop

C) static compliance (inspiratory hold)

D) airway resistance (inspiratory hold)

Ans: B

Response:
Of the tests listed, only the flow-volume loop would help detect the presence of auto-PEEP on
a patient receiving ventilatory support. When viewing the flow-volume loop of a patient with
auto-PEEP, you will note that the expiratory flow does not return baseline before start of next
breath.

6. The wife of a patient receiving post-operative incentive spirometry asks if this therapy will
help get rid of his snoring, daytime sleepiness, and morning headaches. In communicating this
information to the patient's surgeon, you would recommend which of the following diagnostic
procedures?
A) lateral neck X-ray

B) arterial blood gas

C) polysomnography

D) diffusing capacity

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 Ans: C

Response:
You should recommend polysomnography for patients who complain of or exhibit signs or
symptoms associated with sleep-disordered breathing, e.g., daytime somnolence and fatigue;
morning headaches; pulmonary hypertension, and polycythemia.

7. To continuously monitor the adequacy of ventilation of a patient in ICU being supported by

mask BiPAP™, you would recommend which of the following?
A) transcutaneous PCO2

B) pulse oximetry

C) ABG analysis

D) capnography

Ans: A

Response:
Although traditionally used only with infants and children, recent research indicates that the
transcutaneous PCO2 is an accurate measure of ventilation in hemodynamically stable adults,
making it a good choice for continuously monitoring of ventilation when capnography is
unavailable or impractical, e.g., during noninvasive ventilation.

8. As you are fitting him with a nonrebreathing mask, a 62 YO patient in the Emergency
Department complains of severe chest pain. Which of the following tests would you first
recommend for this patient?
A) arterial blood gas

B) electrocardiogram (ECG)

C) V/Q scan

D) bedside spirometry

Ans: B

Response:
You should recommend obtaining an electrocardiogram to screen for heart disease, rule out
heart disease in surgical patients, evaluate patients with chest pain, follow the progression of
patients with CAD and evaluate heart rhythm disorders

9. To assess tissue oxygenation in a patient with ARDS, you would recommend which of the
following?
A) a CVP line

B) a pulmonary artery catheter

C) an arterial line

D) pulse oximetry

Ans: B

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 Response:
To assess how well the tissues are getting oxygenated, we need to know how much oxygen is
left over after the blood leaves the capillaries. This measure, called the mixed venous oxygen
content (CvO2) can only be obtained from the distal port of a pulmonary artery catheter.

10. You would consider recommending all of the following procedures to help diagnose a
pulmonary embolism EXCEPT:
A) helical CT scan

B) angiography

C) V/Q scan

D) chest X-ray

Ans: D

Response:
Traditionally, V/Q scans have been used as the screening test for pulmonary embolism, with
pulmonary angiography applied as the 'gold standard' to confirm the diagnosis. Helical CT
angiography is replacing both of these tools in diagnosing pulmonary embolism. A standard
chest X-ray does not reliably detect pulmonary embolism.

11. A two year-old child is admitted to the Emergency Department with stridor, nasal flaring,
tachypnea and inspiratory retractions. Which of the following procedures would you
recommend to help diagnose this patient's problem?
A) ventilation-perfusion scan

B) AP and lateral neck X-rays

C) arterial blood gas analysis

D) bedside spirometry

Ans: B

Response:
Stridor and respiratory distress in children indicates upper airway obstruction, usually due to
either infection (croup or epiglottitis) or aspirated foreign bodies. In combination, AP and
lateral neck X-rays can help differentiate among these problems.

12. Which of the following would you recommend to help guide a physician in locating the
appropriate needle insertion site for thoracentesis performed at the bedside?
A) ultrasound

B) CT scan

C) thoracic MRI

D) bronchoscopy

Ans: A

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 Response:
Thoracic ultrasound is indicated to guide thoracentesis and percutaneous needle biopsies. In
addition, this toll can be used to detect (1) free fluid in the thorax (pleural or pericardial
effusion, hemithorax, etc.); (2) pneumothorax; (3) mediastinal masses; and (4) pulmonary
atelectasis or consolidation. Thoracic ultrasound can also be used to assess the pleural surfaces
for pleuritis or granulomatous processes and identify thoracic wall lesions and rib masses.
Last, ultrasound exams can help diagnose trauma to the diaphragm, heart and large thoracic
blood vessels, as well as fractures of the ribs and sternum.

13. You normally should recommend AGAINST performing a diagnostic bronchoscopy on which
of the following patients?

I. a patient with severe refractory hypoxemia

II. a patient who is hemodynamically unstable
III. a patient with a an uncorrected bleeding disorder
A) I and II only

B) II and III only

C) I and III only

D) I, II and III

Ans: D

Response:
According to the AARC, you should recommend against performing diagnostic bronchoscopy
in patients who (1) cannot be adequately oxygenated during the procedure (severe refractory
hypoxemia); (2) have a bleeding disorder that cannot be corrected; (3) have severe obstructive
airways disease; and (4) are hemodynamically unstable.

14. An ambulatory care patient has a white blood cell count (WBC) of 20,000, along with
increased sputum production. Which of the following tests would you recommend for this
patient?
A) sputum Gram stain, culture & sensitivity

B) arterial blood gas analysis

C) lab spirometry (FVC volumes/ flows)

D) bronchoalveolar lavage

Ans: A

Response:
The patient's WBC is elevated above normal (10,000), suggesting an acute bacterial infection.
You should recommend a sputum Gram stain and culture and sensitivity (C&S) on any patient
suspected of having a respiratory track infection. By identifying whether the organisms are
primarily Gram+ or Gram-, the Gram stain can be used to as a general guide to initial
antibiotic therapy. By determining which specific antibiotics that the organisms are
susceptible to, the subsequent C&S study can help the doctor decide on the most appropriate
drug or drugs to prescribe for the patient

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15. Due to her patient's minimal response to the standard prescription for an aerosolized
bronchodilator, a doctor asks your advice on how best to adjust the dosage. You would
recommend:
A) peak expiratory flow rate monitoring

B) methacholine challenge (provocation) test

C) carbon monoxide diffusing capacity (DLco)

D) pre/post bronchodilator spirometry

Ans: D

Response:
At this stage in the patient's management, the best way to determine if a change in dose,
frequency, or medication is needed for this patient would be pre/post bronchodilator
spirometry. Peak expiratory flow rate monitoring is used primarily to assess asthma patients'
airway tone over time, whereas the methacholine challenge test is used mainly to assess the
severity of airway hyperresponsiveness or evaluate occupational asthma

16. A doctor asks your advice on the best way for his home care asthma patient to assess changes
in her airway tone over time. You would recommend:
A) peak expiratory flow rate monitoring

B) methacholine challenge (provocation) test

C) carbon monoxide diffusing capacity (DLco)

D) pre/post bronchodilator spirometry

Ans: A

Response:
Peak expiratory flow rate monitoring is the primary means by which asthma patients can
assess their airway tone over time, as well as changes in tone in response to bronchodilator
therapy. Pre/post bronchodilator spirometry is used primarily to determine the effectiveness of
bronchodilator therapy or the need for a change in the drug dose or frequency of
administration. Methacholine challenge testing is used mainly to assess the severity of airway
hyperresponsiveness or evaluate occupational asthma

17. A doctor suspects that a patient's asthma-like symptoms are due to airway hyperreactivity. She
asks your advice on the best way to confirm this diagnosis. You would recommend:
A) peak expiratory flow rate monitoring

B) bronchial provocation testing

C) carbon monoxide diffusing capacity

D) pre/post bronchodilator spirometry

Ans: B

Response:
Bronchial provocation testing (aka methacholine challenge testing) is used to confirm or
exclude a diagnosis of airway hyperreactivity. It also may be used to determine the relative
risk of developing asthma, evaluate patients for occupational asthma, and assess the response
to therapeutic interventions.

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18. Which of the following tests of lung mechanics would you recommend to detect suspected
overinflation on a patient receiving ventilatory support?
A) pressure-volume curve

B) flow-volume curve

C) static compliance (inspiratory hold)

D) airway resistance (inspiratory hold)

Ans: A

Response:
On patients receiving ventilatory support, a pressure-volume curve can detect changes in
compliance (slope of curve) and resistance (width of curve), as well as suspected overinflation
("beaking" appearance). A pressure-volume curve can also help determine the optimum PEEP
level (just above lower inflection point).

19. Which of the following would you recommend to determine actual blood O2 saturation of a
patient being treated for methemoglobinemia?

I. blood gas analysis

II. hemoximetry (CO-oximetry)
III. pulse oximetry
A) I or II

B) II or III

C) II only

D) I, II or III

Ans: C

Response:
Methemoglobin (metHb) is an abnormal hemoglobin most commonly cause by environmental
exposure to oxidizing drugs and their metabolites (such as benzocaine, dapsone and nitrates).
Only hemoximetry (CO-oximetry) can accurately metHb and other common abnormal
hemoglobins (HbCO, sulfhemoglobin) and determine actual blood O2 saturation (as opposed
to that computed with a simple blood gas analyzer)

20. In which of the following circumstances would you recommend using pulse oximetry?
A) to assess changes in oxygenation during procedures that can cause hypoxemia

B) to monitor oxygenation in patients with poor peripheral perfusion

C) to obtain precise/accurate assessment of a patient's blood oxygenation

D) to monitor for or warning of hyperoxemia in infants

Ans: A

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 Response:
Pulse oximetry is best used for basic monitoring of a patient's arterial O2 saturation, including
the response to therapeutic intervention or to diagnostic procedure (e.g., bronchoscopy).
However, pulse oximetry should never be substituted for ABG analysis or hemoximetry when
the clinical situation demands accurate assessment blood oxygenation. You should also
recommend against reliance on pulse oximetry data for patients with poor peripheral perfusion
and when there is a need to monitor for or warn of hyperoxemia, as when protecting
premature infant against retrolental fibroplasia.

21. Which of the following would you recommend to provide graphic data useful in evaluating
the ventilator-patient interface?
A) capnography

B) pulse oximetry

C) hemoximetry

D) electrocardiography

Ans: A

Response:
Capnography (expired CO2 analysis) provides a noninvasive method for assessing both the
effectiveness (PETCO2) and efficiency (PaCO2-PETCO2) of a patient's ventilation. It also
provides graphic data useful in evaluating the ventilator-patient interface. Analysis of the
shape of the capnogram at high sweep speed can be helpful in identifying conditions such as
circuit rebreathing, esophageal intubation, and maldistribution of ventilation. In addition,
capnography can be used to monitor levels of therapeutically administered CO2 gas and
measure CO2 production.

22. You detect an irregular pulse and pulse deficit in a patient by palpation and auscultation, and
suspect atrial fibrillation as the cause. Which of the following tests would you recommend to
confirm if atrial fibrillation is the problem?
A) cardiac catheterization

B) electrocardiogram

C) coronary angiogram

D) echocardiogram

Ans: B

Response:
You should recommend obtaining an electrocardiogram to screen for heart disease, rule out
heart disease in surgical patients, evaluate patients with chest pain, follow the progression of
patients with CAD and evaluate heart rhythm disorders, such as atrial fibrillation.

23. All of the following are contraindications against systemic arterial monitoring via arterial line
EXCEPT:
A) severe coagulopathy

B) presence of a dialysis shunt

C) cardiovascular instability

D) inadequate collateral circulation

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 Ans: C

Response:
Contraindications against systemic arterial monitoring via arterial line include: (1) inadequate
collateral arterial circulation (negative Allen Test); (2) evidence of infection or peripheral
vascular disease in the selected limb; (3) severe coagulopathy, e.g., platelet count <50,000 or
PTT > 37 sec; and (4) presence of a surgical/dialysis shunt in the selected arm (consider
contralateral limb). The need to continuously monitor arterial pressure in unstable/hypotensive
patients is an indication for systemic arterial monitoring.

24. For which of the following reasons would you recommend overnight oximetry?

I. to determine if COPD patients desaturate during sleep

II. to assess sleep apnea patients' response to CPAP
III. to identify patients with obstructive sleep apnea
A) I and II only

B) II and III only

C) I and III only

D) I, II and III

Ans: D

Response:
You should recommend overnight oximetry to: (1) help identify patients with obstructive
sleep apnea-hypopnoea syndrome (SAHS); (2) help assess SAHS patients' response to
therapy, such as CPAP; and (3) identify whether serious desaturation occurs in COPD patients
during sleep. In terms of diagnosing SAHS, the gold standard is lab polysomnography.
However, polysomnography is expensive and not readily available to all patients. In
comparison, overnight oximetry is readily available, inexpensive, and can be performed in the
patient's home.

25. A physician requests transcutaneous blood gas monitoring on a premature infant in the NICU.
Which of the following conditions would cause you to recommend against using this device to
monitor this patient?
A) hemodynamic instability

B) congenital heart disease

C) respiratory distress syndrome

D) meconium aspiration

Ans: A

Response:
You should avoid using a transcutaneous monitor on patients with poor skin integrity or those
with an adhesive allergy. Since accurate PtcO2 and PtcCO2 values generally require that the
patient be hemodynamically stable, you should not use these devices on patients in shock or
with poor peripheral circulation. Lengthy set-up and stabilization time (10-20 minutes) also
makes the transcutaneous monitor a poor choice for assessing gas exchange in emergency
situations.

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