ACCS Oakes practice Exam Questions and answers with 100% correct solutions | A+ Grade

A difficult intubation is anticipated with an obese pt. The decision is made to intubate by video laryngoscopy. Which of the following is LEAST likely to be needed: A) Cook's Exchanger B) Rigid Stylet C) Cuffed Endot ...

A difficult intubation is anticipated with an obese pt. The decision is made to intubate by video laryngoscopy. Which of the following is LEAST likely to be needed: A) Cook's Exchanger B) Rigid Stylet C) Cuffed Endotracheal Tube D) Video-enabled Laryngoscope ✔✔A) cook's exchanger Video laryngoscopy involves use of a normal ET Tube with the addition of a rigid stylet, as well as a video-enabled laryngoscope and other normal intubation equipment. A Cook's Tube Exchanger is not necessary - this is used to exchange tubes already in place. A 5'6" female has been transferred from Intermediate Care to Intensive Care in respiratory distress. She is intubated with a silver-coated #7.0 Endotracheal tube. CXR immediately following intubation shows Right Upper Lobe infiltrate with bibasilar atelectasis. The ET Tube is noted to be approximately 4 cm above the carina. The Respiratory Therapist would BEST recommend: A) Initiation of broad-spectrum antibiotics for probably pneumonia B)Withdraw Endotracheal tube at least 3 cm C) Use tube exchanger to replace Endotracheal tube from silver-coated to a low-pressure/high-volume cuffed tubeD) Immediate V/Q Scan ✔✔Correct answer is A This pt has gone into respiratory failure, requiring intubation. The X-ray is consistent with a possible pneumonia diagnosis. The best option therefore is to start antibiotics. Withdrawing ET Tube is not indicated as 4 cm is likely adequate. Pulling back 3 cm could result in inadvertent extubation and would cause harm to patient Use of tube exchanger is unnecessary. A silver-coated endotracheal tube is intended to help prevent VAP Immediate V/Q scan is not indicated - it is a poor use of resources for what is needed right away. You are part of Physician Rounding this morning, and consulting on a patient who is currently on APRV. They were originally admitted with a pneumonia which developed into ARDS with a P/F ratio as low as 110. The patient was transitioned to APRV from PC due to an elevated Plateau Pressure required to maintain VT around 4 cc/kg IBW. The patient is arousable and taking breaths on their own. The physician has asked you what should be done to address the patient's latest ABG. Ph 7.16 PaCo2 49 PaO2 88 torr HCO3 19 Mode- APRV Phigh- 24Plow- 0 Thigh- 5.0 sec Tlow- o.5 sec PS- 26 FiO2- 80% A) Increase Phigh to 28 cmH2O B) Decrease Phigh to 20 cmH2O C) Increase sedation D) Increase Thigh to 6.0 sec ✔✔Correct answer is A This ABG may look deceptively metabolic but is truly a mixed Respiratory and Metabolic Acidosis. The PaCO2 has risen, slightly, as a result of the Metabolic Acidosis. The correct solution is to increase Phigh to 28 cmH2O (increasing your delta-P to increase minute volume. Decreasing Phigh will decrease minute volume. Increasing Thigh will increase MAP (good if oxygenation), but will also lower the number of "releases" - which are primarily responsible for dumping CO2. Increasing sedation in a patient who is spontaneously breathing on APRV will result in a lowered minute volume and worsening acidosis. While controversy exists, you may also consider increasing PS if the pt is breathing spontaneously. A 56-year old woman was admitted for rapid development of respiratory failure following a suspected aspiration. Her past medical history includes Diabetes, medication-controlled Hypertension, and she has a 30-pack year smoking history. She has been intubated and placed on a Ventilator. Patient dataPh 7.19 PaCO2 62 mmHg PaO2 54 mmHg HCO3 18 mEq/L Mode - pressure control Set PIP- 24 cm H2O VTE- 380 ml measured Rate- 24/min PEEP- 8 cm H2O FiO2- 100 This data is MOST consistent with the following diagnosis: A) ARDS B) Tension Pneumothorax C) Pulmonary Hypertension D) Exacerbation of COPD ✔✔Correct answer A The data is overall representative of ARDS. The CXR shows bilateral infiltrates (and relative white-out). P/F ratio is easily calculable on FIO2 100%: 54. A P/F < 200 is consistent with ARDS. The process was acute onset (sudden). All of the following have been shown to reduce VAP, EXCEPT: A) subglottic suctioning B) aggressive endotracheal suctioning C) Use of specialty airways, such as a silver-coated endotracheal tubeD) Aggressively weaning patients to minimize time on the ventilator ✔✔Correct answer B Aggressive endotracheal suctioning does NOT prevent VAP (though subglottic suctioning may). Which of the following pharmacologic agents is MOST indicated in an intubated patient who was admitted to Trauma ICU with multiple gunshot wounds to the abdomen and upper thigh. A) propofol B) ativan C) norepinephrine D) vecuronium ✔✔This patient is likely in pain following their injuries. Initially, pain and sedation are most indicated. Now it is important to pick out the correct medication from those given to you: vecuronium is a paralytic (not indicated) ativan is an anti-anxiety medication (not indicated) norepinephrine is a pressor (not indicated) propofol is a sedative (correct answer) You are asked to consult on a patient in the ED who is being admitted to the Medical ICU. ABG is below. CXR shows flattened diaphragms with hyperlucency in the apices. ABG shows: Ph 7.29 PaCO2 66 PaO2 56 HCO3 30 What do you recommend as the BEST choice? A) Intubate patient and place on a Pressure-Control mode of VentilationB) Oxygen by Nasal Cannula, start at 2L C) NPPV via Face Mask D) I.V. Steroids, maintain on RA to avoid hypoxic drive ✔✔Correct answer C First you have to figure out what is going on with this patient. CXR and ABG both support a COPD diagnosis (remember that COPD is truly diagnosed via a PFT). The pt is sitting up, leaning forward, complaining of SOB. The ABG shows Acute on Chronic Respiratory Acidosis, and is mildly hypoxic. The best treatment in this case is NPPV to help alleviate WOB and treat hypoxia while other treatments are being initiated (steroids, bronchodilators, etc.). Note that both 2L NC and RA are not appropriate as the pt is in distress and hypoxic which must be treated. Intubating a pt with COPD, while sometimes necessary, also creates unique concerns with attempts to wean after such an unload of work of breathing. On assessment, a patient is noted to have coarse crackles throughout all lung fields, an increased work of breathing, and steadily increasing FIO2 demand. Which medication will best address this? A) Lasix B) Albuterol sulfate C) Atropine D) 1L Normal Saline ✔✔Correct answer is A The assessment is consistent with fluid overload. Lasix is a diuretic and will address this. Albuterol is a bronchodilator and may help briefly with dyspnea but will not treat underlying cause. Atropine is a muscarinic receptor antagonist, an important cardiac medication Normal Saline will potentially worsen the problem, and would be indicated instead in a patient who needs to be fluid resuscitated (temporary solution for improving hypotension)You have been asked to make a recommendation regarding specialty airways that help prevent colonization of organisms on it which might lead to VAP. What would you recommend? A) Microcuff Tube B) Silver-coated Endotracheal Tube C) Use of ET Tube with closed suctioning only D) Mercury-coated Endotracheal Tube ✔✔Correct answer B Silver-coated endotracheal tubes are designed to help prevent Ventilator Associated Pneumonias. Mercury-Coated Endotracheal Tubes don't exist (would be harmcul). Use of ET tube with Closed Suctioning might help prevent VAP but not Colonization on the Tube. Microcuffs are again intended on preventing VAP by preventing microaspiration, but does not act by reducing colonization. A 58 y/o is in the cardiac critical care unit. You are called urgently to his room as he has gone into flash pulmonary edema. You note the following data: RR: 30 breaths/minute HR: 132 bpm, gallop noted (S3) BP: 84/64 GCS: 9T Disposition: Obtunded Skin: mottled, clammy Jugular Veins: distended ABGpH 7.49 PaCO2 24 mmHg PaO2 60 mmHg HCO3 24 mEq/L BE 0 Urinary Output 10 mL/hour This presentation supports a classification of: A) Cardiogenic Shock B) Hypovolemic Shock (non-hemorrhagic) C) Distributive (septic) Shock D) Obstructive Shock ✔✔Correct answer A This presentation is consistent with cardiogenic shock, including decreased pulse pressure, hypotension, decreased UO, JVD, initial respiratory alkalosis, flash pulmonary edema, mottling, etc. Full discussion of shock is beyond the scope of this explanation - we recommend reviewing relevant content for a detailed explanation Which of the following is LEAST likely to reduce incidence of VAP? A) Frequent oral care and hygiene using Chlorhexidine B) Administration of an H2 receptor inhibitor C) Daily sedation vacation and assessment of readiness to extubateD) Prophylactic use of antibiotics ✔✔Correct answer D The VAP Bundle is a list of recommendations based on evidence-based medicine. These recommendations have been show to reduce the incidence of VAP, and include: 1. Elevation of the Head of Bed 2. Daily Sedation Vacation and Assessment of Readiness to Extubate 3. Peptic Ulcer Disease Prophylaxis (H2 Receptor Inhibitor is most supported) 4. Deep Venous Thrombosis Prophylaxis 5. Daily Oral Care with Chlorhexidine Note that prophylactic use of antibiotics is not indicated, and really is contraindicated as it may build resistance in the patient. Which of the following pharmacologic agents is MOST indicated in a patient who has been intubated for several weeks, who becomes tachypneic and tachycardic during every attempt to wean from ventilator? A) propofol B) ativan C) lopressor D) pancuronium ✔✔Correct answer B This patient is possibly anxious around the process of weaning, a fairly typical response after being on a ventilator for a period of time. pancuronium is a paralytic (contraindicated) ativan is an anti-anxiety medication (correct choice)lopressor is a pressor (not indicated) propofol is a sedative (contraindicated) A new RN has asked you what you recommend to help sedate a patient who is fighting the ventilator. The graphics show double-stacking with breaths, and the patient appears uncomfortable. He is currently on V-CMV, and his SpO2 has been steadily drifting down. Which of the following drugs is MOST appropriate? A) Lopressor B) Albuterol C) Precedex D) Ativan ✔✔Correct answer C Precedex is a sedative which is usually easy to metabolize. The other medications are not sedatives: Ativan is an anti-anxiety, Lopressor is a pressor, and Albuterol is a bronchodilator You are transporting a patient with a PA Line. What value must you watch continuously during the trip? A) PAP B) PCWP C) CVP D) LVEDP ✔✔Correct answer A It is very important to ensure that the PA Catheter does not float into an incorrect (and dangerous!) position, such as in the right ventricle or a capillary (wedge). The only way to do this is to monitor the Pulmonary Artery Pressure (PAP). The other values will not provide this information. A 28-year-old female has suffered an MI with anoxic brain injury. Current data: HR 76/min RR 16/minTemp 35.5° C ABG pH 7.43 PaCO2 37 torr PaO2 186 torr HCO3 20 mEq/L The team has decided upon proceeding with diagnosis of brain death. The best way to do this is: A) EEG B) Perform Apnea Test C) Perform Brain Perfusion Study D) Determination by Cardiac Death ✔✔Correct answer C The first temptation for many on this question is to go with the Apnea Test. That is, after all, what most of us do clinically. With all these types of question, carefully considers the Indications and Contraindications for each test: Apnea Test: Contraindication includes pts who are not normothermic. This pt is hypothermic so does not meet the criteria. EEG: This test is not considered definitive. Cardiac Determination: Is an option when patients have a drive to breathe so will obviously fail the Apnea Test. This is not the best choice. Brain Perfusion: This test is a definitive test of brain death. You are called emergently to a patient's room who has become increasingly lethargic following repeated administration of morphine due to pain throughout the last few hours. Current SpO2 is 92% on NC 4LPM. Respirations are shallow, at about 8 breaths/minute. The BEST course of action is: