Egan's Chapter 37 pt.1

1. What is the primary indication for tracheal suctioning?

Retention of secretions

2. What is the most common complication of suctioning?

Hypoxemia

3. Complications of tracheal suctioning include which of the following?

1. Bronchospasm

2. Hyperinflation

3. Mucosal trauma

4. Elevated intracranial pressure

1, 3, and 4 only

4. How often should patients be suctioned?

When physical findings support the need

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

-120 to -150 mm Hg

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

-100 to -120 mm Hg

7. 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.

10 Fr

8. 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?

14 Fr

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

Preoxygenate the patient with 100% oxygen.

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

Use a closed-system multiuse suction catheter.

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

10 to 15 sec

12. 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?

Stop suctioning and immediately administer oxygen.

13. 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.

1, 2, and 3

14. 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.

2 and 4 only

15. Absolute contraindication for nasotracheal suctioning includes which of the following?

1. Epiglottitis

2. Croup

3. Irritable airway

1 and 2 only

16. 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.

1, 3, and 4 only

17. 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?

Stop the bleeding and use a nasopharyngeal airway for access.

18. 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?

The patient has hyperactive airways and has developed bronchospasm.

19. What general condition requires airway management?

1. Airway compromise

2. Respiratory failure

3. Need to protect the airway

1, 2, and 3

20. 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.

1, 2, 3, and 4

21. 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

1, 2, 3, and 4

22. 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

2, 3, and 4 only

23. 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

3 and 4 only

24. 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

1, 3, and 4 only

25. 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

2, 3, and 4 only

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

1, 2, and 3

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

15-mm external diameter

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

Ensure gas flow if the main port is blocked.

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

To seal off and protect the lower airway

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

To monitor cuff status and pressure

31. 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

1 and 2 only

32. 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

1 and 3 only

33. What is the purpose of a tracheostomy tube obturator?

To minimize trauma to the tracheal mucosal during insertion

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

Orotracheal intubation

35. 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

2, 3, and 4 only

36. 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

1, 2, and 3 only

37. 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?

Check and replace the bulb in the MacIntosh blade.

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

4.5 to 5.0 mm

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

3.0 mm

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

8 mm

41. What is the purpose of an endotracheal tube stylet?

It adds rigidity and shape to ease insertion.

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

Neck flexed, with head supported by towel and tilted back

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

30 sec

44. Which of the following statements are true about methods used to displace the epiglottis during oral intubation?

a. Regardless of the blade used, the laryngoscope is lifted up and forward.

b. The curved (MacIntosh) blade lifts the epiglottis indirectly.

c. The straight (Miller) blade lifts the epiglottis directly.

d. Levering the laryngoscope against the teeth can aid displacement.

1, 2, and 3 only

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

Until its cuff has passed the cords

46. 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.

1, 2, and 3

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

3 to 6 cm

48. Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachel.

Fiberoptic laryngoscopy

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

21 to 23 cm

50. 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?

The bulb fails to reexpand upon release.

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

Placement of the endotracheal tube in the esophagus

52. 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)?

Cardiac arrest

53. 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?

Return of spontaneous circulation

54. Serious complications of oral intubation include which of the following?

1. Cardiac arrest

2. Acute hypoxemia

3. Bradycardia

4. Tongue lacerations

1, 2, and 3 only

55. 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?

Intubate via the nasal route.

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

Mixture of 0.25% phenylephrine and 3% lidocaine

57. 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

2 and 3 only

58. What is the primary indication for tracheostomy?

When a patient has a long-term need for an artificial airway

59. 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.

1, 2, 3, 4, and 5

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

Through or between the second and third tracheal rings

61. 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?

Withdraw the oral tube 2 to 3 in while the incision is made.

62. 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.

1, 2, and 3 only

63. 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

1, 2, 3, and 4

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

Hoarseness

65. 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?

STAT racemic epinephrine aerosol treatment

66. 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.

Vocal cord paralysis

67. Which of the following injuries are seen with tracheostomy tubes?

1. Tracheomalacia

2. Tracheal stenosis

3. Glottic edema

4. Vocal cord granulomas

1 and 2 only

68. 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

1, 2, and 3

69. 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?

Tracheal stenosis

70. 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?

Tracheoesophageal fistula

71. 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?

Switch from the T tube to a tracheostomy collar.

72. 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

1, 2, and 3

73. 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?

3 to 6 cm

74. 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?

Withdraw the tube by 2 to 3 cm (using tube markings as a guide).

75. 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.

1 and 3 only

76. 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?

32° to 35° C

77. 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.

2, 3, and 4 only

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

Using a low-residual-volume, low-compliance cuff

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

20 to 25 mm Hg

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

Decrease cuff pressure.

81. 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.

The tube chosen is too small for the patient.

82. Which of the following is false about cuff inflation techniques (MOV= minimal leak technique).

The MLT approach negates the need for pressure monitoring.

83. 120. What is the normal range of negative pressure to use when suctioning infants?

-80 to -100 mm Hg

84. Which of the following statements are true about the potential for aspiration in patients with cuffed tracheal tubes?

1. Periodic oropharyngeal suctioning can help to minimize aspiration.

2. Aspiration is least likely in spontaneously breathing patients.

3. The methylene blue test can help detect leakage-type aspiration.

4. Aspiration is more likely with tracheostomy tubes than with endotracheal tubes.

1, 3, and 4 only

85. To minimize the problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend?

1. Position patients in semi-recumbent position.

2. Insert the feeding tube into the duodenum.

3. Suction above the tracheal tube cuff.

4. Provide continuous aspiration of subglottic secretions.

1, 2, 3, and 4

86. A patient with a tracheal airway exhibits signs of tube obstruction. Which of the following are possible causes of this obstruction?

1. The tube cuff has herniated over the tip of the tube.

2. The tube is obstructed by a mucus plug or secretions.

3. The tube is kinked, or the patient is biting the tube.

4. The tube orifice is impinging on the tracheal wall.

1, 2, 3, and 4

87. A patient with a tracheostomy tube is receiving positive-pressure ventilation through a volume ventilator. Over the past 5 min, the peak inspiratory pressure has risen, and the pressure limit alarm is now sounding. On quick examination, you notice a generalized decreased in breath sounds. Which of the following problems is most likely?

Partial obstruction of the tracheostomy tube

88. A patient with a tracheal airway exhibits severe respiratory distress. On quick examination, you notice the complete absence of breath sounds and no gas flowing through the airway. What is most likely the problem?

Complete tube obstruction

89. After determining a patient has a complete obstruction of an oral endotracheal tube, your efforts to relieve the obstruction by moving the patient's head and neck and deflating the cuff both fail. What should be your next step?

Immediately extubate the patient.

90. A patient receiving mechanical ventilatory support accidentally displaces the endotracheal tube out of the trachea. What would be the most appropriate action at this time?

Remove the tube and provide manual ventilation or oxygenation as necessary.

91. What does a positive cuff leak test indicate?

The patient is at minimal risk for upper airway obstruction.

92. Which of the following indicate that a patient being considered for extubation can provide adequate clearance of pulmonary secretions?

1. The patient has a maximum inspiratory pressure of 73 cm H2O.

2. The patient is alert and cooperative.

3. The patient has a dead space-to-tidal volume ratio of 0.7.

4. The patient coughs rigorously on suctioning.

1, 2, and 4 only

93. Which of the following equipment would you gather before assisting in extubation of a patient?

1. Suctioning apparatus

2. Oxygen or aerosol therapy equipment

3. Manual resuscitator and mask

4. Nebulizer with racemic epinephrine

5. Intubation tray

1, 2, 3, 4, and 5

94. A physician has requested your assistance in extubating an orally intubated patient. Which of the following should be done before the tube itself is removed?

1. Suction the orolaryngopharynx

2. Preoxygenate the patient

3. Suction the endotracheal tube

4. Confirm cuff inflation.

1, 2, 3, and 4

95. Although different techniques are used to actually remove the endotracheal tube during an extubation procedure, all aim to ensure which of the following?

Maximal abduction of the vocal cords

96. To minimize laryngeal swelling, a physician orders "continuous aerosol therapy" after the extubation of a patient. Which of the following specific approaches would you recommend?

Cool mist therapy through a jet nebulizer and aerosol mask

97. You have been asked to monitor a patient who has just been extubated. Which of the following parameters would you monitor?

1. Color

2. Breath sounds

3. Vital signs

4. Inspiratory force.

1, 2, and 3 only

98. An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend?

Administer a racemic epinephrine treatment.

99. What is a rare but serious complication associated with endotracheal tube extubation?

Laryngospasm

100. Which of the following approaches may be used in "weaning" a patient from a tracheostomy tube?

1. Using progressively smaller tubes

2. Using a fenestrated tube

3. Using a tracheostomy button

1, 2, and 3