When there is blunting of the costophrenic angle on a chest x-ray, you should automatically know that a pleural effusion is present.

Blunting of the costophrenic angle = Pleural effusion

The question even states that the left costophrenic angle is blunted, so you should have immediately recognized that a pleural effusion is present on the left side. The question also states that the patient has a history of CHF which is indicative of a pleural effusion as well.

None of the other answer choices really make sense in this situation, so we know that the correct answer has to be B.

First and foremost, you had to know that furosemide is another name for Lasix — which, of course, is a diuretic agent that is given for patients with fluid overload.

In general, you need to know that when Lasix (or any diuretic agent) is given, the patient will excrete a large amount of potassium. And remember, potassium levels are associated with the heart, so this explains why the patient has a new arrhythmia.

There is no indication to give more Lasix, nor is there an indication to give epinephrine. Also, there is no indication to defibrillate the patient.

After reading the question, it should immediately jump out to you that this is a COPD patient that is having an acute exacerbation, but let’s break it down.

Negative results for troponin would rule out a myocardial infarction. Negative results for BNP would rule out CHF. So now, basically, you just have to choose between pneumonia and COPD.

You can look at the patient’s ABG results and it’s a dead giveaway. COPD patients typically have fully compensated respiratory acidosis, but since this patient is having an acute exacerbation, her ventilatory status is deteriorating and the body can only compensate so much, which explains the partial compensation.

The first thing that should stand out in the question is that the patient has asthma, which we know is an obstructive disease. And we know that air trapping is a commonality in obstructive diseases.

If a patient has a significant difference between their slow vital capacity and forced vital capacity, this indicates that air is trapped in the lungs when the patient exhales forcefully.

Because the airways are obstructed or constricted, as with bronchospasm in asthma, all of the air can be expelled if the patient exhales slowly, it just takes longer. This explains why the values are lower for the FVC as compared to the SVC.

There are a few things about this question that stand out, so let’s break it down. First, you needed to know that acetylcysteine is another name for Mucomyst, which is a drug that is typically given for retained secretions.

Also, you needed to recognize that the question tells us the patient has an inadequate cough. This means that they will have trouble clearing secretions on their own, which tells us that some type of intervention must be performed.

Of the answer choices that are listed, the best way to help remove the secretions would be to NT suction the patient after the treatment is given.

Dornase alfa (Pulmozyme) is a medication that is used to treat patients with cystic fibrosis, and none of the other answer choices really make sense in this situation.

To get this one right, you needed to have a basic understanding of the different types of bronchodilators.

Albuterol, levalbuterol, and metaproterenol are all fast-acting sympathomimetic bronchodilators — so we can rule them out immediately.

Brovana, on the other hand, is a long-duration controller-type medication that is intended to help stable patients with chronic bronchospasm.

Whenever you see an infant with bradycardia and spells of apnea, you should automatically know to initiate mechanical ventilation, as these are indications.

CPAP helps with oxygenation but not ventilation, so you know it can’t be that one. There is no indication for a bronchodilator, nor is there an indication for surfactant either at this time.

To get this one correct, you simply needed to know the common signs that occur when an infant is in respiratory distress.

The most common signs include:

• Tachypnea

• Nasal flaring

• Grunting

• Chest wall retractions

Please remember these because you will (most likely) see them again on the TMC Exam.

To get this one correct, you needed to be able to interpret the ABG results and make the most appropriate changes for the patient.

By looking at the results, you can see that hypoxemia is present because the PaO2 and SaO2 are both decreased.

A BiPAP isn’t indicated in this case because the patient is ventilating fine, as you can see with a pH that is in the normal range. A nonrebreathing mask isn’t indicated either because that would provide too much oxygen for this patient — especially since the question tells us that the patient has COPD.

Switching to a 24% air entrainment mask will likely decrease her inspired level of oxygen(since she is technically getting 28% with the 2 LPM she is on now), so we can rule that one out as well.

In this case, the best action to take is to increase the oxygen flow to 3 L/min and continue to monitor the patient.

To get this one correct, you have to look at all the details that were provided in the question and break it all down.

Atelectasis is a common problem that you want to avoid after a patient has had surgery. But we can rule it out in this case because the question tells us that there was no tracheal shift on the chest x-ray. Remember, when atelectasis is present, the trachea will shift towards the affected side.

We can also rule out a pneumothorax and pleural effusion as well because there would have been a tracheal shift away from the affected side in both conditions.

On the TMC Exam, whenever you see that a patient has consolidation on a chest x-ray, you should automatically think that pneumonia is present. This is what is causing the shortness of breath for the patient in this question.

The first thing you have to interpret is that the patient has a higher than normal ICP. Remember, the normal range for ICP is 10-15 mmHg.

PEEP is not indicated and there is no indication to decrease the tidal volume, so we can rule those two out right away.

Remember that for patient with a high ICP, you can actually lower it by purposefully hyperventilating the patient.

And since this patient is already slightly acidotic with an elevated PaCO2, hyperventilation could help to lower the PaCO2 and ICP all at the same time. So in order to hyperventilate the patient, we need to increase the minute ventilation

To get this one correct, you must be able to interpret the blood gas results and make the necessary changes.

You can see that the acid-base status of this infant is within normal range. With that said, you can see that the patient has severe hypoxemia by looking at the PaO2. This is most likely due to shunting caused by the IRDS.

In this case, an initial trial of nasal CPAP should be attempted before intubation and mechanical ventilation.

To get this one right, you simply needed to know the normal range for the FEV1/FVC ratio as a percentage.

In general, patients with normal lungs should be able to exhale at least 70% of their vital capacity within the first 1 second (FEV1).

Patients with an obstructive disease will show a reduced FEV1% value, while patients with restrictive diseases will show a normal or sometimes high FEV1% values.

First and foremost, you must interpret the ABG results. In this case, the patient shows acute respiratory acidosis. And by looking at the PaO2 and SpO2, we can determine that her oxygenation status is satisfactory.

To correct acute respiratory acidosis, we need to blow off some of that CO2 and we can do that by increasing the minute ventilation. This means that we need to either increase the rate or increase the tidal volume.

The question provides her weight of 52 kg and the set tidal volume of 400 mL, so we can calculate that the tidal volume is set appropriately:

400/52 = 8 mL/kg

So since the tidal volume is set correctly, we know that in order to lower the PaCO2, we need to increase the rate.

To get this one correct, you needed to have a basic understanding of what happens when you adjust the pressure limit on a ventilator.

By increasing the pressure limit, you will increase the infant’s tidal volume which can increase the risk of their lung tissues being overinflated and torn. Of course, this can result in barotrauma which can lead to a pneumothorax.

Oxygen toxicity occurs when the patient receives a high percentage of oxygen for a prolonged period of time. Retinopathy of prematurity is a complex condition related to prematurity and frequent swings in the patient’s arterial blood oxygen and carbon dioxide levels.

A tracheoesophageal fistula can be the result of a developmental defect or caused by tissue damage from an endotracheal tube and nasogastric tube. None of which are occurring here

To get this one correct, you needed to know that an adverse effect of PEEP is a decreased cardiac output.

This is clearly what’s going on with this patient because the question tells us that there is a rapid drop in a blood pressure and rise in heart rate.

As a Respiratory Therapist, when there is an adverse response to any type of therapy, your first reaction should be to stop the therapy and restore the patient to their prior state. In this case, it only makes sense to lower the PEEP back to the previous setting of 10 cm H2O.

This is your typical PFT interpretation question. You will see a few of these on the TMC Exam. And to get them right, you must understand what each value means in regards to knowing the difference between an obstructive and restrictive disease.

Since this patient has a normal FEV1/FVC ratio, this indicates that there is not an obstructive disease.

And since the FEV1, FVC, and TLC are all reduced, this indicates a restrictive disease.

To get this one correct, you needed to have a basic understanding of chest radiograph findings and what they tell you about a patient’s condition.

In general, you should remember that the heart and mediastinum are pulled toward areas of collapse and pushed away from areas containing abnormal air or fluid.

So in this case, since there is a shift of the heart position to the right, that means that there is either a collapse on the right, or there is excess air or fluid on the left.

With that said, now we just have to go through the answer choices to come up with the correct answer. Atelectasis on the left side would pull the heart to the left. A pneumothorax or a pleural effusion on the right side would push the heart away to the left side.

However, a pneumothorax on the left side would push the heart away from the affected side to the patient’s right.

The first thing you need to do is interpret the ABG results. By doing so, you will see that all of the values fall within the normal ranges. And by looking at the ventilator settings that are provided in the question, everything appears to be set appropriately.

Therefore, no changes are indicated at this time. The settings should be left unchanged.

The question tells us that it took the patient too long to reach the peak expiratory flow, which means that the patient simply isn’t exhaling fast enough. This can cause invalid results.

In this case, you should simply instruct the patient to blast the air out faster at the beginning of the maneuver and this will correct the issue.

Taking a deeper breath will not fix the issue and the patient doesn’t seem to have a problem hesitating. Blowing out longer isn’t going to fix the issue either

To get this one correct, you first needed to know what tactile fremitus is.

Tactile fremitus refers to the vibrations that can be felt as you palpate the chest wall. There is usually increased tactile fremitus over areas of consolidation, such as pneumonia and pulmonary edema.

Tactile fremitus would be reduced in conditions like COPD and a pneumothorax because the lung is overinflated. It would also be reduced in a pleural effusion because the effusion would block and decrease the sounds coming from the lungs

First we must interpret the ABG results. By doing so, we can see that the patient is in acute respiratory acidosis and needs full ventilatory support. This means that we can immediately rule out any of the answer choices with BiPAP and CPAP.

The SIMV mode at a rate of 6/min is only going to provide partial ventilatory support, so we can rule that one out as well.

The best option for this patient is assist/control ventilation at a normal rate with an initial tidal volume of about 8 mL/kg

After reading the question and answer choices, first we must determine if the right size suction catheter is being used. A simple way to do that is to “double the ET tube size number and then take the next size down.”

So with a size 7 endotracheal tube, you double that number to get 14. Then take the next smallest catheter size, which is 12. So a size 12 Fr catheter is appropriate in this case, which rules out C and D.

Usually when you are unable to pass a suction catheter, it indicates that there is an obstruction in the tube. And most obstructions are either caused by a mucus plug or kinking or biting of the tube.

Even if the tube is in the right mainstem bronchus, you should still be able to pass the suction catheter beyond the tip of the tube.

To get this one correct, you just needed to know what medications are typically given to patients on the ventilator for sedation.

Nimbex is a neuromuscular blocking agent, not a sedative. Dexedrine is a stimulant and Prozac is an antidepressant — so we can rule these out right away.

Versed is a benzodiazepine that is used to provide sedation for patients receiving mechanical ventilation and, of course, is the correct answer.

Other common medications that are used to sedate mechanically ventilated patients include hypnotics like propofol (Diprivan), alpha-2 agonists like Precedex, and opioid analgesics like fentanyl.

To get this one correct, you simply need to know how to calculate the patient’s TLC using the information that is given in the question. This can easily be done using the “lung box.”

We recommend that you draw the “lung box” on your scratch paper before you begin the exam. That way you can use it on the PFT questions (like this one) throughout the exam.

But for this one, basically all you have to do is subtract the ERV from the FRC which will give you the patient’s residual volume. Then you can get the TLC by adding the residual volume and vital capacity together.

5.8 – 1.2 = 4.6

4.6 + 3.4 = 8

TLC = 8