Wilkins: Egan's Fundamentals of Respiratory Care, 9th Edition

Chapter 33: Airway Management/Artificial Airway

MULTIPLE CHOICE 1. What is the primary indication for tracheal suctioning? A. presence of pneumonia B. presence of atelectasis C. ineffective coughing D. retention of secretions REF: 695 2. What is the most common complication of suctioning? A. hypoxemia B. hypotension C. arrhythmias D. infection REF: 695 3. Complications of tracheal suctioning include all of the following except: A. bronchospasm B. hyperinflation C. mucosal trauma D. elevated intracranial pressure REF: 695

4.How often should patients be suctioned? A. at least once every 2 to 3 hours B. whenever they are moved or ambulated C. when physical findings support the need D. whenever the charge nurse requests it REF: 695 5. 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 REF: 695 6. 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. 150 to 200 mm Hg REF: 695 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? A. 6 Fr B. 8 Fr C. 10 Fr D. 14 Fr REF: 695

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? A. 8 Fr B. 10 Fr C. 12 Fr D. 14 Fr REF: 695 9. 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 minutes. REF: 695 10. 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 seconds. B. Use a closed-system multiuse suction catheter. C. Limit suctioning to once an hour. D. Use the smallest possible catheter. REF: 695 11. Total application time for endotracheal suction in adults should not exceed which of the following? A. 20 to 25 seconds B. 15 to 20 seconds C. 10 to 15 seconds D. 3 to 5 seconds REF: 697 12. While suctioning a patient, you observe an abrupt change in the electrocardiogram wave form 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. REF: 698 13. Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning?

A. B. C. D.

I. Limit the amount of negative pressure used. II. Hyperinflate the patient before and after the procedure. III. Suction for as short a period of time as possible. I and II I and III II and III I, II, and III

REF: 698 14. Which of the following can help to minimize the likelihood of mucosal trauma during suctioning? I. Use as large a catheter as possible. II. Rotate the catheter while withdrawing. III. Use as rigid a catheter as possible. IV. Limit the amount of negative pressure. A. B. C. D. I and II II and IV III and IV I, II, and IV

REF: 698 15. Absolute contraindication for nasotracheal suctioning includes which of the following? I. epiglottitis II. croup III. irritable airway A. B. C. D. I and II I and III II and III I, II, and III

REF: 698 16. Which of the following equipment is NOT needed to perform nasotracheal suctioning? A. suction kit (catheter, gloves, basin, etc.) B. laryngoscope with MacIntosh and Miller blades C. oxygen delivery system (mask and manual resuscitator) D. bottle of sterile water or saline solution See Box 33-1. REF: 698 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?

A. B. C. D.

Perform a tracheotomy for better access to the lower airway. Discontinue nasotracheal suctioning for 48 hours and reassess. Stop the bleeding and use a nasopharyngeal airway for access. Orally intubate the patient for better access to the lower airway.

REF: 700 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? 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. REF: 700 19. What general condition requires airway management? I. airway compromise II. respiratory failure III. need to protect the airway A. B. C. D. I and II I and III II and III I, II, and III

REF: 700 20. Which of the following conditions require emergency tracheal intubation? I. upper airway or laryngeal edema II. loss of protective reflexes III. cardiopulmonary arrest IV. traumatic upper airway obstruction A. B. C. D. I and IV III and IV I, II, and III I, II, III, and IV REF: 700

21. Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management? I. hypotension II. bradycardia III. cardiac arrhythmias IV. laryngospasm A. B. C. D. . I, II, and III I and IV III and IV I, II, III, and IV

REF: 700 22. All of the following indicate an inability to adequately protect the airway except: A. wheezing B. coma C. lack of gag reflex D. inability to cough REF: 700 23. Which of the following types of artificial airways are inserted through the larynx? I. pharyngeal airways II. tracheostomy tubes III. nasotracheal tubes IV. orotracheal tubes

A. B. C. D.

I and IV I, II, and III III and IV I, II, III, and IV

REF: 703 24. Compared with the nasal route, the advantages of oral intubation include all of the following except: A. reduced risk of kinking B. less retching and gagging C. easier suctioning D. less traumatic insertion REF: 703 25. Compared with the oral route, the advantages of nasal intubation include all of the following except: A. reduced risk of kinking B. less retching and gagging C. less accidental extubation D. greater long-term comfort REF: 703 26. Compared with translaryngeal intubation, the advantages of tracheostomy include all of the following except: A. greater patient comfort B. reduced risk of bronchial intubation C. no upper airway complications D. decreased frequency of aspiration

REF: 703 27. 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 REF: 703 28. 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 REF: 703 29. What is the purpose of a cuff on an artificial tracheal airway? A. seal off and protect the lower airway B. stabilize the tube and prevent its movement C. provide a means to determine tube position via radiograph D. help clinicians determine the depth of tube insertion . REF: 703 30. What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube? A. help ascertain proper tube position B. minimize mucosal trauma during insertion C. monitor cuff status and pressure D. protect the airway against aspiration REF: 703 31. Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement? I. length markings on the curved body of the tube II. imbedded radiopaque indicator near the tube tip III. additional side port (Murphy eye) near the tube tip A. B. C. D. I and II I and III II and III I, II, and III

REF: 703

32. The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes? I. aid in routine tube cleaning and tracheostomy care II. prevent the tube from slipping into the trachea III. provide a patent airway should it become obstructed A. B. C. D. I and III II and III III only I, II, and III

REF: 705 33. What is the purpose of a tracheostomy tube obturator? A. minimize trauma to the tracheal mucosal during insertion B. provide a patent airway should the tube become obstructed C. help ascertain the proper tube position by radiograph D. provide a means to inflate and deflate the tube cuff REF: 706 34. 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 REF: 706 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? I. obturator II. syringe(s) III. resuscitator bag or mask IV. tube stylet A. B. C. D. I, II, and III II and IV II, III, and IV I, II, III and IV

REF: 706

36. Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following? I. laryngoscope light source II. endotracheal tube cuff III. suction equipment IV. cardiac defibrillator A. B. C. D. I, II, and III II and IV III and IV I, III, and IV

REF: 706 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? 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. REF: 706 38. 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 REF: 706 39. 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 REF: 706

40. What size endotracheal tube would you select to intubate an adult female? A. 6 mm B. 7 mm C. 8 mm D. 9 mm REF: 706 41. What is the purpose of an endotracheal tube stylet? A. helps ascertain proper tube position B. adds rigidity and shape to ease insertion C. minimizes mucosal trauma during insertion D. protects the airway against aspiration REF: 707 42. To make oral intubation easier, how should the patients 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 REF: 707 43. What should be the maximum time devoted to any intubation attempt? A. 30 seconds B. 60 seconds C. 90 seconds D. 2 minutes REF: 707 44. Which of the following statements are FALSE 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. REF: 708 45. 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 inches D. until its tip has passed the cords by 2 to 3 cm REF: 708
R

46. Immediately after insertion of an oral endotracheal tube on an adult, what should you do? I. Stabilize it with your right hand. II. Inflate the tube cuff. III. Provide ventilation or oxygenation. A. B. C. D. I and II I and III II and III I, II, and III

REF: 708

47. Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned about how far above the carina? A. 1 to 3 cm B. 4 to 6 cm C. 7 to 9 cm D. 4 to 6 inches REF: 709 48. 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 REF: 709 49. 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 REF: 710 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? 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. REF: 710 51. 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 REF: 710

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)? A. cardiac arrest B. gastric CO2 diffusion C. right mainstem intubation D. delivery of a high FIO2 REF: 710 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? 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 REF: 710

54. Serious complications of oral intubation include which of the following? I. cardiac arrest II. acute hypoxemia III. bradycardia IV. tongue lacerations A. B. C. D. II and IV I, II, and III II, III, and IV I, II, III, and IV

REF: 712 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? A. Intubate via the oral route. B. Insert an oropharyngeal airway. C. Perform an emergency tracheotomy. D. Intubate via the nasal route. REF: 712 56. To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend? A. nasal spray of 0.25% racemic epinephrine B. SVN aerosol delivery of 2% lidocaine for 10 minutes C. nasal spray of 0.25% racemic epinephrine/2% lidocaine D. SVN aerosol delivery of 0.25% racemic epinephrine for 10 minutes REF: 712 57. What is the average depth of proper nasal endotracheal tube insertion in adult men? A. 23 cm from the patients teeth B. 28 cm from the external naris C. 28 inches from the tube connector D. 32 cm from the patients teeth REF: 712 58. When performing blind nasotracheal intubation, successful tube passage through the larynx is indicated by which of the following? I. louder breath sounds II. harsh cough III. vocal silence A. I and II B. I and III

C. II and III D. I, II, and III REF: 713 59. 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 hours D. when a patient has upper airway obstruction due to secretions REF: 713 60. Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube? I. patients tolerance of the endotracheal tube II. relative risks of continued intubation versus tracheostomy III. patients severity of illness and overall condition IV. length of time that the patient will need an artificial airway V. patients ability to tolerate a surgical procedure A. B. C. D. I, III, and IV III, IV, and V II, III, IV, and V I, II, III, IV, and V

REF: 713 61. 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 REF: 713 62. 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 inches while the incision is made. REF: 714 63. Compared with traditional surgical tracheostomy, all of the following are TRUE about percutaneous dilatational tracheostomy except: A. Percutaneous dilatational tracheostomy has a lower incidence of complications. B. Percutaneous dilatational tracheostomy is faster that traditional tracheostomy. C. Percutaneous dilatational tracheostomy can be performed at the bedside. D. Percutaneous dilatational tracheostomy does not require anterior neck dissection. REF: 714

64. Which of the following techniques may be used to diagnose injury associated with artificial airways? I. laryngoscopy or bronchoscopy II. physical examination III. air tomography IV. pulmonary function studies A. B. C. D. I and II I and III II, III, and IV I, II, III, and IV

REF: 715 65. 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 REF: 715 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 hours D. immediate reintubation via the nasal route REF: 715

67. 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 REF: 716 68. Which of the following injuries are NOT seen with tracheostomy tubes? I. tracheomalacia II. tracheal stenosis III. glottic edema IV. vocal cord granulomas A. B. C. D. I and IV II and IV III and IV I, II, and III

REF: 716 69. Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur? I. cuff site II. tip of the tube III. stoma site A. B. C. D. I and II I and III II and III I, II, and III

REF: 716 70. 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 REF: 716

71. 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 REF: 717 72. 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. REF: 717 73. Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma? I. regular aseptic stoma cleaning II. adherence to sterile techniques III. regular change of tracheostomy dressings A. B. C. D. I and II I and III II and III I, II, and III

REF: 717 74. 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. 4 to 6 cm D. 6 to 8 cm REF: 717 75. 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). REF: 717-718 76. 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? I. Use a letter, phrase, or picture board. II. Consider switching to a fenestrated tracheostomy tube. III. Consider a talking tracheostomy tube.

A. B. C. D.

I and II I and III II and III I, II, and III

REF: 718 77. 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 REF: 720 78. Tracheal airways increase the incidence of pulmonary infections for all of the following reasons except: A. lower levels of humidification B. increased aspiration of pharyngeal material C. contaminated equipment or solutions D. ineffective clearance through cough REF: 720 79. 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 hours REF: 720 80. 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 REF: 720 81. 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 ANS: C Attaching the measurement system to the pilot tube evacuates some volume from the cuff (and lowers its pressure). For this reason, you should always adjust the pressure to the desired level, never just measure it. REF: 720 82. 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 mainstem bronchus. D. The cuff has herniated over the tube tip. REF: 720-721 83. Which of the following is false about cuff inflation techniques (MOV = minimal occluding volume; MLT = minimal leak technique)? A. The MLT approach negates the need for pressure monitoring. B. The MLT allows a small leak at peak or end of inspiration. C. At MOV, air leakage around the tube cuff should cease. D. With MLT, secretions tend to be blown upward during inflation. REF: 722 84. Which of the following tracheal tube cuff designs are used as alternatives to cuff pressure measurement? I. Kamen-Wilkinson foam cuff II. low-residual-volume cuff III. Lanz pressure-regulated cuff A. B. C. D. I and II I and III II and III I, II, and III

REF: 722 85. Which of the following statements is false about the potential for aspiration in patient with cuffed tracheal tubes?

A. B. C. D.

Periodic oropharyngeal suctioning can help to minimize aspiration. Aspiration is least likely in spontaneously breathing patients. The methylene blue test can help detect leakage-type aspiration. Aspiration is more likely with tracheostomy tubes than with endotracheal tubes.

REF: 723