Clinical Assessment Review

Jul 6, 2024

Exam Review: Clinical Assessment Procedures

Exam Focus

  • Clinical assessment procedures for patient data.
  • Interpreting procedure results and recommending diagnostic procedures.

Key Points by Question

Question 1: Neonate with Unilateral Chest Expansion

  • Scenario: 28-week neonate, sudden tachypnea with unilateral chest expansion.
  • Answer: Transillumination of the chest.
    • If the transilluminator shows a large pocket of light, it indicates air (pneumothorax).
  • Chapter: 13

Question 2: Alveolar Minute Volume

  • Scenario: Calculate alveolar minute volume for 75 kg patient on 40% aerosol mask.
  • Formula: (Tidal Volume - Anatomical Dead Space) × Respiratory Rate.
    • Dead Space: 1 mL per pound of body weight.
    • Calculation: (500 mL - 165 mL) × 12 = 4 liters.
  • Answer: A
  • Chapter: 3

Question 3: ET Tube Position

  • Scenario: Chest X-ray reveals ET tube at the level of the fourth rib (Carina level).
  • Action: Withdraw tube to 23 cm mark.
  • Key Concepts: ET tube position should be 2–5 cm above the Carina.
  • Answer: A
  • Chapter: 4

Question 4: Tracheal Mucosa Damage

  • Scenario: Identifying factors that increase the potential for tracheal damage by an ET tube.
  • Answer: Maintaining cuff pressure at 40 cm H2O (should be 20-30 cm H2O).
  • Chapter: 4

Question 5: Transcutaneous Oxygen Monitoring

  • Scenario: Calibrating transcutaneous oxygen sensors in neonates.
  • Steps: Remove from baby, expose to room air, calibrate, reattach.
  • Temperature: 42-44°C.
  • Answer: B (Membrane is damaged).
  • Chapter: 13

Question 6: Blood Gas Interpretation

  • Scenario: Second blood gas values after increasing O2 from 40% to 50% in hypoxemic patient.
  • Expected Change: Increase in paO2 and CO2.
  • Answer: C
  • Chapter: 1

Question 7: Sputum Analysis

  • Scenario: Sputum specimen that is odoriferous and separates into layers.
  • Condition: Bronchiectasis.
  • Answer: C
  • Chapter: 12

Question 8: Blood Gases Indicating Need to Wean

  • Scenario: Weaning COPD patient using SIMV.
  • Key Value: paO2 = 64 mmHg (acceptable range for COPD).
  • Answer: B
  • Chapter: 11

Question 9: Diagnosing Sleep Apnea

  • Scenario: Patient with high blood pressure and daytime sleepiness.
  • Diagnostic Procedure: Polysomnography.
  • Answer: B
  • Chapter: 12

Question 10: Optimal PEEP

  • Scenario: Determining optimal PEEP.
  • Concepts:
    1. Highest paO2 without cardiovascular side effects.
    2. Highest static lung compliance.
    3. Highest SVO2.
    4. Using pressure-volume loops.
  • Answer: C (Static compliance).
  • Chapter: 11

Question 11: Dead Space Calculation

  • Scenario: Calculating dead space based on CO2 differences.
  • Formula: [(Paco2 - PeTCO2) / Paco2] × Vt.
  • Answer: Dead space is 40% (dead space fraction).
  • Chapter: 11

Question 12: Paradoxical Chest Movement

  • Condition: Flail chest.
  • Answer: D
  • Chapter: 3

Question 13: Ventilatory Status Evaluation

  • Scenario: COPD patient on oxygen showing lethargy.
  • Test: ABG to check CO2 levels.
  • Answer: C (Obtain ABG).
  • Chapters: 10, 12

Question 14: Differentiating Pneumothorax Types

  • Scenario: Patient with high pressure alarm post PA catheter insertion.
  • Concept: Differentiate between regular and tension pneumothorax.
    • Regular Pneumothorax: No tracheal deviation, normal BP, elevated HR.
    • Tension Pneumothorax: Tracheal deviation, high HR, low BP (needle decompression).
  • Answer: A
  • Chapters: 3, 5, 12

Question 15: A-a Difference Calculation

  • Scenario: Calculate alveolar-arterial (A-a) gradient.
  • Shortcut Method & Formula.
  • Answer: A
  • Chapters: 1, 10

Question 16: Response to Oxygen Therapy

  • Scenario: Asthma patient on 28% O2 with increased CO2.
  • Concept: Correct response to O2 therapy increasing CO2.
  • Answer: D (Continue at 28%).
  • Chapter: 1

Question 17: Determining Cardiogenic Pulmonary Edema

  • Key Measure: Pulmonary capillary wedge pressure.
  • Answer: A
  • Chapter: 9

Question 18: Lung Compliance in Fluid Overload

  • Concept: Fluid overload results in worsening lung compliance.
  • Critical Measure: A-a difference increases in fluid overload.
  • Answer: B (A--a difference).
  • Chapters: 1, 10

Question 19: Parameters for Weaning from Ventilation

  • Key Parameters: MIP, VC, Spont. TV, RSBI, Dead Space, A-a, PF Ratio, PEEP.
  • Specific Value Accepted: MIP of –32.
  • Answer: B
  • Chapter: 11

Question 20: Optimal PEEP Using PVO2

  • Concept: Highest pvo2 indicates optimal PEEP.
  • Answer: 39 mmHg pvo2 at PEEP of 9.
  • Answer: C
  • Chapter: 11

Question 21: Static Lung Compliance Calculation

  • Formula: Vt / (Plat - PEEP).
  • Calculation: 600 / 20 = 30 mL/cm H2O.
  • Answer: Direct Calculation.
  • Chapter: 11

Question 22: Airway Inflammation Indicator

  • Measure: Exhaled nitric oxide (FENO) levels.
  • Critical Levels: >35 ppb in children, >50 ppb in adults indicates inflammation.
  • Answer: A
  • Chapter: 12

Question 23: Right Heart Failure in COPD

  • Symptoms: Pedal edema, jugular venous distension.
  • Condition: Right ventricular failure.
  • Answer: D
  • Chapter: 3

Question 24: Oxygen Carrying Capacity

  • Key Measure: Total CaO2 (including oxyhemoglobin).
  • Answer: C (CaO2).
  • Chapters: 1, 10

Question 25: Blood Gas Interpretation in CO Poisoning

  • Scenario: Non-rebreather mask, metabolic acidosis.
  • True Statement: Hypoxia (due to CO).
  • Answer: C
  • Chapter: 13

Question 26: Assessing Chest X-ray Quality

  • Parameter: Inspiratory effort visible with 9-11 ribs.
  • Answer: D
  • Chapter: 3

Question 27: Underexposed Chest X-ray

  • Scenario: Vertebral processes not visible, increased opacity.
  • Conclusion: Underexposure.
  • Answer: C
  • Chapter: 3

Question 28: Elevated CO2 in Capnography

  • Concept: Potential causes for elevated capnometry values.
  • Exception: Esophageal intubation (low or zero CO2).
  • Answer: B
  • Chapter: 1

Question 29: Pulmonary Embolism Indicators

  • Scenario: Sudden dyspnea, chest pain, high HR, high RR, divergence in CAPnometry and PAco2.
  • Condition: Pulmonary embolism (Dead Space defect).
  • Answer: A
  • Chapters: 1, 12

Question 30: Toxic Exposure Monitoring

  • Scenario: Benzene exposure in industrial accident.
  • Diagnostic Tool: Co-oximetry (hemoximetry).
  • Answer: D
  • Chapter: 10

Important Concepts Reviewed

  • Calculation methods for Alveolar Minute Volume, Dead Space, and Static Lung Compliance.
  • Differentiating types of pneumothorax, optimal PEEP methods, and respiratory monitoring tools.
  • Interpreting clinical signs and lab values for diagnostic and therapeutic decisions.